Treatment Criteria for Removal of Third Molars: Erupted Third Molars
Definition
An erupted third molar is one so positioned that the entire clinical crown is visible.
Introduction
Based upon a review of the current literature on the topic of third molar extractions, there is nearly unanimous agreement regarding treatment for fully erupted third molars. The following indications and contraindications reflect the current rationale for removal of erupted third molars. Final determinants for treatment, however, will always be the practitioner's clinical judgment and the patient's informed consent.
Indications for Removal*
- Non-restorable, carious tooth.
- Clinical findings of pulp exposure by dental caries.
- Clinical findings of fractured tooth.
- Internal or external resorption of tooth or of adjacent tooth.
- Non-treatable pulpal or periapical lesion.
- Acute and/or chronic infection (abscess or cellulites).
- To limit or manage progression of periodontal disease.
- Tooth shape, size, or position which prevents normal function in the arch.
- Hyper-erupted or ectopic tooth causing occlusal or soft tissue interference.
- To facilitate prosthetic rehabilitation.
- To facilitate orthodontic tooth movement and stability.
- Tooth in the line of jaw fracture complicating fracture management.
- Tooth involved in resection of pathologic lesion.
- Tooth interfering with orthognathic or reconstructive surgery.
- Prophylactic removal, when indicated, for patients with medical or surgical conditions (e.g., organ transplants, alloplastic implants, chemotherapy, radiation therapy).
- Patients informed refusal of non-surgical treatment options.
- No opposing tooth and not needed for prosthetic rehabilitation.
Contraindications for Removal*
- Patient's informed refusal of surgical treatment options.
- Asymptomatic teeth without indications for removal.
- Medical complications.
- Age of the patient (see flow chart in the original guideline).
- Postradiation patients.
- Possibility of damage to important adjacent structures.
- Bisphosphonate therapy (current or history of).
- Post head and neck radiation therapy.
*Note: Indications and contraindications are relative, not absolute.
Treatment Criteria for Removal of Third Molars: Partially Erupted Third Molars
Definition
A partially erupted tooth is one so positioned that only a portion of the clinical crown is visible.
Introduction
Based upon a review of the current literature, the following indications and contraindications reflect the current rationale for removal of partially erupted third molars. Final determinants for treatment will always be the practitioner's clinical judgment and the patient's informed consent.
Indications for Removal*
- Non-restorable, carious tooth.
- History of pericoronitis, or initial incident of pericoronitis with poor prognosis for full eruption or for oral hygiene maintenance.
- Non-treatable pulpal or periapical lesion.
- Acute or chronic infection.
- To facilitate prosthetic rehabilitation.
- To limit or manage progression of periodontal disease.
- Ectopic position and/or tooth shape or size which prevents normal function within the dental arch.
- Tooth in line of jaw fracture, complicating fracture management.
- Tooth involved in resection of pathologic lesion.
- Tooth interfering with orthognathic or reconstructive surgery.
- Prophylactic removal, when indicated, for patients with certain medical or surgical conditions (e.g., organ transplants, alloplastic implants, chemotherapy, and radiation therapy).
- Pathology associated with tooth follicle (e.g., cysts and tumors).
- Clinical findings of fractured tooth or adjacent tooth.
- Internal or external resorption of tooth or adjacent tooth.
- Patients informed refusal of non-surgical treatment options.
- Need for donor transplant.
- Caries on distal of second molar.
Contraindications for Removal*
- Patient's informed refusal of surgical treatment options.
- Asymptomatic with no pathology.
- Medical complications.
- Age of the patient (see flow chart in original guideline).
- Post-radiation patients.
- Possibility of damage to important adjacent structures.
- Asymptomatic with good prognosis for future full eruption.
- First occurrence of pericoronitis, with good prognosis for future maintenance.
- Bisphosphonate therapy (current or history of).
- Post head and neck radiation therapy.
*Note: Indications and contraindications are relative, not absolute.
Treatment Criteria for Removal of Third Molars: Unerupted Third Molars
Definition
An unerupted third molar is one that has not penetrated through the bone and/or soft tissue and entered the oral cavity by an age when such eruption is expected.
Introduction
The indications for removal of unerupted third molars when associated with pathology have been clearly established. Absolute indications and contraindications for the removal of unerupted asymptomatic third molars cannot be established because no long term studies exist which validate the benefit to the patient either of early removal or deliberate retention of these teeth.
*Note: Indications and contraindications are relative, not absolute.
Indications for Removal*
- Pathology associated with tooth follicle (e.g., cyst, tumor).
- To facilitate the management of periodontal disease.
- Resorption of adjacent tooth.
- To facilitate orthodontic treatment.
- Unerupted molar under a prosthetic appliance.
- Tooth in the line of a jaw fracture.
- Tooth involved in the resection of pathologic lesion.
- Tooth interfering with orthognathic or reconstructive surgery.
- Prophylactic tooth removal, when indicated, for patients with medical or surgical conditions or treatments (e.g., organ transplants, alloplastic implants, chemotherapy, radiation therapy).
- Internal or external resorption of tooth.
- Need for donor transplant.
Contraindications for Removal*
- Patient refuses treatment.
- Compromised medical condition.
- Age of patient (see flow chart).
- Increased probability of damage to important adjacent structures.
- Bisphosphonate therapy (current or history of).
- Post head and neck radiation therapy.
*Note: Indications and contraindications are relative, not absolute.
Suggestions to Clinicians
In summary, the following suggestions for treatment, referral and monitoring asymptomatic impacted third molars are provided:
- If the patient is over 30 years of age, third molars should be monitored. Suggested monitoring regimen is an annual radiograph and clinical examination.
- If the patient is between 14 and 30 years of age and root formation is at least 1/2 to 2/3 complete, the examining dentist should review treatment options including risks and benefits. Referral to an oral and maxillofacial surgeon for consultation can be made as indicated.
- If there are multiple third molars present, the treating general dentist or oral surgeon will consult on the advisability of removal of all third molars simultaneously.
