The increasing lifespan and trend toward retention of third molars has led to a growing population of older adults with impacted third molars. While traditionally managed through early prophylactic extraction, contemporary evidence suggests that asymptomatic impacted third molars in healthy elderly patients may be safely monitored or managed conservatively. However, when intervention becomes necessary, advanced age presents unique surgical challenges, including prolonged healing, increased complication rates, and higher anesthetic risks. This review examines the current evidence on pathology prevalence, risk stratification, surgical considerations, and alternative treatment approaches, including coronectomy and watchful monitoring strategies, in the geriatric population.