Is the recommendation for the enucleation or the … is for French practitioners, dentists and stomatologists and for all sectors of public health. 1977 Charron, M.C.5 (‘‘Is there

DOI: 10.1051/odfen/2014024 J Dentofacial Anom Orthod 2014;17:403� RODF / EDP Sciences

1

Article received: 06-06-2014Accepted for publication: 11-06-2014

Is the recommendation for theenucleation or the extraction of3rd molars in subjects during orat the end of dento-facial orthopedictreatment always justified? Theviewpoint of a practitioner after40 years of orthodontic practice

J.-M. Salagnac

ABSTRACT

Orthodontists frequently prescribe prophylactic enucleation of the lowerthird molars. These teeth are mostly totally asymptomatic. This practice isbeing recommended more and more frequently, even though publishedstudies are more reserved in this respect. Orthodontists have to reconsidertheir recommendations for prophylactic enucleation of the lower third molars,but they have to make sure whether or not these teeth will erupt into theircorrect positions in the arch.

KEY WORDS

Prescription for enucleation of the lower 3rd molars in orthodontic practice

INTRODUCTION

Extraction or conservation of the 3rdmolars, also known as wisdom teeth, is arecurring question in DFO, discussedfor many decades, still unresolved, and

continues to be an object of great contro-versy, that may very well explain the greatvariability for its indication and practices.Orthodontists are heavy prescribers of

Address for correspondence:

Jean-Michel Salagnac - Service de stomatologyet chirurgie-maxillo-faciale (Pr Mercier Jacques) - CHUNantes - 44300 [email protected]

Article available at http://www.jdao-journal.org or http://dx.doi.org/10.1051/odfen/2014024

http://www.jdao-journal.org

http://dx.doi.org/10.1051/odfen/2014024

enucleations of the 3rd molars with athree-fold prophylactic objective(sometimes curative for some of us!)for:

– preventing the development ofdelayed mandibular incisor-canine crowding due to a ‘‘mesialpressure’’ from the third molars;

– treating or preventing ‘‘posteriordiscrepancies’’;

– preventing accidents of eruption:inflammations, cellulitis, gang-lions , thrombophlebitis, tumors,neural accidents, development ofdentigerous cysts. . .

But is our prescription for extrac-tions solely based on the presump-

tion that wisdom teeth are the

cause?

Over time, this presumption of re-sponsibility for the 3rd molars has be-come a certainty that allows us tohide our lack of understanding of thecause of late incisor-canine crowding.Unfortunately (or fortunately), the im-plication of the 3rd molars is com-monly accepted among practitionersand by the general public alike. Andit’s in good faith and with a clear con-science that some practitioners pre-scribe their removal and patientsaccept this! This certitude is sostrong that some patients wonderand insist on their extraction: ‘‘Thesewisdom teeth shouldn’t ruin all thework that you’ve done!’’

This conviction is reinforced by twowidespread and generally acceptedideas that over time and as a conse-quence of evolution, the human jawswill become shorter and there will notbe enough room for the 3rd molars,and that eventually these teeth will nolonger serve any purpose and hencethey will be useless!

These ‘‘new truths’’ are in additionto emerging paramedical specialtiesthat blame these teeth for a wholevariety of problems. We can then un-derstand why there is a runaway in-flation of prescriptions for theremoval of the 3rd molars whether ornot they have erupted.

But la vox populi has never hadprobative scientific value!!!

All experienced practitioners have:– noticed that young adolescents

report, many times prior to theeruption of the 3rd molars, var-ious sensations of pushing, ten-sion, pressure, primarily in theregion of the anterior mandiblethat are often concomitant withthe appearance of incisor-caninecrowding;

– noted that the appearance of lateincisor-canine crowding is asso-ciated with the agenesis of the3rd molars, and with the pre-sence of diastemas in the lateral(buccal) sectors;

– heard patients complain of pain inthe TMJ after enucleation of the3rd molars;

– discovered with surprise andregret following a clinical exam,many years after enucleation,sufficient space for the 3rd mo-lars behind the 2nd molars.

Enucleation of the wisdom teethhas become the most frequent pro-cedure performed by oral surgeons.It is prescribed before, during and atthe end of orthodontic treatment andin most cases involves totally

asymptomatic teeth. Enucleation isperformed far more often than ex-traction of erupted 3rd molars. It’s in-dication involves essentially thelower 3rd molars but almost routinely

J.-M. SALAGNAC

2 J.-M. Salagnac. Is the recommendation for the enucleation or the extraction of 3rd molars in subjects during or at the end ofdento-facial orthopedic treatment always justified? The viewpoint of a practitioner after 40 years of orthodontic practice

leads to the removal of the maxillary3rd molars. The prevalence of pre-scribing has become virtually auto-matic for some practitioners, butvaries greatly based on the regionand depending on the schools, theorthodontic techniques used and themindset of practitioners regardingfacial growth especially of themandible.

It appears that this procedure isprescribed increasingly more often inyounger children and involves the en-ucleation of the four 3rd molars per-formed under general anesthesia,and frequently without any other ex-amination beyond finding them onthe panoramic xray!

Prescribing the enucleation of the3rd molars under these conditionsmakes light of the psychological trau-ma to the child, the risks incurred,and the costs to the public healthsystem.

This significant increase in the indi-cations for enucleation or extractionof the 3rd molars often creates a pro-blem for practitioners and can causea shift in public opinion as shown bysome articles published recently invarious newspapers (for example thearticles by Dr. Pierre Jacquemart11 inthe magazine Le Point of November16, 2006 ‘‘SOS wisdom teeth,’’ andby Dr. Jean-Baptiste Kerbrat12 ‘‘Is itreally necessary to remove my wis-dom teeth?’’ in the November, 2013edition of the newspaper OuestFrance.

Their prophylactic sacrifice can onlybe acceptable if their responsibilityfor the appearance of crowding inthe anterior regions and their harm-fulness to the dento-skeletal equili-brium has been reliably assessed andproven.

FEATURES OF THE APPEARANCE OF MALPOSITIONS OF THE LOWERINCISOR-CANINE REGION

It seems that their cause is multi-factorial. In fact, they occur:

– in subjects during strong overallgrowth, especially of the cervicalspine with elongation of theneck, descent of the hyoid bone,lowering of the lingual mass,downward and rearward tractionfrom the digastric muscles,strengthening of muscle tone,etc;

– at the time of intense anterior-posterior mandibular growth andsignificant realignment in theregion between the second mo-lar and the entrance of the dental

canal. The lengthening of thiscanal allows for the eruption ofthe molars. Izard9 wrote: ‘‘justbelow and in front of the angle,there exists an area of spongybony mesh with large medullaryspaces that lends itself perfectlyto osseous remodeling. Fromnow on, let’s be aware of theimportance of this area duringcertain therapeutic modifica-tions;’’

– when the transverse growth ofthe mandibular condyles ends,this separates the two ascendingrami of the mandible and

IS THE RECOMMENDATION FOR THE ENUCLEATION OR THE EXTRACTION OF 3RD MOLARS IN SUBJECTS DURING OR AT THE END OF DENTO-FACIAL

ORTHOPEDIC TREATMENT ALWAYS JUSTIFIED? THE VIEWPOINT OF A PRACTITIONER AFTER 40 YEARS OF ORTHODONTIC PRACTICE

Rev Orthop Dento Faciale 2014;17:403. 3

increases the pressure on thesymphysis. The mental symphy-sis is thus a "seismic" zone,which could explain the dentalshifting in this area (fig. 1).

– prior to or sometimes at the timewhen the 3rd molars appear.

Then is this cause and effect orjust simple coincidence?

The arguments of different authorsfor and against the recommendationfor prophylactic removal of the 3rd

molars are summarized in the follow-ing table.

Indications for the enucleation of the3rd molars in a child or adolescent allgoes back to the question of the re-

sponsibility of the 3rd molars for the

appearance of late crowding of the

incisors. The clinical cases treated byDFO and published in specialized litera-ture show the nearly systematic ab-sence of the 3rd molars on radiographspresented at the end of treatment.

REVIEW OF THE LITTERATURE

A study of the odonto-stomatologicalliterature merits particular attentionbecause the articles as publishedseem to contradict the evolution ofcurrent practice and to demonstratea lack of scientific proof of theresponsibility of the 3rd molars for theappearance of lower incisor-caninecrowding. Enucleation as a precaution-

ary measure does not appear to bemedically justified. Many studies werebiased and the methodology was notsufficiently rigorous.

There are few studies on this sub-ject and the most probative weredone in the United States and inScandinavia. However, the articleslisted below show how relevant this

Figure 1: 1. Transverse growth of the condyles isolated from the ascending rami of themandible. The muscles inserted in the symphysis exercises restraining forces in thesymphyseal region that can explain the appearance of pre-pubertal malpositions of theincisor-canines. (After J.M. Salagnac).2. The internal posterior limit of the dento-alveolar arch is situated just in front of theSpine of Spix.

J.-M. SALAGNAC


question is for French practitioners,dentists and stomatologists and forall sectors of public health.

1977 Charron, M.C.5 (‘‘Is there arelation between incisor-caninecrowding and the eruption of the 3rd

molar?’’) studied the relationships be-tween age, incisor-canine crowdingand the state of eruption of the 3rd

molars in 131 subjects aged from 17to 75 years and concluded that therewasn’t any significant link betweenthe crowding and the status of the3rd molars and found that the onlylink was an increase in mandibularcrowding with age.

1981 Lerondeau J.C., Schnirer,M.C., Verdier, M., Scheffer, P.13 (‘‘Isthe enucleation of the wisdom teethtruly useful in orthodontics?’’) con-cludes that:

1. late developing lower incisor mal-positions are accompanied by alingualization of the incisors;

2. the lingualization of the incisorsmight be related to a strengthen-ing of the tone of the lips in thepre- and post-pubertal period;

3. The ‘‘mesial’’ pressure from the3rd molars has never been clearlydemonstrated;

4. Prophylactic enucleation doesnot protect patient from incisormalpositions later on . . . This is a

procedure that is certainly use-

less in many cases!

1983 Fraudet, J. R.7, in responseto the article by Bassigny, F.2 pub-lished in Le concours medical (‘‘Let’sretain wisdom teeth’’), wrote:‘‘crowding in the anterior incisor re-gion, when it appears, is not due toposterior pressure, but on the con-trary, is due to pressure from front toback because of a modification in themuscle tone of the orbicularis mus-cles of the lips, the buccinators andthe masseters that occurs duringpuberty. It is a mistake to perform

enucleations.’’1984 Lindqvist and Thilander14, in

an experiment involving 52 patientswith a median age of 15 and one-halfyears, performed enucleation of one3rd molar on one side and the effectswere observed over 3 years. Theeffect is positive in 70% of cases(appearance of tertiary crowding onthe non-extraction side and not onthe extraction side). They concludethat, in cases of severe crowding, en-ucleations are indicated. However,their study was not able to predictwhich patients would respond favor-ably to enucleation.

1989 The French Society of Dento-Facial Orthopedics asked Bertrand,G., Darque, F., Duhart, A.M., Le Petit,

Objective Arguments in favor Arguments against

1.Prevent the appearance of late mal-

positions (post orthodontic and/or late,

pre and pubertal)

2. Prevent or heal a posterior DDM

3. Prevent accidents due to eruption of

the third molars

• Performed + easier to accomplish

than in adults

• Postoperative morbidity + lesser

• Little or no loss of work

• No relation demonstrated between

pressure from the 3rd molars and the

appearance of incisor crowding

• Often performed under GA, in young

adolescents (between 13-20 years)

• At times, psychological repercussions

• Not insignificant public health costs




Ohayon-Farouz, R., Oriez, D., TruchotG.4 to develop a discussion paper inresponse to their question concern-ing ‘‘The wisdom tooth’’.

One of the conclusions of theauthors was: ‘‘the wisdom teeth par-ticipate without a doubt in a minorway to the etiopathogenic chain re-sponsible for anterior crowding. Itscause is multifactorial and shouldlead the orthodontist to make a well-considered decision and to reconsi-der their extraction on a case by casebasis.’’

1978 Horn, A., Vaugeois M., Scheck,G.8 (‘‘Indication for enucleation of thewisdom tooth.’’) The authors conclude;‘‘Enucleation of the wisdom teeth isnecessary in all cases treated with mul-ti-banded techniques that require maxi-mal or crucial anchorage preparationfor solving the problem of posteriorcrowding.’’ The indication for an enu-cleation is directly related to the tech-

nique used.

1997 L’ANAES1 in its report ‘‘Indi-cations and non-indications for the re-moval of the mandibular 3rd molars’’shows the variability in treatmentpractice and publishes the followingremarks and works:

– the proportion of the subjectswith one 3rd molar, included,retained or impacted was on theorder of 16% for subjects withfull dentition and approximately11% for subjects with an incom-plete arch of teeth;

– the frequency of included orimpacted mandibular 3rd molarswas on the order of 15 to 25%,compared with all mandibular 3rd

molars.

– In the study by Knutsson, 30general dentists received dupli-cate files and gave their opinionson 36 asymptomatic mandibular3rd molars to extract in a rangefrom 0 to 26. There was not asingle case in which all thepractitioners proposed the sameexact treatment. The intra-individual reliability averaged92% with a range from 69% to100%!

– Brickley et al. 1979 compared theclinical decision of six oral sur-geons using the indications es-tablished during a consensusconference on the ‘‘Removal ofthird molars,’’ National Instituteof Dental Research. Each practi-tioner had to establish a treat-ment plan for 72 patients agedfrom 15 to 44 years who werereferred to the National HealthService Teaching Hospital for theassessment of the 3rd molars,139 of which were mandibular3rd molars. The 6 oral surgeonsplanned an intervention for 30patients under general anesthe-sia, for 36 other patients anintervention using local anes-thetic, and for 6 other patientsno intervention. Based on thecriteria of the conference con-sensus, 30% did not correspondto the indications for removal.

– Brickley in a study sought out thepersonal observations of 201dentists and registrants at uni-versity hospitals concerning theirmandibular 3rd molars. ‘‘Virtuallyall the respondents thoughtthat the prophylactic extractionwas not in their best interests.

J.-M. SALAGNAC


Thus they chose to have their 3rd

molars removed solely in casesof well-defined problems.’’

– The studies of Brickley et al. de-monstrated that the optimal strat-

egy, for a patient who has anasymptomatic mandibular 3rd mo-lar, is almost always non-interven-tion. (Recommendation grade A.)

– The study by Tulloch et al. tendsto prove that, in young adoles-cents, in good health with anasymptomatic mandibular thirdmolar, erupted or partial lyerupted, including root develop-ment between half and 2/3, con-servat ion of the tooth ispreferable to prophylactic extrac-tion. The indication for extractionwill only be requested later if thetooth is implicated in a pathologi-cal process (recommendationgrade A).‘‘The variability of treatment prac-tice is explained by the habits,beliefs, the type of training, themethod of remuneration and allthese factors make us think thatthe medical decision is not suffi-ciently based on the facts, on theclinical facts and on evidence-based proof.

– An investigation performed byHazelkorn involving 79 practi-tioners with 4 different modesof practice shows that the indica-tions of extraction of four 3rd

molars are directly linked to the

type of practice and to the

method of payment to the

practitioners.The ANAES1 report concluded:‘‘That the effectiveness of the

removal of the 3rd molars, for the

prevention of mandibular crowding, isnot confirmed by the studies cur-rently available. The enucleation ofthe bud of the 3rd molar in the child,justified by predictive studies, is notan acceptable practice in light of cur-rent knowledge.’’

2005 Jacquemart P. and Diart T.10,in their article ‘‘Conservation or ex-traction of the wisdom teeth,’’ re-mind us that ‘‘the efficacy of theprophylactic removal of the 3rd mo-lars for the prevention of crowding ofthe mandibular incisors is not con-firmed by the studies presently avail-able. Enucleation of the bud of the3rd molar in the child, recommendedby predictive studies is therefore notjustified.’’

Costs to the public healthsystem, recommendations forbest practices

– In France, there is no publishedcost for enucleation of four 3rd

molars under general anesthesia.– In England, the global costs for

prophylactic extractions for theyears 1995-1996 amounted to5.2 million pounds. The removalof an asymptomatic 3rd molar is33% more expensive than thatlinked to abstention, after takinginto consideration follow up treat-ment;

– In England, the implementationof the RPCs has translated intoa 32% reduction in extractions.A strict respect for the RPCrecommendations could lead toa reduction of 60% in the numberof extractions.




CAN WE MAKE AN EARLY AND RELIABLE PREDICTION ABOUT THEDEVELOPMENT OF THE THIRD MOLARS

What can we expect fromconventional radiographicexaminations?

Recap of the development of the

bud of the lower 3rd molars:

– begins formation around 4-5years;

– begins radiologic visibility around10-11 years;

– end of mineralization and crownformation between 13-15 years;

– beginning eruption into the archis very variable among individualsand from one side with the other,with an average around 17-21years. It usually lasts from 1 to2 years between the beginningappearance into the arch andcomplete eruption.

Periapical film: correctly done, itprovides a good quality image, withslight distortion . . .but it is often diffi-cult to obtain correctly in a child andmust be taken for each side.

Orthopantomogram: it accuratelylocates the anterior-posterior and ver-tical position of the 3rd molar but nottransversely and there can be signifi-cant distortions. The image of theanterior border of the ramus doesnot correspond to the posterior limitavailable and therefore is not a reli-able landmark.

Lateral profile head film: it givesa good idea of the orientation of thebuds of the 3rd molars in relation tothe 2nd molars, which for someauthors allows them to make a prog-nosis for the development of thebuds of the 3rd molars, but does not

give any indication for the transverseposition of the bud of the 3rd molar.The bud often appeared radiologicallysituated first over the plane of occlu-sion of the other molars (fig. 2).

The image of the anterior border ofthe ramus is external in relation tothe image of the bud of the 3rd molarand does not correspond to the avail-able posterior limit. In effect, the in-ternal posterior limit of the dento-alveolar arch is positioned just infront of the spine of Spix (fig. 1).

The individual variations of theshapes of the arch, more or less di-vergent in front and in the rear, in-duce different relations between thesuperimpositions of the images ofthe 3rd molars that often show verti-cal gaps, rendering impossible pre-cise identification of the buds.

By just observing the position ofthe buds of the 3rd molars on the lat-eral profile head film, the practitionercannot, except for the position andany aberrant morphology of the buds,conclude that there is an indicationfor prophylactic enucleation.

Frontal head film (fig. 3). Thisview is not sufficiently utilized and

exploited prior to prescribing enu-cleation of the buds of the 3rd molarseven though it clearly shows thetransverse position of the 3rd molar.In effect, the bud of the 3rd molar isnormally positioned transversely

outside in relation to the 2nd molarfrom the moment when it begins itsmovement towards its site of erup-tion, in this case at around 14-15years. The bud of the 3rd molar then

J.-M. SALAGNAC


migrates in a vestibular-lingual direc-tion and bottom up and eventuallyreaches its position behind the sec-ond molar. At this stage, it does notrepresent any hindrance to the ortho-dontic treatment, particularly to anydistal movement.

This view also allows us to assessboth the transverse space availableand the position of the anterior bor-der of the mandibular ramus.

Cone beam: it makes it possibleto clearly view the morphology, thevolume, the position of the roots andthe apices of the 3rd molars and theirrelations with the inferior dentalnerve, the dimensions and the sizeof a potential dentigerous cyst.

Since they were aware of thereservations expressed above, sev-eral authors logically and usefully

proposed some methods to evaluatethe space necessary for the eruptionof the lower 3rd molar before estab-lishing a favorable or non-favorableprognosis for these teeth. All ofthese methods rest principally on theobservation of the inclination of theimage of the buds at the "t" cephalo-metric landmark on the panoramicimage and/or lateral profile head film.Among the authors cited: Ricketts16,Croquet and Delachapelle6, Richardson15,Begtrup, Gronastoo, Christiansen andKjaer3, established a mathematical for-mula to predict the probability of theeruption of the 3rd molars for eachside. All these assessments requiretaking a series of images that must becarried out in the exact same way inorder to be reliable and reproducible.Despite all this, the different methodsremain imprecise. Based on current

Figure 2The bud often appears radiologically positioned first above the plane of occlusion then it descends progressivelybelow the plane of occlusion of the other molars.




findings, it is not possible topredict with sufficient probability thechances of eruption before the age of14-15 years especially since the erup-tion of the 3rd molars is full of sur-prises, both good and bad, given howcomplex its eruptive mechanism is.

Personal method based on the fol-lowing facts:

– a subject presenting with goodskeletal equilibrium and com-plete dentition has the distalfaces of the 3rd molars positioned

on the same vertical plane. Theupper and lower alveolar lengthsare thus equivalent on a lateralprofile head film.

– The proportions between thelength of the upper and loweralveolar processes and their ske-letal bases are well defined bythe dento-skeletal analysis17

(fig. 4A). In a child subject, witha developing dentition, it is easyto measure, with a profile headfilm using the t cephalometriclandmark," the alveolar maxillaryand mandibular alveolar lengthsand to evaluate their dimensionsin relation to their skeletal basesand to provide evidence for thepotential deficits in the length fromone to the other. The observationof the position of the bud of thelower 3rd molar by using a trianglewhose upper or lower apex allowsfor an assessment of the favorableor unfavorable position of thebud without pretending to predicta prognosis for eruption (fig. 4Band 4C).

While still imperfect, this proce-dure, a quick and simple process,has the advantage of being strictly in-dividualized and not dependent onstatistical values.

However none of the methods arevalid and the practitioner still has toperform both the clinical observationand the palpation of the osteo-muscular and mucosal triangle inwhich the 3rd molars must eruptespecially the area of the insertion ofthe soft tissues behind the 2nd mo-lars (fig. 5). An attentive examinationof this zone, as a follow-up to ortho-dontics shows that as the bud of the

Figures 3P-A Frontal head film is not sufficiently utilized and

exploited. It clearly shows the tranverse position ofthe 3rd molar. The bud of the 3rd molar is normally

positioned transversely outside in relation to the2nd molar at the moment when it begins its move-ment towards its site of eruption, namely at around14-15 years of age.

J.-M. SALAGNAC


3rd molar approaches its place oferuption, the insertion of the anteriorpillar migrates distally allowing forthe passage of the tooth. Just as ac-cidents in the eruption of the 3rd mo-

lars involve the soft tissues, it’sthese same tissues that allow or

do not allow the correct placement

of the lower 3rd molar. However,an isolated episode or accident in the

Figures 4Favorable position of the bud of the lower 3rd molar. a) Ideal alveolar-skeletal relation. b) Favorable alveolar andskeletal dimensions for the eruption of the 3rd molar. c) Unfavorable alveolar and skeletal dimensions for the erup-tions of the 3rd molar.




eruption does not automatically con-demn all 3rd molars.

Questions to consider beforemaking a diagnosis about theindications for enucleation ofthe 3rd molars

Is the enucleation of the 3rd molarsindispensible before orthodontictreatment? In certain cases, it is of-ten preferable to consider the re-moval of the 2nd molars.

Are other extractions necessary inorder to proceed with the treatment?Do we have the right to sacrifice aquarter of the dentition of a youngchild in order to align the otherteeth?. . . and to say afterwards incase malpositions appear that theperfect alignment of the incisors isno longer the rule of thumb for mod-ern humans? If this is the case,aren’t we really admitting how inef-fective orthodontic techniques are?

Where then is the patient inhis mandibular growth? Are themaxillary-mandibular skeletal relation-ships normal? We cannot hope tohave sufficient space to conserve allthe teeth without good developmentof the osseous maxillary and mandib-ular supports. Think orthopedics be-fore orthodontics.

Is my patient mature enough to ac-cept the procedure?

Is enucleation of the 3rd molars in-dispensible right after orthodontictreatment?

Is the anatomic environment trulyunfavorable?

Is the position of the buds of theupper and lower 3rd molars surgicallyaccessible without risk?

Is the quality of the hygiene andthe general state of the dentition ofthe patient satisfactory? If the molarshave been treated earlier or restored,it’s preferable to keep the 3rd molars"in reserve."

CONCLUSION

Late incisor crowding has a multi-factorial origin and the 3rd molarsseem to have limited responsibility.

The indication for prophylactic re-moval is however dependent on theorthodontic technics that are utilized.

Figures 5Observation and palpation of the osteo-muscular-mucous triangle in which the 3rd molar will erupt. Thedisposition of the soft tissues is the determinant for thepossibility or not of the placement of this tooth. Themucosal territory for the eruption of the mandibular 3rdmolar: 1: elongation of the anterior pillar of the palatalveil. 2: buccinators. 3: anterior border of the mandibularramus and tendon of the anterior temporal fascia.

J.-M. SALAGNAC


The lack of room for the 3rd molarsoften appears due to a deficit in thedevelopment of the mandible and themaxilla. Think orthopedics beforethinking orthodontics.

The indication for enucleation ofthe 3rd molars must be thought of ona case by case basis after confirma-tion of the clinical examination andradiographs.

The clinical examination is the de-termining factor.

The different methods for predict-ing the eruption of the 3rd molars arerandom.

It is difficult to predict the risks ofimpaction before the age of 14-15years, therefore there are no indica-tions (without exception) for enuclea-

tion or of extraction before this ageand never before the complete erup-tion of the 2nd molars.

All the 3rd molars cannot erupt nor-mally, some will have to be ex-tracted, but orthodontists mustrethink their indication pre- per- andpost-orthodontics for enucleations orprophylactic extractions. Many ofthese indications are not medically

justified during this period.But it is the duty of the orthodon-

tist to verify clinically and radiographi-cally whether or not the 3rd molarsare properly positioned in the arches.

BIBLIOGRAPHY

1. ANAES. Indications et non-indications de l’avulsion des 3es molaires mandibulaires,1997.

2. Bassigny F. Conservons les dents de sagesse. Le Concours medical 1983;17-12;105-47.

3. Begtrup A, Gronastoo H, Christiensen J, Kjaer I. Prediction de l’eruption des 3es

molaires inferieures sur panoramique, apres comparaison entre panoramique etteleradiographie de profil. Eur J Orthod 2013;35:460-466.

4. Bertrand G, et al. La dent de sagesse. Question mise en discussion. OrthodontieFrançaise 1989;V 60-T1:375.

5. Charron M.C. Y a-t-il une relation entre l’encombrement incisivo-canin et l’eruption dela 3e molaire ? Orthodontie Française 1977;48-T1:217.

6. Croquet M, Delachapelle C. Determination cephalometrique de la situation intra-osseuse et du mouvement ontogenique de la 3e molaire inferieure. OrthodontieFrançaise 1978;49-T2:753.

7. Fraudet J.R. La dent de sagesse et l’encombrement anterieur. Le concours medical05-05-1984;106-108.

8. Horn A, Vaugeois M, Schneck G. Indication de la germectomie de la dent de sagesseen ODF. Orthodontie Française 1978;49-T1:543-553.

9. Izard G. Orthodontie. 3e edition. 1950:86.10. Jacquemart P, Diart T. Conserver ou extraire les dents de sagesse. Information

dentaire juin 2005;25.

Conflicts of interest: The author declares noconflict of interest.




11. Jacquemart P. « SOS dents de sagesse », Le point, 16 novembre 2006.12. Kerbrat J.B. « Faut-il enlever mes dents de sagesse ? » Ouest France, novembre

2013.13. Le Rondeau JC, Schnirer MC, Verdier L, Scheffer P. La germectomie des dents de

sagesse est-elle utile en orthodontie. Rev Stomaltol Chir Maxillo Fac 1991;82(2):132-135.

14. Lindqvist B, Thilander B Extraction of third molars in cases of anticipated crowding inthe lower jaw. Am J Orthod 1982;81(2):130-139.

15. Richardson ER, Malhotra SK, Semenya D. Longitudinal study of three views ofmandibular eruption in males. Am J Orthod 1984;86(2):119-129.

16. Ricketts RM. Prediction of lower third molar impaction. Data bits n� 4 Rocky moun-tain data system.

17. Salagnac JM. L’etude dento-squelettique dans l’analyse architecturale et structuralede J. Delaire. Rev Stomato Chir MaxilloFac 1987;88(1):48-55.

J.-M. SALAGNAC


Documents

Is the recommendation for the enucleation or the … is for French practitioners, dentists and stomatologists and for all sectors of public health. 1977 Charron, M.C.5 (‘‘Is there