What is the recommended treatment for an impacted wisdom tooth?

Treatment of Impacted Wisdom Teeth

Surgical extraction is the recommended treatment for impacted wisdom teeth, especially when they are symptomatic or show evidence of pathology, with CBCT imaging being essential for proper surgical planning in complex cases. 1

Diagnostic Approach

Before deciding on treatment, proper diagnostic imaging is crucial:

1. Initial Assessment: Orthopantomography (panoramic X-ray) should be the first diagnostic examination for suspected dental impaction 1

2. Advanced Imaging: CBCT (Cone Beam Computed Tomography) is essential when assessing:

   • Relationship between third lower molars and the mandibular canal
   • Relationship between third upper molars and maxillary sinus floor
   • Cases where external root resorption is suspected 1

Treatment Algorithm

Indications for Extraction

• Symptomatic impacted teeth:

  • Pain and swelling
  • Pericoronitis (inflammation of tissue around partially erupted tooth)
  • Difficulty in mastication
  • Dysphagia 2

• Asymptomatic teeth with pathology:

  • Dental caries on the impacted tooth or adjacent teeth
  • Periodontal disease affecting adjacent second molars
  • Evidence of cysts or tumors
  • External root resorption of adjacent teeth 3

• Preventive extraction considerations:

  • Risk of future pathology (particularly in younger patients)
  • Pre-orthognathic surgery
  • Pre-radiotherapy in affected area 3

When to Consider Retention

• Truly asymptomatic disease-free impacted teeth with:
  • No evidence of pathology
  • Low risk of future complications
  • Older patients where surgical risks may outweigh benefits 3

Surgical Considerations

When extraction is indicated, several factors must be considered:

1. Imaging guidance:

   • For lower third molars: CBCT is essential to assess relationship with mandibular canal to prevent nerve injury 1
   • For upper third molars: CBCT helps evaluate proximity to maxillary sinus 1

2. Surgical approach:

   • Based on tooth angulation (vertical, mesioangular, horizontal, distoangular)
   • Depth of impaction (soft tissue, partial bony, full bony)
   • Relationship to adjacent structures 1

3. Risk minimization:

   • Use of targeted CBCT imaging following the ALARA principle (As Low As Reasonably Achievable) for radiation exposure 1
   • Careful flap design and bone removal techniques

Important Caveats

• Age considerations: Surgical complications increase with age, particularly in patients over 25 years 3

• Controversial evidence: There is insufficient high-quality evidence to determine whether truly asymptomatic disease-free impacted wisdom teeth should be prophylactically removed or retained 3

• Long-term risks of retention: Very low-certainty evidence suggests that retention of asymptomatic impacted wisdom teeth may increase the risk of periodontitis affecting adjacent second molars over time 3

• Follow-up: If retention is chosen, regular clinical assessment is advisable to monitor for development of pathology 3

• Imaging limitations: 2D imaging techniques (panoramic X-rays) are less accurate than 3D CBCT in assessing relationships between impacted teeth and critical anatomical structures 1