Impacted wisdom teeth.

Impacted wisdom teeth Search date October 2013 Thomas B. Dodson and Srinivas M. Susarla ABSTRACT INTRODUCTION: The incidence of impacted wisdom teeth (third molars) is high, with some 72% of Swedish people aged 20 to 30 years having at least one impacted wisdom tooth. Impacted wisdom teeth occur because of a lack of space, obstruction, or abnormal position. They can cause inflammatory dental disease manifested by pain and swelling of infected teeth and may destroy adjacent teeth and bone. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: Should asymptomatic, disease-free impacted wisdom teeth be removed prophylactically? What are the effects of different operative (surgical) techniques for removing impacted wisdom teeth? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2013 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). We performed a GRADE evaluation of the quality of evidence for interventions. RESULTS: We found 11 studies that met our inclusion criteria. CONCLUSIONS: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: prophylactic extraction, active surveillance, and different operative (surgical) techniques for extracting impacted wisdom teeth.

QUESTIONS Should asymptomatic, disease-free impacted wisdom teeth be removed prophylactically?. . . . . . . . . . . . . . . . 3 What are the effects of different operative (surgical) techniques for removing impacted wisdom teeth?. . . . . . . 6 INTERVENTIONS SHOULD ASYMPTOMATIC, DISEASE-FREE IMPACTED WISDOM TEETH BE REMOVED PROPHYLACTICALLY? Unknown effectiveness Prophylactic extraction versus no extraction plus no active surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

DIFFERENT OPERATIVE (SURGICAL) TECHNIQUES Unknown effectiveness Extraction of impacted wisdom teeth: different operative (surgical) techniques (different bone removal techniques versus each other; complete extraction versus coronectomy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Active surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Key points • Impacted wisdom teeth (third molars) occur because of a lack of space, obstruction, or abnormal position. They can cause pain, swelling, and infection, and may destroy adjacent teeth and bone. The incidence of impacted wisdom teeth is high, with some 72% of Swedish people aged 20 to 30 years having at least one impacted wisdom tooth. • Non-RCT evidence indicates that about one third of asymptomatic, unerupted wisdom teeth will change position, resulting in wisdom teeth that are partially erupted but non-functional or non-hygienic. Between 30% and 60% of people who retain their asymptomatic wisdom teeth proceed to extraction of one or more of them between 4 and 12 years after their first visit. • Removal of impacted wisdom teeth (symptomatic and asymptomatic) is a commonly performed procedure. • While symptomatic or diseased impacted wisdom teeth should be recommended for removal, current evidence neither refutes nor confirms the practice of prophylactic removal of asymptomatic, disease-free wisdom teeth. Some non-RCT evidence indicates that extraction of the asymptomatic tooth may be beneficial when disease, such as caries, is present in the adjacent second molar, or if periodontal pockets are present distal to the second molar. • We do not know whether active surveillance is effective for asymptomatic, disease-free wisdom teeth, as we found no RCTs or prospective cohort studies on this topic. • We don't know which is the most effective operative (surgical) technique for extracting impacted wisdom teeth. DEFINITION

Wisdom teeth are present in most adults, and they generally become apparent between the ages of 18 and 24 years, although there is wide variation in the age of presentation. Impacted wisdom teeth are third molars that are not ordinarily expected to erupt into functional teeth. Wisdom teeth become partially or completely impacted owing to lack of space, obstruction, or abnormal position. Impacted wisdom teeth may be diagnosed because of symptoms such as pressure, pain, or swelling; by physical examination with probing or direct visualisation; or incidentally by routine dental radiography.

© BMJ Publishing Group Ltd 2014. All rights reserved.

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Clinical Evidence 2014;08:1302

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INCIDENCE/ PREVALENCE

Wisdom tooth (third molar) impaction is common. More than 72% of Swedish people aged 20 to [1] 30 years have at least one impacted lower wisdom tooth. Removal of impacted wisdom teeth (symptomatic and asymptomatic) is a commonly performed operation. The incidence of wisdom tooth removal is estimated to be 4 per 1000 person-years in England and Wales, making it one of [2] [3] [4] the top 10 inpatient and day-case procedures. In a report from 1994, up to 90% of people [3] on oral and maxillofacial surgery hospital waiting lists were awaiting removal of wisdom teeth. [5] Fewer operations are done now, possibly because of guidance.

AETIOLOGY/ Wisdom tooth impaction may be more common now than in the past, as modern diet tends to be [6] RISK FACTORS softer. PROGNOSIS

Impacted wisdom teeth can cause pain, swelling, and infection, and may destroy adjacent teeth and bone. The removal of diseased or symptomatic wisdom teeth alleviates pain and suffering, and improves oral health and function. About one third of asymptomatic, unerupted wisdom teeth have been found to change position with time, resulting in wisdom teeth that are partially erupted [7] but non-functional or non-hygienic. Three prospective cohort studies have also demonstrated that 30% to 60% of people with previously asymptomatic impacted wisdom teeth will undergo extraction of one or more of their wisdom teeth because of symptoms or disease, between 4 and 12 [8] [9] [10] [11] years following study enrolment. In another cohort study, a surprisingly high percentage (25%) of people with asymptomatic wisdom teeth had periodontal disease, as evidenced by [12] probing depths greater than 5 mm. Probing depths could be an indicator of future periodontal status. One prospective cohort study demonstrated that 40% of people with asymptomatic wisdom teeth with probing depths of more than 4 mm had clinically significant progression of their periodontal [13] status (probing depth increase of >2 mm) in the subsequent 24 months. The same study also found that, for those people with wisdom teeth with a probing depth of less than 4 mm, only 3% of teeth demonstrated progression of periodontal disease as evidenced by increasing probing depths. [13]

AIMS OF To maximise the benefits and minimise the adverse effects of wisdom-tooth management. INTERVENTION OUTCOMES

Dental disease: development or progression of asymptomatic or symptomatic inflammatory dental disease (e.g., caries, acute and chronic periodontal disease, pain); incisor crowding; disruption to regular activities of daily living (e.g., chewing, speaking, and missing work or education); days of disability; oral health profile; damage to adjacent teeth or restorations; maxillofacial lesions (e.g., odontogenic cysts or tumours); facial cellulitis of odontogenic origin; need for future treatment (e.g., extraction) of initially asymptomatic wisdom teeth. Complications or adverse effects of extraction: pain; swelling; prolonged or persistent trismus; persistent or excessive bleeding; surgical-site infection with or without cellulitis or osteomyelitis; disruption to regular activities of daily living (e.g., chewing, speaking, and missing work or education); wound dehiscence; alveolar osteitis; new or persistent periodontal defects on the adjacent teeth; damage to adjacent teeth or restorations; temporary, permanent, or prolonged symptoms related to inferior alveolar or lingual nerve injuries; maxillary tuberosity fracture; temporary or persistent oro-antral communication with or without sinusitis.

METHODS

Clinical Evidence search and appraisal October 2013. The following databases were used to identify studies for this systematic review: Medline 1966 to October 2013, Embase 1980 to October 2013, and The Cochrane Database of Systematic Reviews 2013, issue 10 (1966 to date of issue). Additional searches were carried out in the Database of Abstracts of Reviews of Effects (DARE) and the Health Technology Assessment (HTA) Database. We also searched for retractions of studies included in the review. Titles and abstracts identified by the initial search, run by an information specialist, were first assessed against predefined criteria by an evidence scanner. Full texts for potentially relevant studies were then assessed against predefined criteria by an evidence analyst. Studies selected for inclusion were discussed with an expert contributor. All data relevant to the review were then extracted by an evidence analyst. Study design criteria for inclusion in this review were: published RCTs and systematic reviews of RCTs in the English language, containing at least 20 individuals (at least 10 per treatment arm). Split mouth studies were included, but outcomes on incisor crowding in these studies were not reported due to confounding. There was no minimum length of follow-up, no required level of blinding, and no maximum loss to follow-up (except for Question 2, which implemented a maximum loss to follow-up of 20%). Additionally, specific to Question 1, prospective cohort studies with control groups were included. We included RCTs and systematic reviews of RCTs where harms of an included intervention were assessed, applying the same study design criteria for inclusion as we did for benefits. In addition, we use a regular surveillance protocol to capture harms alerts from organisations such as the FDA and the MHRA, which are added to the reviews as required. To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when


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Impacted wisdom teeth

relating percentages to summary statistics such as relative risks (RRs) and odds ratios (ORs). We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table, p 15 ). The categorisation of the quality of the evidence (high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com). QUESTION

Should asymptomatic, disease-free impacted wisdom teeth be removed prophylactically?

OPTION

PROPHYLACTIC EXTRACTION OF ASYMPTOMATIC, DISEASE-FREE IMPACTED WISDOM TEETH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

•

For GRADE evaluation of interventions for Impacted wisdom teeth, see table, p 15 .

•

We don’t know whether early extraction of asymptomatic, disease-free impacted wisdom teeth is more effective at improving incisor crowding (as indicated by measures of incisor irregularity, inter-canine width, or arch length) compared with no extraction plus no active surveillance.

•

We found no direct information from RCTs or prospective cohort studies with a control group that met Clinical Evidence inclusion criteria on complications or adverse effects of early extraction of asymptomatic, disease-free, impacted wisdom teeth compared with no extraction plus no active surveillance.

•

In summary, we did not find any evidence that prophylactic extraction of impacted wisdom teeth was more effective at improving incisor crowding compared with no extraction plus no active surveillance. Benefits and harms

Prophylactic extraction versus no extraction plus no active surveillance: [14] We found five systematic reviews evaluating the extraction of impacted wisdom teeth (search dates 1997; 2000; [15] [16] [17] [18] 2003; and 2012 ), which between them identified one RCT that met Clinical Evidence inclusion criteria. [19] We have reported the RCT directly from the original report. One further RCT on incisor crowding was identified. [20] However, this was a split-mouth study, and we do not report incisor crowding as an outcome for this type of study [17] [21] (see Comment). The fourth systematic review also identified a further RCT that was discontinued, the results of which have not yet been published. Dental disease Prophylactic extraction compared with no extraction plus no active surveillance We don't know whether early wisdom tooth extraction is more effective at improving incisor crowding (as indicated by measures of incisor irregularity, intercanine width, or arch length) at 5 years in people aged 14 to 18 years with asymptomatic, disease-free impacted wisdom teeth (very low-quality evidence). Ref (type)

Population

Outcome, Interventions

Results and statistical analysis

Effect size

Favours

Dental disease [19]

RCT

164 people, aged 14–18 years, with asymptomatic impacted wisdom teeth

Mean change from baseline in P = 0.56 incisor irregularity , 5 years 0.80 mm with early third-molar extraction 1.10 mm with no extraction of third molars

Not significant

Results based on 77 people There was a large loss to followup in the RCT, which limits reliability (77 [47%] people were followed up, for an average of 66 months) [19]

RCT


Mean change from baseline in P = 0.92 inter-canine width , 5 years –0.37 mm with early third-molar extraction


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Not significant

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Ref (type)

Population



Effect size

Favours

–0.38 mm with no extraction of third molars Results based on 77 people There was a large loss to followup in the RCT, which limits reliability (77 [47%] people were followed up, for an average of 66 months) [19]

RCT


Mean change from baseline in P = 0.001 arch length , 5 years The authors of this RCT did not –1.1 mm with early third-molar consider this difference to be extraction clinically important –2.13 mm with no extraction of third molars

extraction

Results based on 77 people There was a large loss to followup in the RCT, which limits reliability (77 [47%] people were followed up, for an average of 66 months)

Adverse effects No data from the following reference on this outcome.

[19]

Prophylactic extraction versus active surveillance: We found no systematic review, RCTs, or prospective cohort studies with a control group comparing extraction versus active surveillance in people with asymptomatic, disease-free impacted wisdom teeth. See also harms from Extraction of impacted wisdom teeth: different operative (surgical) techniques, p 6 . Comment:

The further RCT (52 people with unerupted wisdom teeth, aged 13–19 years) compared extraction of impacted wisdom teeth versus no extraction (people had impacted wisdom teeth on both sides of the lower jaw, and one molar was randomly selected for removal, and the non-extraction side [20] acted as a control). The RCT was excluded from the fourth review, as it was felt that a split[17] mouth study was not an appropriate study design to assess incisor crowding. The RCT reported that incisor crowding (measured using the length of the arch: a straight line between the central fossa of the second molar and the incisal cross) did not change differently on the extraction side compared with the no extraction side at 3 years (absolute results not reported and significance not assessed). The RCT reported that 19 teeth in the control side were extracted 'for various reasons' (timescale not clear, further details not reported). The RCT found that postoperative adverse effects (pain, infection, or limited mouth opening) occurred in 4/52 (8%) teeth and secondary haemorrhage [20] in 2/52 (4%) teeth in the extraction group. Adverse effects in the control group were not reported. Clinical guide: Prospective cohort studies have shown that 30% to 60% of asymptomatic patients may develop [8] [9] [10] [11] disease or become sufficiently symptomatic to warrant extraction. Delaying extraction of asymptomatic teeth could result in an increased risk for postoperative inflammatory complications [22] [23] and prolonged recovery after extraction. One treatment guideline for managing unerupted and impacted wisdom teeth (search date 2000; 8 clinical studies of different designs; number of [5] people not reported) suggested that removal of asymptomatic disease-free wisdom teeth may


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be beneficial in the presence of caries in the adjacent second molar, which cannot be properly treated without the removal of the wisdom teeth. Extraction may also be beneficial in the presence [24] of periodontal pockets distal to the second molar. The harms associated with prophylactic extraction of asymptomatic, disease-free wisdom teeth are the expected adverse effects associated with any operation (e.g., costs, pain and swelling, loss [25] [26] of work or school time, and undergoing unnecessary surgery). The removal of the lower wisdom teeth also carries the risk of damage to the inferior alveolar nerve (injured in 1%–8% of [27] [28] [29] people and permanently damaged in up to 1% of people ), and to the lingual nerve (permanently damaged in up to 1% of people, although a range of frequencies have been reported, [30] including much lower rates). The risks seem to be greater with greater depth of impaction, and the risks are the same whether the wisdom tooth is symptomatic or asymptomatic. Observational studies have found limited evidence that the complications associated with the removal of wisdom teeth are more frequent when operators are less experienced, and in older people with deeply im[31] [32] [33] [34] [35] [36] pacted teeth. See also harms from Extraction of impacted wisdom teeth: different operative (surgical) techniques, p 6 . Of note, the five systematic reviews identified offer different recommendations for management. [14] [15] [16] [17] [18] This variation may be attributable to the different data identified by each review. [14] The first review identified 12 literature reviews, the second review identified two RCTs and 34 [15] [16] literature reviews, the third review identified five cohort studies, the fourth review identified [17] [18] one RCT, and the fifth review identified four studies. The first and second systematic reviews both advocated against prophylactic removal, but acknowledged that the evidence supporting their [14] [15] position was weak. The third systematic review recommended against prophylactic removal, but, given the low level of evidence supporting this position, deferred to patient preference regarding [16] treatment choice. The fourth systematic review concluded that there was no evidence to support [17] or refute prophylactic removal of asymptomatic wisdom teeth. The fifth review concluded that there was a lack of scientific evidence to justify the indication of the prophylactic extraction of wisdom [18] teeth. When managing asymptomatic, disease-free wisdom teeth, no RCT data are available to guide therapeutic choices. Consistent with the application of evidence-based medicine principles, after a thorough review of the risks and benefits of the treatment alternatives, patient preference should [16] [37] [38] be the factor driving the clinical decision. OPTION

ACTIVE SURVEILLANCE OF ASYMPTOMATIC IMPACTED WISDOM TEETH. . . . . . . . . . . . . .

•


•

We found no direct information from RCTs or prospective cohort studies with a control group to provide guidance as to whether active surveillance is better than extraction, or whether active surveillance is better than no extraction plus no active surveillance in people with asymptomatic impacted wisdom teeth. Benefits and harms

Active surveillance versus no extraction plus no active surveillance: We found no systematic review, RCTs, or prospective cohort studies with a control group comparing active surveillance versus no extraction plus no active surveillance in people with asymptomatic impacted wisdom teeth. Active surveillance versus extraction: We found no systematic review, RCTs, or prospective cohort studies with a control group comparing active surveillance versus extraction. Different forms of active surveillance versus each other: We found no systematic review, RCTs, or prospective cohort studies with a control group comparing different forms of active surveillance versus each other in people with asymptomatic impacted wisdom teeth. See also harms from Extraction of impacted wisdom teeth: different operative (surgical) techniques, p 6 . © BMJ Publishing Group Ltd 2014. All rights reserved.

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Comment:

Clinical guide: Active surveillance is defined for this review as scheduled clinical and radiographical evaluations of wisdom teeth on a regular basis by a healthcare professional trained to discern the disease status of wisdom teeth. The goal of active surveillance is to detect and treat disease early. The benefits of active surveillance include avoiding the costs and adverse effects of prophylactic removal of asymptomatic wisdom teeth. The risks of active surveillance include failure to detect disease in a timely manner due to clinical error or oversight, and failure of the patient to comply with the recommended follow-up schedule, which can lead to delayed extraction. Extraction in people older than 24 years can lead to decreased postoperative quality of life compared with extraction at a [23] younger age. Who should complete the active surveillance evaluations (either generalist or specialist), and the optimum frequency of the evaluations, are open to question: we found no RCTs on these issues. The benefit of having a specialist evaluate the patient lies in having an experienced clinician who will share in the responsibility and consequences of the management choice. However, there is concern that the specialist will remove impacted wisdom teeth unnecessarily. The benefits of having a generalist evaluate patients are decreased cost and increased patient convenience; however, there is concern that the generalist may miss disease or delay referral in a timely manner. The benefits of more-frequent visits are the opportunity to detect and treat disease prior to the development of symptoms or damage to adjacent teeth or bone, and to prevent the progression of disease requiring treatment additional to the removal of the wisdom teeth (e.g., restoration or extraction of a carious second molar or the development of a jaw cyst or tumour). However, longer intervals between visits decrease costs, reduce exposure to radiation, and improve patient convenience. Non-RCT evidence indicates that clinically important changes in periodontal status can occur over a 24-month interval, and provides some basis for selecting examinations every 2 years. [13]

Based on non-RCT evidence, when active surveillance is the recommended management option, the interval for follow-up should be 24 months. In addition to assessing the patient's symptoms, the examination should include physical and radiographical components. QUESTION

What are the effects of different operative (surgical) techniques for removing impacted wisdom teeth?

OPTION

EXTRACTION OF IMPACTED WISDOM TEETH: DIFFERENT OPERATIVE (SURGICAL) TECHNIQUES (DIFFERENT BONE REMOVAL TECHNIQUES VERSUS EACH OTHER; COMPLETE EXTRACTION VERSUS CORONECTOMY). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

•


•

We don’t know whether any one bone-removal technique is consistently more effective than any other at reducing complications or adverse effects of extraction of impacted wisdom teeth.

•

Only a small number of poor-quality RCTs comparing different bone-removal techniques were found.

•

We don’t know whether coronectomy or complete removal differ in their effectiveness for improving outcomes such as pain, delayed healing/infection, and dry socket in people thought to be at high risk of nerve injury.

•

Coronectomy may be more effective than complete removal at reducing inferior alveolar nerve damage in people thought to be at high risk of injury to the inferior alveolar nerve. However, the significance of some of the results was dependent on the exact analysis performed. Benefits and harms

Bone-removal techniques versus each other: [39] [40] [41] We found one systematic review (search date 2010), one additional RCT, and two subsequent RCTs. [42] The systematic review included four RCTs. It reported that the quality of RCTs was poor, and that allocation concealment and blinding was unclear in all four RCTs. It reported that, owing to the lack of quantitative data and [39] heterogeneity, pooling of data was only possible for the outcomes of pain and swelling. The review noted that it was difficult to reach strong conclusions due to the small number of RCTs found, the small numbers of people involved, and the heterogeneity of study methods used. -


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Complications or adverse effects of extraction Bone-removal techniques compared with each other We don’t know whether any one bone-removal technique is consistently more effective than any other at reducing complications or adverse effects of extraction, as we found insufficient evidence from small RCTs (very low-quality evidence). Ref (type)

Population



Effect size

Favours

Pain [39]

Systematic review

82 people with impacted lower third molars 2 RCTs in this analysis

[39]

Systematic review

Pain (assessed using a 4-point P = 0.9661 visual analogue scale) , 7 days The review also reported that with lingual split there was no significant difference between groups at 24 hours with surgical bur (P = 0.0684) and 48 hours (P = 0.0719) postoperatively (2 Absolute results not reported RCTs, 82 people, absolute num[44] One RCT applied a splitbers not reported) mouth design

Not significant

20 people with im- Pain (assessed using a 100 mm P = 0.12 pacted mandibular visual analogue scale) , Days third molars 1 and 2 postoperatively Data from 1 RCT

Not significant

with lingual split with surgical bur Absolute results not reported

[39]

Systematic review

30 people with bilateral impacted lower third molars (split-mouth design) Data from 1 RCT

Pain (assessed by patients’ Significance not reported self-report of the most painful side) , Day 1 and Day 7 postoperatively 8/27 (33%) with lingual split 18/27 (67%) with surgical bur 3 people reported that pain was the same on both sides

[40]

RCT

42 people with par- Proportion of people with pain P = 0.2 tially erupted lower scores 5/10 or more (measured third molars by 10-point visual analogue scale) , Day 7

Not significant

4/20 (20%) with surgical bur 1/22 (5%) with erbium YAG laser [41]

RCT

52 people with bilateral and symmetrically oriented impacted mandibular third molars (split mouth design)

Mean pain scores (assessed P 0.05 The RCT also reported no significant difference between groups on Days 1, 2, 3, 4, and 5 postoperatively

13.23 with surgical bur Sub-group analysis 10.12 with piezoelectric device of 27 people with ‘simple’ extraction Procedures were dichotomised into 27 ‘simple’ (extraction by osteotomy) and 25 ‘complex’ (extrac-


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Not significant

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Ref (type)

Population



Effect size

Favours

tion by osteotomy and coronal section, and complex procedures, i.e., root section) extractions using a modified Parant scale [42]

RCT

26 people with lower impacted third molars (splitmouth design)

Incidence of pain on palpation Reported as not significant , 30 days postoperatively P value not reported 4/26 (15%) with surgical bur The RCT also reported no signifi5/26 (19%) with piezoelectric de- cant difference between groups vice at 7 days: 23/26 (88%) with surgical bur v 14/26 (54%) with piezoelectric device (P value not reported)

Not significant

Swelling [39]

Systematic review

82 people with impacted lower third molars

Swelling (assessed using a 4point visual analogue scale) , 7 days

2 RCTs in this analysis

with lingual split with surgical bur

P = 0.2037 The review reported no significant difference between groups at 24 hours (P = 0.9734) and 48 hours (P = 0.6566) postoperatively

Not significant

Both RCTs applied a split mouthdesign [39]

Systematic review

20 people with im- Swelling (assessed using P = 0.88 pacted mandibular stereometric photogrammetry) third molars with lingual split Data from 1 RCT with surgical bur

Not significant

Absolute results not reported [39]

Systematic review

30 people with bilateral impacted lower third molars (split mouth design) Data from 1 RCT

Swelling (assessed by patients’ Significance not reported self-report of the most painful side) , Day 1 and Day 7 postoperatively 8/27 (33%) with lingual split 18/27 (70%) with surgical bur 3 people reported that swelling was the same on both sides

[42]

RCT

26 people with lower impacted third molars (splitmouth design) Data from 1 RCT

Incidence of persistent oedema Reported as not significant , 30 days P value not reported 1/26 (4%) with surgical bur The RCT also reported no signifi1/26 (4%) with piezoelectric de- cant difference between groups vice at 7 days: 8/26 (31%) with surgical bur v 7/26 (27%) with piezoelectric device (P value not reported)

Not significant

Delayed healing/infection [39]

Systematic review

52 people (splitDelayed healing/infection mouth design) with 3/52 (6%) with lingual split bilateral impacted lower third molars 3/52 (6%) with surgical bur

Reported as not significant P values not reported Not significant

There were 5 dry sockets and 1 abscess reported (unclear as to which groups these were in) [39]

Systematic review

20 people with im- Delayed healing pacted mandibular with lingual split third molars with surgical bur Data from 1 RCT


The review reported that none of the group suffered delayed healing

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Ref (type) [39]

Systematic review

[39]

Systematic review

Population



60 people with im- Delayed healing , 7 days postpacted mandibular treatment third molars with lingual split Data from 1 RCT with surgical bur

The review reported 2 people in the lingual split group had “delayed healing probably due to wound infection”; further details not reported

30 people with bilat- Delayed healing/infection eral impacted lowwith lingual split er third molars (split-mouth dewith surgical bur sign)

It was reported that 1 person developed postoperative alveolitis (further details not reported)

Effect size

Favours

Data from 1 RCT [42]

RCT

[42]

RCT


Incidence of pus , 30 days

Reported as not significant

2/26 (8%) with surgical bur

P value not reported

0/26 (0%) with piezoelectric device

The RCT reported no significant difference between groups at 7 days: 1/26 (4%) with surgical bur v 0/26 (0%) with piezoelectric device (P value not reported)


Incidence of dehiscence , 30 days

Reported as not significant

Not significant

P value not reported

4/26 (15%) with surgical bur

The RCT reported no significant 3/26 (12%) with piezoelectric de- difference between groups at 7 vice days: 8/26 (31%) with surgical bur v 7/26 (27%) with piezoelectric device (P value not reported)

Not significant

Disturbance of nerve function [39]

Systematic review

52 people (split mouth design) with bilateral impacted lower third molars

Disturbance of lingual nerve function (recorded as present or absent by the person) , 7 days postoperatively

Data from 1 RCT

1/52 (2%) with lingual split 4/52 (8%) with surgical bur

[39]

Systematic review

60 people with im- Disturbance of lingual nerve pacted mandibular function (assessed using a 4third molars point visual analogue scale) , 24 hours postoperatively Data from 1 RCT 2.6 with lingual split 2.9 with surgical bur

Reported as not significant P value not reported The review also reported on differences between groups at 6 hours (21% with lingual split v 23% with surgical bur), 24 hours (17% with lingual split v 23% with surgical bur) and 48 hours (10% with lingual split v 15% with surgical bur) postoperatively (absolute numbers not reported; P values not reported)

Not significant

P = 0.004 The review also reported that there were no significant differences between groups at 48 hours postoperatively (2.8 with lingual split v 3.0 with surgical bur; P = 0.08)

lingual split

Visual analogue scores were 1.0 for both groups immediately postoperation [39]

Systematic review

60 people with im- Disturbance of lingual nerve pacted mandibular function (assessed using a 4third molars point visual analogue scale) , 7 days postoperatively Data from 1 RCT 2.9 with lingual split

P = 0.36

Not significant

3.0 with surgical bur [39]

Systematic review

30 people with bilateral impacted lower third molars (split-mouth design)

Disturbance of lingual nerve function with lingual split with surgical bur


The review reported that 7 people who reported worse pain and swelling on the surgical bur side experienced lingual paraesthesia, which resolved within 3 months

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Ref (type)

Population



Effect size

Favours


Systematic review

[39]

Systematic review

52 people (splitDisturbance of inferior alveolar mouth design) with nerve function , 7 days postopbilateral impacted eratively lower third molars 1/52 (2%) with lingual split Data from 1 RCT 0/52 (0%) with surgical bur

60 people with im- Disturbance of inferior alveolar pacted mandibular nerve function (assessed using third molars a 4-point visual analogue scale) , 7 days postoperatively Data from 1 RCT 3.0 with lingual split 3.0 with surgical bur

[39]

Systematic review

30 people with bilateral impacted lower third molars (split-mouth design)

Reported as not significant P value not reported The review also reported on differences between groups at 6 hours (12% with lingual split v 17% with surgical bur), 24 hours (10% with lingual split v 13% with surgical bur) and 48 hours (8% with lingual split v 8% with surgical bur) postoperatively (absolute numbers not reported; P values not reported)

Not significant

P = 1.0 The review also reported on differences between groups immediately postoperatively (1.0 for both lingual split and surgical bur; P value not reported) and at 24 hours (P = 0.36) and 48 hours (P = 1.0) postoperatively

Not significant

Disturbance of inferior alveolar The review reported that no pernerve function son experienced sensory impairment (further details not reported) with lingual split with surgical bur


Systematic review

[42]

RCT

20 people with im- Disturbance of nerve function pacted mandibular with lingual split third molars with surgical bur Data from 1 RCT

The review reported that “no one experienced sensory impairment of the inferior alveolar or lingual nerves” without further qualification

26 people with lower impacted third molars (split mouth design)

The review reported there was “the absence of nerve lesions after either treatment”; further details not reported

Disturbance of nerve function with surgical bur with piezoelectric device

Trismus [39]

Systematic review

20 people with im- Trismus (assessed using calpacted mandibular lipers) , Days 1, 2, and 7 postthird molars operatively Data from 1 RCT

P = 0.03 Further details not reported lingual split

with lingual split with surgical bur

Coronectomy versus complete removal of wisdom tooth: [45] We found one systematic review (search date 2011), which included two RCTs. It only included people at high risk of nerve injury, as defined by radiography. Criteria for high risk of nerve injury included absence of cortical bone between third molar roots and nerve canals, third molar roots touching or overlapping the superior cortical line of nerve canals, loss of lamina dura of nerve canals, and darkening of third molar roots. Only studies that compared coronectomy with total removal for wisdom tooth extraction were included. No antibiotics were prescribed in the two RCTs. In the coronectomy group, roots that were loosened or mobilised during surgery were extracted. In one RCT (128 people), these were re-assigned to a third group called 'failed coronectomy', while the other RCT (231 people) [45] did not consider them in subsequent analysis. The failure rates varied between the two RCTs (see comments). The review reported a per-protocol (treatment received) analysis and intention-to-treat (ITT) analysis. We have reported the ITT analysis unless otherwise stated. © BMJ Publishing Group Ltd 2014. All rights reserved.

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Complications or adverse effects of extraction Coronectomy compared with complete removal of wisdom tooth Coronectomy may be more effective than complete removal at reducing inferior alveolar nerve damage in people thought to be at high risk of injury to the inferior alveolar nerve. However, the significance of some results was dependent on the exact analysis performed. We don’t know whether coronectomy and complete removal differ in effectiveness at improving outcomes such as pain, delayed healing/infection, and dry socket in people thought to be at high risk of nerve injury (very low-quality evidence). Ref (type)

Population



Effect size

Favours

Pain [45]

Systematic review

[45]

Systematic review

128 people (196 Pain , 1 week postoperatively RR 0.59 lower third molars) 12/94 (13%) molars with coronec- 95% CI 0.31 to 1.13 with high risk of tomy nerve injury 22/102 (22%) molars with comData from 1 RCT plete removal 231 people (349 Pain , 1 week postoperatively lower third molars) 69/171 (40%) molars with corowith high risk of nectomy nerve injury 102/178 (57%) molars with comData from 1 RCT plete removal

Not significant

RR 0.70 95% CI 0.56 to 0.88 The RCT also reported that there was no significant difference between groups in pain score at 1 to 24 months (absolute numbers not reported, P value not report[47] ed)

coronectomy

Delayed healing/infection [45]

Systematic review

[45]

Systematic review

128 people (196 Postoperative infection RR 3.26 lower third molars) 3/94 (3%) molars with coronecto- 95% CI 0.34 to 30.75 with high risk of my nerve injury 1/102 (1%) molars with complete Data from 1 RCT removal 231 people (349 Postoperative infection , 1 lower third molars) week postoperatively with high risk of 10/171 (6%) molars with coronecnerve injury tomy Data from 1 RCT 12/178 (7%) molars with complete removal

Not significant

RR 0.87 95% CI 0.38 to 1.95 The RCT also reported that there was no incidence of infection from the third postoperative month in either group, and there was no statistical difference between the two groups throughout the follow-up period (further details not reported, P value not re[47] ported)

Not significant

Disturbance of nerve function [45]

Systematic review

128 people (196 Inferior alveolar nerve injury lower third molars) 5/94 (5%) molars with coronectowith high risk of my nerve injury 19/102 (19%) molars with comData from 1 RCT plete removal

RR 0.29 95% CI 0.11 to 0.73 The review also reported a treatment received analysis in which 36 failed coronectomies were reallocated to the complete removal group: 0/58 (0%) with coronectomy v 24/138 (17%) with complete removal, RR 0.05, 95% CI 0.00 to 0.78

coronectomy

See Comment section [45]

Systematic review

231 people (349 Inferior alveolar nerve injury lower third molars) 2/171 (1%) molars with coronecwith high risk of tomy nerve injury 9/178 (5%) molars with complete Data from 1 RCT removal


RR 0.23 95% CI 0.05 to 1.06 The review also reported a treatment received analysis in which 16 failed coronectomies were reallocated to the complete removal group: 1/155 (1%) with coronectomy v 10/194 (5%) with com-

..........................................................

Not significant

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Ref (type)

Population



Effect size

Favours

plete removal, RR 0.13, 95% CI 0.02 to 0.97 See Comment section

Dry socket [45]

Systematic review

[45]

Systematic review

128 people (196 Dry socket RR 1.19 lower third molars) 11/94 (12%) molars with coronec- 95% CI 0.53 to 2.68 with high risk of tomy nerve injury 10/102 (10%) molars with comData from 1 RCT plete removal

Not significant

231 people (349 Dry socket , 1 week postopera- RR 0.09 lower third molars) tively 95% CI 0.01 to 1.70 with high risk of 0/171 (0%) molars with coronecnerve injury tomy Data from 1 RCT 5/178 (3%) molars with complete removal

Not significant

Re-operation [45]

Systematic review

[45]

Systematic review

128 people (196 Re-operation lower third molars) 0/58 (0%) molars with coronectowith high risk of my nerve injury Re-operation was conducted in Data from 1 RCT people receiving coronectomy Subgroup analysis who had persistent pain, root exof people receiving posure, or persistent apical infeccoronectomy only tions 231 people (349 Re-operation lower third molars) 2/155 (1%) molars with coronecwith high risk of tomy nerve injury Re-operation was conducted in Data from 1 RCT people receiving coronectomy Subgroup analysis who had persistent pain, root exof people receiving posure, or persistent apical infeccoronectomy only tions

Comment:

Of the RCTs identified, most did not specify whether people were symptomatic or asymptomatic. Coronectomy versus complete removal of wisdom tooth: In one RCT (128 people) comparing complete removal versus coronectomy, a large proportion of [46] coronectomies failed (36/94 [38%]) as roots were dislodged during surgery. In the remaining [45] RCT (231 people) included in the review, the failed coronectomy rate was 16/171 (9.4%).

Clinical guide: While there has been disagreement about the removal of asymptomatic, disease-free wisdom teeth, there has been no controversy about the need to remove symptomatic teeth and those showing pathological changes such as infection, non-restorable caries, cysts, tumours, or destruction of adjacent teeth and bone. Most commonly, wisdom teeth are removed because they are impacted against bone or soft tissue, preventing them from fully erupting. Bacteria and debris collect under the overlying flap of tissue and cause infections (pericoronitis), and removal of wisdom teeth in this situation is the management of choice. Wisdom teeth are also removed if they are causing caries of the adjacent tooth. This happens when the tooth is partially erupted, and its position in relation to the adjacent tooth or soft tissues makes the area inaccessible to usual oral hygiene measures. The symptoms of pericoronitis are pain, bad taste, swelling of the gum and face, and restricted mouth opening (trismus). The local infection may spread, resulting in a regional lymphadenopathy, pyrexia, and malaise. Rarely, the swelling may threaten the patency of the airway and breathing. © BMJ Publishing Group Ltd 2014. All rights reserved. .......................................................... 12

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Wisdom tooth caries may also cause pain and, if unmanaged, will ultimately lead to death of the tooth and to abscess formation. Abscess, like pericoronitis, may result in pain, lymphadenopathy, pyrexia, malaise, and, rarely, also threaten the patency of the airway. Removal of the tooth alleviates the symptoms and prevents progress of the disease. It also permits restoration of the adjacent tooth caries. We found one systematic review (search date not reported), including eight studies (6 RCTs and 2 prospective cohorts), which suggested that, overall, the second-molar periodontal probing depth or attachment levels either remained unchanged or improved after wisdom-tooth [48] removal. However, for the subset of people with healthy second-molar periodontium before surgery, the review found an increased risk for worsening of probing depths or attachment levels after wisdom-tooth removal. The clinical significance of this is not clear. There is currently insufficient evidence to show meaningful clinical benefit for one type of surgery versus another.

GLOSSARY Very low-quality evidence Any estimate of effect is very uncertain.

SUBSTANTIVE CHANGES Extraction of impacted wisdom teeth: different operative (surgical) techniques Two systematic reviews added, [39] [45] [41] [42] as well as two RCTs. Categorisation unchanged (unknown effectiveness). Prophylactic extraction of asymptomatic, disease-free impacted wisdom teeth One systematic review updated, [17] [18] and one systematic review added. Categorisation unchanged (unknown effectiveness).

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Thomas B. Dodson Professor and Chair, Department of Oral and Maxillofacial Surgery Associate Dean for Hospital Affairs University of Washington School of Dentistry Seattle US Srinivas M. Susarla Department of Plastic and Reconstructive Surgery Johns Hopkins Hospital Baltimore US Competing interests: TBD is an author of references cited in this review. SMS declares that she has no competing interests. TBD and SMS would like to acknowledge the previous contributors of this review, including Stephen Worrall, Marco Esposito, and Paul Coulthard.

Disclaimer The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients. To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.


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GRADE

Evaluation of interventions for Impacted wisdom teeth.

Important outcomes Studies (Participants)

Complications or adverse effects of extraction, Dental disease Outcome

Comparison

Type of evidence

Quality

Consistency

Directness

Effect size

GRADE

Comment

–2

0

–1

0

Very low

Quality points deducted for sparse data and large loss to follow-up (over 50%); directness point deducted for unclear clinical importance of results

Should asymptomatic, disease-free impacted wisdom teeth be removed prophylactically? 1 (164)

[19]

Dental disease

Prophylactic extraction versus no extraction plus no active surveillance

4

What are the effects of different operative (surgical) techniques for removing impacted wisdom teeth? 7 (at least 252) [43]

[39]

2 (359)

[41]

[46]

[40]

[42]

[45]

Complications or adverse effects of extraction

Bone-removal techniques versus each other

4

–2

0

–1

0

Very low

Quality points deducted for incomplete reporting of results and weak methods; directness point deducted for heterogeneity between RCTs

Complications or adverse effects of extraction

Coronectomy versus complete removal of wisdom tooth

4

–2

0

–2

0

Very low

Quality points deducted for incomplete reporting of results and weak methods; directness points deducted for restricted population in RCTs (high risk of nerve injury) affecting generalisability and small number of events for many outcomes, affecting power to detect differences between groups

We initially allocate 4 points to evidence from RCTs, and 2 points to evidence from observational studies. To attain the final GRADE score for a given comparison, points are deducted or added from this initial score based on preset criteria relating to the categories of quality, directness, consistency, and effect size. Quality: based on issues affecting methodological rigour (e.g., incomplete reporting of results, quasirandomisation, sparse data [

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Double impacted teeth.

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Problems with erupting wisdom teeth: signs, symptoms, and management.

Wisdom teeth extraction in a patient with moyamoya disease.

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Management of multiple impacted teeth: a case report and review.

Impacted Inverted Teeth with their Possible Treatment Protocols.

Targeted traction of impacted teeth with C-tube miniplates.

The study of barium concentration in deciduous teeth, impacted teeth, and facial bones of Polish residents.

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or paracetamol (acetaminophen) for pain relief after surgical removal of lower wisdom teeth.

Melatonin premedication versus placebo in wisdom teeth extraction: a randomised controlled trial.

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Hypodontia and supernumerary and impacted teeth in children with various types of clefts.

Interdisciplinary Management of Impacted Supernumerary Tooth between Roots of Permanent Teeth-A Management Dilemma?

Diode Laser Clinical Efficacy and Mini-Invasivity in Surgical Exposure of Impacted Teeth.

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Prevalence of impacted teeth and associated pathology in middle-aged and older Swedish women.