1102

J Oral Maxillofac SIJQ

52:1102-1112,1994

Report of a Workshop on the Management of Patients With

Third Molar Teeth

In August 1993 AAOMS convened a 2’12-day workshop attended by 24 invited participants. Twenty-two of the par- ticipants were oral and maxillofacial surgeons and one was an orthodontist. Also present as an observer was an epidemi- ologist who presented a paper on the analysis of the scientific and clinical literature. Following is a list of workshop partici- pants, the plenary session agenda, the charge to the work- shop, and the workshop subgroup assignments:

The Organizing Committee

Dr Leon Assael-Chairman Farmington, CT Dr Michael Matzkin Waterbury, CT Dr Daniel M. Laskin Richmond, VA Dr Larry Peterson Columbus, OH Dr James F. Kelly Rosemont, IL (Ex officio: Director, Research, AAOMS)

PARTICIPANTS IN THE DELIBERATIONS

Dr. Harvey A. Akerson Sioux Falls, SD Dr Charles C. Alling Birmingham, AL Dr Rolf Behrents Memphis, TN Dr Francis A. Connor Jr Providence, RI Dr Thomas B. Dodson Atlanta, GA Dr Lewis N. Estabrooks South Portland, ME Dr David E. Frost Chapel Hill, NC Dr John F. Helfrick Houston, TX Dr Carl F. Kugelberg Kalmar, Sweden Dr Jeffrey A. Lane Bethesda, MD Dr Robert D. Marciani Lexington, KY Dr Paul G. Sims Butte, MT Dr James Q. Swift Minneapolis, MN Dr Joseph E. Van Sickels San Antonio, TX Dr Thomas M. Weil Houston, TX Dr David A. Whiston Falls Church, VA Dr Raymond P. White Jr Chapel Hill, NC Dr Deborah L. Zeitler Iowa City, IA

Plenary Session Presentations

The Challenge and Value of Literature Analysis Alexia-Antczak Bouckoms, DMD, ScD, MPH Report on the Workshop Participants’ Analysis of the Third Molar Literature James F. Kelly, DDS, MS

Charge to the Workshop

I. Review and Objectively Analyze the Third Molar Liter- ature

II.

III.

Develop Recommendations for the Clinical Manage- ment of Third Molar Patients Identify Research Questions and Strategies

Workshop Subgroups

Natural Course: Raymond White- Discussion Leader,

Indications for Care:

Thomas Dodson, Jeffrey Lane, David Whiston, and Larry Peterson (Organizing Committee).

John Helfrick-Discussion Leader, Charles Alling, Rolf Behrents, and Michael Mat&in (Organiz- ing Committee).

Perioperative Management: James Swift-Discussion Leader, Harvey Akerson, Frank Connor, Paul Sims, and James Kelly (Organiz- ing Committee).

Wound Healing: David Frost-Discussion Leader, Carl Kugelberg, Deborah Zeitler, and Leon Assael (Organizing Committee).

Complications: Robert Marciani- Discussion Leader, Lewis Estabrooks, Thomas Weil, Joseph Van Sickels, and Daniel La&in (Organizing Committee).

Research Strategy

Subsequent to the workshop a subgroup of the partici- pants, at the direction of AAOMS, developed a protocol for a prospective, multicenter cohort study of patients presenting with third molar teeth. The variables to be studied were selected on the basis of the literature analysis and the work- shop deliberations. The protocol will be submitted to federal and private sector funding sources. Partial funding will be provided by AAOMS.

Report of the Workshop

The following is a report of the workshop deliberations on the clinical management of third molar patients. The state- ments made and recommendations presented represent a con- sensus of the workshop participants and are not an official statement of the AAOMS.

REPORT OF THIRD MOLAR WORKSHOP 1103

The information contained in this report reflects the scien- tific literature related to third molar management. In prepara- tion for the workshop deliberations, participants were sent reprints of 186 published articles. These articles had been selected by the organizing committee from a list of 1,120 articles identified through a Medline search. The participants were requested to familiarize themselves with the material and to rate each article for scientific value according to a method previously reported for rating articles on temporo- mandibular joint implants (J Oral Maxillofuc Surg 5 1: 1164, 1993). They were asked to score the papers as adequate (1) fair (2) or inadequate (3) against 10 criteria and also to establish an overall rating using the same scale. The partici- pants were provided a document that contained definitions for each of the 10 criteria. A mean score for all reviewers of each article was calculated before the workshop. Those articles (55) with a score greater than 2.0 were re-reviewed and those with weak scientific validity were excluded from discussion and are not included in the list of references ap- pended to this report (Appendix A).

The findings of this report are based on consensus achieved during the deliberations of the subgroups and dis- cussions during the final plenary session of the workshop. The procedures followed in reviewing the literature in prepa- ration for this workshop had a definite, although not measur- able, influence on the recommendations. The participants expressed the opinion that their input to the deliberations was significantly affected by the manner in which they were asked to analyze the literature. Although they were familiar with the literature, having previously read many of the papers and reports provided, their conclusions were influenced by the application of the objective criteria.

It is evident that final treatment decisions should be based on the views of the patient and the clinician. Such decisions should be made in light of reported scientific and clinical information concerning the condition or procedure under consideration. There may be good clinical reasons to deviate from existing patient management recommendations (eg, pa- rameters of care, consensus reports, guidelines). When a surgeon chooses to deviate from existing recommendations, based on the circumstances of an individual patient, it is advisable to document in the patient’s record the reasons for the procedure followed. Additionally, in those instances where the patient has been advised of the risks associated with a clinical course of action (ie, retaining/removing third molars) and refuses treatment, it is advisable to document the informed refusal of the patient.

Subgroup Reports

Natural Course

Clinical decision-making in the management of third mo- lar pathology depends on the anticipated natural course. If the third molar is to be retained, the clinician and the patient need to know what outcomes to expect. The decision to retain a third molar should be based on valid evidence.

The following questions were addressed concerning the natural course of patients with retained third molar teeth:

Do third molar teeth cause mandibular dental arch crowding?

Crowding of anterior and posterior teeth is a multifacto- rial issue. Crowding seems to be related to tooth/jaw size discrep- ancy.

Impacted permanent/supernumerary teeth may be asso- ciated with malalignment/malposition of teeth in an arch segment. Although dental arch crowding is often associated with impacted third molars, impaction may not be. the cause of crowding. No clinically measurable role exists for implicating im- pacted third molars in anterior arch crowding.

Is the change in third molar tooth position in adults pre- dictable?

Accurate prediction of changes in position/eruption of third molar teeth in a given individual is not possible. Progressive uprighting of third molars commonly oc- curs up to age 25. Unerupted third molars in vertical position most com- monly proceed to full eruption. Unerupted third molar teeth can change position at least until the middle of the third decade and perhaps longer. Third molar tooth movement may or may not be favor- able. Retained/impacted third molar teeth should be moni- tored professionally.

1. Patients younger than 25 years of age should be monitored more frequently than older patients.

2. Insufficient data exist as to exact intervals for monitoring.

When can a decision be made that a third molar tooth is impacted ?

Unerupted teeth can continue to change position after skeletal growth is complete and the tooth is fully formed. Insufficient information exists to clearly define when, in an individual, a permanent tooth will remain unerupted. Virtually all horizontally impacted teeth, teeth in the vertical ramus, and those unerupted by the middle of the third decade remain impacted. When making a treatment decision based on these rec- ommendations, the risks/benefits of removal must be weighed against the cost and availability of professional clinical monitoring for an individual patient.

Under what circumstances do third molar teeth cause resorption of the second molar root?

There is insufficient data to explain the pathophysiology of root resorption. It occurs more frequently with hori- zontal and mesioangular impactions, and generally progresses with age.

What are the risks of retained (impacted and erupted) third molar teeth?

1. Cysts and tumors

a. Tooth-related lesions (relationship to patho- physiology is clear, ie, dentigerous cyst)

b. Associated lesions (causal relationship not established)

i. Keratocyst ii. Odontogenic tumor

iii. Carcinoma

2. Infections

a. Chronic periodontitis b. Pericoronitis-acute/chronic c. Osteomyelitis d. Head and neck infection

3. Periodontal defect distal to the second molar 4. Dental caries

1104 REPORT OF THIRD MOLAR WORKSHOP

5. Second molar root resorption 5. 6. Risks affecting other treatment 6.

Ectopic position causing disability. Abnormalities of tooth size or shape precluding nor- mal function.

a. Periodontal, eg, access to second molars I. b. Orthodontic, eg, space needs 8. c. Prosthodontic, eg, coverage by a prosthesis 9. d. Grthognathic surgery, eg, problems with os- 10.

teotomies 11. e. Trauma, eg, healing of fracture site

The following table presents an estimation of the fre- quency and morbidity of the above conditions as judged by the subgroup:

12.

13. Conditions Frequency Morbidity

To facilitate prosthetic rehabilitation. To facilitate orthodontic tooth movement. Tooth in the line of fracture. Tooth involved in tumor resection. Tooth interfering with orthognathic and/or recon- structive surgery. Preventive or prophylactic removal for patients with major medical or surgical conditions or treatments (eg, organ transplants, alloplastic implants, chemo- therapy, radiation therapy). Patient’s informed refusal of non-surgical treatment options.

Cysts/tumors Rare Wide range Infections

Periodontal disease High Low Pericoronitis Moderate Low Osteomyelitis Rare High Head and neck infection Low High

Dental caries Moderate Low Resorption of second molar roots Rare Low Risks affecting other treatment Moderate Low (periodontal, prosthodontic, orthognathic surgery)

Partially Erupted Third Molar Teeth: a “partially erupted tooth” is one so positioned that only a portion of the clinical crown is visible.

1. 2. 3. 4. 5. 6. 7.

Pericoronitis.

Is third molar tooth position a predictorforpericoronitis? Pericoronitis is positively correlated with angulation, degree of eruption, and anatomic factors. Teeth that are vertical or distoangular, and are soft tissue/partial bony impacted, are at highest risk. Horizontal, full bony im- pactions have the least risk.

Tooth, non-restorable, due to caries. To facilitate management of periodontal disease. Non-treatable pulpal or periapical lesion. Acute or chronic infection (eg, cellulitis, abscess). Ectopic position causing disability. Abnormalities of tooth size or shape precluding nor- mal function.

8. 9.

10. 11. 12.

Do third molar teeth adversely affect periodontal health? Third molar tooth sites, particularly partially erupted teeth, serve as reservoirs for periodontal pathogens. Pathogenic flora are greater in number and variety in quadrants with impacted teeth. Periodontal pockets are frequent around partially erupted third molar and adja- cent second molar teeth. Removing such third molar teeth reduces the number of pathogenic microorganisms around adjacent teeth. Plaque accumulation and soft tissue bleeding are common around third molar teeth that are partially erupted or not in function.

13.

14.

To facilitate prosthetic rehabilitation. To facilitate orthodontic tooth movement. Tooth in the line of fracture. Tooth involved in tumor resection. Tooth interfering with orthognathic and/or recon- structive jaw surgery. Preventive or prophylactic tooth removal for patients with major medical or surgical conditions or treat- ments (eg, organ transplants, alloplastic implants, che- motherapy, radiation therapy). Patient’s informed refusal of non-surgical treatment options.

Unerupted Third Molar Teeth: an “unerupted tooth” is one so positioned that it will probably erupt by the middle of the third decade.

Indications for Care 1.

There are numerous indications for the removal of third molar teeth; however, this is only one facet of the overall management of these teeth.

2.

Pathology associated with the tooth follicle (eg, cyst, tumor). Abnormalities of tooth size or shape precluding nor- mal function.

Given the following indications and the goal to limit surgi- cal side-effects, a decision should be made by the middle of the third decade as to whether a third molar tooth should be electively removed.

3. 4. 5. 6. 7. 8.

J&DICTATIONS FORREMOVAL OF THIRD MOLAR TEETH

Erupted Third Molar Teeth: an “erupted tooth” is one so positioned that the entire clinical crown is visible.

9.

10.

To limit periodontal disease. Resorption of adjacent tooth. To facilitate orthodontic tooth movement. Tooth in the line of fracture. Tooth involved in tumor resection. Tooth interfering with orthognathic and/or recon- structive jaw surgery. Preventive or prophylactic removal of tooth for pa- tients with major medical or surgical conditions or treatments (eg, organ transplants, alloplastic implants, chemotherapy, radiation therapy). Patient’s informed refusal of non-surgical treatment options.

1. Tooth non-restorable due to caries or fracture. 2. To facilitate the management of periodontal disease. 3. Non-treatable pulpal or periapical lesion. 4. Acute or chronic infection (eg, cellulitis, abscess).

Impacted Third Molar Teeth: an “impacted third molar tooth” is one that is so positioned that it will probably not erupt by the middle of the third decade.

REPORT OF THIRD MOLAR WORKSHOP

1.

2. 3. 4. 5. 6. 7.

8.

9.

10.

11.

Pathology associated with tooth follicle (eg, cyst, tu- the incidence of postoperative swelling, pain, and mor). trismus. Resorption of adjacent tooth. To limit periodontal disease. To facilitate orthodontic tooth movement. Tooth in the line of fracture. Tooth involved in tumor resection. Tooth interfering with orthognathic and/or recon- structive jaw surgery. Preventive or prophylactic removal for patients with major medical or surgical conditions or treatments (eg, organ transplants, alloplastic implants, chemo- therapy, radiation therapy). An impacted third molar tooth that is only partially covered by bone and/or is in communication with the oral cavity (by probing). To limit surgical morbidity, the prudent time for removal is prior to complete root development. An impacted tooth that is totally covered by bone and does not meet the previous indications for surgery should not be removed, but must be monitored be- cause of the potential for change in position and/or development of pathology. Patient’s informed refusal of non-surgical treatment options.

What is the role of perioperative antibiotics? There is insufficient evidence to determine whether rou- tine perioperative systemic antibiotics decreases the postoperative incidence of pain, swelling, alveolar oste- itis, or infection.

What is the current assessment of the lingual split tech- nique in the United States?

This technique is not widely taught or used in the United States. There is no evidence that the technique is prefer- able to the currently, more widely used buccal approach.

What can be recommended regarding pain management? Perioperative use of steroids appears to decrease postop- erative pain. No literature was reviewed in this work- shop concerning the role of analgesics. The use of long- acting local anesthetics appears to be efficacious in decreasing postoperative pain.

Is primary closure or closure leaving a gap distal to the second molar preferable following the removal of third mo- lar teeth?

Tight, primary (“water tight”) closure appears to in- crease postoperative pain and swelling.

Other considerations It is recommended that additional studies be done con- cerning the following topics:

1. The effectiveness of various analgesics and long-acting local anesthetics for pain management

2. The relationship of temporomandibular disorders to third molar surgery

Perioperative Management

Perioperative management includes preoperative patient evaluation, risk assessment, operative management, and postoperative care with the objective of minimizing known risks and complications. Because the literature review dealt almost exclusively with the management of mandibular third molars, this report is focused mainly on these teeth. More literature pertaining to maxillary third molars would be desir- able.

PREOPERATIVE ASSESSMENT

Preoperative assessment should be appropriate to the pa- tient’s medical condition, the type of anesthetic to be used and the operative procedure to be performed. The preopera- tive assessment must include: 1) a review of the patient’s medicabdental history; 2) a physical examination; 3) preop- erative risk assessment; and 4) an imaging examination ap- propriate to the patient’s presenting condition.

The following questions were addressed concerning the management of patients undergoing the removal of third molar teeth.

What is the proper means of preventing alveolar osteitis? There is no definitive evidence that any technique elimi- nates alveolar osteitis. The literature and clinical experi- ence supports the use of topical antimicrobial agents in the tooth socket to decrease the incidence of alveolar osteitis. The use of chlorhexidine mouth rinses may be efficacious in reducing the incidence of alveolar osteitis. Concurrent use of multiple treatments in the prevention of alveolar osteitis has not been studied.

What is the role of intraoperative lavage? Lavage of the tooth socket with saline appears to be efficacious in reducing the incidence of alveolar osteitis.

What is the role of perioperative skin disinfection? The use of perioperative skin disinfection does not ap- pear to reduce morbidity in the operative site.

What is the role of perioperative steroids? The administration of steroids has been shown to reduce

1105

3. The effectiveness of polyglycolic acid and polylactic acid sutures in extraction sites

4. The type and effectiveness of cold therapy for the man- agement of postoperative pain and swelling

Wound Healing

The following questions were addressed concerning the management of patients undergoing the removal of third molar teeth:

Is there a preferred flap design for the removal of third molar teeth?

Two relatively well-controlled prospective studies have shown no difference between flap designs that provide anterior vestibular release and those that do not.

What are the risk factors for alveolar osteitis? Smoking and bacterial contamination (as with pericoro- nitis) are clearly risk factors. Increased age also appears to be a risk factor. It is not clear whether the principle risk factor is decreased vascularity, increased exposure to bacterial contamination (ie, periodontitis) or a history of heavy smoking. The literature on the influence of gender and oral contra- ceptive use is not definitive. Information concerning whether there is a relationship to the day of the men- strual cycle and the type of birth control medication being used would be helpful because they may influence the incidence of alveolar osteitis. Experience of the surgeon, the amount of surgical trauma, and the time of surgery are factors that appear to influence the incidence of alveolar osteitis. A consistent definition of alveolar osteitis currently does not exist in the scientific literature.

Is pericoronitis a risk factor for operative morbidity? Pericoronitis appears to be a risk factor for alveolar osteitis and postoperative infection. The influence of

1106

pericoronitis on other types of morbidity needs further study.

Is proximity of the tooth to the inferior alveolar nerve, as seen on radiographic examination, a risk factor for nerve injury?

Deflection of the canal, loss of lamina dura of the canal, shadowing of the roots, and to a lesser extent, narrowing of the canal are seen as significant radiographic indica- tors of increased chance of nerve injury.

What is the natural course of neurosensory deficits after nerve injury?

Neurosensory deficits after third molar surgery disap- pear within 4 to 6 months in 75% of cases. Those that do not are likely to remain as a permanent alteration of sensation that is not usually considered to be noxious.

When should third molars be removed to minimize prob- lems of wound healing?

The literature supports that the least morbidity arises with early removal of third molars before complete root development.

Whatfactors influence healingfollowing third molar tooth removal?

Several significant factors can be identified that increase the risk of poor wound healing after impacted third molar removal:

1. Plaque accumulation on the distal surface of the second molar

2. Periodontal defect distal to the second molar 3. Pathological widening of the follicle 4. Smoking 5. Age greater than 25 years

Several factors affect wound healing at all ages, al- though the effect is more pronounced in the older pa- tient:

1. Presence of an infrabony defect distal to the sec- ond molar tooth

2. Increased mesioangular inclination of the thiid molar

3. Increased contact area of the third molar with the second molar root

4. Presence of resorption of the second molar root

The presence of at least three of these factors leads to increased risk of poor healing. Each risk factor may lead to an increased depth of the infrabony defect of 0.5 to 1 .O mm per risk factor. Perioperative periodontal scaling has no effect on wound healing after third molar removal.

Complications

Potential complications were identitied and the following format for evaluation was established:

1. Frequency 2. Significance

a. Reversibility b. Degree of morbidity c. Disability d. Complexity of management

The following questions concerning possible complica- tions in patients undergoing the removal of third molar teeth were addressed:

REPORT OF THIRD MOLAR WORKSHOP

What is the risk of neurosensory injury?

1. Frequency

Various reports indicate an incidence of injury to the inferior alveolar nerve of 1 .O to 7.1%. These data have a moderate level of confidence due to variability in testing, objectivity, and subjectivity. The incidence of injury to the lingual nerve is lower, the reports in the literature ranging from 0.02% to 0.06%. Injury of the buccal and mylohyoid nerves is not routinely reported and the incidence of change in sensation has not been documented in the litera- ture.

2. Significance

Reversibility: Most nerve injuries are reversible. Degree of morbidity: The density and persistence of unpleasant sensation (pain, burning) will effect morbidity. Disability: Minimal for the majority of patients. Complexity of management: Data on timing of surgical correction and outcome assessment is lacking. Microsurgical repair of the damaged nerve is potentially complex.

What are the variables in neurosensory risk?

1. 2. 3. 4. 5. 6. 7. 8. 9.

Relationship of tooth to nerve Hone density Dilaceration of roots Flap design Thickness of lingual plate Anatomic variation Use of a local anesthetic Mechanical trauma (burs, chisels, retractors) Surgical approach (lingual technique)

What is the risk of major infection after third molar sur-

gery?

1. A major infection is defined as one requiring intrave- nous antibiotic therapy and/or hospitalization

2. Infections can be classified into four categories:

a. Immediate major b. Immediate minor c. Delayed major d. Delayed minor

3. Frequency

a. Immediate major: extremely low b. Immediate minor: low c. Delayed major: lower than immediate major d. Delayed minor: low

4. Significance

a. Reversibility: usually complete b. Degree of morbidity: varies with severity c. Disability: usually short-term d. Complexity of management: varies with severity

5. The overall frequency of infection has been reported to be. 0.06% to 4.3%.

REPORT OF THIRD MOLAR WORKSHOP 1107

What are the indications for surgical repair of sensory nerve injury?

There was insufficient literature available to answer this question because studies prospectively comparing out- comes were not identified.

Is there an association between the development of TMD and third molar surgery?

1. Frequency: extremely low -no data are available 2. Significance

a. Reversibility: generally reversible b. Degree of morbidity: minimal c. Disability: usually short term and minimal d. Complexity of management: usually minimal in-

volving symptomatic care

Specific Complications Discussed

Alveolar Osteitis

1. Frequency: difficult to establish as the diagnostic criteria are variable. Range reported from 1% to 30%.

2. Significance

a. Reversibility: universally reversible b. Degree of morbidity: generally short-term (mani-

festations are locally severe; hygiene is a prob- lem; diet is altered)

c. Disability: short-term d. Complexity of management: generally uncompli-

cated

Fractured Jaw (Maxilla) 1. Frequency: low; usually involves the tuberosity 2. Significance

a. Reversibility: generally reversible b. Degree of morbidity: minimal c. Disability: minimal d. Complexity of management: simple

Fractured Jaw (Mandible)

1. Frequency: extremely low; however, increases with age, physical and medical status, and complexity of procedure (~0.01%)

2. Significance

a. Reversibility: generally reversible b. Degree of morbidity: significant c. Disability:

i. Short-term: minimal, with loss of masticatory efficiency and decreased jaw function.

ii. Long-term: rare, with nonunion and some de- gree of neurologic impairment.

d. Complexity of management: moderately com- plex; increases with long-term disability.

Hemorrhage

1. Frequency (Overall incidence for all categories 0.2 to 1.4%)

a. Intraoperative: rare b. Immediate postoperative: rare c. Delayed: rare

2. Significance

a. Reversibility: routine cases readily reversible b. Degree of morbidity: very low c. Disability: low d. Complexity of management: usually simple

Unusual variation of routine postoperative sequelae (ex- cessive swelling. severe dysphasia, severe pain, severe trismus)

1. Frequency: low (frequency data unavailable) 2. Significance

a. Reversibility: readily reversible b. Degree of morbidity: low c. Disability: short-term but severe d. Complexity of management: generally self-lim-

iting and reversible

Airway Obstruction

1. Frequency: extremely low (no data available) 2. Significance

a. Reversibility: generally reversible b. Degree of morbidity: moderate to grave c. Disability: short-term but severe d. Complexity of management: moderate to com-

plex

Oral Antral Fistula

1. Frequency: extremely low (0.6%) 2. Significance

a. Reversibility: generally reversible b. Degree of morbidity: low c. Disability: low d. Complexity of management: low to moderate

Displaced teeth (antrum, submandibular space, airway, GI tract, infratemporal fossa)

1. Frequency: low 2. Significance

a. Reversibility: generally reversible b. Degree of morbidity: low c. Disability: low d. Complexity of management: low to moderate

1108 REPORT OF THIRD MOLAR WORKSHOP

Appendix A

Final Listing of Literature Reviewed and Incorporated into Each Subgroup Findings Third Molar Workshop

August 6-8, 1993

Natural Course

Ades, A.G., Joondeph, D.R., et al. A long-term study of the relationship of third molars to changes in the mandibular dental arch, Am. J. Orthod. Dentofac. Orthop.; 97: 323-35, 1990.

Ahlqwist, M. and Grondahl, H.G. Prevalence of impacted teeth and associated pathology in middle-aged and older Swedish women. Community Dent. Oral Epidemiol.; 19: 116-9, 1991.

Brown, L.H., Berkman S., et al. A radiological study of the frequency and distribution of impacted teeth. J. Dent. Assoc. S. Afr.; 37: 627-30, 1982.

Camilla Tulloch, J.F., Antczak, A.A. and Wilkes, J.W. The application of decision analysis to evaluate the need for extraction of asymptomatic third molars. J. Oral Maxillofac. Surg.; 45: 855-63, 1987.

Capelli, J. Mandibular growth and third molar impaction in extraction cases. Angle Orthod.; 61: 223-9, 1991. Clow, I.M. A radiographic survey of third molar development: A comparison. Br. J. Orthod.; 11: 9-15, 1984. Cohen, M.C., Arthur, J.S., and Rodden, J.W. Application of decision analysis to the management of third molars (Letter to

the Editor). J. Dent. Ed.; 52: 191, 1988. Cohen, M. E., Walter, R.G., et al. Age-specific angulation of unerupted human third molar teeth in a cross-sectional sample.

Arch. Oral Biol.; 30: 441-4, 1985. Eliasson, S., Heimdahl, A. and Nordenram, A. Pathological changes related to long-term impaction of third molars. A

radiographic study. Int. J. Oral Maxillofac. Surg.; 18: 210-2, 1989. Engstrom, C., Engstrom, H. and Sagne, S. Lower third molar development in relation to skeletal maturity and chronological

age. Angle Orthod.; 53: 97-106, 1983. Forsberg, C.M. Tooth size, spacing, and crowding in relation to eruption or impaction of third molars. Am. J. Orthod, Dentofac.

Orthop.; 94: 57-62, 1988. Forsberg, C.M., Vingren, B. and Wesslen, U. Mandibular third molar eruption in relation to available space as assessed on

lateral cephalograms. Swed. Dent. J.; 13: 23-31, 1989. Garcia, R.I. and Chauncey, H.H. The eruption of third molars in adults: A IO-year longitudinal study. 0. Surg. 0 Med. 0

Path.; 68: 9-13, 1989. Gorgani, N., Sullivan, R.E. and DuBois, L. A radiographic investigation of third molar development. ASDC J. Dent. Child.;

57: 106-10, 1990. Halverson, B.A. and Anderson, W.H. The mandibular third molar position as a predictive criterion for risk of pericoronitis:

A retrospective study. Military Med.; 157: 142-5, 1992. Hugoson, A. and Kugelberg, CF. The prevalence of third molars in a Swedish population. An epidemiological study. Commu-

nity Dent. Health; 5: 121-38, 1988. Kugelberg, C.F. Impacted lower third molars and periodontal health. An epidemiological, methodological, retrospective and

prospective clinical study. Swed. Dent. J. Suppl.; 68: I-52, 1990. Kugelberg, CF. Third molar surgery. Oral Maxillofac. Surg. Infections; 2: 9-16, 1992. Leone, S.A. and Edenfield, M.J. Third molars and acute pericoronitis: A military problem. Military Med.; 152: 146-9, 1987. Lindqvist, B. and Thilander, B. Extraction of third molars in cases of anticipated crowding in the lower jaw. Am. J. Orthod.;

81: 130-9, 1982. Main, D.M.G. Follicular cysts of mandibular third molar teeth: Radiological evaluation of enlargement. Dentomaxillofac.

Radiol.; 18: 156-9, 1989. Murtomaa, H., Turtola, L., et al. Status of the third molars in the 20- to 21-year old Finnish university population. J. Am.

COB. Health; 34: 127-9, 1985. Ng, F., Bums, M., and Kerr, W.J.S. The impacted lower third molar and its relationship to tooth size and arch form. Eur. J.

Orthod.; 8: 254-8, 1986. Nitzan, D., Keren, T. and Marmary, Y. Does an impacted tooth cause root resorption of the adjacent one? 0. Surg. 0. Med.

0. Path.; 51: 221-4, 1981. Piironen, J. and Ylipaavalniemi, P. Local predisposing factors and clinical symptoms in pericoronitis. Proc. Finn. Dent. Sot.;

77: 278-82, 1981. Raustia, A.M. and Oikarinen, K.S. Effect of surgical removal of the mandibular third molars on signs and symptoms of

temporomandibular dysfunction: A pilot study. J. Craniomandib. Prac.; 9: 356-60, 1991. Richardson, M. Pre-eruptive movements of the mandibular third molar. Angle Orthod.; 48: 187-93, 1978. Richardson, M. Lower third molar space. Angle Orthod.; 57: 155-61, 1987. Richardson, M. The effect of mandibular first premolar extraction on third molar space. Angle Orthod.; 59: 291-4, 1989. Richardson, M. Lower arch crowding in the young adult. Am. J. Orthod. Dentofac. Orthop.; 101: 132-7, 1992. Richardson, M. Changes in lower third molar position in the young adult. Am J. Orthod. Dentofac. Orthop.; 102: 320-27,

1992. Richardson, E.R., Malhotra, S.K. and Semenya, K. Longitudinal study of three views of mandibular third molar eruption in

males. Am. J. Orthod.; 86: 119-29, 1984.

REPORT OF THIRD MOLAR WORKSHOP 1109

Sampson, W.J., Richards, L.C. and Leighton, B.C. Third molar eruption patterns and mandibular dental arch crowding. Aust. Orthod. J.; 8: 10-20, 1983.

Schersten, E., Lysell. L. and Rohlin, M. Prevalence of impacted third molars in dental students. Swed. Dent. J.; 13: 7-13, 1989.

Schroeder, D.C., Cecil, J.C. and Cohen, M.E. Retention and extraction of third molars in Naval personnel. Milituly Med.; 148: 50-3, 1983.

Sewerin, I. and von Wowem, N. A radiographic four-year follow-up study of asymptomatic mandibular third molars in young adults. ht. Dent. J.; 40: 24-30, 1990.

Southard, T.E., Southard, K.A. and Weeda, L.W. Mesial force from unerupted third molars. Am. J. Dentofuc. Orthop.; 99: 220-5, 1991.

Staggers, J.A., Germane, N. and Fortson, W.M. A comparison of the effects of first premolar extractions on third molar angulation. Angle Orthod.; 62: 135-8, 1992.

Stanley, H.R., Alattar, M., et al. Pathological sequelae of “neglected” third molars. J. Oral Path.; 17: 113-7, 1988. Svendsen, H., Malmskov, 0. and Bjork, A. Prediction of third molar impaction from the frontal cephalometric projection.

Eur. J. Orthod.; 7: I-16, 1985. Vent& I., Murtomaa, H., et al. Assessing the eruption of lower third molars on the basis of radiographic features. Br. J. Oral

Maxillofac. Surg.; 29: 259-62, 1991. Vent& I., Murtomaa, H., et al. Clinical follow-up study of third molar eruption from ages 20 to 26 years. 0. Surg. 0. Med.

0. Path.; 72: 150-3, 1991. von Wowem, N. and Nielsen, H.O. The fate of impacted lower third molars after age 20. Znt. J. Oral Maxillofuc. Surg.; 18:

2 77-80, 1989. Ylipaavalniemi, P., Turtola, L., et al. Effect of position of wisdom teeth on the visible plaque index and gingival bleeding

index. Proc. Finn. Dent. Sot.; 78: 47-9, 1982.

In addition, the following articles were incorporated into the Subgroup’s discussion but were not subject the objective scoring review by all the workshop participants.

Camilla Tulloch, J.F., Antczak-Bouckoms, A.A., and Ung, N. Evaluation of the costs and relative effectiveness of alternative strategies for the removal of mandibular third molars. int. J. Technol. Assess. Health Cure; 6: 505-15. 1990.

Ganss, C., Hochban, W., Kielbassa, et al. Prognosis of third molar eruption. 0. Surg. 0. Med. 0. Path., 76; 688-93, 1993. Giglio, J.A., Gunsolley, J.C., La&in, D.M. and Short, K. Effect of removing impacted third molars on plaque and gingival

indices. J. Oral Maxillofac. Surg.; 52, 584-7, 1994. Rajasuo, A., Meurman, J.H., et al. Effect of extraction of partly erupted third molars on subgingival microorganisms. 0. Surg.

0. Med. 0. Path.; 74: 431-6, 1992. Rajasuo, A., Murtomaa, H., and Meurman, J.H. Comparison of the clinical status of third molars in young men in 1949 and

in 1990. 0. Surg. 0 Med. 0. Path., 76, 694-8, 1993. Vent& I. Predictive model for impaction of lower third molars. 0. Surg. 0. Med. 0. Path., 76, 699-703, 1993. Vent& I., Turtola, L., et al. Third molars as an acute problem. 0. Surg. 0. Med. 0. Path., 76, 135-40, 1993.

Indications for Care

Al-Khateeb, T.L., El-Mama& A.I. and Butler, N.P. The relationship between the indications for the surgical removal of impacted third molars and the incidence of alveolar osteitis. J. Oral Maxillofac. Surg.; 49: 141-5, 1991.

Alling, C.C. 3rd. Management of impacted teeth. J. Oral Maxillofac. Surg.; 51 (Suppl. 1): 3-6, 1993. Bishara, S.E. and Andreasen, G. Third molars: A review. Am. J. Orthod.; 183: 31-7, 1983. Camilla Tulloch, J.F., and Antczak-Bouckoms, A.A. Decision analysis in the evaluation of clinical strategies for the management

of mandibular third molars. J. Dent. Ed.; 51: 652-60, 1987. Camilla Tulloch, J.F., Antczak-Bouckoms, A.A. and Ung, N. Evaluation of the costs and relative effectiveness of alternative

strategies for the removal of mandibular third molars. Znt. J. Technol. Assess. Health Care; 6: 505-15, 1990. Fielding, A.F., Douglass, A.F. and Whitley, R.D. Reasons for early removal of impacted third molars. Clin. Prev. Dent.; 3:

19-23, 1981. Friedman, J.W. Containing the cost of third molar extractions; A dilemma for health insurance. Public Health Rep.; 98: 376-

84, 1983. Knutsson, K., Brehmer, B., et al. Asymptomatic mandibular third molars: Oral surgeons’ judgment of the need for extraction.

J. Oral Maxillofac. Surg.; 50: 329-33, 1992. Knutsson, K., Brehmer, B., et al. General dental practitioners’ evaluation of the need for extraction of asymptomatic mandibular

third molars. Community Dent. Oral Epidemiol.; 20: 347-50, 1992. Leone, S.A., Edenfield, M.J. and Cohen, M.E. Correlation of acute pericoronitis and the position of the mandibular third

molar. 0. Surg. 0. Med. 0. Path.; 62: 245-50, 1986. Lysell, L. and Rohlin, M. A study of indications used for removal of the mandibular third molar. Int. J. Oral Maxillofac.

Surg.; 17: 161-4, 1988. Mercier, P. and Precious, D. Risks and benefits of removal of impacted third molars: A critical review of the literature. J.

Orat Maxillofac. Surg.; 21: 17-27, 1992. Nordenram, A., Hultin. M., et al. Indications for surgical removal of the mandibular third molar. Swed. Dent. J.; 11: 23-9,

1987.

1110 REPORT OF THIRD MOLAR WORKSHOP

Peterson, L.J. Rationale for removing impacted teeth: when to extract or not to extract. JADA; 123: 198-202, 1992. Poswillo, D. Surgical options for third molars: A review. J. R. Sot. Med.; 74: 911-3, 1981. Richardson, M. The role of the third molar in the case of late lower arch crowding: A review. Orthod. Dentofuc. Or&p.;

95: 79-83, 1989. Vent& L., Turtola, L., et al. Third molars as an acute problem in Finnish university students. Accepted for publication: 0.

Surg. 0. Med. 0. Path. Ylipaavahtiemi, P., Turtola, L., et al. Evaluation of the need for third molar removals among 20 to 21 year old Finnish

university students. Proc. Finn. Dent. Sot.; 81: 222-5, 1985.

Wound Healing

Ash, M.M., Costich, E.R. and Hayward, J.R. A study of periodontal hazards of third molars. J. Periodontal.; 33: 209-15, 1962.

Chin Quee, T.A., Gosselin, D., et al. Surgical removal of the fully impacted mandibular third molar. J. Periodontal.; 56: 625- 30, 1985.

Dubois, D.D., Pizer, M.E. and Chinnis, R.J. Comparison of primary and secondary closure techniques after removal of impacted mandibular third molars. J. Oral Maxillofac. Surg.; 40: 631-4, 1982.

Holland, C.S. and Hindle, M.O. The influence of closure or dressing of third molar sockets on postoperative swelling and pain. Br. J. Oral Maxillofac. Surg.; 22: 65-71, 1984.

Kugelberg, CF. Periodontal healing two and four years after impacted lower third molar surgery. Int. J. Oral Muxillofuc. Surg.; 19: 341-5, 1990.

Kugelberg, C.F., Ahlstrom, U., et al. The influence of anatomical pathophysiological and other factors on periodontal healing after impacted third molar surgery. J. Clin. Periodontal.; 18: 37-43, 1991.

Kugelberg, C.F., Ahlstrom, U., et al. Periodontal healing after impacted lower thiid molar surgery. A retrospective study, Znt. J. Oral Surg.; 14: 29-40, 1985.

Kugelberg, C.F., Ahlstrom, U., et al. Periodontal healing after impacted third molar surgery in adolesents and adults. Znt. J. Oral Maxillofac. Surg.; 20: 18-24, 1991.

Marmary, Y., Brayer, L., et al. Alveolar bone repair following extraction of impacted mandibular third molars. 0. Surg. 0. Med. 0. Path.; 60: 324-6, 1985.

Meister, F., Net-y, E.B., et al. Periodontal assessment following surgical removal of mandibular third molars. Gen. Dent.; IZO- 3, 1986,

Neupert, E.A. 3rd, Lee, J.W., et al. Evaluation of dexamethasone for reduction of postsurgical sequelae of third molar removal. J. Oral Maxillofac. Surg.; 50: 1177-82, 1992.

Osborne, W.H., Snyder, A.J. and Tempel, T.R. Attachment levels and crevicular depths at the distal of mandibular second molars following removal of adjacent third molars. J. Periodontol.; 53: 93-5, 1982.

Ritzau, M., Hillerup, S., et al. Does metronidazole prevent alveolitis sicca dolorosa? A double-blind, placebo-controlled clinical study. Int. J. Oral Maxillofac. Surg.; 21: 299-302, 1992.

Schofield, I.D.F., Kogon, S.L. and Donner, A. Long-term comparison of two surgical flap designs. J. Cunud. Dent. Assoc.; 54: 689-91, 1988.

Stephens, R.J., App, G.R. and Foreman, D.W. Periodontal evaluation of two mucoperiosteal flaps used in removing impacted mandibular third molars. J. Oral Maxillofac. Surg.; 41: 719-24, 1983.

Perioperative Management

Amler, H.A. The age factor in human extraction wound healing. J. Oral Surg.; 35: 193-7, 1977. Beime, O.R. and Hollander, B. The effect of methylprednisolone on pain, trismus, and swelling after removal of third molars.

0. Surg. 0. Med. 0. Path.; 61: 134-8, 1986. Berge, T.I. Visual analogue scale assessment of postoperative swelling. A study of clinical inflammatory variables subsequent

to thud-molar surgery. Acta Odontol. Stand.; 46: 233-40, 1988. Bet-wick, J.E. and Lessin, M.E. Effects of chlorhexidine gluconate oral rinse on the incidence of alveolar osteitis in mandibular

third molar surgery. J. Oral Maxillofac. Surg.; 48: 444-B. 1990. Bruce, R.A., Frederickson, G.C. and Small, G.S. Age of patients and morbidity associated with mandibular third molar surgery.

JADA; 101: 240-5, 1980. Bystedt, H. and Nord, C.E. Effect of antibiotic treatment on postoperative infections after surgical removal of mandibular

third molars. Swed. Dent. J.; 4: 27-38, 1980. Bystedt, H. and Nordenram, A. Effect of methylprednisolone on complications after removal of impacted mandibular thiid

molars. Swed. Dent. J.; 9: 65-9, 1985. Chapnick, P. and Diamond, L.H. A review of dry socket: A double-blind study on the effectiveness of clindamycin in reducing

the incidence of dry socket. J. Canad. Dent. Assoc.; 58: 43-52, 1992. Davis, W.H., Hochwald, D.A. and Kaminishi, R.M. Modified distolingual splitting technique for removal of impacted mandibu-

lar third molars: Technique. 0. Surg. 0. Med. 0. Path.; 56: 2-8, 1983. Falconer, D.T. and Roberts, E.E. Report of an audit into third molar exodontia. Br. J. Oral Muxillofac. Surg.; 30: 183-5,

1992.

REPORT OF THIRD MOLAR WORKSHOP 1111

Fisher, SE., Frame, J.W., et al. Factors affecting the onset and severity of pain following the surgical removal of unilateral impacted mandibular third molar teeth. Br. Dent. J.; 164: 351-4, 1988.

Forsgren, H., Heimdahl, A., et al. Effect of application of cold dressings on postoperative course in oral surgery. ht. .I. Oral Surg.; 14: 223-8, 1985.

Fotos, P.G., Koorbusch, G.F., et al. Evaluation of intra-alveolar chlorhexidine dressings after removal of impacted mandibular third molars. 0. Surg. 0. Med. 0. Path.; 73: 383-8, 1992.

Fridrlch, K.L. and Olson, R.A.J. Alveolar osteitis following surgical removal of mandibular third molars. Anesth. Prug.; 37: 32-41, 1990.

Hall, H.D., Bildman, B.S. and Hand, C.D. Prevention of dry socket with local application of tetracycline. J. Oral Surg.; 29: 35-7, 1971.

Happonen, R.P., Backstrom, A.C. and Ylipaavalniemi, P. Prophylactic use of phenoxymethylpenicillin and tinidazole in mandibular third molar surgery, a comparative placebo controlled clinical trial. Br. J. Oral and Maxillofac. Surg.; 28: 12-5, 1990.

Hellem, S. and Nordenram, A. Prevention of postoperative symptoms by general antibiotic treatment and local bandage in removal of mandibular third molars. ht. .I. Oral Surg.; 2: 273-8, 1973.

Kalamchi, S. and Hensher, R. The management of impacted third molars. Dent. Update; 14: 437-40, Dec. 1987. Kaziro, G.S.N. Metronidazole (flagyl) and Arnica Montana in the prevention of post-surgical complications: A comparative

placebo controlled clinical trial. Br. J. Oral Maxillojizc. Surg.; 22: 42-9, 1984. Koemer, K.R. Steroids in third molar surgery: A review. Gen. Dent.; 35: 459-63, 1987. Krekmanov, L. and Hallander, H.O. Relationship between bacterial contamination and alveolitis after third molar surgery. ht.

J. Oral Surg.; 9: 274-80, 1980. Larsen, P.E. Alveolar osteitis after surgical removal of impacted mandibular third molars: Identification of the patient risk. 0.

Surg. 0. Med. 0. Path.; 73: 393-7, 1992. Larsen, P.E. The effect of a chlorhexidine rinse on the incidence of alveolar osteitis following the surgical removal of impacted

mandibular third molars. J. Oral Maxillofac. Surg.; 49: 932-7, 1991. Larsen, P.E. Use of chlorhexidine to prevent alveolar osteitis (Letter to the Editor). J. Oral Maxillofac. Surg.; 1244-5, 1990. Loukota, R.A. The effect of pre-operative perioral skin preparation with aqueous providone-iodine on the incidence of infection

after third molar removal. Br. J. Oral Maxillofac. Surg.; 29: 336-7, 1991. Lyall, J.B. Third molar surgery: The effect of primary closure. J. R. Army Med. Corps; 137: 100-3, 1991. MacGregor, A.J. Reduction in morbidity in the surgery of the third molar removal. Dent. Update; 411-4, 1990. MacGregor, A.J. and Addy, A. Value of penicillin in the prevention of pain, swelling and trismus following the removal of

ectopic mandibular third molars. Int. J. Oral Surg.; 9: 166-72, 1980. Meechan, J.G., MacGregor, I.D.M., et al. The effect of smoking on immediate post-extraction socket filling with blood and

on the incidence of painful socket. Br. J. Oral Maxillofac. Surg.; 26: 402-9, 1988. Meyerowitz, C., Jensen, O.E., et al. Extraction of the third molar and patient satisfaction. 0. Surg. 0. Med. 0. Path.; 65: 396-

400, 1988. Middlehurst, R.J., Barker, G.R. and Rood, J.P. Postoperative morbidity with mandibular third molar surgery: A comparison

of two techniques. J. Oral Maxillofac. Surg.; 46: 474-6, 1988. Montgomery, M.T., Hogg, J.P., et al. The use of glucocorticosteroids to lessen the inflammatory sequelae following third

molar surgery. J. Oral Maxillofac. Surg.; 48: 179-87, 1990. Nordenram, A., Sydnes, G. and Odegaard, J. Neomycin-bacitracin cones in impacted third molar sockets. Znt. J. Oral Surg.;

2: 279-83, 1973. Pedersen, A. Decadron phosphate in the relief of complaints after third molar surgery. ht. J. Oral Surg., 14: 235-40, 1985. Pedersen, A. Interrelations of complaints after removal of impacted mandibular third molars. Int. J. Oral Surg.; 14: 241-4,

1985. Ragno, J.R. and Szkutnik, A.J. Evaluation of 0.12% chlorhexidine rinse on the prevention of alveolar osteitis. 0. Surg. 0.

Med. 0. Path.; 72: 524-6, 1991. Rood, J.P. Degrees of injury to the inferior alveolar nerve sustained during the removal of impacted mandibular third molars

by the lingual split technique. Br. J. Oral Surg.; 21: 103-16, 1983. Rood, J.P. and Murgatroyd, J. Metronidazole in the prevention of “dry socket”. Br. J. Oral Surg.; 17: 62-70, 1970-80. Rood, J.P. Permanent damage to inferior alveolar and lingual nerves during the removal of impacted mandibular third molars.

Comparison of two methods of bone removal. Br. Dent. J.; 172: 108-10, 1992. Rubin, M.M., Koll, T.J. and Sadoff, R.S. Morbidity associated with incompletely erupted third molars in the line of mandibular

fractures. J. Oral Maxillofac. Surg.; 48: 1045-7, 1990. Rud, J. Reevaluation of the lingual split-bone technique for removal of impacted third molars. J. Oral Maxillofac. Sltrg.; 42:

14-7, 1984. Seymour, R.A., et al. An investigation into post-operative pain after third molar surgery under local analgesia. Br. J. oral

Maxillofac. Surg.; 23: 410-8, 1985. Seymour, R.A. and Walton, J.G. Pain control after third molar surgery. Int. J. Oral Surg.; 13: 457-85, 1984. Swanson, A.E. A double-blind study on the effectiveness of tetracycline in reducing the incidence of fibrinolytic alveolitis. J.

Oral Maxillqfac. Surg.; 47: 165-7, 1989. Sweet, J.B., Butler, D.P. and Drager, J.L. Effects of lavage techniques with third molar surgery. 0. Surg. 0. Med. 0. Path.;

41: 152-68, 1976. Sweet. J.B. and Butler, D.P. The relationship of smoking to localized osteitis. J. Oral Surg.; 37: 732-5, 1979. Tuffin, J.R., Cunliffe, D.R. and Shaw, S.R. Do local analgesics injected at the time of third molar removal under general

anaesthesia reduce significantly postoperative analgesic requirements? A double-blind controlled trial. Br. J. Oral Maxillo- fat. Surg.; 27: 27-32. 1989.

1112 REPORT OF THIRD MOLAR WORKSHOP

Complications

Alling, C.C. 3rd. Management of impacted teeth. J. Oral Maxillofac. Surg.; 51 (Suppl. 1): 3-6, 1993. Bjomland, T., Haanes, H.R., et al. Removal of third molar germs. Study of complications. Znt. J. Oral Maxillofac. Surg.; 16:

385-90, 1987. Cade, T.A. Paresthesia of the inferior alveolar nerve following the extraction of the mandibular third molars: A literature

review of its causes, treatment, and prognosis. Military Med.; 157: 389-91, 1992. Carmichael, F.A. and McGowan, D.A. Incidence of nerve damage following third molar removal: A West of Scotland oral

surgery research group study. Br. J. Oral Maxillofac. Surg.; 30: 78-82, 1992. Eslami, A., Sadeghi, E. and Van Swol, R.L. The prevalence of osseous defects on the distal aspect of the mandibular second

molar in the absence of the third molar in a dental student population. Quintessence Znt.; 16: 363-6, 1985. Goldberg, M.H., Nemarich, A.N. and Marco, W.P. Complications after mandibular third molar surgery: A statistical analysis

of 500 consecutive procedures in private practice. JADA; 111: 277-9, 1985. Griindahl, H.-G. and Lekholm, U. Influence of mandibular third molars on related supporting tissues. Znt. J. Oral Surg.; 2:

137-42, 1973. Herpy, A.K. A monitoring and evaluation study of third molar surgery complications at a major medical center. Military Med.;

156: 10-2, 1991. Indresano, A.T., Haug, R.H. and Hoffman, M.J. The third molar as a cause of deep space infections. J. Oral Maxillofac.

Surg.; 50: 33-5, 1992. Jones, R.H. Microsurgical repair of nerves injured during third molar surgery. Aust. Dent. J.; 37: 253-61, 1992. Kipp, D.P., Goldstein, B.H., and Weiss, W.W. Dysesthesia after mandibular third molar surgery: A retrospective study and

analysis of 1,377 surgical procedures. JADA; 100: 185-92, 1980. Krekmanov, L. Alveolitis after operative removal of third molars in the mandible. Int. J. Oral Surg.; 10: 173-9, 1981. Krekmanov, L. and Nordenram, A. Postoperative complications after surgical removal of mandibular third molars. ht. J. Oral

Maxillofac. Surg.; 15: 25-9, 1986. Kugelberg, C.F., Ahlstrom, U., et al. Periodontal healing after impacted lower third molar surgery. Precision and accuracy of

radiographic assessment of intrabony defects. Int. J. Oral Maxillofac. Surg.; 15: 675-86, 1986. Mason, D.A. Lingual nerve damage following lower third molar surgery. Int. J. Oral Maxillofac. Surg.; 17: 290-4, 1988. Nickel, Jr., A.A. A retrospective study of paresthesia of the dental alveolar nerves. Anesth. Prog.; 37: 42-5, 1990. Nordenram, A. and Grave, S. Alveolitis sicca dolorosa after removal of impacted mandibular third molars. Znt. J. Oral Surg.;

12: 226-31, 1983. Oberman, M., Horowitz, I. and Ramon, Y. Accidental displacement of impacted third molars. Znt. J. Oral Maxillofac. Surg.;

15: 756-8, 1986. Obiechina, A.E. Paresthesia after mandibular third molar extractions in Nigerians. Odonto-Stomatol. Trop.; 13: 113-4, 1990. O&a&en, K. and Rasanen, A. Complications of third molar surgery among university students. J. Am. Coll. Health; 39: 281-

5, 1991. Osbom, T.P., Frederickson, G.C., et al. A prospective study of complications related to mandibular third molar surgery. J.

Oral Maxillofac. Surg.; 767-9, 1985. Rajasuo, A., Meurman, J.H., et al. Effect of extraction of partly erupted third molars on subgingival microorganisms. 0. Surg.

0. Med. 0. Path.; 74: 431-6, 1992. Rezai, R.F., Bayley, N.C. and Austin, K. Lingual nerve damage: Causative factors and management. Quintessence Znt.; 19:

295-8, 1988. Robinson, P.P. Observations on the recovery of sensation following inferior alveolar nerve injuries. Br. J. Oral Maxillofac.

Surg.; 26: 177-89, 1988. Rood, J.P. Lingual split technique. Damage to inferior alveolar and lingual nerves during removal of impacted mandibular

third molars. Br. Dent. J.; 154: 402-3, 1983. Rood, J.P. and Nooraldeen Shehab, B.A.A. The radiological prediction of inferior alveolar nerve injury during third molar

surgery. Br. J. Oral Maxillofac. Surg.; 28: 20-5; 1990. Sisk, A.L., Hammer, W.B., et al. Complications following removal of impacted third molars: The role of the experience of

the surgeon. J. Oral Maxillofac. Surg.; 44: 855-9, 1986. Swanson, A.E. Removing the mandibular third molar: Neurosensory deficits and consequent litigation. J. Canad. Dent. Assoc.;

55: 383-6, 1989. Swanson, A.E. Incidence of inferior alveolar nerve injury in mandibular third molar surgery. J. Canad. Dent. Assoc.; 57: 327-

8, 1991. Van Swol, R.L. and Mejias, J.E. Management and prevention of severe osseous defects distal to the second molar following

third molar extraction. Int. J. Periodont. Restorative Dent.; 3: 46-57, 1983. Wofford, D.T. and Miller, R.I. Prospective study of dysesthesia following odontectomy of impacted mandibular third molars.

J. Oral Maxillofac. Surg.; 45: 15-9, 1987.