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NICE guidance for mandibular third molars has been available since 2000. This was set up to limit the surgical treatment of these teeth to symptomatic patients. There are numerous risks involved with surgical treatment of mandibular third molars and these should be explained in detail to the patient. Common and serious complications of mandibular third molar surgery are damage to the inferior alveolar and lingual nerve. Predicting the risk of inferior alveolar nerve injury is useful for treatment planning. The orthopantomogram (OPT) is the baseline special test for assessing this and numerous signs on an OPT can predict an increased risk of injury to the nerve. Cone beam computed tomography (CBCT) is being more frequently used to assess this relationship further and can influence treatment planning. Coronectomy is a technique whereby the crown of the tooth is sectioned and removed leaving the roots in situ. This has proven to be a useful technique in high risk cases, but is not without its own complications. The increase in availability of CBCT imaging and the recent resurgence of coronectomy as a treatment modality can increase the number of treatment options available to patients. We have proposed an algorithm to aid the treatment planning and informed consent processes associated with mandibular third molar surgery.
CPD/Clinical Relevance: This article is relevant to primary and secondary care dental practitioners as it will aid the investigation, treatment planning, correct referral and management of patients with problematic mandibular third molars.
Article
In March 2000 the National Institute for Health and Care Excellence (NICE) issued guidance on the extraction of wisdom teeth. This guidance stressed the discontinuation of prophylactic surgical removal of pathology free impacted third molars in the NHS and illustrated indications for removal. Simultaneous guidance from the Scottish Intercollegiate Guidelines Network (SIGN) from 2000 was withdrawn to be revised in February 2015, owing to a need for a review of the evidence as the document is over 10 years old.
The NICE guidance suggests limiting third molar surgery to patients with pathology, including unrestorable caries, untreatable pulpal or periapical pathology, cellulitis, abscess and osteomyelitis, resorption of the tooth or adjacent teeth, diseases of the follicle including cysts or tumours, teeth impeding surgery, teeth in the field of tumour resection. Severe or multiple episodes of pericoronitis indicate surgery.1
The SIGN guidance included some indications for prophylactic removal such as pre-radiotherapy or cardiac surgery, where the risk of retaining the wisdom tooth would outweigh the risks of removal. Other examples of indications for removal without symptoms as outlined by SIGN are periodontal disease associated with the second molar due to the position of the third molar and in those patients who have an occupation or lifestyle which inhibits access to regular dental care. The SIGN guidance also explicitly included caries in second molars judged to be caused by the impacted third molar, which could not be restored without removal of the third molar. The NICE guidance does include unrestorable caries in third molars, however it does not include removal of third molars in order to render second molars restorable.2 Since the implementation of the NICE guidance, the incidence of distal mandibular second molar caries has risen from 5% to 19%.3
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