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J Oral Maxillofac Surg

73:804-805, 2015

Current Care Guidelines for Third Molar


Teeth
Irja Vent
a, DDS, PhD
services and current care editorial and secretarial
services were available to the working group. Before
Internet publication, the guidelines were circulated
to specific interest groups countrywide and edited
according to their comments. Members of the working group were not paid for the task, but all their
expenses were reimbursed. Funding for guideline
production was from public sources.

National guidelines are seldom accessible to interested


oral and maxillofacial surgeons in other countries
because the guidelines are written in the national
language. The Finnish Current Care Guidelines for
the third molar were updated in 2014 and its essential
portion also is published in English.1 All guidelines
worldwide are based on the same international literature. However, the conclusions reached can differ by
culture, resources, treatment environment, surgical
trends, reimbursement by insurance companies, and
government actions. When creating these guidelines,
the aim was to define the best possible care for the
patient without weighing this against the resources
of the health care system.
The updated guidelines for the third molar are based
on evidence, with an extensive review of 180 references. The opinions of all relevant dental specialists,
such as orthodontists, periodontists, radiologists, and
oral and maxillofacial surgeons, are considered. One
of the 3 primary aims of the guidelines is to prevent
health problems related to third molars. Because nerve
injuries continue to be the most common reason for
malpractice claims submitted to the Finnish Patient Insurance Center, this issue warrants attention. Another
important issue is the controversy surrounding the
preventive, prophylactic, early, or elective removal of
third molars; 4 distinct groups are suggested as candidates for early removal.
The Current Care Guidelines are independent,
evidence-based clinical practice guidelines. The
guidelines cover important issues in medicine and
dentistry. Currently, there are more than 100 separate guidelines, with 7 related to dentistry. The
working group for each guideline is appointed by
the Finnish Medical Association Duodecim with
the appropriate specialist association. The working
group for the third molar was comprised of 6 volunteer dental health care experts. All information

Emphasis on Avoiding Nerve Injuries


Injuries of the lingual and inferior alveolar nerves
are infrequent, but cause considerable discomfort to
the patient. Most of these injuries could be avoided
with careful decision making and referral to experienced specialists. When considering the reasons for
lingual nerve injuries, the anatomic location of the
nerve must be kept in mind. During mandibular nerve
block, an adequate nerve block technique, integrity
of the needle tip, and determined entry of the needle
are emphasized. During surgery, the use of a lingual
periosteal elevator between the periosteum and the
bone is not recommended. Any kind of activity on
the lingual soft or hard tissue is discouraged. To
decrease the risk of inferior alveolar nerve injury,
additional images, such as cone-beam computed tomograms, should be obtained to provide better information about the relation between the root end and the
mandibular canal. In addition, the opening incision
should be made to the buccal gingiva, the tooth should
be split if needed, and excessive force should be
avoided. When the risk of nerve injury is high,
removing only the crown (coronectomy) is recommended. When the risk of mandibular bone fracture
and nerve injury is present, it is sometimes indicated
to expose the crown and then use orthodontic traction to pull the tooth closer to the occlusal surface
before extraction.

Associate Professor, Department of Oral and Maxillofacial Diseases,

Received December 18 2014

Faculty of Medicine, University of Helsinki, Helsinki, Finland.

Accepted December 30 2014


2015 American Association of Oral and Maxillofacial Surgeons

Address correspondence and reprint requests to Dr Venta:


Department of Oral and Maxillofacial Diseases, University of Hel-

0278-2391/15/00009-9

sinki, PO Box 41, Helsinki FI-00014, Finland; e-mail: irja.venta@

http://dx.doi.org/10.1016/j.joms.2014.12.039

helsinki.fi

804


IRJA VENTA

805

Table 1. INDICATIONS FOR ELECTIVE EARLY


REMOVAL OF MANDIBULAR THIRD MOLARS
ACCORDING TO THE FINNISH CURRENT CARE
GUIDELINES FOR THE THIRD MOLAR

Indication
Risk of inferior
alveolar nerve
injury

Risk of
pericoronitis

Risk of bone defect


Risk of caries

Clinical Findings

Maximum
Age
of Patient at
Removal

Incomplete root end 19-20 yr


close to mandibular
canal
Lack of space for
Before root
eruption
end is
complete
Partially erupted
20-25 yr
Vertical or
distoangular
Enlarged follicle
Close to occlusal
surface
Horizontal position
Partially erupted
Completely erupted
Partially erupted
Inclined forward

25 yr
25 yr

Irja Vent
a. Current Care Guidelines for Third Molar Teeth. J Oral
Maxillofac Surg 2015.

Indications for Preventive Removal of


Third Molars
In view of the primary aim of preventing health
problems, patients would benefit markedly from elective preventive removal of third molars. Preventive
removal is defined as removal of a symptomless third
molar before the development of anticipated problems. Preventive removal of mandibular third molars
is recommended in 4 situations to prevent injury of
the inferior alveolar nerve, pericoronitis, postoperative bone defects, and caries (Table 1).
1. If the mandibular third molar is developing in a
position in which the root of the tooth and the

mandibular canal are superimposed on the radiograph and there is insufficient space for the tooth
to erupt or if the direction of eruption is unfavorable, then removal of the tooth is recommended
before the growth of the root end is complete to
prevent injury to the inferior alveolar nerve.
2. Acute pericoronitis in 20- to 25-year-old patients
can be prevented by electively removing the
partially erupted third molars in a vertical and
distoangular position and close to the occlusal surface. The patient also can prevent the development of pericoronitis by improving oral hygiene.
3. Postoperative bone defects of partially erupted
mandibular third molars that are in a horizontal
position or deeply inclined forward can be prevented by removal before 25 years of age.
4. Because partially erupted third molars increase
the amount of salivary bacteria that cause caries
and visible plaque in neighboring teeth, the
removal of partially erupted third molars considerably decreases visible plaque throughout
the dentition, the amount of bacteria causing
periodontal infection in neighboring teeth, and
the amount of salivary bacteria causing caries.
There are only 2 contraindications for removal: 1)
an unerupted, disease-free, symptomless third molar
totally covered with bone and 2) when removal constitutes an unreasonable risk to the general or local
health of the patient.
To conclude, many national guidelines have been
published, are underway, or are under consideration.
During our work, we became inspired by other national guidelines; the Finnish Current Care Guidelines
for the third molar could have a similar inspiring effect
on oral and maxillofacial surgeons worldwide.

Reference
1. Venta I, P
ollanen M, Ingman T, et al: Current care guidelines.
Third molar. Working group set up by the Finnish Medical Society
Duodecim and the Finnish Dental Society Apollonia, Helsinki.
Available at: http://www.kaypahoito.fi/web/english/guidelines/
guideline?id=ccg00003. Published December 18, 2014. Accessed
December 18, 2014