DENTOALVEOLAR SURGERY

What is the Risk of Future Extraction

of Asymptomatic Third Molars? A Systematic
Review
Gary F. Bouloux, DDS, MD, MDSc, FRACDS(OMS),* Kamal F. Busaidy, BDS, FDSRCS,y
O. Ross Beirne, DMD, PhD,z Sung-Kiang Chuang, DMD, MD,x
and Thomas B. Dodson, DMD, MPHk
Purpose: The purpose of our report was to determine clinically whether young adults who elect to
retain their asymptomatic third molars (M3s) have a risk of undergoing 1 or more M3 extractions in the
future.
Materials and Methods: To address our clinical question, we designed and implemented a systematic
review. The studies included in the present review were prospective, had a sample size of 50 subjects or
more with at least 1 asymptomatic M3, and had at least 12 months of follow-up data available. The primary
study variables were the follow-up duration (in years) and the number of M3s extracted by the end of the
follow-up period or the number of subjects who required at least one M3 extraction. The annual and cu-
mulative incidence rates of M3 removal were estimated.
Results: Seven studies met the inclusion criteria. The samples sizes ranged from 70 to 821 subjects, and
the follow-up period ranged from 1 to 18 years. The mean incidence rate for M3 extraction of previously
asymptomatic M3s was 3.0% annually (range 1 to 9%). The cumulative incidence rate for M3 removal
ranged from 5% at 1 year to 64% at 18 years. The reasons for extraction were caries, periodontal disease,
and other inflammatory conditions.
Conclusions: The cumulative risk of M3 extraction for young adults with asymptomatic M3s is suffi-
ciently high to warrant its consideration when reviewing the risks and benefits of M3 retention as a man-
agement strategy.
Ó 2015 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 73:806-811, 2015

The management of asymptomatic third molars (M3s)
is controversial and currently unresolved. Some inves-
tigators have advocated for M3 retention until the clin-
ical signs and symptoms dictate a need for removal.1,2
Others have advocated for early removal of M3s, given
the potential for caries,3-9 pericoronitis,4,5,7,10-14 and
periodontal disease.6,9,15-18 However, a systematic
review by the Cochrane Collaboration failed to
provide insight and concluded that the evidence was
insufficient to support or refute the removal of M3s
to prevent future problems.19
The American Association of Oral and Maxillofacial
Surgeons (AAOMS) has recommended that young
adults be evaluated to assess for the presence and

*Associate Professor and Residency Program Director, Division of
Oral and Maxillofacial Surgery, Department of Surgery, Emory
University School of Medicine, Atlanta, GA.
yAssociate Professor, Division of Oral and Maxillofacial Surgery,
Department of Surgery, University of Texas Health Sciences
Center, Houston, TX.
zProfessor, Department of Oral and Maxillofacial Surgery,
University of Washington School of Dentistry, Seattle, WA.
xAssociate Professor, Department of Oral and Maxillofacial
Surgery, Harvard University School of Dental Medicine, Boston, MA.
kProfessor and Chair, Department of Oral and Maxillofacial
Surgery; Associate Dean for Hospital Affairs, University of
Washington School of Dentistry, Seattle, WA.
Address correspondence and reprint requests to Dr Bouloux:
Division of Oral and Maxillofacial Surgery, Department of Surgery,
Emory University School of Medicine, 1365B Clifton Rd NE, Suite
2300, Atlanta, GA 30322; e-mail: gbouloux@hotmail.com
Received August 2 2014
Accepted October 24 2014
Ó 2015 American Association of Oral and Maxillofacial Surgeons
0278-2391/14/01628-0
http://dx.doi.org/10.1016/j.joms.2014.10.029

806
BOULOUX ET AL
disease status of M3s. If the M3s are asymptomatic and
disease free, the AAOMS has recommended removal of
M3s to prevent future problems or their retention and
monitoring of M3 status. Individual surgeons should
review the risks and benefits of both treatment options
and make recommendations after considering patient
preference regarding M3 management.20
Commonly, during the presentation of the treat-
ment options, patients may inquire regarding the
future need for M3 removal. The purpose of our report
was to address that issue by determining whether
young adults who elect to retain their asymptomatic
M3s have a risk of undergoing one or more M3 extrac-
tions in the future.
Materials and Methods
To address the research question, we designed and
implemented a systematic review. Online electronic
searches were performed in PubMed, Google Scholar,
and the Cochrane Central Register of Controlled Trials
to identify the studies to include in the review. The
PubMed database was queried for [molar, third] and
[asymptomatic]; [molar, third/surgery] and [epidemio-
logic studies]; [molar, third] and [pubmednotmed-
line]. The abstracts and subject headings from the
resulting searches were manually reviewed to select
those studies mentioning retention of M3s and identi-
fying the type of study done. The selected studies were
reviewed manually for all references using PubMed.
Additionally, Google Scholar was queried for [third
molar asymptomatic]. The abstracts were manually re-
viewed by all 5 of us to select those studies reporting
on retained M3s.
STUDY CRITERIA
The studies were included if they were an English-
language publication, were a prospective study
design, had more than 50 subjects, had recorded the
number of subjects or M3s requiring extraction during
the study period, and had a follow-up duration of 1
year or more. Additional criteria were subjects aged
18 years old or older, at least 1 M3 present at enroll-
ment, and only asymptomatic M3s at enrollment. We
assumed that the teeth had been retained because
they were asymptomatic and disease-free M3s.
The studies identified for possible inclusion from the
reviewed abstracts were obtained and reviewed further
by professional members of the AAOMS M3 Taskforce
(n = 5; G.F.B., K.F.B., O.R.B., S.-K.C., T.B.D.). The studies
identified for detailed analysis were reviewed for quality
by each taskforce member.
DATA EXTRACTION
A standardized data extraction form was used by all
5 task members, who independently extracted and
807
tabulated the data. Discrepancies were resolved by
group discussion. The factors assessed in reviewing
the studies included study design, patient gender, pa-
tient age, practice type, patient smoking status, erup-
tion status, the absence of symptoms, the absence of
caries and periodontal disease, sample size, follow-
up duration, patient attrition, and the number of
subjects or teeth that required removal during the
study period.
STUDY VARIABLES
The primary predictor variable was the follow-up
duration, recorded in years. The primary outcome var-
iable was either the number of M3s removed during
the follow-up period or the number of subjects who
required 1 or more M3s removed during that period.
Other study variables included subject age and the
number of M3s or subjects present at the baseline
examination.
STATISTICAL ANALYSIS
The data were analyzed using descriptive statis-
tics. Limiting studies to only include those with
more than 50 subjects eliminated the need for spe-
cial considerations for the statistical distribution of
small sample sizes. To estimate the cumulative inci-
dence rate of M3 removal, the number of M3s (or
subjects) removed during the follow-up period was
divided by the total number of M3s (or subjects).
The annual incidence rate was estimated by dividing
the cumulative incidence rate by the total number of
follow-up years.
Results
During the initial data search, 65 studies were iden-
tified that had reported on the number of teeth or
subjects who required extraction of previously asymp-
tomatic M3s during the study period. Of the 65
studies, one study was excluded as it was non English
while 22 were excluded because they had used a retro-
spective study design. Of the remaining 42 studies, 35
were excluded because of 1 or more of the following
criteria: insufficient follow-up period, at least 1 3M
was not present at study inception, or the outcomes
were not reported as the number of teeth extracted
or subjects who had undergone extractions. Thus, 7
studies were included in the present analysis (Fig 1).
All 7 studies reported the number of subjects, the
follow-up period, and the number of M3s at incep-
tion.1,9,21-25 The mean age of the subjects at inception
in the 5 studies that provided data was 25.2 years.
All 7 studies included mandibular M3 extractions, and
4 studies included maxillary and mandibular
M3s (Table 1).
808 RISK OF FUTURE EXTRACTION OF ASYMPTOMATIC THIRD MOLARS

Idenficaon
Records idenfied through Addional records idenfied
database searching through bibliographies
(n =44 ) (n = 21 )

Records aer duplicates removed

(n = 65)
Screening

Records screened Records excluded

(n = 65 ) (Non English)
(n=1)

Full-text arcles excluded,

Eligibility

Full-text arcles assessed (Retrospecve, <50

for eligibility subjects, Follow-up < 1
(n =64) year)
(n = 57)

Studies included in
Included

analysis
(n = 7)

FIGURE 1. Flow chart outlining the systematic review method.

Bouloux et al. Risk of Future Extraction of Asymptomatic Third Molars. J Oral Maxillofac Surg 2015.

M3S EXTRACTED Although the annual risk of extracting at least 1 orig-

The follow-up period ranged from 1 to 18 years (mean
8.8). Four studies reported the number of M3s extracted
during the study period.1,9,23,24 Two studies reported
the percentage of M3s extracted.21,25 The cumulative
incidence for M3 extraction varied from 5 to 64% and
was associated with the follow-up duration. The annual
incidence rate for M3 extraction varied from 1 to 9%,
with a mean of 3.0% annually (Table 2).
One study reported the percentage of subjects who
required M3 extraction, with 31% of subjects requiring
at least 1 M3 extraction within 5 years, for an annual
incidence of 6% of subjects annually22 (Table 3).
Discussion
The purpose of the present study was to address
whether young adults with asymptomatic M3s have
a future risk of M3 removal over time. The results of
our review suggest that the mean annual rate for M3
extraction is 3% of previously retained asymptomatic
M3s during the age range studied.
inally asymptomatic, disease-free M3 was low at 3%,
the cumulative extraction risk over time appears to in-
crease with the follow-up duration, with a risk of
extraction of 64% after an 18-year follow-up period
in 1 study. The point at which the M3s were extracted
during the studies was not reported. This prevented
calculation of the variation in the rate of extraction
over time using a life table analysis, which would
have provided a better understanding of the age-
related changes in the frequency of M3 extractions.
The 3% annual risk of M3 extraction is unlikely to be
constant over time. It is likely that the risk of extrac-
tion decreases with age, but that the initial risk of
extraction might actually be greater than the 3%
we found.
Patients who initially present with caries, peri-
odontal disease, pericoronitis, or other pathologic fea-
tures related to M3s are appropriate candidates for M3
removal. A more controversial situation arises for
young patients who initially present with asymptom-
atic and disease-free M3s. Deferring M3 extraction in
BOULOUX ET AL 809

Table 1. DESCRIPTIVE STATISTICS

Age Gender M3s Present at

Investigators Country Subjects (n) (yr) (M/F) M3 Site Baseline (n)

von Wowern et al,24 Denmark 70 20.3 24/46 Mandibular 130

1989
Garcia et al,9 1989 US 97 47 97/0 Maxillary and mandibular 151
Venta et al,1 2000 Finland 81 20.7 32/49 Maxillary and mandibular 285
Kruger et al,21 2001 New Zealand 821 18.0 417/404 Maxillary and mandibular 2652
Venta et al,25 2004 Finland 118 20.2 37/81 Maxillary and mandibular 402
Hill et al,22 2006 UK 228 NA 150/78 Mandibular 427
Fernandes et al,23 2010 UK 613 NA 250/363 Mandibular 676

Abbreviations: F, female; M, male; M3, third molar; NA, not available; UK, United Kingdom; US, United States.
Bouloux et al. Risk of Future Extraction of Asymptomatic Third Molars. J Oral Maxillofac Surg 2015.

this patient population until signs or symptoms of
pathologic features develop might initially appear a
logical choice; however, given an annual 3% risk of
extraction, it might be more prudent to remove even
asymptomatic M3s. Although the studies only re-
ported currently asymptomatic M3s, it is not clear
whether the subjects had previously experienced
signs and symptoms related to these teeth. It is, there-
fore, also possible that the initially asymptomatic M3s
had subclinical disease at study inception. This could
also have influenced the likelihood of subsequent
extraction. Caries, periodontal disease, and other in-
flammatory conditions were the reasons most identi-
fied for subsequent extractions. It is also possible
that some of the M3s that were extracted were disease
free and asymptomatic. This could have contributed to
an overestimation of the cumulative annual risk of M3
extraction.
The complications from M3 removal have generally
been minor and infrequent; however, the incidence
and severity can vary considerably.26,27 Pain, edema,
and decreased function are typical; however, these
symptoms will normally resolve within a few days of
the procedure.28,29 The greatest concern relates to
lingual and inferior alveolar nerve injury. Several
factors influence the risk of this complication,
including M3 position (degree of impaction) and
advancing patient age.26-31 The potential for an
increased complication rate in patients who initially
defer M3 extraction, but who ultimately require M3
removal at an older age might also support the
extraction of initially asymptomatic M3s.
The AAOMS and the American Academy of Pediatric
Dentistry have both advocated for the removal of asymp-
tomatic M3s if future pathologic features are likely.32-34
This preventative approach to M3 pathologic features
has not been supported in the United Kingdom by the
National Institute for Clinical Effectiveness (NICE),
given the purported low risk of pathologic features
developing and the cost-effectiveness of prophylactic
removal.2 The cost-effectiveness of prophylactic M3
removal was also questioned by Edwards et al.35

Table 2. RISK RATE OF THIRD MOLAR EXTRACTION (TEETH)

Mean Patient M3s M3s Cumulative Annual

Follow- Age at Retained at Extracted Analysis Extraction Extraction
Investigators Up (yr) Inception (yr) Baseline (n) (n) Unit Incidence Incidence

Fernandes et al,23 2010 1 NR 676 37 Teeth 0.05 0.05

von Wowern et al,24 4 20.3 130 49 Teeth 0.38 0.09
1989
Kruger et al,21 2001 8 18.0 2,652 790 Teeth 0.30 0.02
Garcia et al,9 1989 10 47 151 18 Teeth 0.12 0.01
Venta et al,1 2000 12 20.7 285 135 Teeth 0.47 0.04
Venta et al,25 2004 18 20.2 402 257 Teeth 0.64 0.04
Mean 8.8  6.0 25.2  12.2 716  969.2 214.3  295.6 — 0.30 0.03

Abbreviation: M3, third molar.

Bouloux et al. Risk of Future Extraction of Asymptomatic Third Molars. J Oral Maxillofac Surg 2015.
810 RISK OF FUTURE EXTRACTION OF ASYMPTOMATIC THIRD MOLARS
Table 3. SUBJECT LEVEL ESTIMATE OF M3
EXTRACTION RISK
Variable Result
Investigator Hill et al,22 2006
Follow-up (yr) 5
Age at inception (yr) NR
Subjects at baseline (n) 228
Subjects undergoing extraction (n) 71
Baseline M3s (n) 427
Extracted M3s (n) NR
Analysis unit Subjects
Cumulative incidence of extraction 0.31
Annual relative extraction risk 0.06
Abbreviations: M3s, third molars; NR, not reported.
Bouloux et al. Risk of Future Extraction of Asymptomatic Third
Molars. J Oral Maxillofac Surg 2015.
However, a review of the current patterns of M3 extrac-
tion in the United Kingdom, after NICE guideline imple-
mentation, has revealed that despite an initial decrease
in M3 extractions, a delayed, but significant, increase
has occurred in the number of M3 extractions per-
formed. Most interesting was the finding that the
mean age of patients undergoing M3 extractions has
increased and the reason for extraction has become pre-
dominantly caries, periodontal disease, and pericoroni-
tis rather than impaction.4,36
The present systematic review of published studies
has identified a tangible and measurable, albeit unpre-
dictable, risk of future M3 extraction among cohorts
who retained M3s that were asymptomatic and disease
free at the baseline examination. Although the annual
risk is relatively low, the cumulative lifetime risk is
considerably greater. The best method to estimate
the risk of extraction would be a life table analysis,
which was not possible in the present review owing
to the lack of reported data. Future investigators
should collect and report data that will allow a time-
to-event analysis to enable a more accurate age-
related risk of M3 extraction.
In conclusion, when counseling patients regarding
their options for managing asymptomatic, disease-
free M3s, clinicians should review the risks and bene-
fits of extraction and retention. The discussion should
include providing an estimate of the risk of M3
removal over time if the M3s are retained. Given the
increased complication rate for M3 extraction with
increasing age, it might be more prudent to extract
M3s at a relatively younger patient age.
Acknowledgments
The authors would like to thank Mr Martin Gonzalez and Ms Pat
Pinkowski for the administrative support they provided in preparing
our report.
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