Removal of Impacted Third

Molar
Indications & Contraindications

CDA Oasis Resource

Adapted from: Manual of Minor Oral Surgery for the General Dentist
Introduction
• Removal of impacted third molars is the most common surgery
in the dental office.

• Impaction: lack of eruption of a tooth into the dental arch within

the expected time.
• Tooth is impacted because eruption is prevented by:
• Physical barrier (adjacent tooth, dense overlying bone, or excessive
soft tissue).
• Inadequate arch length.

• Most common impacted teeth: maxillary and mandibular third

molars, followed by maxillary canines and mandibular
premolars.
Introduction

• All impacted teeth should be evaluated for treatment, either:

• Observation,
• Removal, or
• Surgically assisted eruption.

• Preventive dentistry indicates that impacted teeth be removed

before complications arise.
Indications for Removal of Impacted Third Molar
Pericoronitis
• Infection of the soft tissue that usually occurs around the crown
of a partially impacted tooth.

• Transient decreases in host defenses can precipitate a bacterial

surge and subsequently cause infection that results in
moderate to severe pain and/or trismus.

• Infection may spread to adjacent head and neck fascial spaces.

• Initial treatment: mechanical debridement to cleanse the area,

prescription of oral rinses (e.g. chlorhexidine to reduce bacterial
load), and the use of antibiotics with oral flora coverage.
Indications for Removal of Impacted Third Molar
Periodontal Disease
• Retention of an impacted third molar can compromise the bone
housing the second molar and might predispose it to
periodontal defects.
• Can progress to clinical recession and pocketing leading
ultimately to possible root caries and/or mobility.

Caries
• The posterior position of a third molar presents a hygiene
challenge to the most meticulous of patients.
• Dental caries and pulpal necrosis contribute to an increasing
number of third molar extractions with increasing age.
Indications for Removal of Impacted Third Molar
Root Resorption
• Root resorption associated with an impacted third molar is common
in the 21- to 30-year age group.
• The most common site for root resorption is the middle third of the
distal surface of the adjacent second molar.
Removable Prostheses
• Close attention should be paid to the presence of impacted third
molars as retention of these teeth under prostheses may lead to
their eruption.
• Continued pressure can initiate remodeling of the bone overlying the
tooth, eventually leading to ulceration of the soft tissue and exposure
of the previously un-erupted tooth.
Indications for Removal of Impacted Third Molar
Pathology
• Certain types of tumors and cysts have been associated with the follicles
of impacted teeth.
• Recommended that if impacted teeth have pathology associated with
them, they should be removed, and the pathologic cyst or tumor sent for
histopathological examination.

Management of Dental Crowding/Adjunct to Orthodontic Treatment

• Impacted third molar may interfere with orthodontic movement and is
suspected to provide a long-term mesially directed force that may
contribute to relapse.
• Removal may create some additional space in the posterior jaws for
orthodontic distalization of teeth.
• Timing of removal may be dictated by the orthodontic treatment plan, age
of the patient, and stage of development of the teeth.
Indications for Removal of Impacted Third Molar
Preparation For Orthognathic Surgery
• Recommended to remove such teeth at least 6–9 months to
permit adequate healing of the bone.
• The newly formed bone will allow for a more predictable bone
separation during surgery as well as providing more osseous
bulk for rigid fixation and stability.

Management of Facial Pain

• Third molars may cause pain due to the proximity of the
temporomandibular joint (TMJ) and associated musculature.
Indications for Removal of Impacted Third Molar

Prevention of Pathologic Mandible Fracture

• When a tooth is embedded within the mandible, it occupies
space that would otherwise be bone contributing to its strength.
• If the position of the impaction permits minimal continuity of
bone, it might represent a point of weakness.
• This situation could predispose an individual to fracture of the
mandible in the area of the impaction.
Contraindications for Removal of Impacted Third Molar
Damage to Adjacent Structures
• Many vital structures surround third molars, and with varying
degrees of impactions come varying degrees of risk to these
areas.

• Careful clinical and radiographic analysis is needed to examine

teeth proximity to these structures of concern and to gauge the
extent of surgery required to remove these teeth.

• The analysis is important in determining the extent of morbidity

associated with any procedure.
Contraindications for Removal of Impacted Third Molar
Patient’s Age
• There is some controversy as to the most optimal time for removal.

• General consensus in one area: “Removal of third molar teeth should

be deferred until one can determine whether or not they may remain
impacted.”

• Third molars can be removed at any age; however, surgery is easier

and associated with less morbidity when performed in patients who are
in their late teens or early 20’s.

• Older patients tend to respond less favorably to the removal of teeth,

particularly impacted third molars, due to bone rigidity.
Contraindications for Removal of Impacted Third Molar
Medical Compromise
• A thorough review of the patient’s medical history is required and the
patient must be informed of any issues that may preclude the
removal of a tooth or the need for further preoperative preparation.
• Removal of asymptomatic impacted teeth must be viewed as
elective.
• Consider deferring surgery in cases of cardiovascular or respiratory
conditions, immune compromise, or a significant coagulopathy.
• Non-elective cases: further preoperative preparation, involvement of
the patient’s physician, and possible hospitalization may be
required.
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