Teeth and Wisdom Teeth
Should the Asymptomatic Impacted Third Molar Be Removed?
Major General Robert B. Shira, D.D.S.
Dr. Shira was a professor of oral surgery and Dean Emeritus at Tufts University School of Dental Medicine and advisory member of the American Dental Society Anesthesiology and the Army Medical Research And Development Command.
For many years, dentists have assumed a “wait and see attitude towards the asymptomatic impacted third molar. They have advised patients to leave these teeth undisturbed unless they cause symptoms. While it is true that some patients may retain unerupted teeth throughout life without apparent ill effect, others may develop alarming and severe complications. In the practice of the specialty of oral surgery, older patients are frequently seen who are having complications associated with impacted teeth. When asked the reason for not having the impactions removed at a earlier age, they invariably reply: My dentist recommended leaving them alone until they bother me”. Other frequently quoted statements are: “Wait until they cause symptoms”. “Let sleeping dogs alone’. “Don’t bother them until they bother you’. Do nothing about them unless they cause pin’. “We will keep them under observation”.
In light of present knowledge this is not considered the proper advice for the management of this important problem. Current thinking advocates the taking roentgenogralns at the time teeth should be normally erupt and, if they are found to be hopelessly impacted and cannot possibly erupt into the mouth and become serviceable teeth, they should be prophylactically removed at this time.
If impacted teeth are eventually to be removed, it is much preferable to perform the surgery in the 18-25 year age group. Extraction at this time is usually uncomplicated procedure. Because of the size of the dental follicle, the character of the bone with its higher percentage of organic matrix, and the incomplete formation of the roots, the teeth are more easily removed at this age.
When the procedure is postponed until later in life, the dental follicle is partially or completely resorbed, the bone becomes hard and dense and the completely formed roots are often curved and tortuous; all of which adds to the difficulty of the surgical procedure. Furthermore, younger patients have fewer complications associated with the surgical procedure. Their recuperative power is greater, the incidence of alveolar osteitis is less, and future complications associated with the prolonged retention of these teeth are avoided.
It is well known that some impacted teeth remain dormant in the jaws and do not produce symptoms or cause problems. Yet it is equally well known that some in fact do cause symptoms and problems. It would be ideal if, at an early age, it could be determined which teeth were going to produce problems and which would remain dormant. If this were possible it would be logical to remove those that were to cause problems and allow the others to remain. However, with the present state of knowledge, it is impossible to make the determination and hence serious consideration should be given to the prophylactic removal of impacted third molars that cannot erupt and become serviceable teeth.
There are several potential dangers related to the retention of impacted teeth, they. may migrate and resorb the roots of the adjacent second molar. They may resorb the bone distal the second molar and create a periodontal problem in the area. As the roots of the impacted tooth continue to develop, they may Involve other important structures such as the mandibular canal and the maxillary sinus.
When allowed to remain, the impacted teeth usually continue to develop cementum which increases the size of the roots, which adds to the magnitude of the surgical procedure if removal of the tooth becomes indicated. They often are responsible for the formation of follicular cysts which may become large, destructive lesions which often involve other segments of the detention. Also, on occasion, they may be responsible for the development of an ameloblatoma, which is an extremely difficult tumor to treat. Finally, in rare instances a malignancy may develop from the residual epithelium frequently present in the follicle associated with the impacted tooth.
When one considers them magnitude of these problems it seems logical that serious considerations should be given to their prevention. In light of present knowledge, it is difficult to understand how dentists can recommend the “wait and see” attitude in regard to this problem. Many progressive dentists believe that a tooth that is hopelessly impacted and cannot possibly erupt and become a serviceable tooth cannot possibly benefit the patient but has the real potential of causing of causing serious problems. For this reason, they are recommending the prophylactic removal of these teeth at the age when they should normally erupt.
The best way
to treat a disease process is not to have the disease. Prevention
is an integral and important part of modem dentistry. The
alert, conscientious dentist who wishes to provide the best
care for his or her patients should include the prophylactic
removal of the asymptomatic third molars in the preventive
aspects of their practice.