The consensus for the management of impacted third molars with pathological conditions is extraction. However, the best management for asymptomatic impacted third molars is still a matter of debate. Third molars or also known as wisdom teeth, generally erupt when a person is 17-26 years old. However, this third molar may be impacted due to insufficient eruption space in the jaw and disruption of its eruption path due to the surrounding teeth.

Should the Impacted Third Molars be Extracted?
the blue arrow points to the impacted third molars
image source: http://www.drjjournal.net


The prevalence of impacted third molars reached 24%, higher than the other teeth. Although tooth impacted is not a pathological condition, it is whole or partially associated with pathological conditions such as pericoronitis, root resorption, periodontal disease, caries, cysts, and tumors.

The extraction of the third molar is one of the most common procedures performed by a dentist. In the United States, 95% of tooth extractions between the ages of 16 and 21 are extracted from this third molar. Such extraction is carried out, especially if some initial signs or symptoms suggest a pathological condition.

Retention or Extraction Considerations for Impacted Third Molar

In general, there are two contraindications to third molar extraction, namely:
  1. A fully developed third molar, but still buried in the bone without any signs or symptoms of pathology
  2. The extraction procedure endangers the patient's systemic and local health
Although extraction is the most preferred treatment for impacted third molars, retention may also be an option. A study found several reasons that dentists consider retaining impacted third molars:
  • If the tooth eventually begins to erupt and there is indeed room for the tooth to erupt.
  • Refusal, in other words, the patient did not give informed consent.
  • There are contraindications, such as systemic health problems.
  • There are no pathological signs or symptoms, especially in patients aged 30 years and over.
Most general dentists choose to perform extractions to prevent future problems (prophylactic extraction), or because according to evaluation, the tooth orientation did not allow a proper eruption. Conversely, dentists can also choose to make prior observations to not make premature decisions about extractions, especially if the patients have no complaints.


Risks of Complications of  Impacted Third Molar Extraction

Complications after tooth extraction are also considered in choosing treatment. Localized osteitis, trigeminal nerve damage, postoperative infection, and bleeding are potential complications after the extraction of impacted third molars.



Retention vs Extraction in Impacted Asymptomatic Third Molar

In 2000, The National Institute for Health and Care Excellence (NICE) argued that there was no strong evidence to perform prophylactic extraction of impacted third molars and without symptoms or signs of disease.

Not only from NICE, but clinical guidelines from the SIGN (Scottish Intercollegiate Guidelines Network, 2000) and KCE (Belgian Health Care Knowledge Center, 2012) also recommend against prophylactic extraction of third molars due to the lack of scientific evidence that the third molar will potentially become a problem.

A systematic review published in May 2020 in the Cochrane Database of Systematic Reviews attempted to analyze whether the extraction of impacted third molars was supported by adequate scientific evidence. We found one prospective cohort study and one clinical trial to be included in the analysis, with 493 patients. The review results show that there is not enough scientific evidence to support the pros and cons of extraction or retention in asymptomatic third molars cases. Researchers advise dentists to rely on clinical experience, national or local guidelines, and patient preferences in making decisions.

Another systematic review in the same year, published by Vandeplas et al., attempted to analyze whether retention of third molars was associated with certain pathological conditions. This study found that it was rare to find cases of third molars left in the bone or partial eruptions that were not accompanied by pathological conditions. Caries and periodontal disease are two conditions that are usually associated with the retention of impacted molars in the jaw. 



Summary
Extraction is the treatment of choice in cases of impacted third molars (M3) accompanied by pathological conditions, such as caries and periodontal disease. However, in cases where pathological conditions did not accompany M3 impaction, prophylactic extraction benefits have not been supported by sufficient high-quality scientific evidence. This extraction act is not without risks. Extraction of M3 impaction can cause post-procedure pain, bleeding, and even serious trigeminal nerve damage. Clinical trials with larger sample sizes are still needed before more definitive conclusions can be drawn.