Should impacted third molars be removed

In relation to third molars, caries can affect the third molar itself or more significantly occur in the distal cervical area of the second molar tooth due to the mesio-angular impaction of the third molar against it.

Caries is a disease that is relatively slow to develop compared with pericoronitis and as a consequence caries develops later in patients by comparison. It may be that the rapid dip in the number of third molar extractions in the early s was due to a rigid interpretation and application of third molar guidelines and as such third molars were actively not removed.

This may be true in cases of single or mild forms of pericoronitis or solely the presence of a partially erupted and impacted third molar that may have been used as the indication for removal pre Third molars are not erupting later in life to account for the increase in mean age from 26 to 32 during the last 20 years.

Third molars are being retained for longer, either as a result of lack of disease affecting younger patients, or a palliative approach to the management of third molar disease.

Patients may be more inclined to be treated with antibiotics for recurring episodes of pericoronitis and thus avoid, or more likely, delay the removal of the third molar. The fact that patients are retaining third molars later into life makes them more vulnerable to one of the problematic consequences of the oral environment: dental caries.

The likelihood of this will be evident especially if the teeth are impacted, partially erupted and difficult to clean. Older patients with good dental health are more prone to having third molar teeth removed because of caries related indications such as DCC in the second molar.

This group of patients may be contributing to the rebound increase in the number of third molars being removed. With the mean age of patients increasing from 26 to 32 years of age, we see an increase in the number of patients requiring third molar removal due to caries.

Over the age of 30, patients are more likely to have third molar teeth removed due to the effects of caries than those who are younger. If these problems are detrimental to the dental health of the patient then should we not consider defining the optimum time for removal — either at the time of disease presentation or even prior to the damage that the disease may cause — especially if the damage is related to the second molar in the form of distal cervical caries?

There appears to be a lack of specificity in coding as it relates to studies such as this, which leads to problems in interpretation.

Caries as a diagnosis is too non-specific for coding purposes. Caries associated with the third molar is an indication for third molar removal but distal cervical caries DCC on the second molar in the presence of a mesio-angular third molar is also an indication for third molar removal. Both of these clinical conditions appear to be on the rise in older age groups. Nonetheless, caries related to third molars is on the increase and its consequences have to be managed. If databases are recording ICD codes of K Local periodontal disease affecting the second molar tooth, in addition to periodontal disease of the third molar itself, are distinct indications for third molar removal, but to classify both pericoronitis and periodontal disease together is inappropriate and makes data interpretation difficult.

Impaction and embedded teeth are not in isolation an indication for third molar removal but merely an observation of the ectopic position that the tooth develops into. A tooth's abnormal position is a developmental anomaly and along with other developmental anomalies is defined within the ICD coding system.

In view of the actual HES incidence of impaction being comparable with the reported incidence of pericoronitis, it could be presumed that impaction is being recorded instead of pericoronitis.

Accurate data collection in third molar studies and clinical coding systems is essential if data is to have any meaningful value. If the WHO ICD system is to be used for third molar data collection then it will require an overhaul to be fit for this purpose and to appropriately reflect the actual disease processes that afflict third molars.

With the introduction of clinical guidelines a decline in patients having third molars removed has occurred. This trend, however, has now been reversed and has steadily increased to pre-NICE levels.

Any initial financial savings would have been short-term and with more patients attending secondary care for third molar procedures, costs are now greater than prior to the introduction of NICE. Patients are becoming older and more patients are experiencing caries as an indication for third molar removal even though the dental and oral health of the population continues to improve.

It has been appreciated for some time that as the dental health of the population has improved, the early loss of first molar teeth in children and adolescents does not occur as frequently as before. Conversely, retention of the first molar restricts this space in the retro-molar area and no doubt contributes to the likelihood of impaction of the third molar tooth.

It is likely that the number of patients requiring third molar removal will always be substantial. World Health Organisation. International statistical classification of diseases and related health problems; 10th revision ICD Geneva: WHO, Changes over time in position and periodontal status of retained third molars.

J Oral Maxillofac Surg ; 65 : — Article Google Scholar. National Institute for Clinical Excellence. Guidance on the extraction of wisdom teeth. London: NICE, NIH consensus development conference for removal of third molars. J Oral Surg ; 38 : — Report of a workshop on the management of patients with third molar teeth.

J Oral Maxillofac Surg ; 52 : — Current clinical practice and parameters of care: the management of patients with third molar teeth. Scottish Intercollegiate Guidelines Network. Management of unerupted and impacted third molar teeth. SIGN, Hospital Episode Statistics. HES online. Online information at www. NHS Business Services authority. Dental Services. Digest Search. Statement of dental remuneration Accessed Nov.

Wisdom teeth management. American Association of Oral and Maxillofacial Surgeons. The management of impacted third molar teeth.

Ghaeminia H, et al. Surgical removal versus retention for the management of asymptomatic disease-free impacted wisdom teeth review. Cochrane Database of Systematic Reviews. Renton T, et al. Problems with erupting wisdom teeth: Signs, symptoms, and management. British Journal of General Practice.

Salinas TJ expert opinion. Mayo Clinic, Rochester, Minn. See also Headache Impacted wisdom teeth OraVerse: Reversing dental numbness Integrative approaches to treating pain Nutrition and pain Pain rehabilitation Self-care approaches to treating pain X-ray Show more related content. Mayo Clinic Press Check out these best-sellers and special offers on books and newsletters from Mayo Clinic. There is evidence that supports removing third molars when at least 1 pocket depth of at least 4mm is measured in the third molar region in young adults around an asymptomatic third molar, or distal of an adjacent second molar because of an association with a decreased odds of periodontal disease progressing over time in teeth more anterior in the mouth.

The removal of mandibular third molars appears to significantly improve the periodontal status on the distal root of second molars, positively affecting overall periodontal health. Nevertheless, there are occasions when removal of third molars can either create or exacerbate periodontal problems on the distal aspect of the lower second molar.

Studies evaluating the preoperative administration of NSAIDs and pain in oral surgery have been published. The beneficial effects of the preoperative administration of piroxicam, ketorolac, meloxicam, parecoxib and dexamethasone with rofecoxib have been documented. Some authors found a lower consumption of rescue analgesics and a delay in the onset of pain when the NSAIDs were administered before the surgical procedure.

The maximum plasma peak MMP after the administration of mg of ibuprofen occurs after 32 min. It is also known that the maximum concentrations of prostaglandins around damaged tissues are obtained approximately 1 h after injury.

This is an important consideration and seems to support the use of long-lasting anesthetics to increase the residual analgesic effect. More attention should be given to optimize the use of CBCT to cover difficult cases that may give rise to complications. IAN injury after third molar extraction is normally caused by close anatomic proximity or by the surgical technique.

If the cause of injury is the anatomic relation, then CT would be useful only for diagnostic purposes, i. However, the value and accuracy of this prediction is questionable, because if the cause of the injury is the surgical technique, then CT would help to minimize the risk of IAN injury only if it changed the way the surgeon operates, e.

According to a number of authors, age is the most consistent factor in the determination of surgical difficulty, considering the differences in bone density associated with age. Moreover, the increase in age is associated with complete root formation, which may be related to the higher rate of complications among patients over 25 years of age compared with younger patients.

Bone density of the tooth has been described as important indicator for the prediction of surgical difficulty. Studies indicate that as one becomes older, third molars become more difficult to remove, may take longer to remove, and may result in an increased risk for complications associated with removal.

The age of 25 years appears in many studies to be a critical time after which complications increase more rapidly. There are no studies indicating a decrease in complications with increasing age. It also appears that recovery from complications is more prolonged and is less predictable and less complete with increasing age. As such, many clinicians recommend removal of 3 rd molars in young adults. Removal of third molars can cause or exacerbate pre-existing temporomandibular joint disorders TMD , particularly internal derangements of the tmj.

The relationship, however, is indirect because third molars are often removed in an age group of patients where internal derangements of the TMJ are relatively common. A prospective case-control study involving 72 patients showed that, on examination of patients with TMJ dysfunction, there is either no increase or a statistically insignificantly higher instance of TMJ dysfunction in those who have undergone third molar removal versus those who have not.

A case-control study involving patients with a history of third molar removal and subjects without third molar removal also showed an insignificant increase of TMJ symptoms in those with a history of third molar removal.

Therefore it appears that third molar removal is not a significant factor in the initiation or exacerbation of TMJ problems. Case studies have shown that the inferior alveolar nerve may be involved after third molar removal in anywhere from 0. In many cases this can be predicted preoperatively from panoramic radiographs and, more recently, from cone beam computed tomography scanning, showing the relationship of the inferior alveolar nerve to the roots of the lower third molars.

Lingual nerve involvement associated with third molar removal occurs less frequently but may be more problematic for patients. Estimates of the incidence of lingual nerve involvement from case series show an incidence of between 0. This information is new to the literature and the evidence is strong. The absence of cancellous bone between the nerve and the tooth, in other words, direct contact between the 2 structures, is another independent factor.

Thus IAN position has a close association with the 2 independent predictors of injury, namely direct contact and narrowing of the IAN canal. Fully developed roots increase the risk for postoperative nerve impairment. This was expected because fully developed roots are likely to have closer contact to the IAN bundle. This is another argument for early removal of wisdom teeth.

Darkening of the root where the IAN canal crosses the root, and. Moreover, the legal demand for more detailed information on the incidence of potential complications is met and automatically documented by the imaging study.

Kim showed that age, impaction depth, and the 5 radiographic superimposition signs—darkening of the roots, deflection of the roots, narrowing of the roots, dark and bifid apex of the roots, and narrowing of the canal—were significantly associated with neurosensory deficits of the IAN after mandibular third molar extraction Fig.

Signs significantly associated with neurosensory deficits of the IAN after mandibular third molar extraction. Doucet showed that removing mandibular third molars at the time of the BSSO procedure will minimize postoperative neurosensory disturbance of the IAN by decreasing its entrapment and manipulation. Coronectomy was developed as a relatively new preventive method to decrease the prevalence of IAN injury compared with the conventional total removal of the lower third molar.

The crown of the impacted lower third molar is often the cause of the food impaction, dental caries, or pericoronitis that troubles the patients. By removing the crown and leaving the root s behind, the problems are solved and the risk of an IAN deficit is obviated.

Coronectomy is performed when contact between the mandibular third molar apex and the inferior alveolar nerve is suspected. The efficacy of coronectomy compared with conventional tooth extraction has been recognized in recent years. The absence of transmission images indicative of periapical lesions and the presence of bone covering more than Root eruption can occur in a very small percentage of patients and may require reoperation to remove the root. In the rare event if after coronectomy, the retained roots erupt into the oral cavity and become infected.

In such cases, it is appropriate to extract the retained roots after they move away from the mandibular canal Fig. Coronectomy of an impacted 3 rd molar with nerve involvement. Skip to primary navigation Skip to main content Skip to footer November 7, by Dr. Brian Hart Do I need to remove an impacted wisdom tooth if it is not causing any problems? However, in other instances, impacted wisdom teeth can cause the following symptoms: Swelling, particularly around the gums or around the jaw Jaw pain Bleeding gums this is also a symptom of periodontal disease Bad breath Difficulty opening your mouth An unpleasant taste in your mouth If your impacted wisdom teeth are symptomatic with these symptoms, you probably need to have them removed.

These are: Mesial impaction: This is the most common type of impaction. In this, the tooth is angled too far toward the front of the mouth. Vertical impaction: In this case, the teeth come in fairly straight, but there is not enough room in the mouth to accommodate them. Horizontal impaction: This impaction is caused by teeth that are horizontally impacted, that are lying on their side. Distal impaction: Distally impacted teeth are tilted toward the back of the mouth.

Soft tissue impaction: This occurs when the tooth has erupted through the gum. Bony impaction: This takes place when the tooth is still within the bone, but has emerged through the gum.