Int. J. Oral Surg.

1985: 14: 29-40

(Key words : impaction; defects, intrabony; surgery. oral; healing, periodontal; molar, third)

Periodontal healing after impacted lower third molar surgery

A retrospective study
CARL F. KUGELBERG, ULF AHLSTR<JM, SUNE ERICSON AND ANDERS HUGOSON
Departments of Oral Surgery, Dental Radiology and Periodontology, the Institute for Postgraduate Dental Education, Jdnkoping, Sweden

ABSTRACT - The effect on periodontal tissues of lower third molar surgery, due to impaction or semi-impaction, has been investigated in a retrospective study comprising 215 cases. The post-operative examination took place 2 years after the surgical treatment and included both clinical and radiographic variables. Clinical registrations included the amount of plaque , and presence of gingivitis and periodontal pockets. The results showed a higher incidence of plaque, gingivitis and pockets on the distal surface of the second molar than on other surfaces of the first and second molars. The alveolar bone level distal to the second molar was registered by radiographic examination with a periodontal probe as indicator. 2 years post-operatively, 43.3% of the cases exhibited pocket depths exceeding 7 mm and 32.1 % showed intrabony defects exceeding 4 mm. Some factors affecting the periodontal healing after lower third molar surgery are discussed.

(Received for publication 23 September 1983, accepted 8 February 1984)

Surgical removal of impacted third molars is by far the most common oral surgical procedure. The diagnosis and treatment have often been cited as special problems for the oral surgeon and orthodontist as periodontal considerations have received comparatively little attention. A large number of investigations concerning the third molar have been presented, most of them dealing with the prevalence and classification of impaction, different surgical techniques for its removal, and preand post-operative symptomst-xs

However, there is relatively little information concerning the effect of impaction surgery on the periodontal health of the adjacent second molar 2 . 3 . 2 1 . The authors have mostly concentrated their interest on the surgical technique itself as the main cause of gain or loss of supporting tissues postoperatively. SZMYD & HESTER 29 found a small but significant reduction of crevicular depth distal to the second molar irrespective of whether a high-speed bur or mallet and chisel were used. The results of a pilot study by GROVES & MOORE 9 indicated that flap

30

KUGELBERG, AHLSTROM, ERICSON AND HUGOSON

design had no influence on bone loss distal to the second molar, but could be associated with a decrease in distal pocketing. Other authors 4 6 3 1 also suggested that flap design might have an effect on future periodontal conditions, but studies by STEPHBNS 2 8 and WOOLF et al. 30 indicated that the decision to use any of the various flap designs for access to mandibular third molars should be based on operator preference rather than on the assumption that the periodontal health of the adjacent second molar will be improved. Some authors have studied other factors affecting the periodontal healing. ASH et al.4 found that periodontal hazards involved in extracting third molars were reduced, and reformation of the alveolar bone crest was enhanced, in young individuals in whom the roots of the third molars were not completely developed. ZlEGLER 3 1 has confirmed the results of ASH et al.4 in a similar study . GRONDAHL & LEKHOLM 10 observed a reduction in pocket depth 12 months after surgical removal of lower third molars, but no significant change in the height of the supporting bone distal to the second molar. The lack of sufficient statistical evidence on hazards of lower third molar surgery results in confusion among clinicians because benefit-risk ratios are estimated from clinical impressions only. The NIH sympo-

sium on Third Molars in 19791 9 recommended that both short- and long-term studies be undertaken in a number of areas related to periodontal considerations. The aim of this investigation was to make a retrospective survey of the periodontal healing of the adjacent second molar 2 years after impacted lower third molar surgery.

Material and methods

The study comprised 144 patients referred to the Department of Oral Surgery of the Institute for Postgraduate Dental Education, Jonkoping, Sweden, for removal of 215 mandibular third molars . The impaction surgery was performed during a l-year period in 1978. All patients fulfilled the following criteria: 1. Preoperative history. 2. Radiographic examination including panoramic radiography, posteroanterior cephalometric radiographs with the mouth open, and at least 2 intra-oral X-ray films. 3. Patient willing to participate and recall practicable. Of the 144 persons (age range 16 to 53 years) participating in this study, 73 had one third molar removed and 71 had two third molars removed. No discrepancy existed in the age and sex distribution between those who had one or two molars removed . The distribution concerning angulation and degree of impaction was also equal. Of a total of 215 third molars, 112 molars were from males and 103 were from females (Table 1).

Table 1. Distribution of the 215 molars according to age and sex of the patients Age-group (years) .s;20 21-25 26--30 31-35 >35 Total mean (years) S.D . Male

n (%)
14 (12.5) 30 (26.8) 41 (36.6) 16 (14.3) 11 (9.8) 112 (100.0) 27.4 6.33

Female n (%) 16 (15.5) 30 (29.2) 23 (22.3) 24 (23.3) 10 (9.7) 103 (100.0) 27.0 6.41

Total n (%) 30 (14.0) 60 (27.9) 64 (29.8) 40 (18.6) 21 (9.8) 215 (100.0) 27.2 6.35

PERIODONTAL HEALING AND THIRD MOLARS

Pre-operative examination Both the extra-oral and intra-oral radiographs were taken in a standardised way. Philips Oralix 65 and long-cone technique was used for the intra-oral examination. The intra-oral films were exposed in 2 different projections, isometric and slight over-axial, with the central beam pointed at the centre of the second molar and a focal-object distance of 20 em. The films were processed in a standardised manner in a developing machine. From the radiographs, the state of the alveolar crest and the prevalence of intrabony defects were estimated. Operation technique All the patients were treated under aseptic conditions using local anaesthesia (Xylocainew Adrenaline 20 mg/ml, ASTRA; adrenaline 12.5 t1g/ml). The design of the soft tissue flap was either the classical vertical flap or the envelope flap. Ostectomy and sectioning were performed with a low-speed rotary instrument under constant irri-

31

gation with sterile saline. After removal of the tooth, careful toilet of the extraction socket was performed, including removal of follicular remnants and granulation tissue, and also thorough saline lavage. Finally, the flap was repositioned and sutured. After 1 week, the patient returned either to the Department of Oral Surgery or to the referring dentist for control and removal of sutures. No further steps were taken (e.g., increased oral hygiene etc.) to improve the healing.
Post-operative examination The post-operative examination took place 2 years after the surgical treatment and included both clinical and radiographic variables. All examinations were made by the same investigator (CK). For the clinical and radiographic determinations, certain landmarks were used (Fig. 1). The distance AC was defined as the pocket depth. The distance BD represented the intrabony defect, i.e., the post-operatively remaining intra-osseous defect. The clinical recordings were carried out on the first and second molars adjacent to the extraction site. They comprised registration of dental plaque, gingival health and probing depth for all tooth surfaces. The presence of visibleplaque was recorded and corresponded to Plaque Index (PU) 2 and 3 (SILNESS & LOB 26) . The occurrence of gingival inflammation was recorded according to Gingival Index (Gl) 2 and 3 (LOE & SILNESS 1 7) , i.e., moderate changes in texture and colour and/or bleeding on probing. Pockets exceeding 3 mm were recorded with a periodontal probe (Marquise), Measurements were made from the free gingival margin to the bottom of the pocket to the nearest mm. As a complement to probing pocket depth, radiographs were taken to evaluate the bone level and the prevalence and depth of intrabony defects. The radiographic recordings were performed in the same way as at the pre-operative examination. A periodontal probe (Marquis") with the handle cut-off served as an indicator, and was placed at the bottom of the pocket distal to the second molar. The final positioning of the probe was not assessed until the probe had been placed along the entire distal surface to reach the deepest part. Intra-oral X-ray films were then taken, first with and then without the indicator (Fig. 2). All the measurements on the radiographs were performed by the examiner at the end of the study. The radiographic material was studied

Fig. 1. Landmarks used for clinical and radiographic measurements. (A) indicates the free gingival margin, (B) the cementa-enamel junction, (C) the bottom of the pocket, and (D) the alveolar crest.

32

KUGELBERG. AHLSTROM, ERICSON AND HUGOSON

Examination of the first molar was performed to check whether any changes had occurred other than those due to impaction surgery, such as marginal periodontitis during the follow-up period. The effect of removal of the lower third molar was evaluated by comparing the preoperative and post-operative recordings of the clinical and radiographic variables used.
Statistical methods For related samples where measurements were made on an ordinal scale, the sign test was used for statistical analysis. When the data consisted of frequencies in discrete categories, the X2 test was used to determine the significance of differences between 2 independent samples. An analysis of variance, concerning pocket depths and intrabony defects, showed that there did not exist any dependence between the two operations in the same patient. Each removal was therefore regarded as a single observation.

Results
The results are presented in Tables 2-10. Of the 215 surgical removals of lower third molars, post-operative control was made by the referring dentist in 101 cases and by the Department of Oral Surgery in 114 cases. Of the latter 114 cases, 30.7% were treated on 2 or 3 further occasions because of post-operative symptoms of varying severity.

Fig . 2. Periapical radiographs of the second molar

2 years after lower third molar surgery with (A) and without (B) a periodontal probe as indicator. Patient : female, 29 years of age.

observation binoculars according to The proximal bone level was determined according to BJORN & HOLMBERG 5 . A transparent plastic ruler with 10 equidistant divisions was placed over the radiograph to estimate the bone level in tenths of the total length of the tooth. The measurements were recorded in increments of half a division and multiplied by 10. The depth of the intrabony defect was obtained by measuring the distance between the cementoenamel junction and the bottom of the pocket, distance BD in Fig. 1, with the aid of a mmgraduated transparent plastic ruler. The inaccuracy of the radiographic methods and the imprecision of the measurements were analysed and are presented in a separate report'" . The results showed that the error variances due to examiner inconsistency were between 3% and 4% of the total variances and therefore contributed an insignificant amount.
MATTSSON 18.

using

Plaque Index, Gingival Index, and probing depth

The results of the plaque registrations 2 years post-operatively are presented in Table 2. The distal and lingual surfaces of the first and second molars showed higher plaque scores than the other surfaces. 16.7% of the lingual surfaces of the first molar, 36.3% of the lingual surfaces of the second molar and 25.6% of the distal surfaces of the second molar showed a Plaque Index score of 2 and/or 3, respectively. The distal surface of the second molar showed a significantly higher plaque score than the corresponding surface of the first molar ip : 0.001).37.5% of these surfaces in males

PERIODONTAL HEALING AND THIRD MOLARS Table 2. Plaque Index on first and second molar 2 years post-operatively PLI
n=215

33

Table 3. Gingival Index on first and second molar 2 years post-operatively GI

n=215

0-1 n (%) 210 (97.7) 211 (98.1) 204 (94.9) 179 (83.3) 207 (96.3) 199 (92.6) 160 (74.4) 137 (63.7)

2-3
n (%)

0-1
n (%)

2-3
n (%)

1st molar mesial buccal distal lingual 2nd molar mesial buccal distal lingual

5 (2.3) 4 (1.9) 11 (5.1) 36 (16.7) 8 (3.7) 16 (7.4) 55 (25.6) 78 (36.3)

1st molar mesial buccal distal lingual 2nd molar mesial buccal distal lingual

186 (86.5) 209 (97.2) 177 (82.3) 201 (93.5) 163 (75.8) 202 (94.0) 172 (80.0) 197 (91.6)

29 (13.5) 6 (2.8) 38(17.7) 14 (6.5) 52 (24.2) 13 (6.0) 43 (20.0) 18 (8.4)

lst versus 2nd molar (distal); p < 0.001.

1st versus 2nd molar (distal) NS.

showed a PLI score of 2-3. The corresponding figure for females was 12.6%. The difference is statistically significant (p < 0.001). As shown in Table 3, all the proximal surfaces showed a higher frequency of gingivitis than the buccal and lingual surfaces. The difference between the distal surface of the first and second molar was not statistically significant. 22.3% of these surfaces in males showed a GI score of 2-3. The corresponding figure for females was 17.5%. The

difference between males and females is not statistically significant. As shown in Table 4, a higher incidence of deepened pockets was found on the distal surface of the second molar compared to the same surface of the first molar. The difference is statistically significant (p < 0.00 1). In 93 cases (43.3%), the probing depth on this surface was 7 mm or more. 53.6% of the surfaces in males and 32.0% in females exhibited pockets of 7 mm or deeper (Table

Table 4. Pocket depths (PD) on first and second molars 2 years post-operatively PD (mm)
n=215
~4

5-6
n (%)

n (%)

7-8 n (%)

~9

n (%)

1st molar mesial buccal distal lingual 2nd molar mesial buccal distal lingual

211 (98.1) 213 (99.0) 205 (95.3) 207 (96.2) 206 (95.8) 173 (80.4) 16 (7.4) 196 (91.2)

4 (1.9) 2 (1.0) 9 (4.2) 8 (3.8) 9 (4.2) 39(18.1) 106 (49.3) 18 (8.3)

1 (0.5)

2 (1.0) 70 (32.6) 1 (0.5)

1 (0.5) 23 (10.7)

1st versus 2nd molar (distal) p < 0.001.

34

KUGELBERG, AHLSTROM, ERICSON AND HUGOSON

Table 5. Distribution of pocket depth (PD) on the distal surface of the second molar in males and females
::;4

5-6

PD (mm) males females

n (%)
3 (2.7) 13 (12.6)

n (%)
49 (43.7) 57 (55.3)

7-8 n (%) 46 (41.1) 24 (23.3)

~9

Total

n (%)
14 (12.5) 9 (8.7)

n
112 103

Males versus females; p '" 0.0 I.

5). This difference is statistically significant (p<0.01).

Alveolar bone level The results of registration of the alveolar bone level are presented in Tables 6 and 7. The results are grouped into 2 intervals, comprising 70-41 % and S; 40% of the total length of the tooth. The height of the alveolar crest was normal or reduced by one-third of the root length in the interval 70-41. In the interval 0-40, the bone level was reduced by half or more. The height of the alveolar crest on the mesial surface of the second molar did not change between the 2 examinations - before and 2 years after surgery (Table 6); nor was there any difference between the sexes. The alveolar bone level on the distal surface of
Table 6. Bone level (BL), as % of the total length of the tooth, on the mesial surface of the second molar pre-operatively and 2 years postoperatively BL (%) Mesial surface 70-41 ::;40 Total

the second molar is presented in Table 7. Pre-operatively, 27.4% and 2 years postoperatively 16.3% of the cases were registered within the interval 0-40, corresponding to a reduction of the height of the alveolar crest by half of the root length or more. The males had a significantly lower bone height pre-operatively than the females (p<0.01). The difference was not statistically significant 2 years post-operatively.
Intrabony dejects The results of the registrations of intrabony defects are presented in Tables 8-10. The values are grouped into 4 classes according to the depth of intrabony defects: equal to

Table 7. Bone level (BL), as % of the total length of the tooth, on the distal surface of the second molar pre-operatively and 2 years postoperatively BL (%) Distal surface pre-op. males females total post-op. males females total 70-41 ::;40 Total

n (%)
69 (61.6) 87 (84.5) 156 (72.6) 89 (79.5) 91 (88.3) 180 (83.7)

n (%)
43 (38.4) 16 (15.5) 59 (27.4) 23 (20.5) 12(11.7) 35 (16.3)

n
112 103 215

n (%)
112 (100.0) 103 (100.0) 215 (100.0) 112 (100.0) 102 (99.0) 214 (99.5)

n (%)

n
112 103 215

pre-op. males females total post-op, males females total

1 (1.0) I (0.5)

112 103 215

112 103 215

Males versus females pre-op.; p '" 0.01. Males versus females post-op.; NS.

PERIODONTAL HEALING AND THIRD MOLARS

35

Table 8. Intrabony defects (IBD) on the distal surface of the second molar pre-operatively and 2 years
post-operatively IBD (rom)

53 n (%) 49 (43.8) 76 (73.8) 125 (58.1) 64(57.1) 82 (79.6) 146 (67.9)

4--5 n (%) 29 (25.9) 17(16.5) 46 (21.4) 32 (28.6) 16 (15.5) 48 (22.3)

6-7 n (%) 26 (23.2) 9 (8.7) 35 (16.3) 13 (11.6) 2 (1.9) 15 (7.0)

;;::8 n (%) 8 (7.1) 1 (1.0) 9 (4.2) 3 (2.7) 3 (2.9) 6 (2.8)

Total n 112 103 215 112 103 215

pre-op. males females total

post-op,

males females total

Males versus females pre-op.; P< 0.001. Males versus females post-op.; p< 0.001. Pre-op, versus post-op., total; p < 0.001.

or less than 3 rom, 4-5 mm, 6-7 mm, and equal to or exceeding 8 mm, As Table 8 shows, intrabony defects ~4 mm were present pre-operatively in 41.9%. The corresponding figure 2 years postoperatively was 32.1 %. Thus, almost of the total material showed defects equal to or deeper than 4 mm postoperatively. The distribution of defects ~ 4 rom between men and women was similar pre- and postoperatively. 70% of the intrabony defects were found among men and 30% among women. A cross-tabulation of intrabony defects pre-operatively and 2 years post-operatively is presented in Table 9. Pre-operatively, 90 cases exhibited intrabony defects ;::; 4 rom. Of these defects, 49 showed a decrease in depth, and 41 remained unchanged or increased in depth post-operatively. Of a total of 125 cases with preoperative intrabony defects S 3 mm, 112 showed defects within this limit and 13 showed defects ;::; 4 rom 2 years post-operatively. Among the former 112 cases, an increase in depth of the intrabony defect was registered in 46 cases, no change in 53 cases and a decrease in 13 cases.

Table 10 shows the prevalence and depth of intrabony defects at different ages at the time of the surgical treatment pre-operatively and 2 years post-operatively. Of a total number of 90 cases aged 25 years or younger, 34 (37.8%) showed intrabony defects ;::; 4 mm pre-operatively. The corresponding figure 2 years post-operativelywas 18 (20.0%). Of a total number of 125 cases aged 26 years or older, 56 (44.8%) showed pre-operative defects ~ 4 mm, and 51 (40.8%) showed defects ~4 mm 2 years post-operatively.

Table 9. Cross-tabulation of intrabony defects (IBD) on the distal surface of the second molar pre-operatively and 2 years post-operatively Post-operatively IBD (rom)

s3

4-5 9 26
10

6-7 I 2 10 2 IS

2: 8

Total 125 46 35 9 215

Pre-operatively 112 53 4-5 18 13 6-7 3 ~8 Total 146

3
2 I

3
48

36

KUGELBERG, AHLSTRl>M, ERICSON AND HUGOSON

Table 10. Intrabony defects (IBD) on the distal surface of the second molar pre-operatively and 2 years post-operatively in relation to age IBD (mm) Age (years) pre-op. s20 21-25 26-30 31-35 >35 post-op, .:;;;20 21-25 26-30 31-35 >35 s3 4-5 6-7
~8

Total

n (%)
17 (56.7) 39 (65.0) 35 (54.7) 25 (62.5) 9 (42.9)

n (%)
8 (26.7) 11 (18.4) 14 (21.9) 9 (22.5) 4 (19.0)

n (%)
5 (16.6) 8 (13.3) 12 (18.7) 3 (7.5) 7 (33.3)

n (%)

n
30 60 64 40 21

2 (3.3) 3 (4.7) 3 (7.5) 1 (4.8)

25 47 39 28 7

(83.4) (78.3) (61.0) (70.0) (33.3)

4 (13.3) 10 (16.7) 15 (23.4) 11 (27.5) 8 (38.1)

1 (3.3) 3 (5.0) 5 (7.8) I (2.5) 5 (23.8)

5 (7.8) 1 (4.8)

30 60 64 40 21

Fig. 3. Periapical radiographs of the third molar region. Pre-operatively (A) and 2 years post-

operatively (B). Patients: male aged 36 years (left) and male aged 20 years (right).

PERIODONTAL HEALING AND THIRD MOLARS

37

Discussion
The age and sex distribution in the 144 patients taking part in this retrospective study were typical of those of a clientele referred to a specialist clinic in Sweden for surgical removal of impacted lower third molars. The pre- and post-operative measurements of periodontal healing were mainly based on radiographic registrations, as probing depth measured from the gingival margin seldom corresponds to sulcus or pocket depth. The discrepancy is least in the absence of inflammatory changes but increases with increasing degrees of gingival inflammation. Decreased probing depth measurements following periodontal thera-

py may be due to decreased penetrability of the gingival tissues by the probe!". The results of this study of the effect of lower third molar surgery on periodontal healing of the adjacent second molar show a high rate of remaining deepened pockets and intrabony defects. Thus, 43.3% of the patients demonstrated probing depths ~ 7 mm, and 32.1% showed intrabony defects ~ 4 mID 2 years post-operatively. In apparently similar pre-operative circumstances, third molar removal sometimes resulted in large post-operative intrabony defects and sometimes not (Fig. 3). The defects could be either fairly wide or very narrow (Fig. 4). As a rule, the males showed a higher incidence of plaque and gingivitis at the distal surface of the second molar than the

Fig. 4. Periapical radiographs of the third molar region. Pre-operatively (A) and 2 years post-

operatively (B). Patients: male aged 21 years (left) andmale aged 20 years (right).

38

KUGELBERG, AHLSTROM, ERICSON AND HUGOSON

females. There was also a male dominance concerning deepened pockets (~7 mm). Of the cases with deep probing defects, just over 20% showed pseudopockets, while the rest demonstrated intra-osseous defects corresponding to the probing depth. Healing of intrabony defects after different types of periodontal surgery has been presented by ADELL 1, ELLEGARD & LOEB, POLSON & HBIJL 24 and ROSLING 25. All of these investigators point out the conditions for regeneration, viz. optimal treatment of the root surface and the adjacent soft tissue, followed by meticulous post-operative plaque control. The post-operative plaque scores indicate that the level of plaque control on the distal surface of the second molar of most of the participants was not optimal. Only a few of the patients were plaque-free on this surface. With extreme emphasis on plaque contro124.2s, and continuously plaque-free teeth, improved healing might have been accomplished, but in this study, the participants had not been subjected to increased oral hygiene or special surgical procedures in an attempt to improve healing. Both GROVES & MOORE 9 and SZMYD & HESTER 29 demonstrated post-operative reo duction in pocketing, which is in agreement with the findings of GRONDAHL & LEKHOLM10. One of the explanations could be that these authors studied younger individuals, with a mean age of 23-24 years, while this study comprised patients aged around 27 years. However, in agreement with this study, ASH et al." and ZIEGLER 3 1 found a high incidence of pocketing distal to the second molar both pre- and postoperatively. The results of a study by OsBORNE et al. 2 3 support the finding of ASH et al:" that root planing of adjacent second molars seemed to be of minimal value in reducing crevicular depth or in inducing new attachment at or near original levels. In cases where the root cement has not been

exposed to microbial influence from the dental plaque, wound healing seems to occur without loss of tissues, and with restitutio ad integrum as the final result 27. But in cases with marginal periodontitis, the possibilities of complete regeneration of the tissues are entirely different. Phenomena which may jeopardise new connective tissue attachment to root surfaces are apical migration of junctional epithelium with the establishment of long epithelial attachment, and regrowth of subgingival plaque with resulting chronic inflammationll.16.27. In a recent study, NYMAN et al. 2 2 demonstrated that cement formation and new connective tissue attachment did not occur on root surfaces previously exposed to periodontal pockets and subsequently to scaling and root planing, or on root surfaces surgically deprived of their supporting bone and previously unexposed cement layer. The new attachment between the gingiva and the root was established by epithelium. These are all factors to consider in cases of impacted lower third molar surgery, where intrabony defects, due to the tooth's relation to the adjacent second molar, often seem to occur. Since specific types of bacteria seem to be associated with periodontal disease, the intrabony defects observed in this study may very well be explained by the establishment of a particular pathogen flora 15. 2o. As the distal surface of the second molar always seems to show a higher plaque score than other surfaces, it might be a locus minoris for development of local periodontitis. The least traumatic way to remove an impacted or semi-impacted tooth is by reflecting a flap, removing bone and dividing the tooth into sections. Careful use of elevators and forceps is just as important as judicious ostectomy in preservation of the alveolar bone crest. In this study, the removal of bone was performed under a generous flow of saline to minimise the risk of

PERIODONTAL HEALING AND THIRD MOLARS devitalising the bone by heat, as all devitalised bone is resorbed or sequestered. In spite of this precaution, loss of interproximal bone distal to the adjacent second molar was found in over 40% of 112 cases which pre-operatively exhibited intrabony defects ::; 3 mm (Table 9). This figure must be considered a result of the surgical technique, where one, or more likely several, of the above-mentioned factors have to some extent affected the bone loss. GROVES & MOORE 9 demonstrated bone loss in about 25 % of cases irrespective of the flap design. The same incidence was found whether the lower third molar was nonerupted or erupted at the time of extraction. They also postulated that third molar removal may prevent further deterioration of the periodontal health of the adjacent second molar. Some authors 10 ,2 3 have found that extraction of the third molar does not appear to cause any change in the height of the supporting bone distal to the second molar, while ASH et al." and ZIEGLER 3 1, in agreement with this study, clearly demonstrated the presence of post-operative intrabony defects. In an unspecified group of elderly patients with third molars, GRON10 DAHL & LEKHOLM occasionally found a marked reduction of the supporting bony tissue at the distal surface of the second molar. Although ASH et al.4 only followed 86 of the original 225 cases for 2 years, they found, in agreement with this study, that after the early twenties the risk of loss of periodontal support of second molars seemed to be significantly greater after extraction of adjacent third molars than when they were retained. The National Institutes of Health Consensus Conference on Third Molars-? stated that third molars should be removed in the younger patient where indicated because there is less transitory or permanent morbidity. Table 10 emphasises this, as in the younger group there was an almost 50%

39

reduction in the number of pathological intrabony defects, while only a few % showed complete periodontal healing in the older group. These results suggest that in cases where the need for extraction can be forseen, early removal of the third molar might have a beneficial effect on the periodontal health of the adjacent second molar. ZIEGLER 3 1 found that there was no attachment loss I year after removal of impacted third molars in 15 patients aged 13-16 years. Pocket formation and intrabony defects occurred most frequently and were most severe when the crown of the third molar was in close approximation to, or apparent contact with, the second molar. Similar findings have been noted by other authors 4 ,6 ,3 1 . The size of the contact area seemed to be well correlated to the inclination of the third molar. To elucidate the significance of conceivable factors in relation to the ultimate healing after lower third molar surgery, 71 variables have been computerised for multiple and stepwise analysis of regression and the results will be presented in a subsequent study.
Acknowledgements - The authors would like to thank Dr. Rolf Karlsson for assistance with statisticalanalysis. Thisstudy has been supported by the Swedish Dental Society and the County Council of Jonkoping,

References
1. ADELL, R.: Regeneration of the periodont-

ium. An experimental study in dogs. Thesis. Gothenburg, Sweden. Scand. J. Plastic and Reconstr. Surg., 1974: suppl. 11. 2. App, G. R. & STEPHENS, R. J.: Periodontal considerations and the impacted tooth. Dent.
Clin. North Am. 1979: 23: 359-367. 3. ASH, M.: Third .molars as periodontal problems. Dent. cu North Am. 1964: 18: 51-61.
4. ASH, M., COSTICH, E. R. & HAYWARD, R.: A

study of periodontalhazards of third molars.

J. Periodontol. 1962: 33: 209-219.

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KUGELBERG, AHLSTRL>M, ERICSON AND HUGOSON 20. NIELSEN, I. M., GLAVIND, L. & KARRING, T.: Interproximal periodontal intrabony defects. J. Clin. Periodontol. 1980: 7: 187-198. 21. NITZAN, D., KEREN, T. & MARMARY, Y.: Does an impacted tooth cause root resorption of the adjacent one? Oral Surg. 1981: 51: 221224. 22. NYMAN, S., LINDHE, J. & KARRING, T.: Healing following surgical treatment and root demineralization in monkeys with periodontal disease. J. Clin. Periodontol. 1981: 8: 249258. 23. OSBORNE, W. H., SNYDER, A. J. & TEMPEL, T. R.: Attachment levels and crevicular depth at the distal of mandibular second molars following removal of adjacent third molars. J. Periodontol. 1982: 53: 93-95. 24. POLSON, A. M. & HElJL, L. C.: Osseous repair in infrabony periodontal defects. J. Clin. Periodontal. 1978: 5: 13-23. 25. ROSLING, B.: Plaque control. A determining

5. BJORN, H. & HOLMBERG, K.: Radiographic determination of periodontal bone destruction in epidemiological research. Odontol. Revy 1966: 17: 232-250. 6. COSTICH, E. R.: The role of oral surgery in preventive dentistry. Dent. Clin. North Am. 1965: 19: 475--483. 7. DENTAL CLINICS OF NORTH AMERICA, The. July, 1979: 23 no. 3. 8. ELLEGARD, B. & LOE, H.: New attachment of periodontal tissues after treatment of intrabony lesions. J. Periodontol. 1971: 42: 648652. 9. GROVES, B. J. & MOORE, J. R.: The periodontal implications of flap. design in lower third molar extractions. Dent. Pract. Dent. Rec. 1970: 20: 297-304. 10. GRONDAHL, H. G. & LEKHOLM, U.: Influence of mandibular third molars on related supporting tissues. Int. J. Oral Surg. 1973: 2: 137142. 11. KARRING, T., NYMAN, S. & LINDHE, J.: Healing following implantation of periodontitis affected roots into bone tissue. J. Clin. Periodontol. 1980: 7: 96-105. 12. KILLEY, H. C. & KAY, L. W.: The impacted wisdom tooth. Churchill Livingstone, Edinburgh, London and New York 1975. 13. KUGELBERG, C. F., AHLSTROM, U., ERICSON, S. & HUGOSON, A.: Periodontal healing after lower third molar surgery. Imprecision and inaccuracy in radiographic determination of intrabony defects. In manuscript form. 14. LISTGARTEN, M. A.: Periodontal probing: what does it mean? J. Clin. Periodontol. 1980: 7: 165-176. 15. LISTGARTEN, M. A. & HELLDEN, L.: Relative distribution of bacteria at clinically healthy and periodontally diseased sites in humans. J. Clin. Periodontal. 1978: 5: 115-132. 16. LISTGARTEN, M. A. & ROSENBERG, M. M.: Histological study of repair following new attachment procedures in human periodontal lesions. J. Periodontal. 1979: 50: 333-344. 17. LClE, H. & SILNESS, J.: Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol. Scand. 1963: 21: 533-551. 18. MATTSSON, 0.: A magnifying viewer for photofluorographic films. Acta Radiol. 1953: 39: 412-414. 19. NATIONAL INSTITUTES OF HEALTH Consensus development conference for removal of third molars. J. Oral Surg, 1980: 38: 235-236.

factor in the treatment of periodontal disease.

Thesis. Gothenburg, Sweden 1976. 26. SILNESS, J. & LOE, H.: Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condition. Acta Odontol. Scand. 1964: 22: 121-135. 27. STAHL, S. S.: Gingival repair potential. J. Oral Med. 1976: 31: 104--110. 28. STEPHENS, R. J.: A periodontal evaluation of

two types of mucoperiosteal flaps used for access in removing impacted third molars. M.
S. thesis. Columbus, Ohio, USA 1977. 29. SZMYD, L. & HESTER, W. R.: Crevicular depth of the second molar in impacted third molar surgery. J. Oral Surg. 1963: 21: 185-189. 30. WOOLF, R. H., MALMQUIST, J. P. & WRIGHT, W. H.: Third molar extractions: periodontal implication of two flap designs. Gen. Dent. 1978: 26: 52-56. 31. ZIEGLER, R. S.: Preventive dentistry - new concepts: preventing periodontal pockets. Va. Dent. J. 1975: 52: 11-13.

Address:

Carl F. Kugelberg The Institute for Postgraduate Dental Education Box 1030 S-551 11 Jiinkiiping' Sweden