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Current Thinking in Lower Third Molar Surgery

Ben J Steel, Krisna SB Surendran, Christopher Braithwaite, Darpan Mehta,

PII: S0266-4356(21)00266-7
DOI: https://doi.org/10.1016/j.bjoms.2021.06.016
Reference: YBJOM 6534

To appear in: British Journal of Oral & Maxillofacial Surgery

Received Date: 20 January 2021

Please cite this article as: B.J. Steel, K. SB Surendran, C. Braithwaite, D. Mehta, D. JW Keith, Current Thinking
in Lower Third Molar Surgery, British Journal of Oral & Maxillofacial Surgery (2021), doi: https://doi.org/
10.1016/j.bjoms.2021.06.016

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 Title Page

Manuscript title – Current Thinking in Lower Third Molar Surgery

Authors –

Ben J Steel
MBBS BDS MRCS MFDS
Specialty Registrar, Oral and Maxillofacial Surgery
Sunderland Royal Hospital, Kayll Road, Sunderland, UK, SR4 7TP

Krisna SB Surendran
BDS MFDS
Trust Doctor, Oral and Maxillofacial Surgery
Sunderland Royal Hospital, Kayll Road, Sunderland, UK, SR4 7TP

Christopher Braithwaite
BDS MFDS
Trust Doctor, Oral and Maxillofacial Surgery
Sunderland Royal Hospital, Kayll Road, Sunderland, UK, SR4 7TP

Darpan Mehta
FRCS
Consultant, Oral and Maxillofacial Surgery
Sunderland Royal Hospital, Kayll Road, Sunderland, UK, SR4 7TP

David JW Keith
FRCS
Consultant, Oral and Maxillofacial Surgery
Sunderland Royal Hospital, Kayll Road, Sunderland, UK, SR4 7TP

Corresponding author –

Ben J Steel
MBBS BDS MRCS MFDS
Specialty Registrar, Oral and Maxillofacial Surgery
Sunderland Royal Hospital, Kayll Road, Sunderland, UK, SR4 7TP
Tel 07752299891
Email – [email protected]

Abstract

The removal of lower third molar teeth is one of the most common surgical procedures
performed worldwide. Many concepts in this surgery have been unclear and engendered
different opinions. This paper aims to review current thinking in certain pertinent aspects of
this surgery, to update the reader on the most current research and synthesise it to make
clinical recommendations. Topics covered include pre-operative imaging, timing of removal,
flap design, lingual retraction, coronectomy, lingual split, closure techniques, antibiotics and
steroid use and drains.

1
Keywords

 Third molar extraction

2
 Current thinking in lower third molar surgery

Abstract

The removal of lower third molar teeth is one of the most common surgical procedures performed

worldwide. Many concepts in this surgery have been unclear and engendered different opinions. This

paper aims to review current thinking in certain pertinent aspects of this surgery, to update the reader

on the most current research and synthesise it to make clinical recommendations. Topics covered

include pre-operative imaging, timing of removal, flap design, lingual retraction, coronectomy, lingual

split, closure techniques, antibiotics and steroid use and drains.

Keywords

 Third molar extraction

 Odontectomy

 Coronectomy

 Wisdom tooth

The removal of lower third molar teeth is a very common surgical procedure performed worldwide,

with approximately 60,000 extracted per year in secondary care in the UK alone1. Numerous papers on

lower third molars are published every year however it is notable and surprising given such an

extensive literature that many aspects remain unclear.

The purpose of this paper is to review the literature and draw up clinical recommendations regarding

the following –

 Pre-operative imaging

 Timing of removal

 Methods of removal and techniques

3
 o Flap design

o Lingual retraction

o Coronectomy

o Lingual split

o Closure

 Adjuncts

o Antibiotics

o Steroids

o Drains

Pre-operative Imaging

Radiographic features

Rood and Shehab (1990) described seven radiographic signs indicating close proximity of tooth roots

to the inferior alveolar canal (IAC)2 (see Figure 1), although only three have been subsequently validated

– diversion of the canal, interruption of the white lining of the canal and darkening of the root3. The

presence of any one of these was said to confer an increased inferior alveolar nerve (IAN) injury risk of

8-22%. Figure 2 shows a clinical example of an orthopantomogram (OPT) showing radiographic signs

of close proximity of roots and IAC.

Cone beam Computed Tomography (CBCT) can give more detailed multi-dimensional imaging

compared to plain radiographs, e.g. precise visualisation of caries, root resorption, root position and

morphology and proximity to the IAC4. Signs of proximity on CBCT are direct contact between the IAN

and third molar roots, missing cortication or fenestration of IAC wall and narrowing, dumbbell shape4

or lingual position of the IAC5. Interruption of the white line of the IAC and darkening of roots as seen

on OPT predicts contact between the root and canal on subsequent CBCTs in 23-56% of cases6. The

signs of proximity seen on CBCT are not more predictive of nerve injury than those seen on OPT6.

Figure 3 shows a clinical example of a CBCT with close proximity of roots and IAC.

4
OPG vs. CBCT

The greater detail in a CBCT should theoretically allow more precise surgical planning to minimise IAN

risk, e.g. planning bone removal, elevator placement and direction of delivery. Any advantage has

largely not been borne out in practice. A systematic review by Araujo et al (2019) concluded CBCT did

not change the surgical approach compared to OPT alone and that an OPT was sufficient to decide

between extraction and coronectomy7. Systematic reviews by Araujo et al (2020)8 and Cle-Ovejero et

al (2019)9 showed no reduction in IAN injury rates following extraction when CBCT was obtained

compared to OPT alone.

Guidelines on pre-operative imaging of third molars

Guidelines from the Faculty of General Dental Practice (UK) (FGDP)10 advocate pre-extraction

radiographs for teeth or roots that are impacted, buried or likely to have a close relationship to

important anatomical structures, and imply for third molars this should be an OPT. Guidelines on CBCT

for third molar assessment from the European Academy of DentoMaxilloFacial Radiology (EADMFR)

(2019) advise “great restraint” in the use of CBCT, that it should not be used routinely and only to answer

a “very specific clinical question” that cannot be answered by OPT11.

Recommendations –

 Generally an OPT is sufficient for assessment and treatment planning of lower third

molars. There are 3 validated radiographic signs indicating close proximity of the

IAC and tooth roots.

 CBCT may be required in a small number of select cases.

Timing of removal

The Faculty of Dental Surgeons at the Royal College of Surgeons (1997)12 and the National Institute for

Health and Care Excellence (NICE) (2000)13 have produced guidelines stating the indications for lower

third molar removal.

5
The average age of third molar extraction in the UK increased from 21-25 years before these

guidelines14, to 32 after15. The number of teeth removed remains similar but the proportion removed

due to caries was significantly higher in 2009 (nearly 30%) than in 1995 (10%)15. This is important as

recovery following third molar removal is slower beyond 24 years in terms of quality of life, lifestyle

impact, pain and oral function16,17. Osborn et al (1985) reported a rate of dysaesthesia 6.5 times higher

in those aged over 2418, an effect particularly marked in females. These observations have led to

consistent criticism of the 2000 NICE guidelines – third molars prone to caries (themselves or the

adjacent second molar) are being retained longer, becoming carious and then extracted later when the

recovery and complication profile is worse19. At time of writing (February 2021) NICE has stated it is

reviewing this guidance.

Recommendations –

 Decisions on timing of removal are complex and should include

consideration of risk of morbidity associated with retention and extraction

at an older age

Flap technique

Two main flap techniques – triangular and envelope (see Figure 4) – account for the vast majority of

procedures performed, although various modifications and alternative designs have been described.

A Cochrane Collaboration systematic review published in 201420 and updated in 202021 compared flap

techniques. It found insufficient evidence to compare rates of alveolar osteitis, wound infection or

permanent sensory change. There was some weak evidence of reduced pain at 24 hours for non-

envelope flaps, reduced swelling for non-envelope flaps and reduced trismus for envelope flaps.

Magnitude of all these differences was small. Bleeding rates were not reported.

6
Recommendations –

 Current best evidence does not demonstrate any significant difference in outcomes

between types of flap design

Lingual retraction

Retraction of the lingual tissues with a sub-periosteal instrument can improve access and visibility for

distal bone removal. However an incorrectly selected or positioned instrument can potentially crush,

stretch, even transect, or at least not protect the lingual nerve.

Several reviews have found a higher rate of temporary but no difference in permanent lingual nerve

injury when lingual retraction is used20–23, however retractor types were not differentiated. Rapaport

and Brown (2020) compared repurposed (e.g. Howarth’s) and specifically designed (e.g. Hovell, Walter)

retractors24. The latter are shaped for the purpose of lingual retraction – broader, blunt and with

features to maintain position. Repurposed retractors were associated with more temporary and

permanent lingual nerve injuries compared to no retraction. Specially designed instruments had the

same rate of temporary nerve injury as no retraction with no permanent injuries recorded.

The lingual nerve is potentially at risk at all stages of lower third molar surgery and related to patient,

surgical and tooth factors. Higher risk factors are a lingual, distoangular or unerupted position, access

via lingual flap, requirement for distal bone removal and an inexperienced surgeon25. Avoiding lingual

retraction is recommended unless these specific risk factors are present22.

Recommendations –

 Lingual retraction should be avoided unless specific risk factors are present.

 If it is needed, a purpose-made lingual retractor should be used.

7
Coronectomy

First described in 198426, coronectomy is removal of a tooth crown whilst leaving the roots in situ. For

lower third molars the primary aim is reduction of risk to the IAN. However a survey of UK Oral and

Maxillofacial surgeons found concerns over rates of re-operation, non-IAN complications and absence

of clear evidence of effectiveness27.

Success & Failure

Dalle Carbonare et al (2017) reviewed 2,087 cases from 14 studies and reported a 93% coronectomy

success rate (152 failures)28. “Failure rates” from individual studies varied from 2.3% to 38.2%.

However, failure can be defined by coronectomy being abandoned (converted to extraction) at initial

surgery, or requirement for extraction later. Four studies reported conversion to extraction in 0% to

9.4% with one further outlier at 38.2%29, in all cases due to roots being inadvertently loosened. In the

latter study this occurred more in young female patients with conical roots narrowing close to the IAC29.

When these cases converted to extraction are removed from the totals quoted by Dalle Carbonare et al

(2017)28 to leave 98 failures from the 2,087 coronectomies, the following causes and proportions are

reached – 51% root migration/exposure of root, 14% wound dehiscence, 12% infection, 10% enamel

retention, 4% pulpitis, 4% unknown and 4% other. Time between operation and complications was not

studied. Enamel retention is an problem as it acts as a local foreign body and irritant, preventing healing

and producing a dry-socket-like syndrome30.

Rates of nerve injury

Dalle Carbonare et al (2017)28 compared pooled nerve injury rates from 1,935 successful and 152 failed

coronectomies (by either definition) across 14 studies. An initial IAN injury rate of 0.5% and permanent

0.05% occurred in successful cases and rates of 2.6% and 1.3% respectively in failed cases. One

temporary (rate 0.05%) and no permanent lingual nerve injuries occurred across both groups. Follow-

up was a maximum of 42 months and in many cases much shorter. In one of their included studies IAN

8
injuries occurred in 8% of patients (temporary and permanent not specified) when coronectomy was

converted to extraction29.

Longer-term prospective data are provided by Pedersen et al (2018)31. 2 of 200 coronectomy patients

had IAN hypoaesthesia at 5 years and one further case at 1 year before being lost to follow-up – an IAN

injury rate of 1.3%. No other nerve injuries were detected. Leung et al (2016) reported a prospective

study of 612 coronectomy sites with up to 5 years follow-up, finding one case (0.16%) of temporary IAN

hypoaesthesia and no lingual nerve injuries by subjective and objective measurement32.

Comparison of complications with extraction

Systematic reviews by the Cochrane Collaboration (Coulthard et al (2014)20) and Ali et al (2018)33 both

located the same two RCTs29,34. Both viewed the studies as high risk of bias and could not reach reliable

conclusions. When the Cochrane review was updated in 2020 (Bailey et al21) these two RCTs were

excluded as being unreliable and a new RCT of 30 patients identified (Singh et al35). This RCT itself

reported no difference between the two techniques, although the review found no useable data therein.

Other reviews have included non-randomised studies, finding no significant difference in the incidence

of infection and alveolar osteitis 36–38. Pain scores were lower following coronectomy in one review37

but did not differ in another38. Despite difficulties comparing nerve injury incidence between studies

there is consistent evidence of reduced IAN injury with coronectomy compared to extraction. Pitros et

al (2020) pooled results from four studies and found coronectomy reduced risk of IAN injury by 84%37.

None of these reviews have compared rates of bleeding or lingual nerve injury.

9
Root migration

This is a consequence of persisting normal eruptive forces39 and occurs in up to 97% of cases31. Most

occurs within 12 months of surgery40 although in one series 24.3% moved between 12 and 24 months41.

More movement occurs at younger ages40,42 and is usually a mesio-lingual translation and distal

rotation40 or mesio-coronal movement31,39. Mean movement of 2.2mm at 6 and 3.2mm at 12 months

has been reported42 with 25% migrating over 4mm and 23.2% under 1mm40. Caudal migration was

reported in one study39. Eruption into the mouth occurs in 2%31 – 2.3%32.

Re-operation

Barcellos et al (2019), reviewing 2,062 coronectomies, found a re-operation rate of 5.1% ranging from

6 months to 10 years (mean 10.4 months)43. The main reasons given were root exposure due to

migration (53%), infection (10%), pain (10%) and residual enamel (10%). These are very similar to

figures quoted by Dalle Carbonare et al (2017)28. However the rate of eruption of migrated roots

reported is higher than elsewhere.31,32. Although root exposure is the commonest reason for re-

operation only a small minority of patients with migrated roots will require removal31.

Recommendations –

 Coronectomy is an established and effective alternative to extraction in cases with

high risk of IAN injury

Surgical bur vs. lingual split method

The lingual split technique was first proposed in 1933 and has since been modified several times with a

simplified technique described by Yeh in 199544. Because surgical burs are so readily available its

current use appears to be low and decreasing.

There are no high-quality RCTs comparing these methods. A systematic review by Steel (2012) found 4

RCTs presenting poor evidence allowing no reliable comparison45. This finding was replicated in other

10
systematic reviews20,21. An earlier review in 2001 had found increased temporary lingual nerve injury

following lingual split as compared to surgical bur technique with and without lingual retraction,

quoting figures of 9.6%, 6.4% and 0.6% respectively23. Another review in 2017 found a higher rate of

temporary but not permanent lingual nerve injury, although the authors suggested this be interpreted

with extreme caution22.

Recommendations –

 There is no strong evidence with which to compare the lingual split and surgical bur

methods.

Closure

Following surgical extraction any flap access can be closed primarily or left partially or fully open to heal

secondarily. The purported benefit of the latter is to allow spontaneous drainage of exudate and blood

so reduce pain, swelling and risk of infection.

Quite a number of RCTs comparing primary with secondary healing have individually indicated

superiority of secondary healing, some using partial closure and some no sutures. A meta-analysis by

Bailey et al (2020) found moderate evidence of reduced pain at 24 hours, reduced swelling at one week

and no difference in alveolar osteitis, infection or bleeding with secondary healing as compared to

primary21. Another meta-analysis by Ma et al (2019) found secondary healing was associated with

significantly less pain, swelling and trismus in both early and late phases46. Bleeding and infection were

not studied. Partial closure with a buccal advancement flap over the socket whilst leaving relieving

incisions open is a suggested compromise to minimise food accumulation and allow drainage47.

Comparison of partial closure and suture-less techniques has been little studied and was not considered

in the aforementioned reviews21,46. Alkadi et al (2018) compared one suture to suture-less in a split

11
mouth RCT and found reduced pain and improved wound healing in the one suture group, and no

difference in swelling48.

Overall it is clear that hermetically sealing the socket is worse and leaving a drainage point is beneficial.

Recommendations –

 Leaving lower third molar sockets at least partially open is associated with less pain,

swelling and trismus compared to complete closure.

Antibiotics

UK guidelines from NICE (2019) recommend antibiotics for clean-contaminated surgery (as third molar

removal would be classified) to reduce surgical site infection (SSI), however they are very general and

do not name specific procedures49. More specific guidance from the FGDP (2020) states there is no

evidence for routine use of prophylactic antibiotics to cover extraction of impacted teeth and roots and

recommends they are not used, including in immuno-compromised patients.50

At least 13 systematic reviews have looked at antibiotics in third molar surgery. These reviews

variously concluded either antibiotics should be used, or that infection/dry socket rates are lowered but

insufficiently to justify antibiotic use. There has also been a review of these reviews, which found four

to be low or very low quality, seven moderate and only one high quality51. This high quality review from

the Cochrane Collaboration (Lodi et al (2012)) included 18 RCTs and found moderate quality evidence

of a reduction in SSI and dry socket after lower third molar extraction when antibiotics were used52.

Number needed to treat (NNT) was approximately 12 and 38 respectively, with number needed to harm

21 (generally mild and transient). Pain at 7 days was also significantly reduced in those taking

antibiotics although this could be directly due to the lower infection rate. Swelling, fever and trismus

did not differ. Optimum timing or duration could not be determined. The RCTs were heterogeneous

and had markedly different infection rates showing the influence of other factors. All studied healthy

12
patients in hospital which could potentially underestimate the benefit of antibiotics. The authors did

not feel this benefit was sufficient to justify routine use of antibiotics for this procedure given concerns

over adverse events and antimicrobial resistance. However Ramos et al (2016) in their review

interpreted their very similar NNT of 14 for dry socket and/or infection as evidence that antibiotics

should be used53. It is worth noting in one study which stratified cases by difficulty, even in difficult

cases no benefit to antibiotics was demonstrated54.

When antibiotics are used a single intravenous (IV) dose of amoxicillin is effective55 and should be

administered within 120 minutes of surgery56. A comparison of perioperative IV with postoperative oral

regimes in third molar removal found no difference in SSI57. World Health Organisation (WHO)

guidelines (2017) state prolonged (over 24 hours) prophylactic antibiotic courses give no additional

benefit beyond a single pre-operative dose except for certain specific procedures (none in Oral and

Maxillofacial Surgery)56.

Overall, current best evidence suggest that antibiotics do reduce SSIs but not enough to outweigh

concerns over adverse effects and antimicrobial resistance and justify routine use. There may be some

justification for use of a single pre-operative dose in some more complex cases or immuno-

compromised patients however there is no clear evidence for this.

Recommendations –

 Routine use of prophylactic antibiotics in patients undergoing third molar surgery

is not supported.

Steroids

Many clinical studies and at least nine systematic reviews have examined steroid use in third molar

surgery, with a range of agents, timing and routes of administration.

13
In general terms Herrera-Briones et al (2012) found that steroids of any form reduced the degree of

postoperative trismus and inflammation, that administration parentally was superior to oral, and pre-

operative superior to post-operative58. Steroids have been clearly associated with less deterioration,

and earlier recovery in quality of life following third molar removal59.

Nagori et al (2018) found that methylprednisolone, via all routes of administration, reduced early but

not late swelling in a detailed review60. Oral reduced early and late pain and early trismus, and intra-

masseteric reduced early pain and early and late trismus.

Dexamethasone has been used submucosally to administer steroid local to the surgical site. O’Hare et

al (2019) reviewed 17 trials and found it to reduce early post-operative pain (NNT 4) and early swelling

(NNT 5) but not trismus61. Previous reviews of fewer (some of the same) studies had found reductions

in swelling and trismus62 and swelling and pain63. Any difference between doses (studies used 4-10mg)

was either not sought or could not be identified. A meta-analysis comparing intramuscular

dexamethasone to control found significantly less pain and swelling on days 1, 3 and 7 after surgery64.

When compared to submucosal, pain was lower on day 3 but otherwise no difference in pain and

swelling. Trismus could not be compared.

Overall some degree of effectiveness has been demonstrated for most regimens but differences in study

methodology make comparison difficult. Furthermore, very few studies have reported on harms.

Recommendations –

 Use of steroids has generally been associated with lower pain, and often swelling

and trismus. Optimum drug, route or timing is unclear and may be guided by

patient acceptability, cost and duration of action.

Drains

14
Various types of drain have been used in lower third molar extraction, including rubber, gauze and tube

drains. Bailey et al (2020) found moderate evidence that drains are associated with decreased swelling

and trismus at one week post operatively21. Other studies found drains significantly reduced trismus

and swelling post-operatively and pain in the later post operative period65 whilst others found no

differences66.

Recommendations –

 Use of a drain is an option with some moderate evidence of benefit

Conflict of Interest

None

Ethics statement/confirmation of patient permission

Not required

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List of figures

22
1. Diagram of radiographic signs of close proximity of roots and IAC. Taken from Rood & Shehab

(1990)2. Reproducible here without requirement for specific permissions under STM

Permissions Guidelines. Reproduced here with acknowledgement and thanks to Elsevier.

2. Clinical example of part of OPT radiograph demonstrating radiographic signs of close

proximity of roots to IAC.

3. Clinical example of part of CBCT (in three planes – axial, transverse and coronal)

demonstrating the IAC in close proximity to the lingual aspect of the apical root portions.

4. Diagram of triangular and envelope flap designs. Reproduced from Mobilo N et al. Effect of flap

design and duration of surgery on acute postoperative symptoms and signs after extraction of

lower third molars: a randomized prospective study. J Dent Res Dent Clin Dent Pros

2017;11:156-60. Reproducible freely under Creative Commons Attribution 4.0 International.

23
Figure 1 – Diagram of radiographic signs of close proximity of roots and IAC. Taken from Rood &

Shehab (1990)2. By kind permission of Elsevier.

24
Figure 2 – Clinical example of part of OPT radiograph demonstrating radiographic signs of close

proximity of lower left third molar roots to the IAC – loss of IAC cortication, darkening of root apices

and deviation of the IAC.

25
Figure 3 – Clinical example of part of CBCT (in three planes – axial, coronal and sagittal)

demonstrating the IAC in close proximity to the apical root portions of the lower left third molar.

26
Figure 4 - Diagram of envelope (A) and triangular (B) flap designs. With kind permission of the

Journal of Dental Research, Dental Clinics, Dental Prospects.

27