What is the recommended management for unerupted maxillary and mandibular wisdom teeth with a slightly impacted appearance in the mandible bilaterally?

Management of Unerupted Maxillary and Mandibular Wisdom Teeth with Slight Impaction

Referral to an oral surgeon for clinical and radiographic evaluation is recommended for unerupted maxillary and mandibular wisdom teeth with slightly impacted appearance in the mandible bilaterally, as these teeth may require extraction to prevent future complications. 1

Diagnostic Evaluation

Initial Assessment

• Orthopantomography (panoramic radiograph) should be the first diagnostic examination for suspected dental impaction 1
• Clinical examination to assess:
  • Signs of pericoronitis (inflammation around partially erupted teeth)
  • Occlusal interference
  • Presence of pain or swelling
  • Evidence of caries or periodontal disease in adjacent teeth

Advanced Imaging

• CBCT (Cone Beam Computed Tomography) is indicated when:
  • Orthopantomography cannot provide adequate information 1
  • Assessment of relationship between mandibular third molars and mandibular canal is needed 1
  • Evaluation of root morphology and proximity to maxillary sinus is required (for maxillary molars) 2

Management Algorithm

For Mandibular Impacted Wisdom Teeth:

1. Asymptomatic with slight impaction:

   • Consider prophylactic removal if:
     • Patient is young (under 25 years)
     • Impaction pattern suggests future complications
     • Inadequate space for proper eruption
     • Risk of damage to adjacent second molars

2. Symptomatic with slight impaction:

   • Extraction is indicated for:
     • Recurrent pericoronitis
     • Caries in the third molar or distal aspect of second molar
     • Periodontal defects on the distal aspect of second molar
     • Evidence of pathology (cysts, tumors)

For Maxillary Impacted Wisdom Teeth:

1. Asymptomatic with impaction:

   • Consider removal if:
     • No functional occlusion with opposing teeth
     • Risk of maxillary sinus complications
     • Potential for future pathology

2. Symptomatic with impaction:

   • Extraction is indicated for:
     • Pain or swelling
     • Evidence of pathology
     • Interference with adjacent teeth

Surgical Considerations

Mandibular Third Molars

• Assess proximity to mandibular canal to avoid nerve injury 1
• Consider flap design (triangular flaps associated with 71% reduction in alveolar osteitis compared to envelope flaps) 3
• Evaluate need for sectioning of the tooth to minimize bone removal

Maxillary Third Molars

• Evaluate proximity to maxillary sinus (though radiographic proximity alone is not a reliable predictor of oroantral perforation) 2
• Assess angulation of impaction (vertical and mesioangular being most common) 2

Important Caveats and Pitfalls

• Depth of impaction of maxillary wisdom teeth is a better predictor of potential complications than proximity to sinus 2

• Impacted wisdom teeth may complicate orthognathic surgery if needed in the future 4

• Extraction should be performed before age 25 when possible, as complications increase with age due to:

  • Increased bone density
  • Completed root formation
  • Reduced healing capacity

• The decision to extract should balance the risks of:

  • Nerve damage (inferior alveolar and lingual nerves)
  • Alveolar osteitis (dry socket)
  • Infection
  • Mandibular fracture (rare)
  • Oroantral communication (maxillary teeth)

Against the risks of retention:

• Future pathology development
• Damage to adjacent teeth
• Late-onset symptoms requiring more complicated surgery

In Europe, impaction of third molars is observed in more than 70% of young adults, making extraction of third molars the most frequent procedure in oral surgery 1. Given the potential for future complications and the increased difficulty of extraction with age, proactive management is generally favored over observation for impacted wisdom teeth, particularly in younger patients.