Third molar extractions are a routine yet often daunting procedure, particularly for new dental graduates with limited surgical experience. While these extractions are common, they present varying levels of complexity that require careful consideration of risk factors and a structured approach to planning.
For effective treatment planning, it’s crucial to rely on evidence-based guidelines to guide clinical decisions. New graduates often seek mentorship and attend professional development courses to build confidence in handling such procedures. However, this ongoing learning process is essential for all dental practitioners, not just newcomers. Reviewing cases with a mentor can lead to better outcomes by allowing time to evaluate risks and anticipate potential complications. While one CPD course won't turn a general dentist into an oral surgeon, it can help reduce anxiety, enhance decision-making skills, and improve pre-operative risk assessments.
It’s also important for dentists to recognise when a case falls outside their scope of practice. “Difficult” extractions—those that involve complicated anatomy, potential nerve damage, or significant risk of post-operative complications—are best referred to an oral and maxillofacial surgeon (OMFS). Developing strong critical thinking skills is key to recognising when referral is necessary. This ability to assess the complexity of a case and delegate appropriately can take time to develop, often proving more challenging for new graduates than the technical skills required for extraction itself.
That said, dentistry often involves moments where the team is thrown into situations without the luxury of preparation—usually when the schedule is already running behind, and stress is high. In these moments, it’s important to take a step back and assess the situation. Taking time to step out of the operatory, seek advice, or even grab a quick coffee can help reset focus. A short break can improve performance and ensure mental and physical clarity.
Understanding the difference between professional and individual scope of practice is essential when planning third molar extractions. The Australian Dental Association's Professional Competencies of the Newly Qualified Dental Graduate (2022) outlines these distinctions.
Professional scope refers to the broad range of procedures that the dental profession is expected to be capable of performing. This is the "big picture" of what dentists are trained to do across various treatment areas.
Individual scope, on the other hand, is the smaller, more specific range of procedures that you, as an individual dentist, feel competent and comfortable performing. It’s about asking yourself: Can I manage this case, including potential complications, safely and effectively? If something unexpected happens during the procedure, do I have the confidence and resources to handle it, or refer it appropriately to a colleague or specialist? Having a clear understanding of your own limitations and knowing when to call for help is a critical part of providing safe patient care.
How can we evaluate third molar extractions to determine which cases are within our individual scope? Are there tools or guidelines to help identify less complex, lower-risk cases? Recent systematic reviews have highlighted several factors that contribute to increased operative time, which in turn, correlates with higher surgical difficulty. Key elements such as tooth position, root morphology, and proximity to the inferior alveolar nerve can all increase the complexity of the procedure. Understanding these factors can help anticipate the challenges of the case, and ultimately, whether the case should be managed in-house or referred to a specialist. Higher operative time typically signals increased difficulty and a greater risk of complications, reinforcing the importance of thorough case assessment before proceeding.
The following factors contribute to higher operative time, and thus a higher degree of difficulty:
Patient factors:
Overweight (increased BMI)
Older age
Patient anxiety: can influence the difficulty of the procedure and increase the operative time, this was reported in an analysis within a systematic review by Torres et al (2020)
Complex medical history
Operative factors
Surgeons with little experience: one of the major factors mentioned across all reviews by Torres et al (2020) however can be somewhat subjective and difficult to measure
The use of complex surgical techniques requiring tooth sectioning linked to hard tissue impaction
(Adverse) Radiographic factors:
Deep impaction – full bony impaction increases difficulty for the need to first expose the tooth to be extracted compared to a partial or fully erupted tooth. For maxillary teeth, this correlated to near the maxillary sinus and towards the distal aspect of the second molar were associated with increased difficulty
Unfavourable angulation: horizontal or distoangular impaction, and the presence of divergent or bulbous roots and tooth germ increased the surgical difficulty
Root morphology
Close relationship to the IAN
OAC risk
Proximity to second molar (little-no space)
Regardless of a dentist’s ability to perform a particular extraction, the cornerstone of successful third molar management is a thorough clinical diagnostic process. Proper assessment allows the dentist to risk assess the situation and make informed decisions. Even if a general dentist determines that they are unable to carry out the extraction themselves, the key is that they’ve identified the case's complexity. Allowing enough time to plan and manage these more complex situations is vital.
Dentists in remote and rural areas may face this dilemma more often, as they may have limited access to specialists and are sometimes left with the decision to either perform the extraction themselves or refer the patient. In these cases, understanding individual scope of practice becomes even more important. Knowing when to handle a case and when to seek expert help can prevent unnecessary risks for both the dentist and the patient.
To further illustrate, I’ve included several case examples of third molars with varying degrees of difficulty. By applying the knowledge of risk factors discussed above, look at the radiographs and assess what factors might increase operative time or complicate the procedure. Identifying these elements can help guide your clinical decision-making and ensure you’re prepared for what lies ahead.
All photos are my own taken on a CANON EOS 800D with 100mm macro lens with patient consent to share and distribute de-identified.
Case one
28-year-old patient. Minimal invasive surgical extractions with flap elevation for removal of the 48 and 38. Conventional forceps extraction for the 18 and 28. There was minimal bony impaction for the lower 8’s with full coronal access. There was some soft tissue impaction, but this was dealt with surgically.
Case two
58-year-old patient. We planned for a surgical extraction with ample time under nitrous oxide, this extraction took 25 minutes with approx. 10 minutes suturing and managing bleeding. We chose to leave the impacted 38 in situ as it was submerged in alveolar bone and was not bothering the patient. Had the patient requested this tooth to be extracted, I would have referred to an OMFS for assessment.
Case three
Above is an example of a case on a 24-year-old patient where I removed the 18, 28 and 38 third molars, and judging by the degree of bony impaction and proximity to the IAN I chose to refer the 48 to an OMFS.
Case four
32-year-old patient with impacted 38 surgically removed with flap elevation. Although distoangular, there was no bony impaction at the distal and proximity to the IAN was far enough away. I attempted this extraction noting potential complications.
Dr Saskia Salvestro is a dentist based in Wagga Wagga, graduating from Charles Sturt University with multiple Deans Awards. Primarily in private clinical practice Dr Salvestro focuses on providing ethical and evidence based dentistry within her regional community with focus on restorative dentistry, dentofacial aesthetics and oral surgery. Dr Salvestro has been awarded as a fellow of the International Academy of Aesthetics (IAA) and a fellow of the International Academy for Dentofacial Aesthetics (IADFE) in New York. She is completing membership to the Royal Australasian College of Dental Surgeons (MRACDS) and acts as an advisor on the advocacy Committee of the Australian Dental Association (ADA) as well as fulfilling an academic role at Charles Sturt University teaching clinical dentistry to final year dental students.
Reference:
Sánchez-Torres A, Soler-Capdevila J, Ustrell-Barral M, Gay-Escoda C: Patient, radiological, and operative factors associated with surgical difficulty in the extraction of third molars: a systematic review. Int. J. Oral Maxillofac. Surg. 2020; 49: 655–665.
