Impacted wisdom teeth

Thomas B. Dodson, Professor and Chair, Department of Oral and Maxillofacial Surgery and Dr 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.

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.

About this condition

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.

Incidence/ Prevalence
Wisdom tooth (third molar) impaction is common. More than 72% of Swedish people aged 20 to 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 the top 10 inpatient and day-case procedures. In a report from 1994, up to 90% of people on oral and
maxillofacial surgery hospital waiting lists were awaiting removal of wisdom teeth. Fewer operations are done now, possibly
because of guidance.

Aetiology/ Risk factors

Wisdom tooth impaction may be more common now than in the past, as modern diet tends to be 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 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 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
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 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.

Aims of intervention
To maximise the benefits and minimise the adverse effects of wisdom-tooth management.

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 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). 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).

Table
GRADE Evaluation of interventions for Impacted wisdom teeth.

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

Notes
:
 Notes

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.

Contributor Information
Thomas B. Dodson, Associate Dean for Hospital Affairs, University of Washington School of Dentistry, Seattle, US.

Dr Srinivas M. Susarla, Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, US.

Article information
BMJ Clin Evid. 2014; 2014: 1302.
Published online 2014 Aug 29.

PMCID: PMC4148832
PMID: 25170946

Thomas B. Dodson, Professor and Chair, Department of Oral and Maxillofacial Surgery# and Dr Srinivas M. Susarla#

Thomas B. Dodson, Associate Dean for Hospital A!airs, University of Washington School of Dentistry, Seattle, US;
Contributor Information.
#Contributed equally.

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.

Copyright © BMJ Publishing Group Ltd, All Rights Reserved

This article has been cited by other articles in PMC.

Articles from BMJ Clinical Evidence are provided here courtesy of BMJ Publishing Group

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2014; 2014: 1302.

Published online 2014 Aug 29.

Prophylactic extraction of asymptomatic, disease-free impacted wisdom teeth

Copyright notice

Summary
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:

We found five systematic reviews evaluating the extraction of impacted wisdom teeth (search dates 1997; 2000; 2003; and
2012 ), which between them identified one RCT that met Clinical Evidence inclusion criteria. We have reported the RCT
directly from the original report. One further RCT on incisor crowding was identified. However, this was a split-mouth study,
and we do not report incisor crowding as an outcome for this type of study (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,
inter-canine 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 Population Outcome, Interventions Results and statistical analysis Effect size Favours
(type)

Dental
disease

164 people, aged 14–18 years, with Mean change from Not
RCT asymptomatic impacted wisdom baseline in incisor P = 0.56 significant
teeth irregularity 5 years
0.80 mm with early third-
molar extraction
1.10 mm with no extraction
of third molars

164 people, aged 14–18 years, with Mean change from Not
RCT asymptomatic impacted wisdom baseline in inter-canine P = 0.92 significant
teeth width 5 years
–0.37 mm with early third-
molar extraction
–0.38 mm with no extraction
of third molars

164 people, aged 14–18 years, with Mean change from Effect size extraction
RCT asymptomatic impacted wisdom baseline in arch length 5 P = 0.001 not
teeth years The authors of this RCT did not calculated
–1.1 mm with early third- consider this difference to be clinically
molar extraction important
–2.13 mm with no extraction
of third molars

Adverse e!ects

No data from the following reference on this outcome.

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.

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 acted as a control). The RCT was excluded from the fourth review, as it was felt that
a split-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 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 disease or become sufficiently
symptomatic to warrant extraction. Delaying extraction of asymptomatic teeth could result in an increased risk for
:
 postoperative inflammatory complications 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 people not
reported) suggested that removal of asymptomatic disease-free wisdom teeth may 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 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 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 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, 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 impacted teeth. See also harms from
Extraction of impacted wisdom teeth: different operative (surgical) techniques.

Of note, the five systematic reviews identified offer different recommendations for management. This variation may be
attributable to the different data identified by each review. The first review identified 12 literature reviews, the second review
identified two RCTs and 34 literature reviews, the third review identified five cohort studies, the fourth review identified 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 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 treatment choice.The fourth systematic review concluded that there was no evidence to support 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 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 be the factor driving the clinical decision.

Substantive changes
Prophylactic extraction of asymptomatic, disease-free impacted wisdom teeth One systematic review updated, and one
systematic review added. Categorisation unchanged (unknown effectiveness).

2014; 2014: 1302.

Published online 2014 Aug 29.

Active surveillance of asymptomatic impacted wisdom teeth

Copyright notice

Summary
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.

Di!erent 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.

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 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.

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.

Substantive changes
No new evidence

2014; 2014: 1302.

Published online 2014 Aug 29.

Extraction of impacted wisdom teeth: di!erent operative (surgical) techniques (di!erent

:
 Extraction of impacted wisdom teeth: di!erent operative (surgical) techniques (di!erent
bone removal techniques versus each other; complete extraction versus coronectomy)
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Summary
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:

We found one systematic review (search date 2010), one additional RCT, and two subsequent RCTs. 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 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.

Complications or adverse e!ects 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 Outcome, Interventions Results and statistical analysis Effect Favours
size

Pain

82 people with Pain (assessed using a Not

Systematic impacted lower 4-point visual analogue P = 0.9661 significant
review third molars scale) 7 days The review also reported that there was no
2 RCTs in this with lingual split significant difference between groups at 24
analysis with surgical bur hours (P = 0.0684) and 48 hours (P = 0.0719)
Absolute results not postoperatively (2 RCTs, 82 people, absolute
reported numbers not reported)

20 people with Pain (assessed using a Not

Systematic impacted 100 mm visual P = 0.12 significant
review mandibular third analogue scale) Days 1
molars and 2 postoperatively
Data from 1 RCT with lingual split
with surgical bur
Absolute results not
reported

30 people with Pain (assessed by

Systematic bilateral impacted patients’ self-report of Significance not reported
review lower third molars the most painful side)
:
 (split-mouth Day 1 and Day 7
design) postoperatively
Data from 1 RCT 8/27 (33%) with lingual
split
18/27 (67%) with
surgical bur

42 people with Proportion of people Not

RCT partially erupted with pain scores 5/10 P = 0.2 significant
lower third molars or more (measured by
10-point visual
analogue scale) Day 7
4/20 (20%) with surgical
bur
1/22 (5%) with erbium
YAG laser

52 people with Mean pain scores Effect piezoelectric

RCT bilateral and (assessed using visual P <0.05 size not device
symmetrically analogue scale, 0 = no calculated
oriented impacted pain, 100 = most severe
mandibular third pain imaginable)
molars (split immediately
mouth design) postoperatively
47.23 with surgical bur
36.54 with piezoelectric
device

52 people with Mean pain scores Not

RCT bilateral and (assessed using visual P >0.05 significant
symmetrically analogue scale, 0 = no The RCT also reported no significant difference
oriented impacted pain, 100 = most severe between groups on Days 1, 2, 3, 4, and 5
mandibular third pain imaginable) Day 6 postoperatively
molars (split postoperatively
mouth design) 13.23 with surgical bur
10.12 with piezoelectric
device

26 people with Incidence of pain on Not

RCT lower impacted palpation 30 days Reported as not significant significant
third molars (split- postoperatively P value not reported
mouth design) 4/26 (15%) with surgical The RCT also reported no significant difference
bur between groups at 7 days: 23/26 (88%) with
5/26 (19%) with surgical bur v 14/26 (54%) with piezoelectric
piezoelectric device device (P value not reported)

Swelling

82 people with Swelling (assessed Not

Systematic impacted lower using a 4-point visual P = 0.2037 significant
review third molars analogue scale) 7 days The review reported no significant difference
2 RCTs in this with lingual split between groups at 24 hours (P = 0.9734) and 48
analysis with surgical bur hours (P = 0.6566) postoperatively

20 people with Swelling (assessed Not

Systematic impacted using stereometric P = 0.88 significant
review mandibular third photogrammetry)
molars with lingual split
Data from 1 RCT with surgical bur
Absolute results not
reported

30 people with Swelling (assessed by

:
 Systematic bilateral impacted patients’ self-report of Significance not reported
review lower third molars the most painful side)
(split mouth Day 1 and Day 7
design) postoperatively
Data from 1 RCT 8/27 (33%) with lingual
split
18/27 (70%) with
surgical bur

26 people with Incidence of persistent Not

RCT lower impacted oedema 30 days Reported as not significant significant
third molars (split- 1/26 (4%) with surgical P value not reported
mouth design) bur The RCT also reported no significant difference
Data from 1 RCT 1/26 (4%) with between groups at 7 days: 8/26 (31%) with
piezoelectric device surgical bur v 7/26 (27%) with piezoelectric
device (P value not reported)

Delayed
healing/infection

52 people (split- Delayed Not

Systematic mouth design) healing/infection Reported as not significant significant
review with bilateral 3/52 (6%) with lingual P values not reported
impacted lower split
third molars 3/52 (6%) with surgical
bur

20 people with Delayed healing

Systematic impacted with lingual split The review reported that none of the group
review mandibular third with surgical bur suffered delayed healing
molars
Data from 1 RCT

60 people with Delayed healing 7 days

Systematic impacted post-treatment The review reported 2 people in the lingual split
review mandibular third with lingual split group had “delayed healing probably due to
molars with surgical bur wound infection”; further details not reported
Data from 1 RCT

30 people with Delayed

Systematic bilateral impacted healing/infection It was reported that 1 person developed
review lower third molars with lingual split postoperative alveolitis (further details not
(split-mouth with surgical bur reported)
design)
Data from 1 RCT

26 people with Incidence of pus 30 Not

RCT lower impacted days Reported as not significant significant
third molars (split- 2/26 (8%) with surgical P value not reported
mouth design) bur The RCT reported no significant difference
0/26 (0%) with between groups at 7 days: 1/26 (4%) with
piezoelectric device surgical bur v 0/26 (0%) with piezoelectric
device (P value not reported)

26 people with Incidence of dehiscence Not

RCT lower impacted 30 days Reported as not significant significant
third molars (split- 4/26 (15%) with surgical P value not reported
mouth design) bur The RCT reported no significant difference
3/26 (12%) with between groups at 7 days: 8/26 (31%) with
piezoelectric device surgical bur v 7/26 (27%) with piezoelectric
device (P value not reported)

Disturbance of
nerve function
:
 52 people (split Disturbance of lingual Not
Systematic mouth design) nerve function Reported as not significant significant
review with bilateral (recorded as present or P value not reported
impacted lower absent by the person) 7 The review also reported on differences between
third molars days postoperatively groups at 6 hours (21% with lingual split v 23%
Data from 1 RCT 1/52 (2%) with lingual with surgical bur), 24 hours (17% with lingual
split split v 23% with surgical bur) and 48 hours
4/52 (8%) with surgical (10% with lingual split v 15% with surgical bur)
bur postoperatively (absolute numbers not reported;
P values not reported)

60 people with Disturbance of lingual Effect lingual split

Systematic impacted nerve function P = 0.004 size not
review mandibular third (assessed using a 4- The review also reported that there were no calculated
molars point visual analogue significant differences between groups at 48
Data from 1 RCT scale) 24 hours hours postoperatively (2.8 with lingual split v
postoperatively 3.0 with surgical bur; P = 0.08)
2.6 with lingual split
2.9 with surgical bur

60 people with Disturbance of lingual Not

Systematic impacted nerve function P = 0.36 significant
review mandibular third (assessed using a 4-
molars point visual analogue
Data from 1 RCT scale) 7 days
postoperatively
2.9 with lingual split
3.0 with surgical bur

30 people with Disturbance of lingual

Systematic bilateral impacted nerve function The review reported that 7 people who reported
review lower third molars with lingual split worse pain and swelling on the surgical bur side
(split-mouth with surgical bur experienced lingual paraesthesia, which resolved
design) within 3 months
Data from 1 RCT

52 people (split- Disturbance of inferior Not

Systematic mouth design) alveolar nerve function Reported as not significant significant
review with bilateral 7 days postoperatively P value not reported
impacted lower 1/52 (2%) with lingual The review also reported on differences between
third molars split groups at 6 hours (12% with lingual split v 17%
Data from 1 RCT 0/52 (0%) with surgical with surgical bur), 24 hours (10% with lingual
bur 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)

60 people with Disturbance of inferior Not

Systematic impacted alveolar nerve function P = 1.0 significant
review mandibular third (assessed using a 4- The review also reported on differences between
molars point visual analogue groups immediately postoperatively (1.0 for
Data from 1 RCT scale) 7 days both lingual split and surgical bur; P value not
postoperatively reported) and at 24 hours (P = 0.36) and 48
3.0 with lingual split hours (P = 1.0) postoperatively
3.0 with surgical bur

30 people with Disturbance of inferior

Systematic bilateral impacted alveolar nerve function The review reported that no person experienced
review lower third molars with lingual split sensory impairment (further details not reported)
(split-mouth with surgical bur
design)
Data from 1 RCT
:
 20 people with Disturbance of nerve
Systematic impacted function The review reported that “no one experienced
review mandibular third with lingual split sensory impairment of the inferior alveolar or
molars with surgical bur lingual nerves” without further qualification
Data from 1 RCT

26 people with Disturbance of nerve

RCT lower impacted function The review reported there was “the absence of
third molars (split with surgical bur nerve lesions after either treatment”; further
mouth design) with piezoelectric device details not reported

Trismus

20 people with Trismus (assessed Effect lingual split

Systematic impacted using callipers) Days 1, P = 0.03 size not
review mandibular third 2, and 7 Further details not reported calculated
molars postoperatively
Data from 1 RCT with lingual split
with surgical bur

Coronectomy versus complete removal of wisdom tooth:

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) 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.

Complications or adverse e!ects 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 Outcome, Results and statistical analysis Effect Favours
Interventions size

Pain

128 people (196 Pain 1 week Not

Systematic lower third postoperatively RR 0.59 significant
review molars) with 12/94 (13%) 95% CI 0.31 to 1.13
high risk of molars with
nerve injury coronectomy
Data from 1 22/102 (22%)
RCT molars with
complete
removal

231 people (349 Pain 1 week Small coronectomy

Systematic lower third postoperatively RR 0.70 effect
review molars) with 69/171 (40%) 95% CI 0.56 to 0.88 size
high risk of molars with The RCT also reported that there was no significant
nerve injury coronectomy difference between groups in pain score at 1 to 24 months
:
 Data from 1 102/178 (57%) (absolute numbers not reported, P value not reported)
RCT molars with
complete
removal

Delayed
healing/infection

128 people (196 Postoperative Not

Systematic lower third infection RR 3.26 significant
review molars) with 3/94 (3%) 95% CI 0.34 to 30.75
high risk of molars with
nerve injury coronectomy
Data from 1 1/102 (1%)
RCT molars with
complete
removal

231 people (349 Postoperative Not

Systematic lower third infection 1 RR 0.87 significant
review molars) with week 95% CI 0.38 to 1.95
high risk of postoperatively The RCT also reported that there was no incidence of
nerve injury 10/171 (6%) infection from the third postoperative month in either
Data from 1 molars with group, and there was no statistical difference between the
RCT coronectomy two groups throughout the follow-up period (further details
12/178 (7%) not reported, P value not reported)
molars with
complete
removal

Disturbance of
nerve function

128 people (196 Inferior Moderate coronectomy

Systematic lower third alveolar nerve RR 0.29 effect
review molars) with injury 95% CI 0.11 to 0.73 size
high risk of 5/94 (5%) The review also reported a treatment received analysis in
nerve injury molars with which 36 failed coronectomies were re-allocated to the
Data from 1 coronectomy complete removal group: 0/58 (0%) with coronectomy v
RCT 19/102 (19%) 24/138 (17%) with complete removal, RR 0.05, 95% CI
molars with 0.00 to 0.78
complete See Comment section
removal

231 people (349 Inferior Not

Systematic lower third alveolar nerve RR 0.23 significant
review molars) with injury 95% CI 0.05 to 1.06
high risk of 2/171 (1%) The review also reported a treatment received analysis in
nerve injury molars with which 16 failed coronectomies were re-allocated to the
Data from 1 coronectomy complete removal group: 1/155 (1%) with coronectomy v
RCT 9/178 (5%) 10/194 (5%) with complete removal, RR 0.13, 95% CI 0.02
molars with to 0.97
complete See Comment section
removal

Dry socket

128 people (196 Dry socket Not

Systematic lower third 11/94 (12%) RR 1.19 significant
review molars) with molars with 95% CI 0.53 to 2.68
high risk of coronectomy
nerve injury 10/102 (10%)
Data from 1 molars with
RCT complete
:
 removal

231 people (349 Dry socket 1 Not

Systematic lower third week RR 0.09 significant
review molars) with postoperatively 95% CI 0.01 to 1.70
high risk of 0/171 (0%)
nerve injury molars with
Data from 1 coronectomy
RCT 5/178 (3%)
molars with
complete
removal

Re-operation

128 people (196 Re-operation

Systematic lower third 0/58 (0%)
review molars) with molars with
high risk of coronectomy
nerve injury
Data from 1
RCT

231 people (349 Re-operation

Systematic lower third 2/155 (1%)
review molars) with molars with
high risk of coronectomy
nerve injury
Data from 1
RCT

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 coronectomies failed (36/94
[38%]) as roots were dislodged during surgery. In the remaining 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. 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 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.

Substantive changes
Extraction of impacted wisdom teeth: different operative (surgical) techniques Two systematic reviews added, as well as two
RCTs. Categorisation unchanged (unknown effectiveness).
: