LETTER TO EDITOR
Aydin Gülses
Department of Oral and Maxillofacial Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
Citation: ACTA ODONTOLOGICA SCANDINAVICA 2026; VOL. 85: 209. DOI: https://doi.org/10.2340/aos.v85.45933.
Copyright: © 2026 The Author(s). Published by MJS Publishing on behalf of Acta Odontologica Scandinavica Society. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, with the condition of proper attribution to the original work.
Received: 6 March 2026; Accepted: 28 March 2026; Published: 29 April 2026.
CONTACT: Prof. Dr. Aydin Gülses aydin.guelses@uksh.de Department of Oral and Maxillofacial Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
Regarding: Noro A, Snäll J, Ventä I. The effect of age on third molar extraction difficulty: a retrospective cross-sectional cohort study. Acta Odontol Scand. 2026 Jan 20;85:33–9. https://doi.org/10.2340/aos.v85.45308
I read with great interest the study by Noro et al., which analyzed 12,649 third molar extractions in Helsinki. The authors report that while surgical extractions and simple maxillary extractions become increasingly demanding with age, mandibular extractions appeared to involve lower technical complexity in older patients [1].
I believe that this observed lower apparent difficulty in mandibular extractions warrants further exploration of underlying anatomical and physiological factors, particularly bone quality. In Northern Europe, including Finland, older adults – particularly postmenopausal women – often exhibit reduced bone mineral density (BMD), with densitometric osteoporosis observed in ~21.5% of women and ~6.4% of men aged ≥ 50 years [2]. Emerging evidence suggests that preoperative Cone Beam Computed Tomography (CBCT)‑derived mandibular BMD values correlate with surgical difficulty in impacted mandibular third molar extraction, with higher BMD independently predicting increased operative challenge [3].
Although noteworthy, a mandibular extraction demonstrating technical simplicity should not be equated with clinical safety. Age-related declines in endosteal bone healing, systemic comorbidities, and concomitant medications can impair wound healing and increase the risk of adverse outcomes, including medication-related osteonecrosis of the jaw (MRONJ). Moreover, matched-pair analyses comparing elderly patients (≥ 65 years) with younger adults demonstrate a significantly greater burden of peri- and postoperative morbidity in the older cohort, including higher rates of ankylosis, nerve proximity, and complications necessitating longer operative times and hospital stays, suggesting that delaying extraction into late adulthood may shift the morbidity burden to later life [4, 5].
Therefore, planning third molar removal in older adults should integrate anatomical evaluation with a comprehensive assessment of physiologic, pharmacologic, and systemic risk factors, rather than relying solely on perceived technical simplicity or surgical complexity. Recognizing these limitations is essential to ensure safe and predictable outcomes and to avoid overinterpreting mandibular extraction performance in aging populations.
[1] Noro A, Snäll J, Ventä I. The effect of age on third molar extraction difficulty: a retrospective cross-sectional cohort study. Acta Odontol Scand. 2026;85:33–9. https://doi.org/10.2340/aos.v85.45308
[2] Osteoporosis in Europe: a compendium of country-specific reports.©2022 International Osteoporosis Foundation.[Internet] Available from: https://www.osteoporosis.foundation/sites/iofbonehealth/files/scope-2021/Finland%20report.pdf
[3] Ullah S, Zaman R, Wajid R, Dil F, Saleem I, Ishaq Y. Association between CBCT-derived bone mineral density and surgical difficulty of impacted mandibular third molar extraction. J Popul Ther Clin Pharmacol. 2021;32(8):698–703. https://doi.org/10.53555/49petb37
[4] Seeman E, Delmas PD. Bone quality – the material and structural basis of bone strength and fragility. N Engl J Med. 2006;354:2250–61. https://doi.org/10.1056/NEJMra053077
[5] Baensch F, Otto S, Proff P. Third molar complications in the elderly – a matched‑pairs analysis. J Oral Maxillofac Surg. 2017;75:680–6. https://doi.org/10.1016/j.joms.2016.11.021