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What is the Risk of Future Extraction

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

*Associate Professor and Residency Program Director, Division of Address correspondence and reprint requests to Dr Bouloux:
Oral and Maxillofacial Surgery, Department of Surgery, Emory Division of Oral and Maxillofacial Surgery, Department of Surgery,
University School of Medicine, Atlanta, GA. Emory University School of Medicine, 1365B Clifton Rd NE, Suite
yAssociate Professor, Division of Oral and Maxillofacial Surgery, 2300, Atlanta, GA 30322; e-mail:
Department of Surgery, University of Texas Health Sciences Received August 2 2014
Center, Houston, TX. Accepted October 24 2014
zProfessor, Department of Oral and Maxillofacial Surgery, Ó 2015 American Association of Oral and Maxillofacial Surgeons
University of Washington School of Dentistry, Seattle, WA. 0278-2391/14/01628-0
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.


disease status of M3s. If the M3s are asymptomatic and tabulated the data. Discrepancies were resolved by
disease free, the AAOMS has recommended removal of group discussion. The factors assessed in reviewing
M3s to prevent future problems or their retention and the studies included study design, patient gender, pa-
monitoring of M3 status. Individual surgeons should tient age, practice type, patient smoking status, erup-
review the risks and benefits of both treatment options tion status, the absence of symptoms, the absence of
and make recommendations after considering patient caries and periodontal disease, sample size, follow-
preference regarding M3 management.20 up duration, patient attrition, and the number of
Commonly, during the presentation of the treat- subjects or teeth that required removal during the
ment options, patients may inquire regarding the study period.
future need for M3 removal. The purpose of our report
was to address that issue by determining whether STUDY VARIABLES
young adults who elect to retain their asymptomatic
The primary predictor variable was the follow-up
M3s have a risk of undergoing one or more M3 extrac-
duration, recorded in years. The primary outcome var-
tions in the future.
iable was either the number of M3s removed during
the follow-up period or the number of subjects who
Materials and Methods
required 1 or more M3s removed during that period.
To address the research question, we designed and Other study variables included subject age and the
implemented a systematic review. Online electronic number of M3s or subjects present at the baseline
searches were performed in PubMed, Google Scholar, examination.
and the Cochrane Central Register of Controlled Trials
to identify the studies to include in the review. The STATISTICAL ANALYSIS
PubMed database was queried for [molar, third] and
The data were analyzed using descriptive statis-
[asymptomatic]; [molar, third/surgery] and [epidemio-
tics. Limiting studies to only include those with
logic studies]; [molar, third] and [pubmednotmed-
more than 50 subjects eliminated the need for spe-
line]. The abstracts and subject headings from the
cial considerations for the statistical distribution of
resulting searches were manually reviewed to select
small sample sizes. To estimate the cumulative inci-
those studies mentioning retention of M3s and identi-
dence rate of M3 removal, the number of M3s (or
fying the type of study done. The selected studies were
subjects) removed during the follow-up period was
reviewed manually for all references using PubMed.
divided by the total number of M3s (or subjects).
Additionally, Google Scholar was queried for [third
The annual incidence rate was estimated by dividing
molar asymptomatic]. The abstracts were manually re-
the cumulative incidence rate by the total number of
viewed by all 5 of us to select those studies reporting
follow-up years.
on retained M3s.


The studies were included if they were an English- During the initial data search, 65 studies were iden-
language publication, were a prospective study tified that had reported on the number of teeth or
design, had more than 50 subjects, had recorded the subjects who required extraction of previously asymp-
number of subjects or M3s requiring extraction during tomatic M3s during the study period. Of the 65
the study period, and had a follow-up duration of 1 studies, one study was excluded as it was non English
year or more. Additional criteria were subjects aged while 22 were excluded because they had used a retro-
18 years old or older, at least 1 M3 present at enroll- spective study design. Of the remaining 42 studies, 35
ment, and only asymptomatic M3s at enrollment. We were excluded because of 1 or more of the following
assumed that the teeth had been retained because criteria: insufficient follow-up period, at least 1 3M
they were asymptomatic and disease-free M3s. was not present at study inception, or the outcomes
The studies identified for possible inclusion from the were not reported as the number of teeth extracted
reviewed abstracts were obtained and reviewed further or subjects who had undergone extractions. Thus, 7
by professional members of the AAOMS M3 Taskforce studies were included in the present analysis (Fig 1).
(n = 5; G.F.B., K.F.B., O.R.B., S.-K.C., T.B.D.). The studies All 7 studies reported the number of subjects, the
identified for detailed analysis were reviewed for quality follow-up period, and the number of M3s at incep-
by each taskforce member. tion.1,9,21-25 The mean age of the subjects at inception
in the 5 studies that provided data was 25.2 years.
DATA EXTRACTION All 7 studies included mandibular M3 extractions, and
A standardized data extraction form was used by all 4 studies included maxillary and mandibular
5 task members, who independently extracted and M3s (Table 1).

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

Records aer duplicates removed

(n = 65)

Records screened Records excluded

(n = 65 ) (Non English)

Full-text arcles excluded,


Full-text arcles assessed (Retrospecve, <50

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

Studies included in

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


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

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


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
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.


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