Sir, the debate over the NICE guidelines and deliberations on management of unerupted asymptomatic wisdom teeth is set to continue.1We would like to present an unusual case of bilateral pathological migration of wisdom teeth which remained unnoticed till an acute presentation and eventually required complex surgery.
A 55-year-old gentleman presented to A&E with a large left submandibular and sub masseteric space abscess, secondary to an unerupted lower left wisdom tooth and a radiographically illustrated radiolucent tract. He had previously asymptomatic bilaterally impacted lower wisdom teeth, radiographic evidence showed that the lower wisdom teeth had migrated (Fig. 1). He underwent emergency surgery with extraoral incision and drainage of the abscess under general anaesthetic for the acute presentation. Further imaging (CTv scan) was carried out to plan for the elective surgical removal of the deeply impacted 38.
The patient was advised to have the lower wisdom teeth electively removed but declined removal of the lower right wisdom tooth. We discussed the options of an intraoral approach +/- sagittal split osteotomy to gain access to the tooth or an extraoral approach utilising the pre-existing scar. Clinically, there was no evidence of a communication intraorally from the unerupted lower third molar (no sinus tract on probing). The extra-oral approach was preferred due to the pre-existing scar and improved direct access. The lower left wisdom tooth was removed and the patient made a satisfactory recovery with no complications. The patient and his general dental practitioner were advised regarding the importance of clinical and radiological monitoring of the lower right wisdom tooth on a regular basis.
Pathological migration is an abnormal change in the position of a tooth within the dental arch. There are many aetiological factors associated with this phenomenon, but the exact cause is often difficult to diagnose.2We cannot assertively predict what the future holds for asymptomatic, disease-free teeth.We now see patients returning later in life, with more medical comorbidities for third molar surgery with more advanced wisdom tooth pathology.3 Perhaps it is time to alert the readership to insidious pathology in unerupted wisdom teeth in a patient population in their third, fourth and fifth decades. Moreover, the message to the GDP should be that symptom free does not equal disease free. A comprehensive assessment of wisdom teeth should include adequate and appropriate radiographs at regular intervals.
Renton T. National Institute for Health and Care Excellence Guidance Executive: Review of TA1; Guidance on the extraction of wisdom teeth. Faculty of Dental Surgery response. 2014. Available at: https://www.rcseng.ac.uk/-/media/files/rcs/fds/media-gov/nice-review-of-guidance-on-wisdom-teeth-extraction-fds-response-with-appendices.pdf (accessed February 2020).
Francis P O, Fowler E B, Willard C C. Migrating third molar: a report of a case. Mil Med 2003; 168: 802-806.
Petrosyan V, Ameerally P. Changes in demographics of patients undergoing third molar surgery in a hospital setting between 1994 and 2012 and the influence of the national institute for health and care excellence guidelines. J Oral Maxillofac Surg 2014; 72: 254-258.
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Aristotelous, C., Ryatt, M. & Majumdar, A. Migrating third molar . Br Dent J 228, 228 (2020). https://doi.org/10.1038/s41415-020-1323-2