Teeth and Wisdom Teeth
The Management of Impacted Third Molar Teeth
statements by the American Association of Oral and Maxillofacial Surgeons
Indications for Care. Patients are frequently referred to an oral and maxillofacial surgeon for treatment of impacted teeth. Referrals for evaluation of impacted third molar teeth originate from a variety of health care professionals who understand the problems associated with the lack of normal eruption. Since all impacted third molar teeth are potentially pathologic, prudent care requires removal, exposure, repositioning or, in selected cases, long-term monitoring following appropriate education of the patient. Articles documenting the pathology produced by impacted teeth are numerous. Lesions which may be secondary to or associated with impacted teeth include, but are not limited to, acute and chronic inflammation or infection, resorption phenomenon, carious lesions including those of adjacent teeth, cystic or neoplastic disease and displacement or destruction of adjacent hard tissue structures including teeth and bone. Pathologic conditions are generally more common with an increase in age.
Indications for treatment include, but are not limited to, the following:
the management or limit • Nontreatable pulpal lesion
progression of periodontal disease • Acute or chronic infection (e.g., cellulitis,
• Ectopic position abscess)
• Facilitate prosthetic rehabilitation • Abnormalities of tooth size or shape
• Facilitate orthodontic tooth movement • Findings of periodontal disease
and promote dental stability . Findings of periapical pathology
• Tooth interfering with orthognathic and/or • Preventive or prophylactic removal
reconstructive surgery • Tooth in the line of fracture complicating
• Fractured tooth fracture management
• Nonrestorable caries • Pathology associated with tooth follicle
• Internal or external resorption of tooth (e.g., cysts, tumors)
or adjacent teeth Facilitate management in trauma,
• Tooth involved in tumor resection orthognathic or reconstructive surgery
• Prophylactic removal in patients with certain • Insufficient space to accommodate
medical or surgical conditions or treatments erupting tooth or teeth
(e.g., organ transplants, alloplastic implants, Orthodontic abnormalities (e.g., arch
chemotherapy, radiation therapy) length/tooth size discrepancies)
• Patient’s informed refusal of nonsurgical . Pain
Whenever possible, treatment should be provided before the pathology has adversely affected the patient’s oral and/ or systemic health. The goal should be to limit surgical side effects and to provide an environment for optimal healing.
Consideration may be given to leaving an impacted third molar tooth in place when it has complete root formation, is totally covered by bone and does not meet any of the clinical and/or radiographic indications for removal listed above. In such instances, monitoring should be arranged to assess potential changes in tooth position and/or the development of pathology. When such a recommendation is made in lieu of therapy, the patient should be informed of the potential for development of pathology, the possible need for future treatment and the increased incidence of complications associated with treating impacted teeth at an advanced age.
Medical Necessity. In light of the well documented history of problems associated with impacted teeth, surgical care is considered medically necessary when the indications for treatment of such teeth are consistent with those listed above under “Indications for Care.”
Treatment may include removal, surgical exposure, transplantation
or long-term observation of the impacted tooth. When removal
of an impacted tooth is indicated, it is surgically prudent
and cost beneficial that other impacted teeth be considered
for treatment at the same surgical session. This reduces
the need for additional anesthetic and surgical procedures.
Contraindications to the removal of impacted teeth usually
involve compromise in the patient’s physical or medical
status, extremes of age and the probability of excessive
damage to adjacent structures. The decision to leave an
impacted tooth in place should be based on valid evidence
and expectations. In these cases, long-term clinical and
radiographic observation is necessary and the patient must
be informed of the risks and benefits of removal vs. observation.
Conclusion. The American Association of Oral and Maxillofacial Surgeons recognizes the existence of scientific evidence stating that impacted teeth represent a potentially pathologic entity and that surgical management is the treatment of choice. This is consistent with the findings of the National Institutes of Health Consensus Development Conference: Removal of Third Molars that impaction or malposition of the third molar is an abnormal state.3
To give patients the advantages of rapid healing and the lowest incidence of morbidity, impacted teeth should be treated as it is apparent that they will not properly erupt and occlude within the oral cavity. Treatment of impacted teeth at an early age is associated with a decreased incidence of morbidity and represents an efficient use of health care resources. Treatment at an older age carries with it an increase in the incidence and severity of perioperative and postoperative problems, a longer and more severe period of postoperative recovery, and greater and more costly interference in daily activities and responsibilities.
When making a treatment decision, the risks and benefits of removal of impacted teeth must be weighed against the risks of retention and the cost and availability of professional clinical monitoring for an individual patient. The final decision should be based on valid scientific and clinical information.
of Care for Oral and Maxillofacial Surgery: A Guide for
Practice, Monitoring, and Evaluation (AAOMS Parameters of
Care 95), Journal of Oral and Maxiilofacial Surgery. Volume
53, Number 9, Supplements, September 1995.
2. Report of Workshop on the Management of Patients With Third Molars, Journal of Oral and Maxillofacial Surgery, Volume 53, 1102-1112, 1994.
3. National Institutes of Health Consensus Development Conference: Removal of Third Molars. Washington, DC, National Institutes of llealth, 1979.
4. “Accuracy of Radiographs and Classification of Impacted Third Molars” Chandler, LP, Laskin, D.M. Journal of Oral and Maxillofacial Surgery, 117:461-465, 1988.
5. Peterson, L Principles of Management of Impacted Teeth. In Peterson, L.J., Ellis Ill, E., Hupp, J.R., and Tucker, M.R. (eds): Contemporary Oral and Maxillofacial Surgery. CV Mosby, St. Louis, 1988.