Case of the Month

An intriguing dental scan and how to interpret it

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Inclusion of Third Molars
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  • kV: 90
  • FOV: n.a
  • Axial thickness: 0.250 mm

The case relating to a Cone Beam CT – Lower Arch, in a patient of about 35 years, is presented for a dental evaluation and possible extraction of the Wisdom teeth, 4.8 – 3.8 for inclusion.


Lower arch examination – The bony cortex of the mandible appears within physiological parameters. No alterations of the medullary trabecular architecture are noted. Evidence of bone inclusion of 38 in distomesial decubitus, the apexes in contact with the lower mandibular canal. Evidence of bone inclusion of 48, the apexes in contact with the lower mandibular canal which has a parietal path with respect to the thick apices. Lower mandibular canal of normal radiomorphology and localization. Other dental findings as reported above.

(CBCT Axial Image – Lower Arch – Thickness 1mm)

(Image Cross CBCT – Teeth 4.8 – 3.8 with evident signs of inclusion – Thickness 1mm)

(Panorex CBCT image provided by DIAGNOCAT AI)


A tooth is defined as included, when, after the expected eruption period has passed, it is not yet present in the mouth. The eruption of each tooth should respect a specific time interval considered “normal”. For example, the definitive lower central incisors begin to form in children at the age of 3/4 months and erupt around 6/7 years of age. As for wisdom teeth, eruption is expected between 17 and 30 years of age: a very long period!


In radiographic images, the impacted tooth can present itself, and therefore be classified, in different ways. Usually the dentist evaluates the position with respect to the second molar which, obviously, is located in front of the wisdom tooth.

The third molar can be:

  • Mesio-inclined, therefore with the crown (i.e. the part that should erupt in the arch) facing the second molar;
  • Horizontal and therefore completely “lying down”;
  • Disto-inclined with the roots facing the second molar and the crown in the opposite direction;
  • Reverse, that is, with the roots upwards and the crown downwards (an extremely rare condition)

The dentist also evaluates the position of the tooth with respect to the bone that contains it. The depth of inclusion also plays a fundamental role in analyzing the situation. A tooth located very deep in the bone will be more difficult to reach. This can somewhat complicate the extraction. When this situation occurs, the patient is subject to various ailments, including:

  • Cyst
  • Infections and inflammations
  • Caries
  • Abscesses

Impacted teeth can cause a lot of pain, but most of all they can also damage the surrounding teeth or roots, causing further complications, even more serious. Due to these possible consequences in the past there was a tendency to intervene by extracting the wisdom teeth even before any symptoms appeared, while today each individual case is evaluated with greater attention.


To find out if it is necessary to remove an included third molar or not, it is advisable to undergo a thorough visit to the dentist. If the impacted wisdom tooth does not become inflamed and does not damage neighboring teeth, it can be left in place.

If, on the other hand, the included wisdom tooth causes pain and inflammation, it must be removed through a surgical procedure performed by a surgeon experienced in odontostomatology and dental implantology. Before proceeding with the extraction of the wisdom tooth, the surgeon will check the position of the tooth, which will determine the difficulty and the type of intervention:

  • simple extraction occurs when the tooth is perfectly aligned with the others;
  • the extraction in semi-inclusion involves the removal of a part of the bone tissue, before being able to proceed;
  • extraction in total bone inclusion is the most complicated type of intervention because the tooth is stuck inside the bone and, in order to be able to extract it, it is first necessary to intervene on the structures above and cut the bone.

Local anesthesia is usually performed for this type of surgery. You can opt for general anesthesia only when all 4 wisdom teeth have to be removed, a decision that the surgeon makes, in agreement with the patient, to minimize the discomfort of having to undergo multiple surgeries.

The postoperative course involves the application of ice to the area to reduce swelling and supportive drug therapy (recommended by the doctor), which may include anti-inflammatory drugs and antibiotics. In the days following the surgery, pain and swelling may be felt and slight bleeding may occur. To alleviate these symptoms, you should sleep with your head raised, avoiding placing your face on the side where you were operated on. In any case, it is good to keep the situation under control and notify the doctor if any abnormalities are found.

Furthermore, it is important to follow the dentist’s advice, treat the oral cavity with the same attention as always (without using an electric toothbrush) and rinse the mouth with a specific mouthwash.

After about 6 – 10 days after the operation, you must undergo a check-up to check the healing status of the gum and remove any stitches.

Processed and written by Dr. Lucisano Francesco – DentQ Italy srl

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