Surgical removal versus retention for the management of asymptomatic disease-free impacted wisdom teeth.

BACKGROUND: Prophylactic removal of asymptomatic disease-free impacted wisdom teeth is surgical removal of wisdom teeth in the absence of symptoms and with no evidence of local disease. Impacted wisdom teeth may be associated with pathological changes, such as pericoronitis, root resorption, gum and alveolar bone disease (periodontitis), caries and the development of cysts and tumours. When surgical removal is carried out in older people, the risk of postoperative complications, pain and discomfort is increased. Other reasons to justify prophylactic removal of asymptomatic disease-free impacted third molars have included preventing late lower incisor crowding, preventing damage to adjacent structures such as the second molar or the inferior alveolar nerve, in preparation for orthognathic surgery, in preparation for radiotherapy or during procedures to treat people with trauma to the affected area. Removal of asymptomatic disease-free wisdom teeth is a common procedure, and researchers must determine whether evidence supports this practice. This review is an update of an existing review published in 2012. OBJECTIVES: To evaluate the effects of removal compared with retention (conservative management) of asymptomatic disease-free impacted wisdom teeth in adolescents and adults. SEARCH METHODS: We searched the following electronic databases: Cochrane Oral Health's Trials Register (to 24 May 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 4), MEDLINE Ovid (1946 to 24 May 2016) and Embase Ovid (1980 to 24 May 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing and unpublished studies to 24 May 2016. We imposed no restrictions on language or date of publication in our search of electronic databases. SELECTION CRITERIA: Studies comparing removal (or absence) with retention (or presence) of asymptomatic disease-free impacted wisdom teeth in adolescents or adults. We included randomised controlled trials (RCTs) with no restriction on length of follow-up, if available. We considered quasi-RCTs and prospective cohort studies for inclusion if investigators measured outcomes with follow-up of five years or longer. DATA COLLECTION AND ANALYSIS: Eight review authors screened search results and assessed the eligibility of studies for inclusion according to the review inclusion criteria. Eight review authors independently conducted risk of bias assessments in duplicate. When information was unclear, we contacted study authors for additional information. MAIN RESULTS: This review includes two studies. The previous review included one RCT with a parallel-group design, which was conducted in a dental hospital setting in the United Kingdom; our new search for this update identified one prospective cohort study conducted in the private sector in the USA. Primary outcome No eligible studies in this review reported the effects of removal compared with retention of asymptomatic disease-free impacted wisdom teeth on health-related quality of life Secondary outcomes We found only low to very low quality evidence of the effects of removal compared with retention of asymptomatic disease-free impacted wisdom teeth for a limited number of secondary outcome measures.One prospective cohort study, reporting data from a subgroup of 416 healthy male participants, aged 24 to 84 years, compared the effect of the absence (previous removal or agenesis) against the presence of asymptomatic disease-free impacted wisdom teeth on periodontitis and caries associated with the distal of the adjacent second molar during a follow-up period of three to over 25 years. Very low quality evidence suggests that the presence of asymptomatic disease-free impacted wisdom teeth may be associated with increased risk of periodontitis affecting the adjacent second molar in the long term. In the same study, which is at serious risk of bias, there is insufficient evidence to demonstrate a difference in caries risk associated with the presence or absence of impacted wisdom teeth.One RCT with 164 randomised and 77 analysed adolescent participants compared the effect of extraction with retention of asymptomatic disease-free impacted wisdom teeth on dimensional changes in the dental arch after five years. Participants (55% female) had previously undergone orthodontic treatment and had 'crowded' wisdom teeth. No evidence from this study, which was at high risk of bias, was found to suggest that removal of asymptomatic disease-free impacted wisdom teeth has a clinically significant effect on dimensional changes in the dental arch.The included studies did not measure our other secondary outcomes: costs, other adverse events associated with retention of asymptomatic disease-free impacted wisdom teeth (pericoronitis, root resorption, cyst formation, tumour formation, inflammation/infection) and adverse effects associated with their removal (alveolar osteitis/postoperative infection, nerve injury, damage to adjacent teeth during surgery, bleeding, osteonecrosis related to medication/radiotherapy, inflammation/infection). AUTHORS' CONCLUSIONS: Insufficient evidence is available to determine whether or not asymptomatic disease-free impacted wisdom teeth should be removed. Although asymptomatic disease-free impacted wisdom teeth may be associated with increased risk of periodontitis affecting adjacent second molars in the long term, the evidence is of very low quality. Well-designed RCTs investigating long-term and rare effects of retention and removal of asymptomatic disease-free impacted wisdom teeth, in a representative group of individuals, are unlikely to be feasible. In their continuing absence, high quality, long-term prospective cohort studies may provide valuable evidence in the future. Given the lack of available evidence, patient values should be considered and clinical expertise used to guide shared decision making with patients who have asymptomatic disease-free impacted wisdom teeth. If the decision is made to retain asymptomatic disease-free impacted wisdom teeth, clinical assessment at regular intervals to prevent undesirable outcomes is advisable.

Surgical removal versus retention for the management of asymptomatic impacted wisdom teeth.

BACKGROUND: The prophylactic removal of asymptomatic impacted wisdom teeth is defined as the (surgical) removal of wisdom teeth in the absence of local disease. Impacted wisdom teeth may be associated with pathological changes, such as inflammation of the gums around the tooth, root resorption, gum and alveolar bone disease, damage to the adjacent teeth and the development of cysts and tumours. Other reasons to justify prophylactic removal have been to prevent late incisor crowding. When surgical removal is carried out in older patients, following the development of symptoms, the risk of postoperative complications, pain and discomfort increases. Nevertheless, in most developed countries prophylactic removal of trouble-free wisdom teeth, either impacted or fully erupted, has long been considered as 'appropriate care' and is a very common procedure. There is a need to determine whether there is evidence to support this practice. OBJECTIVES: To evaluate the effects of prophylactic removal of asymptomatic impacted wisdom teeth in adolescents and adults compared with the retention (conservative management) of these wisdom teeth. SEARCH METHODS: The following electronic databases were searched: the Cochrane Oral Health Group's Trials Register (to 30 March 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1), MEDLINE via OVID (1950 to 30 March 2012), and EMBASE via OVID (1980 to 30 March 2012). There were no restrictions on language or date of publication. SELECTION CRITERIA: All randomised controlled trials (RCTs) on adolescents and adults comparing the effect of prophylactic removal of asymptomatic impacted wisdom teeth with no-treatment (retention). DATA COLLECTION AND ANALYSIS: Six review authors screened the results of the search and assessed whether trials met the inclusion criteria for the review. Data extraction and risk of bias assessment were conducted in duplicate and independently by six review authors. Where information was unclear, authors of studies were contacted for additional information. MAIN RESULTS: No RCTs were identified that compared the removal of asymptomatic wisdom teeth with retention and reported quality of life. One RCT on adolescents was identified that compared the removal of impacted mandibular wisdom teeth with retention and only examined the effect on late lower incisor crowding. This study at high risk of bias provided no evidence that extraction of wisdom teeth had an effect on lower incisor crowding over 5 years. AUTHORS' CONCLUSIONS: Insufficient evidence was found to support or refute routine prophylactic removal of asymptomatic impacted wisdom teeth in adults. A single trial comparing removal versus retention found no evidence of a difference on late lower incisor crowding at 5 years, however no other relevant outcomes were measured.Watchful monitoring of asymptomatic third molar teeth may be a more prudent strategy.

The evaluation of mineralized collagen as a carrier for the osteoinductive material COLLOSS(®)E, in vivo.

In this study, the suitability of mineralized collagen, as a carrier for the native bone morphogenetic protein containing product COLLOSS(®)E, was evaluated in a rat subcutaneous implantation model. Tubular-shaped scaffolds were made from mineralized collagen and were left empty (controls), filled with 40 mg COLLOSS(®)E, or filled with a mixture of COLLOSS(®)E and osteoconductive ß-tricalcium phosphate (ß-TCP) granules. Six of all the samples were implanted in 18 animals. During the implantation period, macroscopic examination suggested inflammatory reaction. Histological evaluation after 12 weeks confirmed the presence of inflammatory cells. Although the mineralized scaffold and ß-TCP granules could be clearly seen, no new bone formation was found. This is in contrast to previous reports in a similar set-up wherein a titanium mesh was used as scaffold material in combination with COLLOSS(®)E. It is concluded, therefore, that the osteoinductive capacity of bone morphogenetic proteins or, more specifically, COLLOSS(®)E is inhibited when the carrier gives rise to a significant inflammatory reaction. Additional studies are necessary to assess the effect of combining COLLOSS(®)E with a dimensionally stable and osteoconductive material like ß-TCP.

Bone-like tissue formation using an equine COLLOSS E-filled titanium scaffolding material.

COLLOSS, a bovine extracellular matrix product containing native BMPs has already shown osteoinductive properties. To overcome problems with risk of transmissable spongiform encephalopathy (TSE) infection, an equine derived version was investigated in this study, named COLLOSS E. Disc- and tube-shaped implants were made from titanium fibre mesh. The central space of tubes was filled and the discs were impregnated with the COLLOSS E material to assess osteo-induction. These implants and non-loaded controls were implanted subcutaneously into the back of Wistar rats. After implantation periods of 2, 8, and 12 weeks, the implants were retrieved and sections were made. Histology showed a thin fibrous capsule surrounding the titanium mesh and a very mild tissue reaction. The disc implants, loaded or non-loaded, showed no bone formation at all. After 2 weeks of implantation 3 out of 5 of the loaded tubes showed bone formation with a mean of 0.3 mm2 areas of new formed bone, after 8 weeks 3 out of 6 and 0.7 mm2, and after 12 weeks this increased to 6 out of 6 and 1.0 mm2. In the non-loaded tubes only connective tissue in growth was seen. In conclusion, it was demonstrated that COLLOSS E material, loaded in a titanium fibre mesh tube shows osteoinductive properties. The effect of COLLOSS E has to be investigated further in orthotopic sites, which resemble more the final clinical application for bone reconstruction.