Clinical approach to wisdom teeth

OBJECTIVES The aim of this module is to introduce clinicians to the correct approach for the diagnostic management of third molars, following a protocol based on previously identified influential factors. MATERIALS AND METHODS The most recent national and international literature available through major databases (PubMed, Medline, Scopus, Google Scholar, and Cochrane Library) was analyzed. This review was complemented with ministerial guidelines and clinical experience derived from several years of practice. RESULTS Pre-existing scales assessing surgical difficulty in third molar extraction were compiled. All scales included an initial evaluation aimed at gathering anamnestic data, along with intra-and extra-oral objective examinations. The parameters analyzed included the following: the degree of tooth inclination according to Winter’s classification, the depth of impaction according to Pell and Gregory’s classification, the risk of inferior alveolar nerve (IAN) injury based on Maglione et al.’s classification, the risk of lingual nerve injury according to Juodzbalys and Daugela’s classification, the risk of maxillary sinus invasion following Gay-Escoda et al.’s classification, the possible presence of osteolytic lesions, and root morphology. DISCUSSION For the management of third molars, the first consideration is determining whether there is an indication for surgical extraction, whether symptomatic or asymptomatic. Additionally, it is essential to consider the patient’s systemic medical history to rule out any contraindications to surgery. Once the decision for extraction is made, a preoperative assessment of the degree of surgical difficulty is conducted. Radiographic parameters, such as the degree of tooth inclination and depth of impaction, will guide decisions on the type of incision, the extent of osteotomy, and the need for odontotomy. The type and number of tooth sections will also depend on root morphology. In cases where a Level I radiographic examination indicates a risk of IAN injury, a Level II radiographic investigation should be performed to plan the extraction based on the spatial relationship between the IAN and the third molar. When the third molar is in proximity to the lingual cortical bone, appropriate measures should be taken to protect the lingual nerve using suitable instruments. Finally, in the presence of an osteolytic lesion, an additional histomorphometric investigation should be performed concurrently with enucleation during extraction. CONCLUSIONS A thorough preoperative evaluation, including the collection of medical history, clinical examination, and radiographic data, allows for the classification of surgical difficulty as low, moderate, or high. This classification provides clinicians with a valuable tool for therapeutic planning and determining the need for specialist referral. CLINICAL SIGNIFICANCE To provide a practical and evidence-based protocol for the diagnostic and therapeutic management of third molars, promoting a personalized and multidisciplinary approach that improves therapeutic outcomes and minimizes complications. The text guides the clinician in assessing surgical difficulty by identifying indications, contraindications, and risks to plan safe and effective extractions.