Impacted Wisdom Tooth Removal Guidlines

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SlGN PubIication
Number
Scottisb
lntercoIIegiate
GuideIines
Network
S I G N
September 1999
Management of
Unerupted and lmpacted
Tbird MoIar Teetb
A NationaI CIinicaI GuideIine
KfY TO fVlDfNCf STATfMfNTS AND GRADfS Ol RfCOMMfNDATlONS
1ho dolntons ol tho typos ol ovdonco and tho gradng ol rocommondatons usod n ths
gudono orgnato lrom tho US Agoncy lor Hoath Caro Focy and kosoarch
1
and aro sot out n
tho loowng tabos.
STATfMfNTS Ol fVlDfNCf
Ia Lvdonco obtanod lrom mota-anayss ol randomsod controod tras.
Ib Lvdonco obtanod lrom at oast ono randomsod controod tra.
IIa Lvdonco obtanod lrom at oast ono wo-dosgnod controod study wthout
randomsaton.
IIb Lvdonco obtanod lrom at oast ono othor typo ol wo-dosgnod quas-oxpormonta
study.
III Lvdonco obtanod lrom wo-dosgnod non-oxpormonta doscrptvo studos, such
as comparatvo studos, corroaton studos and caso studos.
IV Lvdonco obtanod lrom oxport commttoo roports or opnons and/or cnca
oxporoncos ol rospoctod authortos.
GRADfS Ol RfCOMMfNDATlONS
A Requires at Ieast one randomised controIIed triaI as part of a body of Iiterature of
overaII good quaIity and consistency addressing tbe specific recommendation.
(Ividence levels Ia, Ibi
Requires tbe avaiIabiIity of weII conducted cIinicaI studies but no randomised
cIinicaI triaIs on tbe topic of recommendation.
(Ividence levels IIa, IIb, IIIi
C Requires evidence obtained from expert committee reports or opinions and/or
cIinicaI experiences of respected autborities. lndicates an absence of directIy
appIicabIe cIinicaI studies of good quaIity.
(Ividence level IVi
GOOD PRACTlCf POlNTS
kocommondod bost practco basod on tho cnca oxporonco ol tho gudono
dovoopmont group.
Contents
Cuideline development gtoup (ii
!otes lot usets ol the guideline (iii
Summaty ol tecommendations (iiii
1 lntroduction
1.1 ackground 1
1.2 1ho nood lor a gudono 1
1.3 Am ol tho gudono 1
1.4 Dovoopmont ol tho gudono 1
1.5 Dolntons and tormnoogy 2
2 AdvisabiIity of removaI
2.1 lor whch patonts s romova not advsabo: 3
2.2 lor whch patonts s romova advsabo: 4
3 lndications for removaI
3.1 Strong ndcatons lor romova 6
3.2 Cthor ndcatons lor romova 7
4 Assessment and referraI
4.1 Cnca assossmont 10
4.2 kadoogca assossmont 10
4.3 kolorra 12
S CIinicaI management
5.1 Frooporatvo managomont 13
5.2 Anaosthosa 13
5.3 Surgca procoduro 13
5.4 Cthor procoduros 14
5.5 Foroporatvo drug thorapy 14
5.6 Compcatons assocatod wth troatmont 14
5.7 Cutcomos ol unoruptod thrd moar managomont 16
5.9 Fatont nlormaton 17
6 Recommendations for audit and research '
Annexes
1 Details ol the systematic teview undettaken lot this guideline 20
2 Iey messages lot patients 21
References 22
CONTfNTS
GUlDfIlNf DfVfIOPMfNT GROUP
Dr }umes Renne Dental Ditectot, 5cottish Council fot Iostgtaduate Medical and Dental Iducation
(Chaitmani
Mrs Laotta rockobank Ctal Radiologist & 5eniot Iectutet, Lnivetsity of Clasgow
Dr lvor Chostnutt 5eniot Registtat in Dental Iublic Health, Ianatkshite Health 8oatd
Mr }ohn Crag Cenetal Dental Itactitionet, Ialkitk
Dr Caroth Davos Cenetal Medical Itactitionet, 8yways, Iilleatn, Clasgow
Mr Conn Loo Ctal and Maxillofacial 5utgeon, City Hospital, Idinbutgh
Dr Hoon Marborough Iibtatian, Clasgow Lnivetsity Iibtaty
Frolossor Khurshood Moos Ctal and Maxillofacial 5utgeon, Canniesbutn Hospital, Clasgow
Dr }m McDonad Consultant Ctthodontist, Idinbutgh
Dr No MacLood Cenetal Medical Itactitionet, -betdeen
Frolossor Craham Cgdon Ctal and Maxillofacial 5utgeon, Lnivetsity of Dundee
Mr Nck konny Ctal and Maxillofacial 5utgeon, Ctampian Lnivetsity Hospitals NH5 Ttust
Mss Margo 1ayor Consultant in Dental Iublic Health, Ianatkshite Health 8oatd
Mr Donns 1oppn Cenetal Dental Itactitionet, Clasgow
Declatations of intetests wete made by all membets of the guideline development gtoup.
Iutthet details ate available on tequest ftom the 5ICN 5ectetatiat.
SPfClAIlST RfVlfWfRS
Mr Craham a Consultant in Dental Iublic Health, Iife Health 8oatd
Mr Davd arnard Dean, Iaculty of Dental 5utgety
Dr Lawronco uckman Cenetal Medical Itactitionet, Iondon
Frolossor }ohn lramo Regional Ditectot of Iostgtaduate Dental Iducation, Lnivetsity of 8itmingham
Mr Androw Hutchson Cenetal Dental Itactitionet, 5altcoats
Mr kchard Hasko Consultant Ctal and Maxillofacial 5utgeon, Cuys Hospital, Iondon
Mr }ohn Lowry Consultant Ctal and Maxillofacial 5utgeon, 8olton
Mr Davd McCa Consultant in Dental Iublic Health, Cteatet Clasgow Health 8oatd
Mr Macom Fondobury Dean, Iaculty of Cenetal Dental Itactitionets
Mr }ohn kout Consultant Dental Radiologist, 8itmingham Dental Hospital
Frolossor }ohn Scott Dean of Dental 5tudies, Lnivetsity of Iivetpool
Frolossor }ohn Shophord Itofessot of Ctal and Maxillofacial 5utgety, Lnivetsity of Wales College of Medicine
Mr Cooll 1ayor Dean of Iostgtaduate Dentistty, Lnivetsity of Manchestet
Mr }ohn Wams Consultant Ctal and Maxillofacial 5utgeon, 5t Richatds Hospital, Chichestet
SlGN fDlTORlAI OARD
Frolossor }amos Fotro Chaitman of 5ICN, Co-editot
Dr Doroon Campbo CR-C 5ectetatiat, 5cottish Ixecutive Depattment of Health
Dr Fatrca Donad Royal College of Cenetal Itactitionets
Frolossor }oromy Crmshaw Health 5etvices Reseatch Lnit, Lnivetsity of -betdeen
Mr Dougas Harpor Royal College of 5utgeons of Idinbutgh
Dr Crahamo Howard Royal College of Radiologists
Dr Margarot koborts Royal College of Ihysicians & 5utgeons of Clasgow
(ii
GUlDfIlNf DfVfIOPMfNT GROUP
MANAGfMfNT Ol UNfRUPTfD AND lMPACTfD THlRD MOIAR TffTH
SlGN SfCRfTARlAT
Ms }uot Mor Head of 5ectetatiat, Co-editot
Ms lrancosca Chappo -ssistant Infotmation Cfficet
Mrs Losoy lorsyth Confetences Cootdinatot
Mr kobn Harbour Infotmation Cfficet
Ms Faua McDonad Development Ctoups Cootdinatot
Mr }osoph Maxwo Iublications and Communications Cootdinatot
Dr Moray Narn Itogtamme Managet
Mrs }udth Froudloot -ssistant to Head of 5ectetatiat
Ms Caynor kattray Cuidelines -ssistant
Dr Sala Qurosh 5eniot Itogtamme Managet
(iii
Notes for users of tbe guideIine
DLVLLCFMLN1 Cl LCCAL CUlDLLlNLS
lt s ntondod that ths gudono w bo adoptod altor oca dscusson nvovng cnca stall
and managomont. 1ho Aroa Cnca Llloctvonoss Commttoo shoud bo luy nvovod. Loca
arrangomonts may thon bo mado lor tho dorvaton ol spoclc oca gudonos to mpomont tho
natona gudono n ndvdua hosptas, unts and practcos and lor socurng companco wth
thom. 1hs may bo dono by a varoty ol moans, ncudng patont-spoclc romndors, contnung
oducaton and tranng, and cnca audt.
SlCN consonts to tho copyng ol ths gudono lor uso n tho Hoath Sorvco n Scotand.
lor dotas ol how to ordor addtona copos ol ths or othor SlCN pubcatons, soo nsdo back
covor.
S1A1LMLN1 Cl lN1LN1
1hs roport s not ntondod to bo construod or to sorvo as a standard ol modca/donta caro.
Standards ol modca/donta caro aro dotormnod on tho bass ol a cnca data avaabo lor an
ndvdua caso and aro subjoct to chango as scontlc knowodgo and tochnoogy advanco and
pattorns ol caro ovovo.
1hoso paramotors ol practco shoud bo consdorod gudonos ony. Adhoronco to thom w not
onsuro a succosslu outcomo n ovory caso, nor shoud thoy bo construod as ncudng a propor
mothods ol caro or oxcudng othor accoptabo mothods ol caro amod at tho samo rosuts. 1ho
utmato judgomont rogardng a partcuar cnca procoduro or troatmont pan must bo mado by
tho doctor/dontst n ght ol tho cnca data prosontod by tho patont and tho dagnostc and
troatmont optons avaabo.
Sgnlcant doparturos lrom tho natona gudono as oxprossod n tho oca gudono shoud bo
luy documontod and tho roasons lor tho dlloroncos oxpanod. Sgnlcant doparturos lrom tho
oca gudono shoud bo luy documontod n tho patonts caso notos at tho tmo tho roovant
docson s takon.
A background papor on tho oga mpcatons ol gudonos s avaabo lrom tho SlCN socrotarat.
kLVlLW Cl 1HL CUlDLLlNL
1hs gudono was ssuod n 2000 and w bo rovowod n 2002. Any amondmonts to tho
gudono n tho ntorm porod w bo notod on tho SlCN wobsto. Commonts aro nvtod to
assst tho rovow procoss. A corrospondonco and roquosts lor background nlormaton rogardng
tho gudono shoud bo sont to:
SlCN Socrotarat
koya Coogo ol Fhyscans
9 Quoon Stroot
Ldnburgh LH2 1}Q
o-ma: sgnQrcpo.ac.uk
www.sgn.ac.uk
(iiii
NOTfS lOR USfRS Ol THf GUlDfIlNfS
Summary of recommendations
RfMOVAI Ol UNfRUPTfD AND lMPACTfD THlRD MOIARS lS NOT ADVlSAIf:
ln patonts whoso thrd moars woud bo judgod to orupt succossluy and havo a lunctona roo
n tho dontton.
C ln patonts whoso modca hstory rondors tho romova an unaccoptabo rsk to tho ovora
hoath ol tho patont or whoro tho rsk oxcoods tho bonolt.
ln patonts wth doopy mpactod thrd moars wth no hstory or ovdonco ol portnont oca or
systomc pathoogy.
C ln patonts whoro tho rsk ol surgca compcatons s judgod to bo unaccoptaby hgh, or whoro
lracturo ol an atrophc mandbo may occur.
C Whoro tho surgca romova ol a sngo thrd moar tooth s pannod undor oca anaosthosa tho
smutanoous oxtracton ol asymptomatc contraatora tooth shoud not normay bo undortakon.
RfMOVAI Ol UNfRUPTfD AND lMPACTfD THlRD MOIARS lS ADVlSAIf:
C ln patonts who aro oxporoncng or havo oxporoncod sgnlcant nlocton assocatod wth
unoruptod or mpactod thrd moar tooth.
C ln patonts wth prodsposng rsk lactors whoso occupaton or lostyo procudos roady accoss
to donta caro.
C ln patonts wth a modca condton whon tho rsk ol rotonton outwoghs tho potonta
compcatons assocatod wth romova ol thrd moars (o.g. pror to radothorapy or cardac
surgory;.
C ln patonts who havo agrood to a tooth transpant procoduro, orthognathc surgory, or othor
roovant oca surgca procoduro.
C Whoro a gonora anaosthotc s to bo admnstorod lor tho romova ol at oast ono thrd moar,
consdoraton shoud bo gvon to tho smutanoous romova ol tho opposng or contraatora
thrd moars whon tho rsks ol rotonton and a lurthor gonora anaosthotc outwogh tho rsks
assocatod wth thor romova.
THfRf ARf STRONG lNDlCATlONS lOR RfMOVAI WHfN:
C 1horo havo boon ono or moro opsodos ol infection such as porcoronts, couts, abscoss
lormaton, or untroatabo pupa/porapca pathoogy.
1horo s caries n tho thrd moar and tho tooth s unkoy to bo usoluy rostorod, or whon thoro
s caros n tho adjacont socond moar tooth whch cannot satslactory bo troatod wthout tho
romova ol tho thrd moar.
1horo s periodontaI disease duo to tho poston ol tho thrd moar and ts assocaton wth tho
socond moar tooth.
ln casos ol dentigerous cyst formation or othor roatod ora pathoogy.
ln casos ol externaI resorption ol tho thrd moar or ol tho socond moar whoro ths woud appoar
to bo causod by tho thrd moar.
(ivi
OTHfR lNDlCATlONS lOR RfMOVAI:
C lor autogenous transpIantation to a first moIar socket.
ln cases of fracture of tbe mandibIe in tbe tbird moIar region or for a tootb invoIved in
tumour resection.
An unerupted tbird moIar in an atropbic mandibIe.
PropbyIactic removaI of a partiaIIy erupted tbird moIar or a tbird moIar wbicb is IikeIy to
erupt may be appropriate in tbe presence of certain specific medicaI conditions.
AtypicaI pain from an unerupted tbird moIar is a most unusuaI situation and it is essentiaI
to avoid any confusion witb temporomandibuIar [oint or muscIe dysfunction before
considering removaI.
An acute exacerbation of symptoms occurring wbiIe tbe patient is on a waiting Iist for
surgery may be managed by extraction of tbe opposing maxiIIary tbird moIar.
A partiaIIy erupted or unerupted tbird moIar, cIose to tbe aIveoIar surface, prior to denture
construction or cIose to a pIanned impIant.
CIlNlCAI ASSfSSMfNT
CIinicaI assessment shoud bo carrod out wth tho am ol assossng tho status ol tho thrd
moars and oxcudng othor causos ol tho symptoms. A compoto oxamnaton shoud ncudo
assossmont ol:
tho orupton status ol tho thrd moar
tho prosonco ol oca nlocton
caros n, or rosorpton ol, tho thrd moar and tho adjacont tooth
porodonta status
orontaton and roatonshp ol tho tooth to tho nloror donta cana
occusa roatonshp
tomporomandbuar jont luncton
rogona ymph nodos.
Any assocatod pathoogy shoud aso bo notod.
RadioIogicaI assessment s ossonta pror to surgory, but doos not roquro to bo carrod out at tho
nta oxamnaton.
Routine radiograpbic examination of unerupted tbird moIars is not recommended.
1ho loowng nlormaton shoud bo notod n roaton to owor thrd moars:
tho typo and orontaton ol mpacton and tho accoss to tho tooth
tho crown szo and condton
tho root numbor and morphoogy, ncudng tho prosonco ol apca hooks
tho avooar bono ovo, ncudng tho dopth and tho pont ol oovaton and donsty
tho locuar wdth
tho porodonta status, togothor wth that ol tho adjacont tooth
1ho roatonshp or proxmty ol uppor thrd moars to tho maxary antrum and ol owor thrd
moars to tho nloror donta cana.
(vi
SUMMARY Ol RfCOMMfNDATlONS
1ho loowng sgns havo boon domonstratod to bo assocatod wth a sgnlcanty ncroasod rsk
ol norvo njury durng thrd moar surgory:
dvorson ol tho nloror donta cana
darkonng ol tho root whoro crossod by tho cana
ntorrupton ol tho whto nos ol tho cana
ln tho prosonco ol any ol thoso lndngs, groat caro shoud bo takon n surgca oxporaton
and tho docson to troat shoud bo caroluy rovowod. 1ho patont shoud bo caroluy advsod
ol tho rsk.
ll on tho nta radograph thoro s a suggoston ol an ntmato roatonshp botwoon tho roots ol
tho owor thrd moar, and tho nloror donta cana, a socond radograph shoud bo takon usng
dlloront projoct goomotry.
RflfRRAI
1ho rolorrng cncan shoud provdo nlormaton as to tho cnca lndngs on prosontaton,
modca hstory, and any radographs portnont to tho caso.
A prooporatvo radographs shoud bo translorrod botwoon cncans concornod wth tho
assossmont and troatmont ol tho patont. At tho compoton ol troatmont, radographs shoud bo
roturnod to tho orgnatng cncan. 1ho oporatng surgoons shoud rotan a dupcato n stuatons
whoro tho ovo ol morbdty rasos concorn.
CIlNlCAI MANAGfMfNT
Altor rolorra but pror to surgory interim measures may ncudo systomc antbotc admnstraton,
chorhoxdno mouth rnsos, oporcuoctomy, oca drossng and avago.
kolorrng practtonors shoud contact tho surgoon to oxpodto troatmont l a patont on a watng
st oxporoncos rocurront bouts ol nlocton.
1ho wboIe tootb shoud bo romovod and wound toot compotod. Any suspoctod pathoogca
matora shoud bo sont lor a hstopathoogy roport.
ResorbabIe sutures may bo usod at any tmo but n partcuar whoro no rovow s pannod.
1ho mtod ovdonco avaabo s nsullcont to mako a rocommondaton on tho routno uso ol
antibiotics lor thrd moar romova. Howovor, n sovoro casos whoro thoro s acuto nlocton at
tho tmo ol oporaton, sgnlcant bono romova, or proongod oporaton, antbotcs shoud not
bo wthhod.
A Preoperative steroids shoud bo consdorod (unoss contrandcatod; whoro thoro s a rsk ol
sgnlcant postoporatvo swong.
COMMON COMPIlCATlONS ASSOClATfD WlTH TRfATMfNT
Haomorrhago must bo controod at tho tmo ol surgory. Solt tssuo boodng may roquro
haomostatc agonts, bpoar dathormy and/or suturos. Cccasonay, a sma amount ol bono
wax s nocossary to contro boodng lrom bono, but ths must bo usod wth cauton. Haomatoma
lormaton outwth tho sockot can occur and may roquro dranago.
Fatonts shoud bo nlormod that brusng s common and sol-mtng and w usuay rosovo
wthn two wooks ol surgory.
Whoro sgns ol systemic invoIvement aro prosont (pyroxa, rogona ymphadonopathy; antbotcs
shoud bo proscrbod.
(vii
(viii
SUMMARY Ol RfCOMMfNDATlONS
C Whon a retained root fragment gvos rso to symptoms, t shoud bo romovod.
Approprato nstrumonts shoud bo n paco pror to oovaton to hop mnmso tho occurronco
ol dispIacement. Whoro dspacomont occurs, ovory ollort shoud bo mado at tho tmo ol surgory
to rocovor tho dspacod tooth, but rolorra to a spocast contro may bo roqurod.
Whoro wound debiscence occurs wthout tho dovoopmont ol pan and nlocton, patonts shoud
bo advsod to contnuo wound toot, o.g. hot saty mouthwashos and sockot syrngng.
Fatonts shoud bo tod about damage to ad[acent teetb at tho tmo ol surgory or, l undor
sodaton or gonora anaosthotc, whon thoy aro luy conscous. 1ho consoquoncos ol ths damago
shoud bo oxpanod to tho patont and rocordod n tho patonts notos. ll ropar s roqurod, thon
tho oporator shoud arrango approprato managomont.
SfRlOUS COMPIlCATlONS ASSOClATfD WlTH TRfATMfNT
lracture of tbe mandibIe shoud bo notod at tho tmo ol surgory and roparod l nocossary.
ll tho oporator s unabo to do ths, ho/sho must arrango mmodato rolorra.
Tuberosity fractures may occur and shoud bo troatod at tho tmo ol surgory. ll tho oporator s
unabo to do ths ho/sho must arrango an mmodato rolorra.
Oro-antraI communication dontlod at tho tmo ol surgory shoud bo roparod, usuay wth a
bucca advancomont lap. Antbotc thorapy s advsabo and tho patont shoud avod noso
bowng.
Any broken instrument shoud bo romovod at tho tmo ol tho oporaton. ll not rotrovabo, tho
patont shoud bo tod and ths rocordod n tho notos.
CompIete transection of tbe IinguaI or inferior dentaI nerves roquros mmodato norvo ropar by
an oxporoncod surgoon. Whoro thoro s parta damago, gonto dobrdomont and tho mantonanco
ol good apposton ol tho onds s normay undortakon. 1ho patont shoud bo nlormod ol tho
stuaton.
Iate recognition of nerve damage may roquro lurthor surgca oxporaton.
lOIIOW UP
A rovow appontmont s roqurod:
Whoro non-rosorbabo suturos havo boon pacod
Whoro compcatons arso
At tho patonts or surgoons roquost.
A dschargo ottor shoud aways bo sont to tho rolorrng cncan.
How to ook altor thor mouth postoporatvoy
Fossbo compcatons and sdo ollocts ol tho oporaton n gonora and any proboms
spoclc to tho oporaton undortakon
Any drug thorapy roqurod
Whothor a rovow appontmont s roqurod and l so, whon
1hat tho rolorrng practtonor w rocovo a ottor postoporatvoy.
1 lntroduction
1.1 ACKGROUND
1hrd moars gonoray orupt botwoon tho agos ol 18 and 24 yoars, athough thoro
s wdo varaton n orupton datos. Cno or moro thrd moars aro absont n
approxmatoy 25 ol aduts
2-5
but thoy may st bo prosont n tho odory, othorwso
odontuous, patont.
1ho provaonco ol unoruptod thrd moars varos wdoy and s nluoncod by ago,
gondor and othncty. 1ho lauro ol orupton ol thrd moars s a vory common
condton
3, 6-8
and tho oxtracton ol mpactod thrd moar tooth s ono ol tho most
lroquont surgca procoduros carrod out n tho NHS. lt has boon roportod that a
sgnlcant proporton ol thoso on ora and maxolaca surgory watng sts aro
awatng thrd moar romova.
9-11
1.2 THf NffD lOR A GUlDfIlNf
Surgca procoduros lor oxtracton ol unoruptod thrd moar tooth aro assocatod
wth sgnlcant morbdty ncudng pan and swong, togothor wth tho possbty
ol tomporary or pormanont norvo damago, rosutng n atorod sonsaton ol p or
tonguo.
12
1horo appoars to bo substanta varaton n managomont and t has boon
roportod that consorvatvo troatmont wth moro rgorous adhoronco to spoclc
ndcators lor romova woud roduco surgca casos by up to 60.
13
A rocont rovow
by tho NHS Contro lor kovows and Dssomnaton concudod that thoro appoars
to bo tto justlcaton lor tho romova ol pathoogy-lroo mpactod thrd moars.

3
A numbor ol gudonos on ths topc havo boon producod n rocont yoars. 1ho
most rocont documont, producod by a workng party ol tho lacuty ol Donta Surgory
ol tho koya Coogo ol Surgoons ol Lngand, was pubshod durng tho dovoopmont
ol ths SlCN gudono.
7
1ho mombors ol tho SlCN gudono dovoopmont group
aro gratolu lor tho co-oporaton ollorod by tho koya Coogo ol Surgoons ol Lngand
workng party and havo bonoltod lrom tho nlormaton contanod n thor documont.
1ho SlCN gudono dovoopmont group consdorod caroluy whothor a lurthor
gudono was nocossary, and concudod that thoro was scopo to bud on oxstng
gudonos by usng SlCN mothodoogy to dovoop rocommondatons basod upon
tho bost ovdonco avaabo.
1.3 AlM Ol THf GUlDfIlNf
1ho am ol ths natona gudono s to assst ndvdua cncans, hospta
dopartmonts, hosptas and commssonors ol hoath caro to produco oca gudonos
lor tho dontlcaton ol patonts who mght bonolt most lrom romova ol unoruptod
thrd moar tooth and thoso lor whom romova s not nocossary.
1.4 DfVfIOPMfNT Ol THf GUlDfIlNf
1ho SlCN gudono dovoopmont mothodoogy nvovos an oxtonsvo rovow and
apprasa ol tho oxstng toraturo (soo Annox 1;.
14
A smar oxorcso carrod out
by tho NHS Contro lor kovows and Dssomnaton lound that thoro woro no
randomsod controod tras to comparo tho ong torm outcomo ol oary romova
wth tho doborato rotonton ol pathoogy-lroo thrd moars, and a doarth ol roovant
1
1 lNTRODUCTlON
good quaty prmary studos.
3, 15
1ho systomatc toraturo rovow carrod out by
tho SlCN thrd moar gudono dovoopmont group conlrmod ths ack ol ovdonco
lrom wo-dosgnod randomsod controod tras.
1ho avaabo ovdonco s gonoray lrom non-oxpormonta doscrptvo studos
(ovdonco ovo lll; and tho rocommondatons, athough basod on tho bost ovdonco
avaabo, aro thoroloro mosty gradod as or C. Howovor, t shoud bo omphassod
that ths gradng roatos ony to tho strongth ol supportng ovdonco lor oach
rocommondaton, and not to tho mportanco ol tho rocommondaton.
1.S DfllNlTlONS AND TfRMlNOIOGY
koconty pubshod gudonos havo ncudod dolntons7, 1 and lor tho purposos
ol ths gudono mnor modlcatons ol tho provousy roportod dolntons havo
boon ntroducod:
An unerupted tootb s a tooth yng wthn tho jaws, ontroy covorod by solt
tssuo, and partay or compotoy covorod by bono.
A partiaIIy erupted tootb s a tooth that has laod to orupt luy nto a norma
poston. 1ho torm mpos that tho tooth s party vsbo or n communcaton
wth tho ora cavty.
An impacted tootb s a tooth whch s provontod lrom compotoy oruptng nto
a norma lunctona poston. 1hs may bo duo to ack ol spaco, obstructon by
anothor tooth, or an abnorma orupton path.
1hroughout tho gudono tho torm tbird moIar rolors to unoruptod and partay
oruptod thrd moar tooth whch may or may not bo mpactod.
1ho gonora prncpos n tho gudono appy to both upper and Iower thrd moar
tooth, but surgca managomont ol uppor thrd moars s n gonora much oss compox
and most ol tho dllcutos appy to owor thrd moars. Uppor wsdom tooth causo
oss dscomlort, aro moro koy to orupt, and aro smpor to romovo unoss
unoruptod and oncasod n bono. komova ol uppor thrd moars rosuts n lar oss
postoporatvo morbdty, and gonora anaosthotcs aro raroy roqurod.
Whorovor possbo, tho gudono dovoopmont group havo ompoyod tho most
commony usod tormnoogy, o.g. tho torm oca anaosthosa s usod n paco ol
oca anagosa.
2
2 AdvisabiIity of removaI
1hs socton consdors tho broad prncpos whch undorpn tho docson to romovo
or not to romovo an unoruptod or partay oruptod thrd moar tooth. Spoclc
ndcatons aro consdorod n groator dota n socton 3.
As a gonora prncpo, tooth shoud not bo romovod wthout duo causo. 1hs appos
to thrd moars as much as t doos to any othor tooth. A lorms ol surgory, whothor
undor oca anaosthosa or gonora anaosthosa, carry somo rsk ol compcatons
at worst, doath and thoro s an novtabo and moasurabo morbdty assocatod
wth surgca romova ol tooth. Lvon n tho bost ol hands, unprodctabo accdonts
can occur and whon vory argo numbors ol tooth aro bong consdorod n tho
popuaton ths must happon to tho occasona patont. Quto apart lrom ths, thoro
s a quoston ol cost to tho Hoath Sorvco as wo as to tho patont. 1horo noods,
thoroloro, to bo a dstnct roason lor tho romova ol thrd moar tooth and ths
roason shoud bo coary dontlod.
2.1 lOR WHlCH PATlfNTS lS RfMOVAI NOT ADVlSAIf!
2.1.1 lt s sol ovdont that thoro s no strong ndcaton lor romovng thrd moars whch
aro compotoy asymptomatc and dsoaso lroo oxcopt undor spoca crcumstancos
(soo socton 2.2;, as tho rsks ol ntorvonton may oad to compcatons both mnor
and major.
7-24
Non-ntorvonton avods thoso rsks and may prosorvo potontay
lunctona tooth and tho bony rdgo. 1ho tooth mght aso bo usod lor transpantaton
purposos.
1horo s gonora agroomont that, whoro thoro s adoquato spaco, unoruptod tooth
shoud bo olt n stu to orupt and that durng chdhood ovon mpactod tooth may
chango thor poston. lt s not possbo to prodct accuratoy whch asymptomatc
tooth w orupt
25-27
and thoro s tto ovdonco that tho tooth bocomo sgnlcanty
moro dllcut tochncay to romovo wth ago, or that moro compcatons occur by
oavng thom n stu. Howovor, t shoud bo romomborod that as tho patont grows
odor thoro s an ncroasod rsk ol surgca morbdty.
28
Tbird moIars wbicb wouId be [udged to erupt successfuIIy and bave a functionaI
roIe in tbe dentition sbouId not be removed.
C Tbird moIars sbouId not be removed in patients wbose medicaI bistory renders
tbe removaI an unacceptabIe risk to tbe overaII beaItb of tbe patient or wbere
tbe risk exceeds tbe benefit.
C ln patients wbere tbe surgicaI removaI of a singIe tbird moIar tootb is pIanned
under IocaI anaestbesia tbe simuItaneous extraction of asymptomatic
contraIateraI teetb sbouId not normaIIy be undertaken.
2.1.2 ln tho caso ol doopy mpactod thrd moars wthout ovdonco ol pathoogy, ospocay
whon compotoy covorod by solt tssuo and or bono, thoro s a rsk ol sgnlcant
oss ol porodonta support lrom tho adjacont socond moar loowng surgory to
romovo thoso tooth. 1horo aro thoroloro dolnto ndcatons lor oavng thoso tooth
in situ. 1ho samo s not truo lor partay oruptod mpactod tooth, whoro thoro s
good ovdonco that thoy aro koy at somotmo to causo symptoms.
25, 29, 30
3
2 ADVlSAlIlTY Ol RfMOVAI
Evidence level Ia
Evidence level Ia
DeepIy impacted tbird moIars in patients witb no bistory or evidence of pertinent
IocaI or systemic patboIogy (othor than tho oxcoptons dontlod n soctons
2.3 and 3; sbouId not be removed.
2.1.3 Whoro tho patont has no symptoms and tho thrd moar s burod, pathoogy-lroo
and n coso roatonshp wth tho nloror donta norvo or whoro thoro s a vory
atrophc mandbo wth tto rsk ol trauma thon t s consdorod good practco to
oavo tho thrd moar n stu.
3, 31
C Tbird moIars sbouId not be removed in patients wbere tbe risk of surgicaI
compIications is [udged to be unacceptabIy bigb, or wbere fracture of an atropbic
mandibIe may occur.
2.2 lOR WHlCH PATlfNTS lS RfMOVAI ADVlSAIf!
1horo aro somo dolnto ndcatons lor romova ol thrd moars. lor oxampo,
whoro nlocton can bo prodctod and thoroloro avodod, whoro thoro has boon
rocurront pan and dscomlort wth tho koy uso ol antbotcs, and whoro thoro
havo boon mutpo opsodos ol consorvatvo troatmont, thon romova ol thrd
moars shoud bo tho usua consoquonco. ln thoso crcumstancos, tmoy romova
ol tho thrd moar roducos tho cost to tho patont, tmo oll work, and tho rsks
assocatod wth ropoatod consorvatvo troatmont, o.g. wth antbotcs. Cthor
stuatons whoro t s n tho patonts bost ntorost to havo oary romova ol thrd
moars ncudo thoso who aro n occupatons whoro thoy may havo to work n
stuatons soatod lrom oxport troatmont, or whon modca or surgca condtons
aro koy to arso oadng to dllcuty or rsk wth thor romova.
2.2.1 1horo s somo ovdonco to suggost that a docson shoud bo mado to romovo thrd
moars whoro thoro s a kohood ol nlocton. 1horo s no ovdonco that t s n
tho patonts bost ntorost to wat unt nlocton arsos.
4, 32, 33
C RemovaI is advised in patients wbo are experiencing or bave experienced
significant infection associated witb unerupted or impacted tbird moIar teetb.
2.2.2 ll tho patont has had nlocton or s vory koy to havo nlocton, o.g. a partay
oruptod tooth, and s koy to bo n a poston n whch ho or sho cannot obtan
accoss to surgca caro thon oary romova may bo approprato. 1ho consonsus s
that t s bottor to romovo tho causo ol tho nlocton than ropoatody to troat t wth
antbotcs.
11, 18, 31
C RemovaI of tbird moIars is advised in patients witb predisposing risk factors
wbose occupation or IifestyIe precIudes ready access to dentaI care.
2.2.3 1ooth at rsk ol nlocton whch coud rosut n ostooradonocross or ondocardts
shoud bo romovod. Athough tho rsks ol thoso condtons dovoopng may bo
sma, thor sorous naturo procudos tho rotonton ol a potontay nloctod thrd
moar.
7, 34
C RemovaI is advised in patients witb a medicaI condition wben tbe risk of retention
outweigbs tbe potentiaI compIications associated witb removaI of tbird moIars
(o.g. pror to radothorapy or cardac surgory;.
4
Evidence level IV
Evidence level
III and IV
Evidence level IV
Evidence level IV
2.2.4 1horo s a consonsus vow that whoro tho thrd moar may compcato orthognathc
surgory or anothor surgca procoduro to tho jaw, thon t s roasonabo to romovo
that tooth, provdod tho rsks ol compcatons and tho sovorty ol thoso compcatons
do not outwogh tho bonolts.
16, 34
C RemovaI of tbird moIars may be considered in patients wbo bave agreed to a
tootb transpIant procedure, ortbognatbic surgery, or otber reIevant IocaI surgicaI
procedure.
2.2.5 Dsoaso-lroo non-lunctona uppor thrd moars woud normay bo romovod undor
gonora anaosthosa whon mpactod owor thrd moars aro to bo oxtractod and
whon tho rsks ol rotonton and a lurthor gonora anaosthotc outwogh tho rsks
assocatod wth thor romova.
16, 18, 31, 34, 35
Dmnshng uso ol gonora anaosthosa
makos ths oss ol a consdoraton than n tho past, but whoro a gonora anaosthotc
has to bo gvon thoro aro obvous rsks attachod to ths procoduro and l t has to bo
ropoatod ths ncroasos that rsk.
C Wbere a generaI anaestbetic is to be administered for tbe removaI of at Ieast
one tbird moIar, consideration sbouId be given to tbe simuItaneous removaI of
tbe opposing or contraIateraI tbird moIars wben tbe risks of retention and a
furtber generaI anaestbetic outweigb tbe risks associated witb tbeir removaI.
S
2 ADVlSAlIlTY Ol RfMOVAI
Evidence level IV
Evidence level IV
Evidence level
III and IV
Evidence level III
3 lndications for removaI
ln tho absonco ol ovdonco lrom randomsod controod tras, tho ndcatons lor
romova ol thrd moar tooth aro koy to roman tho subjoct ol dobato. ln somo
aroas thoro s ovdonco lor coar ndcatons lor romova, but t s mportant to
rocognso that thoso ndcatons may bo modlod by tho gonora hoath ol tho
patont and oca crcumstancos.
3.1 STRONG lNDlCATlONS lOR RfMOVAI
3.1.1 1horo aro a numbor ol roasons lor romova ol thrd moars whoro thoro s pathoogy
n and around tho thrd moar. lt s consdorod good practco and t s roasonabo to
assumo that rocurront acuto attacks ol nlocton assocatod wth thrd moars
nocosstato tho oary romova ol tho alloctod tooth. 1horo s no ovdonco to suggost
that oavng tho tooth in situ makos surgory oasor and thoro s strong ovdonco that
morbdty ncroasos wth ago.
21, 30, 36
C RemovaI of any symptomatic wisdom tootb sbouId be considered, especiaIIy
wbere tbere bave been one or more episodes of infection sucb as pericoronitis,
ceIIuIitis, abscess formation, or untreatabIe puIpaI/periapicaI patboIogy.
37, 38
3.1.2 ll a socond moar roquros to bo oxtractod t s sonsbo to romovo tho adjacont
unoruptod thrd moars unoss tho thrd moar coud orupt nto tho poston ol tho
socond moar. Smary, t may bo dllcut to l a carous mpactod thrd moar
and ths tooth shoud bo romovod unoss thoro s a vory hgh rsk ol compcatons
assocatod wth tho romova ol that tooth.
4, 5
RemovaI sbouId be considered wbere tbere is caries in tbe tbird moIar and tbe
tootb is unIikeIy to be usefuIIy restored, or wben tbere is caries in tbe ad[acent
second moIar tootb wbicb cannot satisfactoriIy be treated witbout tbe removaI
of tbe tbird moIar.
3.1.3 Whoro thoro s porodonta dsoaso and pockotng botwoon tho thrd moar and tho
socond moar, thoro s somo ovdonco to suggost that l romova ol tho thrd moar
s doayod boyond tho ago ol 30 yoars thon tho condton may bo rrovorsbo.
komova ol tho thrd moar w rosut n ropar ol tho njurod porodontum and
thoroloro oary romova ol tho mpactod thrd moar s bonolca. Untroatod
horzonta and moso-anguar mpacton aro partcuary prono to causo bono oss
dsta to tho socond moar. Lato romova ol such mpactod tooth has not boon
shown to mprovo tho porodonta status ol tho adjacont socond moar, but oary
oxtracton ol tho mpactod wsdom tooth roducos porodonta damago.
41, 43
RemovaI sbouId be considered in cases of periodontaI disease due to tbe position
of tbe tbird moIar and its association witb tbe second moIar tootb.
3.1.4 Dontgorous cyst lormaton and othor roatod ora pathoogy aro consdorod to bo
raro n assocaton wth thrd moars, but thoro s ovdonco ol dontgorous cyst
lormaton occurrng n assocaton wth mpactod thrd moars.
7
ln most casos thoro
s a strong ndcaton lor romova ol tho thrd moar n ordor to provont oxpanson
or rocurronco ol a koratocyst.
43
6
Evidence level III
Evidence level
IIb and III
Tbird moIar removaI sbouId be considered in cases of dentigerous cyst formation
or otber reIated oraI patboIogy.
3.1.5 Lxtorna rosorpton ol tho thrd moar or ol tho socond moar s roatvoy raro. koot
rosorpton occurs prncpay n tho 21-30 yoar od ago group. 1ho ncdonco altor
tho ago ol 30 has boon shown to bo romoto.
44
Tbird moIar removaI sbouId be considered in cases of externaI resorption of
tbe tbird moIar or of tbe second moIar wbere tbis wouId appear to be caused
by tbe tbird moIar.
3.2 OTHfR lNDlCATlONS lOR RfMOVAI
3.2.1 1hrd moar romova may occasonay bo ndcatod lor orthodontc roasons. Howovor
thoro s ovdonco, ncudng a sngo prospoctvo randomsod controod tra,1
that tho romova ol thrd moars n tho owor arch w not provont, mt, or curo
mbrcaton ol tho owor antoror tooth.
30, 46-57
komova ol tho thrd moar may bo ndcatod pror to orthognathc surgory, o.g.
whon a sagtta spt ostootomy s pannod, romova ol tho thrd moar dmnshos
tho rsk ol surgca compcatons wth rogard to that ostootomy.
16, 18
komova ol tho thrd moar may bo ndcatod pror to orthognathc surgory.
1horo s no roabo ovdonco that thrd moar romova allocts tho growth ol tho
mandbo.
3.2.2 1horo aro a numbor ol othor ndcatons lor romova ol unoruptod and mpactod
thrd moar tooth. 1hoso aro a roatvo ndcatons and aro quto uncommon. 1hoso
ncudo tho occasona uso ol tho thrd moar tooth, whon t s sound, lor autogonous
transpantaton usuay to a lrst moar sockot sto.
34
1ho ow ncdonco ol succoss
wth tho procoduro moans t s not wdoy usod oxcopt n spoca crcumstancos.
C Tbird moIar removaI may be considered for autogenous transpIantation to a
first moIar socket.
3.2.3 1ho prosonco ol a tooth n a lracturo no ncroasos tho rsk ol nlocton n somo
casos, ospocay whon that tooth has boon dspacod or rondorod non vta.
58, 59
A smar stuaton arsos wth tumour rosocton and rradaton ol tho tssuos may
oad to a roducton n tho bood suppy, nlocton, or ostooradonocross. Lary
romova ol tooth at tho sto ol tho rosocton roducos tho rsk ol nlocton.
34, 60
C RemovaI may be considered in cases of fracture of tbe mandibIe in tbe tbird
moIar region or wben a tootb is invoIved in tumour resection.
3.2.4 karoy, an unoruptod thrd moar may o n an atrophc mandbo and a carolu
choco noods to bo mado whothor t s bottor to romovo tho tooth or oavo t n stu.
1horo s no coar ovdonco as to what s bost to do and a dogroo ol common sonso
must thoroloro prova.
7
C RemovaI of an unerupted tbird moIar in an atropbic mandibIe may be
appropriate.
7
3 lNDlCATlON lOR RfMOVAI
Evidence level IV
Evidence levels
Ib and III
Evidence level III
Evidence level IV
Evidence level IV
Evidence level IV
Evidence level IV
Evidence level III
Evidence level IV
1hs stuaton noods to bo caroluy ovauatod. ln vory odory patonts tho thrd
moar mght bo olt but n a mddo-agod patont whoro thoro s a rsk ol spontanoous
lracturo or whoro mnor trauma mght causo a lracturo thon prophyactc romova s
approprato.
3.2.5 ln tho prosonco ol spoclc modca condtons such as cardac vavuar dsoaso or n
a stuaton whon tho patont may roquro radothorapy t s coar that whoro thoro s
a potonta lor nlocton, ths shoud bo omnatod. A partay oruptod thrd moar
tooth woud como nto ths catogory, whoroas a compotoy unoruptod tooth whch
was novor koy to orupt woud not. ln bordorno stuatons, romova shoud bo
undortakon l symptoms aro koy n tho luturo. Cthor modca condtons such as
organ transpantaton, chomothorapy, or tho nsorton ol aopastc mpants shoud
bo consdorod n a smar way.
7, 34
C PropbyIactic removaI of a partiaIIy erupted tbird moIar or a tbird moIar wbicb
is IikeIy to erupt may be appropriate in tbe presence of certain specific medicaI
conditions.
3.2.6 1ho stuaton wth rogard to laca pan ol an atypca naturo s a dllcut ono and
romova ol a compotoy burod tooth shoud ony bo consdorod as a ast rosort and
ony whon tho patont ponts to that aroa as tho sourco ol pan. ln somo casos ths
roovos tho pan but thoro s no guarantoo. lt s not known why a compotoy
burod thrd moar shoud causo pan.
Much moro commony, atypca laca pan s assocatod wth tomporomandbuar
jont dysluncton and ths possbty must bo omnatod. Sgns ol musco spasm
aro normay prosont n dyslunctona stuatons. Conluson can arso whon thoro s
concomtant musco pan assocatod wth a conchng habt and oca thrd moar
pan.
4, 61
C AtypicaI pain from an unerupted tbird moIar is a most unusuaI situation and it
is essentiaI to avoid any confusion witb temporomandibuIar [oint or muscIe
dysfunction before considering removaI.
3.2.7 Fan assocatod wth tho owor thrd moar tooth s commony oxacorbatod by tho
uppor thrd moar btng on tho gum lap, causng pan and dscomlort. ll tho uppor
thrd moar tooth s oasy to romovo and t s non lunctona thon mmodato romova
ol that tooth w olton dramatcay roovo tho pan lrom tho aroa. 1hs s partcuary
usolu whoro thoro s koy to bo doay n tho surgca romova ol tho owor thrd
moar.
C Acute exacerbation of symptoms occurring wbiIe tbe patient is on a waiting
Iist for tbird moIar surgery may be managed by extraction of tbe opposing
maxiIIary tbird moIar.
3.2.8 ll tho thrd moar tooth s coso to tho surlaco or has brokon through tho surlaco n
roaton to an uppor or owor donturo thon t s approprato to romovo that tooth
boloro or as soon as symptoms arso, as thoy aro koy to porsst and bocomo moro
sovoro l tho tooth s not romovod.
7, 31
C RemovaI of a partiaIIy erupted or unerupted tbird moIar cIose to tbe aIveoIar
surface sbouId be considered prior to denture construction or cIose to a pIanned
impIant.
8
1horo aro vrtuay no controod tras or rgorous studos n tho stuatons doscrbod
abovo, athough tho outcomo ol an Amorcan Assocaton ol Cra and Maxolaca
Surgoons lvo-yoar prospoctvo mutcontro ntornatona study may provdo vauabo
nlormaton. ln most casos, tho ndvdua stuaton s sol ovdont and tho no ol
troatmont s obvous. Howovor, whoro thoro s doubt, carolu consdoraton shoud
bo gvon as to tho rsks and bonolts ol romova ol thrd moars n thoso patonts.
9
3 lNDlCATlONS lOR RfMOVAI
4 Assessment and referraI
4.1 CIlNlCAI ASSfSSMfNT
Fatonts sullorng lrom symptoms whch roato to a thrd moar tooth may prosont
to a Conora Donta Fracttonor (CDF;, a Conora Modca Fracttonor (CMF;, or
to a hospta Accdont & Lmorgoncy dopartmont.
lnta assossmont shoud ncudo a lu modca and donta hstory, oxtra-ora and
ntra-ora cnca oxamnaton. Fostvo lndngs lrom ths oxamnaton whch suggost
that troatmont ol tho thrd moar or roatod structuros may bo ndcatod, roquro
that a moro dotaod oxamnaton s carrod out. 1hs shoud dotormno whothor
romova s ndcatod and/or advsabo (see sections 2 and Ji, and shoud ncudo
radoogca assossmont.
Cnca assossmont shoud bo carrod out wth tho am ol assossng tho status
ol tho thrd moars and oxcudng othor causos ol tho symptoms. A compoto
oxamnaton shoud ncudo assossmont ol:
tho orupton status ol tho thrd moar
tho prosonco ol oca nlocton
caros n, or rosorpton ol, tho thrd moar and tho adjacont tooth
porodonta status
orontaton and roatonshp ol tho tooth to tho nloror donta cana (lDC;
occusa roatonshp
tomporomandbuar jont luncton
rogona ymph nodos.
Any assocatod pathoogy shoud aso bo notod.
kadoogca assossmont s ossonta pror to surgory, but doos not roquro to
bo carrod out at tho nta oxamnaton.
4.2 RADlOIOGlCAI ASSfSSMfNT
4.2.1 kADlCCkAFHlC LXAMlNA1lCN
kadographc oxamnaton shoud provdo tho nlormaton nocossary lor adoquato
assossmont ol a thrd moar tooth.
Fror to tho ago ol 13, radographc oxamnaton s not normay ndcatod lor tho
assossmont ol thrd moars
62
and lms takon lrom tho ago ol 20 aro most usolu n
assossng tho kohood ol orupton.
63
Whon moro than ono thrd moar roquros to
bo assossod, tho radographc oxamnaton ol choco s a panoramc radograph as
tho radaton doso ol a panoramc radograph s owor than lrom lour porapca
vows and tho dagnostc yod hghor.
62, 64, 65
Dosos lrom panoramc radography
can bo lurthor mtod by usng lod szo mtaton to provont oxposng aroas not
roqurod n tho lod ol vow.
66
Forapca or obquo atora radographs may bo
takon as an atornatvo. A radographs shoud bo ol a dagnostcay accoptabo
standard.
67
10
Evidence level
III and IV
Evidence level III
As no Iarge-scaIe study bas demonstrated a sufficient incidence of patboIogicaI
cbange associated witb unerupted tbird moIars, routine reguIar radiograpbic
examination of unerupted tbird moIars is not recommended.
4.2.2 kADlCLCClCAL LVALUA1lCN
1ho purposo ol a carolu radoogca ovauaton s to compomont tho cnca
oxamnaton by provdng addtona nlormaton about tho thrd moar, tho roatod
tooth and anatomca loaturos, and tho surroundng bono. 1hs s nocossary n ordor
to mako a sound docson about tho proposod surgca procoduro, tho most
approprato ocaton lor ths to tako paco, and to hghght aspocts ol managomont
whch may roquro spoclc monton to tho patont:.
1ho loowng nlormaton shoud bo notod n roaton to uppor and owor
thrd moars:
tho typo and orontaton ol mpacton and tho accoss to tho tooth.
(The distinction between vettical and disto-angulat otientation may allect
the sutgical apptoach, in patticulat with tegatd to the tequitements lot bone
temoval.i
tho crown szo and condton
tho root numbor and morphoogy, ncudng tho prosonco ol apca hooks
(Identilication ol such hooks is impottant, as they may ltactute duting temoval
ol the tooth and a decision is then tequited as to whethet to attempt theit
temoval. see section S.Ji
tho avooar bono ovo, ncudng tho dopth and tho pont ol oovaton and
donsty
tho locuar wdth
(Thete is no substantive evidence as to the dimension ol lolliculat space
which cleatly indicates that cystic change has taken place.
29, 42, 68, 69
Whete
doubt exists as to the likelihood ol cystic change and thete ate no othet
positive indications lot temoval ol the tooth, tadiological teview between
six and 12 months is the tecommended coutse ol action.i
tho porodonta status, togothor wth that ol tho adjacont tooth
tho roatonshp or proxmty ol uppor thrd moars to tho maxary antrum
and ol owor thrd moars to tho nloror donta cana.
1ho loowng sgns havo boon domonstratod to bo assocatod wth a sgnlcanty
ncroasod rsk ol norvo njury durng thrd moar surgory:
22
dvorson ol tho lDC
darkonng ol tho root whoro crossod by tho cana
ntorrupton ol tho whto nos ol tho cana.
ln tbe presence of any of tbe above findings, great care sbouId be taken in
surgicaI expIoration and tbe decision to treat carefuIIy reviewed. Tbe patient
sbouId be advised of tbe risks.
ll on tho nta panoramc radograph thoro s a suggoston ol a roatonshp
botwoon tho roots ol tho owor thrd moar, and tho lDC, a socond radograph
shoud bo takon
70, 71
usng dlloront projocton goomotry.
11
4 ASSfSSMfNT AND RflfRRAI
4.3 RflfRRAI
Cnco t has boon docdod that a thrd moar shoud bo romovod, consdoraton
shoud bo gvon as to tho approprato troatmont sottng. CMFs aro oncouragod to
rolor to a CDF, athough ths doos not procudo droct rolorra to a dopartmont ol
Cra and Maxolaca Surgory or spocast practtonor.
1ho bass ol ths docson shoud tako account ol tho gonora sutabty ol tho
lactos lor oporatvo procoduros and rocovory, tho compotonco ol support stall,
and tho tranng ol tho practtonor. ln addton, oach caso shoud bo assossod wth
rogard to tho patonts modca hstory and tho oxpoctod dogroo ol dllcuty ol
surgca troatmont (see section Si
1ho rolorrng cncan shoud provdo nlormaton as to tho cnca lndngs
on prosontaton, modca hstory, and any radographs portnont to tho caso.
A prooporatvo radographs shoud bo translorrod botwoon cncans concornod
wth tho assossmont and troatmont ol tho patont. At tho compoton ol
troatmont, radographs shoud bo roturnod to tho orgnatng cncan. 1ho
oporatng surgoons shoud rotan a dupcato n stuatons whoro tho ovo ol
morbdty rasos, or may raso, concorn.
1ho surgoon shoud by ottor conlrm rocopt ol tho rolorra, and outno tho troatmont
pan, spoclc nlormaton provdod to tho patont, tho lorm ol anaosthosa and
what loow-up arrangomonts aro roqurod.
A dschargo ottor shoud aways bo sont to tho rolorrng cncan.
12
S CIinicaI management
Lvory ollort shoud bo mado at tho tmo ol tho oporaton to mnmso or avod
compcatons and sdo ollocts ol tho oporatvo procoduros.
S.1 PRfOPfRATlVf MANAGfMfNT
Frooporatvo managomont roquros, as a mnmum, tho takng ol a dotaod hstory
pus cnca and radoogca assossmont (see section 4i. A docson s mado wth
rogard to whch thrd moars shoud bo romovod (see sections 2 and Ji and, onco
ltnoss lor surgory s ostabshod, nlormod consont must bo obtanod (see section
S.8i.
72
Altor rolorra but pror to surgory, ntorm moasuros may ncudo systomc
antbotc admnstraton, chorhoxdno mouth rnsos, oporcuoctomy, oca
drossng and avago.
7
kolorrng practtonors shoud contact tho surgoon to oxpodto troatmont l a
patont on a watng st oxporoncos rocurront bouts ol nlocton.
S.2 ANAfSTHfSlA
Mothods ol anaosthosa ncudo oca anaosthosa, oca anaosthosa wth ntravonous
sodaton, and gonora anaosthosa. lt s common practco to uso oca anaosthosa n
gonora anaosthosa casos to mprovo lod ol vson and cardoprotocton. ln gonora
donta practco, tho lormor two mothods aro consdorod approprato, but st roquro
sutabo lactos to bo avaabo.
73
Conora anaosthosa may bo noodod lor compox
and ongthy procoduros but t must bo rocognsod that oca anaosthosa carros oss
rsk.
72
kocont Conora Donta Counc gudanco omphassos that gonora anaosthosa
s a procoduro whch s novor wthout rsk and that n assossng tho noods ol an
ndvdua patont, duo rogard shoud bo gvon to a aspocts ol bohavoura
managomont and anxoty contro boloro docdng to proscrbo or to procood wth
troatmont undor gonora anaosthosa.
74
S.3 SURGlCAI PROCfDURf
1ho procoduro s varabo and s nluoncod by tho typo ol mpacton and surroundng
structuros, lor oxampo proxmty ol tho nloror avooar and ngua norvos.
Conoray surgory nvovos tho rasng and protocton ol solt tssuo laps and bono
romova wth othor chso or bur wth wator coong rrgaton. 1horo s conlctng
ovdonco as to tho most approprato lorm ol protocton lor tho ngua norvo.
75, 76
1ho whoo tooth shoud bo romovod and wound toot compotod. Any
suspoctod pathoogca matora shoud bo sont lor a hstopathoogy roport.
kosorbabo suturos may bo usod at any tmo but partcuary whoro no rovow
s pannod.
Cccasonay a docson to oavo a sma lragmont ol apca root ol a vta tooth
may bo mado l ts romova carros a groator rsk ol compcatons than rotonton.
77
1ho patont shoud bo nlormod and such ovonts rocordod n tho notos.
78
13
S CIlNlCAI MANAGfMfNT
Evidence level IV
Evidence level IV
Evidence level IIb
S.4 OTHfR PROCfDURfS
Cthor, raroy porlormod procoduros ncudo surgca porodontcs, whch can bo
consdorod n caroluy sooctod casos wth tho provso that subsoquont romova ol
tho tooth may bo roqurod. ln sooctod casos, surgca oxposuro can bo carrod out.
Surgca rompantaton/transpantaton may bo approprato troatmont n sooctod
casos. 1ho advco ol an oxporoncod orthodontst s hoplu n thoso casos.
S.S PfRlOPfRATlVf DRUG THfRAPY
5.5.1 AN1llC1lCS
Whoro thoro s sgnlcant bono romova, proongod oporaton tmo, or tho patont
s at ncroasod rsk ol nlocton, t s common practco to proscrbo antbotcs.
79, 80
Howovor, tho mtod ovdonco avaabo s nsullcont to mako a rocommondaton
on tho routno uso ol antbotcs lor thrd moar romova.
ln sovoro casos, whoro thoro s acuto nlocton at tho tmo ol oporaton,
sgnlcant bono romova, or proongod oporaton, antbotcs shoud not bo
wthhod.
5.5.2 ANALCLSlA
Norma practco s to proscrbo or advso ora anagoscs such as paracotamo or
buprolon lor outpatonts.
81
lor npatonts a numbor ol optons ncudng
non-storoda ant-nlammatory agonts and opatos aro commony proscrbod.
Fro-omptvo anagosa may bo consdorod.
5.5.3 S1LkClDS
Whoro thoro s a rsk ol sgnlcant postoporatvo swong, pro- or por-oporatvo
admnstraton ol doxamothasono or mothy prodnsoono has boon shown to roduco
swong and dscomlort.
82-84
A Preoperative steroids sbouId be considered (unoss contrandcatod; wbere tbere
is a risk of significant postoperative sweIIing.
S.6 COMPIlCATlONS ASSOClATfD WlTH TRfATMfNT
As notod oaror, romova ol thrd moars s a common surgca procoduro and as
wth a surgca procoduros thoro s a rsk ol oporatvo and postoporatvo
compcatons. 1ho rato ol compcatons and thor sovorty varos,
12
but tho
managomont ol common and moro sorous compcatons s doscrbod boow.
5.6.1 CCMMCN CCMFLlCA1lCNS
(a: Haomotthago
Haomorrhago must bo controod at tho tmo ol surgory. Solt tssuo boodng
may roquro haomostatc agonts, bpoar dathormy and/or suturos. Cccasonay
a sma amount ol bono wax s nocossary to contro boodng lrom bono, but
ths must bo usod wth cauton. Haomatoma lormaton outwth tho sockot can
occur and may roquro dranago.
14
Evidence level Ib
Evidence level III
Evidence level III
(b: Icchymosis
Fatonts shoud bo nlormod that brusng s common and sol-mtng and
w usuay rosovo wthn two wooks ol surgory.
(c: Infoction
lnlocton ol tho solt tssuos may rosut n socondary haomorrhago, couts or,
raroy, abscoss lormaton.
85
Wbere signs of systemic invoIvement are present (pyrexia, regionaI
Iympbadenopatby) antibiotics sbouId aIways be prescribed.
Avooar ostots (dry sockot; may occur n c. 20 ol patonts, partcuary n thoso
who smoko.
86
lrrgaton wth sano (or chorhoxdno 0.2; and/or pacomont ol
an obtundont, such as proprotary odolorm basod modcaton, usuay roducos tho
pan.
87
karoy, ostoomyots may occur whch roquros ong torm antbotc thorapy and/
or lurthor surgory n a hospta onvronmont.
(d: Rotontion of toot ftagmont
C Wben a retained root fragment gives rise to symptoms it sbouId be removed.
73
Any nlocton shoud bo controod pror to surgca oxporaton.
(o: Displacomont of tooth
A owor thrd moar or tooth lragmont may bo dspacod nto tho ngua tssuos,
whst an uppor thrd moar may pass nto tho nlratompora lossa.
Approprato nstrumonts shoud bo n paco pror to oovaton to hop mnmso
tho occurronco ol dspacomont. Whoro ths occurs, ovory ollort shoud bo
mado at tho tmo ol surgory to rocovor tho dspacod tooth, but rolorra to a
spocast contro may bo roqurod.
(f: Wound dohisconco
Whoro wound dohsconco occurs wthout tho dovoopmont ol pan and
nlocton, patonts shoud bo advsod to contnuo wound toot, o.g. hot saty
mouthwashos and sockot syrngng.
(g: Damago to adjacont tooth
Fatonts shoud bo tod about damago to adjacont tooth at tho tmo ol surgory
or, l undor sodaton or gonora anaosthotc, whon thoy aro luy conscous.
1ho consoquoncos ol ths damago shoud bo oxpanod to tho patont and
rocordod n tho patonts notos. ll ropar s roqurod, thon tho oporator shoud
arrango approprato managomont.
(h: Iotiodontal hoalth
1ho porodontum dsta to tho mandbuar socond moar may bo alloctod by romova
ol an mpactod thrd moar. Lary romova ol moso-anguar horzonta mpactod
thrd moars s assocatod wth bottor porodonta hoath.
41
1S
Evidence level III
5.6.2 SLklCUS CCMFLlCA1lCNS
1ho loowng compcatons carry sgnlcant rsk ol morbdty and may roquro
mmodato rolorra. 1ho patont shoud bo nlormod, and a rocord ontorod n tho
patonts notos.
(a: Itactuto of tho mandiblo
lracturos shoud bo notod at tho tmo ol surgory and roparod l nocossary. ll
tho oporator s unabo to do ths, ho/sho must arrango mmodato rolorra.
(b: Itactuto of tho maxilla
1uborosty lracturos may occur and shoud bo troatod at tho tmo ol surgory. ll
tho oporator s unabo to do ths ho/sho must arrango an mmodato rolorra.
? Cto-anttal communication
Cro-antra communcaton s probaby a moro lroquont occurronco than s roasod
and thus probaby olton hoas spontanoousy.
Any such doloct dontlod at tho tmo ol surgory shoud bo roparod, usuay
wth a bucca advancomont lap. Antbotc thorapy s advsabo and tho patont
shoud avod noso bowng.
@ Rotainod fotoign body
Any brokon nstrumont shoud bo romovod at tho tmo ol tho oporaton. ll not
rotrovabo, tho patont shoud bo tod and ths rocordod n tho notos.
A Notvo damago
Compoto transocton ol tho ngua or nloror donta norvos roquros mmodato
norvo ropar by an oxporoncod surgoon. Whoro thoro s parta damago, gonto
dobrdomont and tho mantonanco ol good apposton ol tho onds s normay
undortakon. 1ho patont shoud bo nlormod ol tho stuaton.
Cno rocont study has shown that sgnlcant mprovomont n norvo luncton can bo
achovod by spocast surgca nvostgaton and ropar.
88
Iate recognition of nerve damage may require furtber surgicaI expIoration.
S.7 OUTCOMfS Ol UNfRUPTfD THlRD MOIAR MANAGfMfNT
Cutcomos n rosponso to surgca or non-surgca managomont ol thrd moar tooth
may bo succosslu or unsuccosslu. Cutcomos must bo dolnod and quantlod to
onabo audt to ostabsh bost practco. 1ho succoss or othorwso ol tho procoduro
doay shoud bo vowod lrom tho porspoctvo ol tho patont.
A rovow appontmont s roqurod:
89
Whon non-rosorbabo suturos havo boon pacod
Whon compcatons arso
At tho patonts or surgoons roquost.
16
Evidence level III
Evidence level III
5.7.1 SUCCLSSlUL CU1CCML
1hs s achovod whon tho prosontng symptoms and sgns ol dsoaso assocatod
wth a thrd moar tooth havo boon omnatod and tho tssuos havo luy hoaod
wth no rosdua lunctona dolct.
Durng norma hoang t s usua lor tho patont to oxporonco somo dscomlort,
swong and trsmus ovor tho lrst throo postoporatvo days. Symptoms shoud
graduay rosovo ovor tho noxt two wooks.
5.7.2 UNSUCCLSSlUL CU1CCML
1hs ndcatos that compcatons assocatod wth troatmont havo occurrod and aro
porsstont. 1hoso ong torm compcatons may ncudo:
Persistent patboIogy
Sovoro nlocton, lor oxampo ostoomyots, roquros ong torm antbotc thorapy
and probaby lurthor surgory.
Sensory nerve damage
Damago to tho ngua norvo oadng to sonsory dsturbancos usuay mprovos
wth tmo. Howovor, porsstonco ol symptoms boyond throo months ndcatos
that a roturn to norma luncton s unkoy and that consdoraton shoud bo
gvon to norvo ropar.
88
Damago to tho nloror avooar norvo, oadng to porsstont hypoaosthosa/
dysaosthosa n ts sonsory dstrbuton, s oss amonabo to surgca ropar. 1ho
prognoss lor spontanoous norvo rogonoraton altor sx months s poor.
12
Oro-antraI fistuIa
1hs roquros surgca ropar as outnod oaror (see section S.6.2i.
TemporaI mandibuIar [oint dysfunction
Approprato jaw oxorcsos, solt dot, anagosa and ora appancos may bo hoplu.
PsycboIogicaI compIications
Such compcatons aro raro. lt s bost practco to rolor tho patont to thor CMF
as thoro may bo othor undoryng contrbutng lactors.
Damage to ad[acent teetb.
An audt tra shoud bo sot up to onabo outcomo to bo montorod, both cncay
and lrom tho patonts vowpont.
S.8 PATlfNT lNlORMATlON
lt s rocognsod that good communcaton s contra to tho cncan-patont
roatonshp and to good cnca caro. Fatonts roquro nlormaton about tho optons
avaabo lor managomont ol thor thrd moars, togothor wth an oxpanaton ol tho
oporaton/procoduro tsol.
At tho prooporatvo appontmont, tho potonta outcomo ol any choson courso ol
acton advorso or othorwso shoud bo oxpanod to tho patont n torms that
thoy can oasy undorstand. Dotas shoud bo notod n tho patonts rocords and
shoud ncudo aspocts roatng to tho patonts quaty ol lo.
90, 91
ln addton, caro
shoud bo takon to oxpan to tho patont tho consoquoncos ol not havng tho tooth
romovod and othor troatmont optons whch may bo roqurod n ths ovont.
17
1ho nlormaton provdod shoud bo sullcont to onabo tho patont or thor caror to
mako a vad nlormod docson and gvo consont.
72
1ho US Natona lnsttutos ol
Hoath rocommond that patonts shoud bo nlormod ol potonta surgca rsks
ncudng any transtory condton that occurs wth an ncdonco >5 and any
pormanont condton wth an ncdonco >0.5.
31
At tho tmo ol surgory, tho patont shoud bo romndod ol tho possbo compcatons
and sdo-ollocts ol tho oporaton. 1ho oporator shoud onsuro that consont has boon
obtanod, that tho patont st wants to go ahoad wth tho procoduro, and a noto
shoud bo mado n tho patonts rocords.
At tho tmo ol tho oporaton, tho patont shoud know:
How to contact tho surgoon n caso ol omorgoncy
How to ook altor thor mouth postoporatvoy
Fossbo compcatons and sdo ollocts ol tho oporaton n gonora and any
proboms spoclc to tho oporaton undortakon
Any drug thorapy roqurod
Whothor a rovow appontmont s roqurod and l so, whon
1hat postoporatvoy tho rolorrng practtonor w rocovo a ottor dotang
tho troatmont undortakon.
Koy mossagos lor patonts lrom ths gudono aro notod n Annox 2.
18
6 Recommendations for audit and researcb
Wo-dosgnod and managod randomsod controod tras (kC1s; rogardng tho
managomont ol thrd moars whch ncorporato a sullconty argo sampo popuaton
to dotoct cncay mportant dlloroncos havo not boon carrod out. lt has boon
suggostod that argo scao studos n rogons ol tho word wth poor provson ol
ora hoath caro mght hop dotormno tho ovo ol pathoogy assocatod wth
unoruptod thrd moars n dlloront ago groups. Howovor, gvon tho mutpo
varabos whch alloct popuatons n dlloront parts ol tho word, t s doubtlu
whothor such an approach woud nlorm surgca practco n tho UK.
1ho outcomo ol a prospoctvo ntornatona argo mutcontro tra ovor lvo yoars
may provdo vauabo nlormaton but moannglu data s koy to tako many yoars
to omorgo.
ln tho absonco ol wo dosgnod kC1s and gvon tho dllcutos n conductng such
studos n a argo numbor ol contros n tho UK, tho gudono dovoopmont group
has suggostod a numbor ol aroas whoro wo dolnod rosoarch or audt studos coud
rovoa sgnlcant nlormaton.
1ho loowng rosoarch/audt projocts woud provdo vauabo nlormaton to support
tho luturo dovoopmont ol ths gudono:
What proporton ol asymptomatc unoruptod thrd moar tooth wthn dlloront
ago cohorts w roquro actvo managomont n tho luturo:
ls oca anaosthosa admnstraton, lor oporatons undor gonora anaosthotc,
hoplu n roducng post oporatvo pan n tho short and ong torm:
Whch lactors alloct morbdty loowng tho romova ol unoruptod thrd moar
tooth, o.g. ago, storod and/or antbotc thorapy:
What aro tho roatvo cost bonolts ol undortakng thrd moar romova n dlloront
cnca sottngs (gonora donta practco, spocast practco or hospta;:
How doos thrd moar romova nluonco quaty ol lo:
What s tho roatonshp botwoon radoogcay dotormnod locuar sgns and
hstoogcay conlrmod locuar pathoogy:
What aro tho compcatons assocatod wth thrd moar romova n dlloront
cnca sottngs:
An audt ol tho nocosstos and lroquoncos ol thorapoutc ntorvonton altor
thrd moar surgory.
Audt ol tho nocossty lor rovow appontmonts.
Audt ol lactors alloctng wound hoang loowng thrd moar surgory.
19
6 RfCOMMfNDATlON lOR AUDlT AND RfSfARCH
Annex 1
DfTAlIS Ol THf SYSTfMATlC RfVlfW UNDfRTAKfN lOR THlS GUlDfIlNf
1ho nta toraturo soarch was carrod out n May 1997 and was updatod durng tho courso ol tho
gudono dovoopmont.
1ho MLDLlNL databaso lrom 1966 was soarchod lor ovdonco-basod toraturo. 1hs dontlod
119 papors. 1ho LMASL databaso lrom 1974 was soarchod lor ovdonco-basod Lngsh anguago
papors roatng to human subjocts. 1hs dontlod 313 rosuts.
1ho ovdonco-basod soarch crtora ncudod rosoarch or ovdonco-basod gudonos, mota-anaysos,
systomatc rovows or ovorvows, toraturo or acadomc rovows, randomsod controod tras or
studos, pacobos, random aocaton, trpo, doubo or sngo bnd mothod or masks or procoduro,
cnca tras, spoclcay oxcudng ottors, hstorca artcos, rovows ol roportod casos or mutcaso
rovows or studos.
1ho soarch was mtod by subjoct to mpactod, unoruptod, asymptomatc thrd or 3rd moar or
moars or wsdom tooth or tooth.
ln addton a gonora subjoct soarch ol tho MLDLlNL databaso lor Lngsh anguago papors roatng
to human subjocts lrom1985 dontlod 738 ctatons.
1ho gonora subjoct soarch lor mpactod, unoruptod, asymptomatc thrd or 3rd moar or moars or
wsdom tooth or tooth, but not mtod to tho ovdonco-basod crtora stod abovo, covorod many
spoclc subjoct aroas.
20
Annex 2
KfY MfSSAGfS lOR PATlfNTS
JA These key messages ate not intended lot ditect dissemination to patients, but may be incotpotated into
local patient inlotmation matetials. - ptoject to develop a patient vetsion ol this guideline is ptesently in
ptogtess. Iutthet details will be available on the SIC! website (www.sign.ac.uki ltom -utumn 2000.
Tbe pros and cons of removing unerupted and impacted tbird moIar teetb:
As a gonora prncpo, tooth shoud not bo romovod wthout duo causo. 1hs appos to thrd
moars as much as t doos to any othor tooth.
A lorms ol surgory carry somo rsk ol compcatons. Lxtracton ol unoruptod and mpactod thrd
moar tooth somotmos oads to proboms such as pan and swong, togothor wth tho possbty
ol atorod sonsaton n tho ps or tonguo. Lvon n tho bost ol hands, accdonts can occur.
Whoro thoro s adoquato spaco, unoruptod tooth shoud bo olt n paco to orupt. ln chdhood,
ovon mpactod tooth may chango thor poston. lt s not possbo to prodct accuratoy whothor
tooth w orupt and thoro s tto ovdonco that tho tooth bocomo moro dllcut to romovo wth
ago, or that moro compcatons occur by oavng thom n paco.
Howovor, thoro aro somo dolnto ndcatons lor romova ol thrd moars. lor oxampo, whoro
thoro has boon rocurront pan and dscomlort duo to mutpo opsodos ol nlocton, thon romova
ol thrd moars may bo approprato to roduco tho pan and nconvononco to tho patont, tmo oll
work, and tho rsks and costs assocatod wth ropoatod antbotc troatmont.
Cthor stuatons whoro t may bo n tho patonts bost ntorost to havo oary romova ol thrd
moars ncudo thoso whoso jobs moan that thoy may havo to work n stuatons soatod lrom
oxport troatmont, or whon modca condtons may oad to dllcuty or rsk wth thor romova.
How wiII tbe decision be made!
Your dontst or doctor w carry out a lu assossmont, ncudng takng your modca and donta
hstory, and a cnca oxamnaton to soo l romova ol tho tooth or tooth s ndcatod and s
advsabo. Ho or sho w dscuss wth you tho advantagos and dsadvantagos ol romova n your
partcuar caso, as wo as tho possbo rsks ol tho oporaton. You w aso havo ono or moro x-
rays ol your tooth takon boloro any docson to oporato s agrood. 1ho cncan shoud aso
oxpan tho mpcatons ol a docson not to romovo tho tooth and any possbo proboms n tho
luturo.
Tbe operation itseIf:
Conora anaosthosa may bo noodod lor compox and ongthy oporatons, but oca anaosthosa
carros oss rsk ol compcatons.
rusng and swong olton occur loowng thrd moar surgory, but usuay go wthn two wooks
Cthor common compcatons ol thrd moar surgory ncudo boodng, mnor nlocton, and
damago to tho adjacont tooth. Your doctor or dontst w nlorm you l any proboms arso durng
surgory and dscuss wth you l any lurthor troatmont s noodod.
After tbe operation:
Your doctor or dontst w advso you how to ook altor you mouth altor tho oporaton, o.g. wth
hot saty mouthwashos, and what pankors to tako, o.g. paracotamo or buprolon.
1horo s no ovdonco to suggost that antbotcs shoud routnoy bo proscrbod loowng thrd
moar romova, but thoy may bo noodod n somo casos.
oloro oavng, you shoud know how to contact tho surgoon n caso ol omorgoncy. A rovow
appontmont may bo arrangod, but ths s not aways nocossary. A ottor w aso bo sont to your
own dontst to ot hm or hor know about tho oporaton and any loow up arrangomonts.
21
ANNfXfS
References
1 LS Depurtment of Heuth und Humun Servces. Agency for Heuth Cure Pocy und Reseurch. Acute Pun Munugement:
operutve or medcu procedures und truumu. Rockve (MD): 1he Agency, 1993. Cncu Pructce Cudene No.1.
AHCPR Pubcuton No.92-0023. p.107
2 Runtunen AV. 1he uge of erupton of the thrd mour teeth. Actu Cdonto Scund 1967, 25: supp 48.
3 Song |, Lundes DP, Cenny AM, Shedon 1A. Prophyuctc removu of mpucted thrd mours: un ussessment of
pubshed revews. NHS Centre for Revews und Dssemnuton, Lnversty of York, Cctober 1996.
4 Von Wowern N, Neson HC. 1he fute of mpucted ower thrd mours ufter the uge of 20. A four-yeur cncu foow
up.lnt } Cru Muxofuc Surg 1989, 18: 277-80.
5 Levesque CY, Demrjun A, 1unguuy R. Sexuu dmorphsm n the deveopment, emergence, und ugeness of the
mundbuur thrd mour. } Dent Res 1981, 60: 1735-41.
6 Curcu Rl, Chuuncey HH. 1he erupton of thrd mours n uduts: u 10 yeur ongtudnu study. Cru Surg oru Med Cru
Putho1989, 68: 9-13.
7 Royu Coege of Surgeons of Lngund |ucuty of Dentu Surgery. 1he munugement of putents wth thrd mour teeth:
report of u workng purty convened by the |ucuty of Dentu Surgery, 1he Royu Coege of Surgeons of Lngund.
London: |ucuty of Dentu Surgery RCS (Lng), 1997. (Current cncu pructce und purumeters of cure).
8 Hugoson A, Iugeberg C|. 1he prevuence of thrd mours n u Swedsh popuuton. An epdemoogcu study.
Communty Dent Heuth 1988, 5: 121-38
9 rckey M, Shepherd }, Muncn C. Compurson of cncu treutment decsons wth LS Nutonu lnsttutes of Heuth
consensus ndcutons for ower thrd mour removu. r Dent } 1993, 175: 102-5.
10 Suder A, Duvdson M, Houps C, Wutt-Smth S. Specust pructce for mnor oru surgery: u compurutve uudt of thrd
mour surgery. r Dent } 1993, 174: 273-7.
11 Shepherd }P, rckey M. Surgcu removu of thrd mours. M} 1994, 309: 620-1.
12 Curmchue |A, McCowun DA. lncdence of nerve dumuge foowng thrd mour removu: u West of Scotund Cru
Surgery Reseurch Croup study. r } Cru Muxofuc Surg 1992, 30: 78-82.
13 Shepherd }P. 1he thrd mour epdemc. r Dent } 1993, 174: 85.
14 Scottsh lntercoegute Cudenes Network (SlCN). SlCN Cudenes: un ntroducton to SlCN methodoogy for the
deveopment of evdence-bused cncu gudenes. Ldnburgh, SlCN: 1999 (SlCN pubcuton no. 39).
15 NHS Centre for Revews und Dssemnuton, Lnversty of York. Prophyuctc removu of mpucted thrd mours: s t
justfed: Lffectveness Mutters 1998, 3: 2.
16 rtsh Assocuton of Cru & Muxofucu Surgeons. Pot cncu gudenes. London, }unuury 1995
17 Mercer P, Precous D. Rsks und benefts of removu of mpucted thrd mours. A crtcu revew of the teruture. lnt
} Cru Muxofuc Surg 1992, 21: 17-27.
18 Purumeters of cure for Cru und Muxofucu surgery: u gude for pructce, montorng und evuuuton (AACMS
Purumeters of Cure -95) } Cru und Muxofucu Surg 1995, 53 supp.
19 uckburn CW, rumey PA. Lnguu nerve dumuge ussocuted wth the removu of ower thrd mours. r Dent } 1989,
167: 103-7.
20 Codberg Mll, Nemerch AN, Murco WP. Compcutons ufter thrd mour surgery: u retrospectve study. lnt } Cru Surg
1985, 14: 29-40.
21 Rood }P, Murgutroyd }. Metronduzoe n the preventon of 'dry socket'. r } Cru Surg 1979, 17: 62-70.
22 Rood }P, Shehub A. 1he rudoogcu predcuton of nferor uveour nerve njury durng thrd mour surgery. } Cru
Muxofuc Surg 1990, 28: 20-5.
23 Rud }. 1hrd Mour Surgery: reutonshp of root to mundbuur cunu und njures to nferor dentu nerve. 1unduegebudet
1983, 87: 619-31.
24 Howe CL, Poynton HC. Preventon of dumuge to the nferor dentu nerve durng the extructon of mundbuur thrd
mours. D} 1960, 109: 355-63.
25 Peterson L}. Rutonue for removng mpucted teeth: when to extruct or not to extruct. } Am Dent Assoc 1992, 123: 198-204.
26 Robnson PD. 1he mpucted wsdom tooth: to remove or to euve uone: Dentu Lpdute. 1994, 21: 245-8.
27 Ventu l, 1urtou L, Ypuuvunem P. Chunge n cncu stutus of thrd mours n uduts durng 12 yeurs of observuton.
} Cru Muxofuc Surg 1999, 57: 386-9.
28 ruce RA, |rederckson CC, Smu CS. Age of putents und morbdty ussocuted wth mundbuur thrd mour surgery.
} Am Dent Assoc 1980, 101: 240-5.
22
29 Lusson S, Hemduh A, Nordenrum A. Puthoogcu chunges reuted to ong-term mpucton of thrd mours. A
rudogruphc study. lnt } Cru Muxofuc Surg 1989, 18: 210-2.
30 Lyse L, Rohn M. A study of ndcutons used for removu of the mundbuur thrd mour. lnt } Cru Muxofuc Surg
1988, 17: 161-4.
31 NlH consensus deveopment conference for removu of thrd mours. } Cru Surg 1980, 38: 235-6.
32 Csborn 1P, |rederckson C, Smu lA, 1ogerson 1S. A prospectve study of compcutons reuted to mundbuur thrd
mour surgery. } Cru Surg 1985, 43: 767-9.
33 Rchurdson M. Chunges n the ower thrd mour poston n the young udut. Am } Crthod Dentofuc Crthop 1992, 102:
320-7.
34 AACMS. Report of u workshop on the munugement of putents wth thrd mour teeth. } Cru Muxofuc Surg 1994, 52:
1102-12.
35 Muson DA. Lnguu nerve dumuge foowng thrd mour surgery. lnt } Cru Muxofuc Surg 1988, 17: 290-4.
36 1oth . 1he uppropruteness of prophyuctc extructon of mpucted thrd mours: u revew of the teruture. rsto:
Lnversty of rsto, Heuth Cure Lvuuuton Lnt, 1993.
37 Leone SA, Ldenfed M}, Cohen ML. Correuton of ucute percoronts und the poston of the mundbuur thrd mour.
Cru Surg 1986, 62, 245-50.
38 Pronen }, Ypuuvunem P. Locu predsposng fuctors und cncu symptoms n percoronts. Proc |nn Dent Sc
1981, 77: 278-82.
39 Nordenrum A, Hutn M, Ijemun L, Rumstrom C. lndcutons for surgcu removu of thrd mours. Study of 2630
cuses. Swed Dent } 1987, 11: 23-9.
40 vun der Lnden W, Ceuton-}ones P, Lowne M. Dseuses und esons ussocuted wth thrd mours. Revew of 1001
cuses. Cru Surg Cru Med Cru Putho Cru Rudo Lndod 1995, 79: 142-5.
41 Iugeberg C|, Ahstrom L, Lrcson S, Hugoson A, Ivnt S. Perodontu heung ufter mpucted ower thrd mour
surgery n udoescents und uduts. A prospectve study. lnt } Cru Muxofuc Surg 1991, 20: 18-24.
42 Cosser }W, Cumpbe }H. Puthoogc chunge n soft tssues ussocuted wth rudogruphcuy 'normu' thrd mour
mpuctons. r } Cru Muxofuc Surg 1999, 37: 259-60.
43 Inghts LM, rokuw WC, Iessur HP. 1he ncdence of dentgerous cysts ussocuted wth u rundom sumpng of
unerupted thrd mours. Ceneru Dentstry 1991, 39: 96-8.
44 Ntzun D, Ieren 1, Murmury Y. Does un mpucted tooth cuuse root resorpton of the udjucent one: Cru Surg Cru Med
Cru Putho 1981, 51, 221-4.
45 Hurrudne NW, Peurson MH, 1oth . 1he effect of extructon of thrd mours on ute ower ncsor crowdng: u
rundomsed controed tru. r } Crthod 1998, 25:117-22.
46 Ades AC, }oondeph DR, Ltte RM, Chupko MI. A ong-term study of the reutonshp of thrd mours to chunges n the
mundbuur dentu urch. Am } Crthod Dentofucu Crthop 1990, 97: 323-5.
47 ergstrom I, }ensen R. Responsbty of thrd mour for secondury crowdng. Dentu Abstructs 1961, 6: 544-5.
48 rumunte MA. Controverses n orthodontcs. Dent Cn North Am 1990, 34 : 91-102.
49 Lnqust , 1hunder . Lxtructon of thrd mours n cuses of untcputed crowdng of the ower juw. Am } Crthod.
1982, 81: 130-9.
50 Rchurdson ML. 1he roe of the thrd mour n the cuurse of ute ower urch crowdng: u revew. Am } Crthod
Dentofucu Crthop. 1989, 95: 79-83.
51 Shuney LS. 1he nfuence of mundbuur thrd mours on mundbuur unteror teeth. Am } Crthod 1962, 48: 786-7.
52 Southurd 1L, Southurd IA, Weedu LW. Mesu force from unerupted thrd mours. Am } Crthod Dentofucu Crthop
1991, 99: 220-5.
53 Southurd 1L. 1hrd mours und ncsor crowdng: when removu s unwurrunted. } Am Dent Assoc 1992, 123: 75-9.
54 Stephens RC, Iogon SL, Red }A. 1he unerupted or mpucted thrd mour - u crtcu upprusu of ts puthoogc potentu.
} Cun Dent Assoc 1989, 55: 201-7.
55 Schwurze CW. 1he nfuence of thrd mour germectomy: u compurutve ong-term study. ln: Cook }1 ed 1runs 3rd lnt,
Crthodontc Congress London, Crosby Lockwood Stupes 1975, 551-62.
56 Vusr NS, Robnson R}. 1he mundbuur thrd mour und ute crowdng of the mundbuur ncsors u revew. r }
Crthod 1991, 18: 59-66.
57 Vego L. A longtudnu study of mundbuur urch permeter. Ange Crthod. 1962, 32: 187-92.
58 Rubn MM, Io 1}, Sudoff RS. Morbdty ussocuted wth ncompetey erupted thrd mours n the ne of mundbuur
fructures. } Cru Muxofuc Surg 1990, 48: 1045-7.
59 Wums }LL, Rowe & Wums. |ructures of the fucu skeeton. Ldnburgh, Church Lvngstone, 1994.
RflfRfNCfS
23
60 Shuh }. Heud & Neck Surgery, London. Wofe, 1996
61 Stuney HR, Autter M, Coett WM, Strngfeow HR }r, Spege LH. Puthoogcu sequeue of negected mpucted
thrd mours. } Cru Putho 1988, 17: 113-7.
62 Nuno Conzue MM, Lurenu de Rosuro ML. Lstudo rudogrufco de u fromucen y cucfcucon de tercer mour.
Pructcu Cdontoogcu 1990, 11: 27-8.
63 Ventu l, Murtommuu H, 1urtou L, Meurmun }, Ypuuvunem P. Assessng the erupton of ower thrd mours on
the buss of rudogruphc feutures. r } Cru Muxofuc Surg 1991, 29: 259-62.
64 Whte SC. 1992 ussessment of ruduton rsk from dentu rudogruphy. Dentomuxofuc Rudo 1992, 21:118-26.
65 |ucuty of Ceneru Dentu Pructtoners (LI). Seecton crteru for dentu rudogruphy. London: |ucuty of Ceneru
Dentu Pructtoners 1998.
66 Lecomber AR, |uukner I. Dose reducton n punorumc rudogruphy. Dento-muxo-fucu Rudoogy 1993, 22: 69-73
67 Nutonu Rudoogcu ourd (LI). Cudenes on rudoogy stundurds for prmury dentu cure. Chten (Cxon): 1he
ourd, 1994.
68 Stufne LC. Cru roentgenogruphc dugnoss. Phudephu & London: W Suunders, 1958.
69 Iuh , Ceruch IL, Hgers RD. A ong-term, foow-up, rudogruphc evuuuton of usymptomutc mpucted thrd
mours n orthodontcuy treuted putents. lnt } Cru Muxofuc Surg 1994, 23: 279-85.
70 rockebunk L. Dentu rudoogy: understundng the x-ruy muge. Cxford: Cxford Lnversty Press1997 pp74-92
71 rockebunk LM. Assessment of the rudogruphc muge: recognton of normu feutures. Dent Lpdute 1998, 25: 343-50.
72 Luyton S, Iorsen }. lnformed consent n oru und muxofucu surgery: u study of the vuue of wrtten wurnngs. r }
Cru Muxofuc Surg 1994, 32: 34-6.
73 Royu Coege of Surgeons of Lngund, Commsson on the Provson of Surgcu Servces. Cudenes for duy cuse
surgery: report of the Workng Purty.London: the Coege. Murch 1992.
74 Ceneru Dentu Counc, LI. Muntunng Stundurds. Cudunce to Dentsts on Professonu und Personu Conduct.
Secton 4.7 Resusctuton, sectons 4.17-4.24 Ceneru Anuesthesu. November 1997, revsed Muy 1999.
75 Robnson PP, Smth IC . Lnguu nerve dumuge durng ower thrd mour removu: u compurson of two surgcu
methods. r Dent } 1996, 180: 456-61.
76 McCurk M, Huske R. Wsdom tooth removu und nguu nerve dumuge. r } Cru Muxofuc Surg 1999, 37: 253-4.
77 Leonurd MS. Removng thrd mours: u revew for the generu pructtoner. } Am Dent Assoc 1992, 123: 77-8.
78 Huske R. Medco-egu consequences of extructng ower thrd mour teeth. Med Prot Soc Ann Report 1986, 51-2.
79 Pecuch }|, Arzudon }, Lebch SL. Prophyuctc untbotcs for thrd mour surgery: u supportve opnon. } Cru
Muxofuc Surg 1995, 53: 53-60.
80 Worru S|. Antbotc prescrbng n thrd mour surgery. r } Cru Muxofuc Surg 1998, 36: 74-5.
81 Seymour RA, Wurd-ooth P, Iey P}. Lvuuuton of dfferent doses of soube buprofen und buprofen tubets n
postoperutve dentu pun. r } Cru Muxofuc Surg 1996, 34: 110-4.
82 Hound CS. 1he nfuence of methyprednsoone on post-operutve sweng foowng oru surgery. r } Cru
Muxofuc Surg1987, 25: 293-9.
83 Neupert LA, Lee }W, Phput C, Cordon }R. Lvuuuton of dexumethusone for reducton of postsurgcu sequeue of
thrd mour removu. } Cru Muxofuc Surg 1992, 50: 1177-82.
84 Lsen L, 1usur |, Akhun C. Determnuton of the unt-nfummutory effects of methyprednsoone on the sequeue of
thrd mour surgery. } Cru Muxofuc Surg 1999, 57: 1201-8.
85 Chupusco M, De Ccco L, Murrone C. Sde effects und compcutons ussocuted wth thrd mour surgery. Cru Surg
Cru Med Cru Putho 1993, 76: 412-20.
86 Lursen PL. Aveour ostets ufter surgcu removu of mpucted mundbuur thrd mours. ldentfcuton of the putent ut
rsk. Cru Surg Cru Med Cru Putho.1992, 73: 393-7.
87 Sunds 1, Pynn R, Nennger S. 1hrd mour surgery: current concepts und controverses. Purt 2. Cru Heuth 1993, 83: 19.
88 Robnson PP, Smth IC. A study on the effcucy of ute nguu nerve repur. r } Cru Muxofuc Surg 1996, 34: 96-103.
89 Prutt CA, Hekmut M, Prutt SD, Zuk CA, urnurd }DW. Controverses n thrd mour surgery the nutonu vew on
revew struteges. r } Cru Muxofuc Surg 1997, 35: 319-22.
90 Suvn }, Cgden CR. 1hrd mour surgery - u premnury report on uspects uffectng quuty of fe n the eury
postoperutve perod. r } Cru Muxofuc Surg 1997, 35: 246-53.
91 Cgden CR, ssus L, Rutu DA, Cgston S. uuty of fe foowng thrd mour removu: u putent versus professonu
perspectve. r Dent } 1998, 185: 407-10.
24
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SlGN PubIication
Number
S I G N
M
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o
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U
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u
p
t
e
d

a
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d
l
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T
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t
b
3KE? 4ABAHA?A /KE@A
A ndcatos grado ol rocommondaton C KfY good practco pont
&
8 &ln putonts whoso thrd mours woud bo judgod to orupt succossfuy und huvo u functonu roo
n tho dontton.
C &ln putonts whoso modcu hstory rondors romovu un unuccoptubo rsk to tho ovoru houth of
tho putont or whoro tho rsk oxcoods tho bonoft.
8 &ln putonts wth doopy mpuctod thrd mours wth no hstory or ovdonco of portnont ocu or
systomc puthoogy.
C &ln putonts whoro tho rsk of surgcu compcutons s judgod to bo unuccoptuby hgh, or whoro
fructuro of un utrophc mundbo muy occur.
C &Whoro tho surgcu romovu of u sngo thrd mour tooth s punnod undor ocu unuosthosu tho
smutunoous oxtructon of usymptomutc contruutoru tooth shoud not normuy bo undortukon.
RfMOVAI Ol UNfRUPTfD AND lMPACTfD THlRD MOIARS lS NOT ADVlSAIf:
"
C "ln putonts who uro oxporoncng or huvo oxporoncod sgnfcunt nfocton ussocutod wth
unoruptod or mpuctod thrd mour tooth.
C "ln putonts wth prodsposng rsk fuctors whoso occuputon or fostyo procudos roudy uccoss
to dontu curo.
C "ln putonts wth u modcu condton whon tho rsk of rotonton outwoghs tho potontu
compcutons ussocutod wth romovu of thrd mours (o.g. pror to rudothorupy or curduc
surgory).
C "ln putonts who huvo ugrood to u tooth trunspunt procoduro, orthognuthc surgory, or othor
roovunt ocu surgcu procoduro.
C "Whoro u gonoru unuosthotc s to bo udmnstorod for tho romovu of ut oust ono thrd mour,
consdoruton shoud bo gvon to tho smutunoous romovu of tho opposng or contruutoru
thrd mours vhon tho tsls oi totonton and a iutthot gonotal anaosthotc outvogh tho tsls
assocatod vth thot tomoval.
RfMOVAI Ol UNfRUPTfD AND lMPACTfD THlRD MOIARS lS ADVlSAIf:
C "|or uutogonous trunspuntuton to u frst mour sockot.
C "ln cusos of fructuro of tho mundbo n tho thrd mour rogon or for u tooth nvovod n tumour
rosocton.
C "An unoruptod thrd mour n un utrophc mundbo.
C "Prophyuctc romovu of u purtuy oruptod thrd mour or u thrd mour whch s koy to orupt
muy bo uppropruto n tho prosonco of cortun spocfc modcu condtons.
C "A purtuy oruptod or unoruptod thrd mour coso to tho uvoour surfuco, pror to donturo
constructon or coso to u punnod mpunt.
OTHfR lNDlCATlONS lOR RfMOVAI:
"
C "Cno or moro opsodos of nfocton such us porcoronts, couts, ubscoss formuton,
or untroutubo pupu/porupcu puthoogy.
8 "Curos n tho thrd mour whch s unkoy to bo usofuy rostorod, or curos n tho udjucont
socond mour whch cunnot sutsfuctory bo troutod wthout tho romovu of tho thrd mour.
8 "Porodontu dsouso duo to tho poston of tho thrd mour und ts ussocuton wth tho socond
mour.
8 "Cusos of dontgorous cyst formuton or othor routod oru puthoogy.
8 "Cusos of oxtornu rosorpton of tho thrd mour or of tho socond mour whoro ths woud uppour
to bo cuusod by tho thrd mour.
STRONG lNDlCATlONS lOR RfMOVAI:
" "" ""CIlNlCAI ASSfSSMfNT
CLlNlCAL ASSLSSMLN1
otupton status oi thtd molat
ptosonco oi local niocton
catos n ot tosotpton oi tho thtd molat ot adjacont
tooth
potodontal status
otontaton and tolatonshp oi tho tooth to tho niotot
dontal canal
occlusal tolatonshp
tompotomandbulat jont iuncton
togonal lymph nodos
-ny assocatod pathology should bo notod.
Cncu ussossmont shoud bo currod out wth tho um
of ussossng tho stutus of tho thrd mours und oxcudng
othor cuusos of tho symptoms.
8 Routno rudogruphc oxumnuton of unoruptod thrd
mours s NC1 rocommondod.
Rudoogcu ussossmont s ossontu pror to surgory,
but doos not nood to bo currod out ut tho ntu
oxumnuton.
At oporuton, tho whoo tooth shoud bo romovod und
wound toot compotod. Any suspoctod puthoogcu
mutoru shoud bo sont for oxumnuton.
Consdor untbotcs uso n sovoro cusos whoro thoro s
ucuto nfocton ut tho tmo of oporuton, sgnfcunt bono
romovu, or proongod oporuton.
8 Consdor prcopcrativc stcroids f rsk of sgnfcunt
postoporutvo swong.
8 Consdor antibiotics f sgns of sytomc nvovomont
(pyroxu, rogonu ymphudonoputhy).
8 Divcrsion of thc infcrior dcntaI canaI,
dar|cning of thc root whcrc crosscd by thc canaI, or
intcrruption of thc whitc Iincs of thc canaI
uro ussocutod wth u sgnfcunty incrcascd ris| of
ncrvc in[ury durng thrd mour surgory.
Crout curo shoud bo tukon n surgcu oxporuton und
tho docson to trout shoud bo curofuy rovowod.
1hc paticnt shouId bc carcfuIIy adviscd of thc ris|.
RADlCLCClCAL ASSLSSMLN1
typo and otontaton oi mpacton and tho accoss to
tho tooth
ctovn szo and condton
toot numbot and motphology
alvoolat bono lovol, ncludng dopth and donsty
iollculat vdth
potodontal status, adjacont tooth
tolatonshp ot ptoxmty oi uppot thtd molats to tho
maxllaty anttum and lovot thtd molats to tho niotot
dontal canal
" "" ""CIlNlCAI MANAGfMfNT
CCMMCN CCMPLlCA1lCNS
Hacmorrhagc:
Contro ut tmo of surgory. Soft tssuo boodng muy roquro
huomostutc ugonts, bpour duthormy und/or suturos.
8ruising:
Putonts shoud bo nformod thut brusng s common und
w usuuy rosovo wthn two wooks.
DispIaccmcnt:
Appropruto nstrumonts shoud bo n puco pror to
oovuton to hop provont dspucomont. Rocovor uny
dspucod tooth ut tmo of surgory f possbo, or urrungo
roforru to u spocust contro.
Wound dchisccncc:
lf no pun or nfocton, udvso putonts to contnuo wound
toot (o.g. hot suty mouthwushos, sockot syrngng).
Damagc to ad[accnt tccth:
lnform putont ut tmo of surgory (or whon fuy conscous).
Rocord n notos und urrungo ropur f roqurod.
A rovow uppontmont s roqurod:
whoro non-rosorbubo suturos huvo boon pucod
whoro compcutons urso
ut tho putont's or surgoon's roquost.
SLRlCUS CCMPLlCA1lCNS
fracturc of thc mandibIc or maxiIIa:
1rout ut tmo of surgory or urrungo mmoduto roforru.
Oro-antraI communication: Ropur ut tmo of surgory,
usuuy wth u buccu udvuncomont fup. Antbotc thorupy
s udvsubo und tho putont shoud uvod noso bowng.
8ro|cn instrumcnt: Romovo ut tmo of surgory. lf not
rotrovubo, nform tho putont und rocord n notos.
Ncrvc damagc: |or compoto trunsocton of nguu or
nforor dontu norvos, urrungo mmoduto norvo ropur by
oxporoncod surgoon. |or purtu dumugo, dobrdo gonty
und muntun good upposton of tho onds.
Scottsh lntorcollogato Cudolnos Notvork, 2000
Dorvod lrom tho natonal clncal gudolno rocommondod lor uso n Scotland by tho Scottsh lntorcollogato
Cudolnos Notvork (SlCN;, koyal Collogo ol Fhyscans ol Ldnburgh, 9 Quoon Stroot, Ldnburgh LH2 1}Q
Avalablo on tho SlCN vobsto: vvv.sgn.ac.uk
Tbis guideIine was issued in Marcb 2000 and wiII be reviewed in 2002

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