Oral surgery Lecture 7 Done by: Bayan Mrayan Impacted wisdoms Today we are going to talk about impacted

wisdoms, now whats the difference between impacted teeth and unerupted teeth? ,,every impacted tooth is unerupted tooth but not every unerupted tooth is an impacted one, if we have a10 years old child who doesnt have the 6es and they are still in the jaw do we call this case an impaction ? No, of course we call it unerupted which might erupt or may not erupt, now an impacted teeth is simply a tooth that has passed the time of eruption and it cant erupt any more . Now what are the indications to take wisdoms out.. In the past American dentists used to take the wisdoms out whether the case indicates extraction or not, for personal gains to take money from their patients, on the other hand British were honest in dealing with their patients so they put specific guidelines (medical indications to take wisdoms out). There is a group of people called NICE Stands for National institute for clinical excellence they are Belonging to the Ministry of Health they are responsible for putting these guidelines The indications are . 1. If there is evidence of pathology like a cyst or tumor surrounding the wisdoms or any sort of Pathology. 2. A tooth that is involved in osteomylitis (sclerosing osteomylitis Chronic focal sclerosing osteomyelitis is a periapical lesion that involves reactive osteogenesis evoked by chronic inflammation of the dental pulp. In most cases, this lesion develops in the mandibular molar region in response to a low-grade infection of the pulp that results from a deep carious lesion. A case is presented in which incomplete tooth

fracture was the apparent cause of this type of periapical pathosis. 3. teeth are impeding surgery the patient has problems in opening the mouth and the surgeon wants to move the mandible, some time the presence of wisdoms prohibits the movement of the jaw anteriorly or posteriorly in this case we need to take the wisdoms out 4. Gum Infection (Pericoronitis) its an infection in the soft tissues that surround partially erupted wisdom tooth When a wisdom tooth is partially erupted, food and bacteria collect under the gum causing a local infection. This may result in bad breath, pain, swelling and trismus (inability to open the mouth fully). The infection can spread to involve the cheek and neck. Once the initial episode occurs, each subsequent attack becomes more frequent and more severe. The patient come to you complaining from swelling in his mouth this is what we called MILD PERICORONITIS. After that the swelling gets bigger and a limitation in mouth opening starts to appear this is what we called MODERAT PERICORONITIS ,when there is severe trismus and signs and symptoms of infection redness ,malaise ,pain that gradually increase till it reaches to its severe stage This is called SEVERE PERICORONITIS ,now here the infection starts to convert itself to an abscess which is problem because this abscess can go through the spaces, like submassetric space because this space is closed by both massetric and buccinators muscles, it diffuse to the sulcus near 6or 7 which we called migratory abscess of pericoronitis .Now how do we manage this case ,if its mild we can just irrigate under the operculum its the soft tissue that covers partially erupted tooth by using( hydrogen peroxide(extra information)),and OHI, there is no need to give antibiotic because there is no signs of systemic involvement ,in moderate and sever we need to give antibiotic the eventual solution is extraction of the tooth but according to NICE guideline pericoronitis is considered as indication for extraction if it comes twice or more than twice a year, but after the episode of pericoronitis is resolved not immediately.

5. Caries, here we dont treat wisdoms conservatively like other teeth , extraction takes the priority here . 6. As a cause of periodontal disease to the adjacent tooth, when the tooth is Lying on the adjacent tooth it can cause resorption to the inter septal bone distally to the second molar 7. resorbtion to the 2nd molar due to horizontal positioning of 3rd molar and eruption capacity when the root are still small . 8. Cyst and tumor like dentigerous cyst and odontogenic tumer like Ameloblastoma this is dentigerous cyst .

9. Prosthetic reasons, for example a patient needs a complete denture but he has impacted teeth here there is two different decision you can make either to extract it ,because with time the ridge will resorbe and the tooth will reveal or you can leave it and remove it later on. 10. orthodontic reasons :some orthodontist claim that third molars can cause later lower anterior teeth crowding ,other orthodontic reasons, is making space to push molars posteriorly to make space for other teeth to move . 11. Socio economic reasons just to avoid any expected complications that may impede their work or the patient social life and business, the doctor Showed a picture of ameloblastoma surrounding an impacted molar and pushing it downward here is one picture .

12.unexplained facial pain they found that some patient when you examine their wisdoms you dont find any indications for extraction but they have pain ,when you take their wisdom out they feel better this for small percent1-2% of people not always right they may have TMG dysfunction syndrome that explain that pain . 13. prevention of fracture usually wisdoms are found at the angle of the mandible imagine that they are deeply impacted and horizontal they will occupy most of the angle, if the patient was beaten on his mandible the area occupied by the molar will fracture because its weak those people advised to take wisdoms out to lay down bone at the area of extraction Now moving to the contra indication for extraction 1. Extreme age, he may have medical problems ,his mandible will be so thin so in those patient we have to weigh things carefully in our mind before taking wisdom out . 2. medically compromised patient like systemic diseases or bleeding problems ,local factor like radiotherapy, or a patient who has a tumor, now if the operator is intending to take the tumor out we remove the tooth that is involved in that tumor , but in a case that the patient has a tumor in the neck and the tumor is expanding to the mandible there is no definitive management to this patient we Shouldnt mess with them as we may cause transferring of the tumor from side to side . 3. potential damage to adjacent structure like if the tooth is very close to vital structure like ID canal we may cause

parasthesia to the nerve ,if we extract it in the usual ways so we do whats we called decavitation to the tooth by removing the crown and leaving the roots as not to cause injury. or in the case of the upper were its closed to the sinus or infratemporal space behind the maxilla, so we dont extract it ,we give antibiotic if its inflamed and we treat it conservatively not to get benefit of it but rather not to extract it . Now moving to operative assessment related to patient it self .. First of all as we know we take history and whats we called general assessment, like the patient age and personality in many cases of extraction the pain is not the main problem, rather the stress is the main problem so if the patient from the beginning is frightened his pain threshold will be very low, so you as a surgeon has to decide whether to do it under sedation with local anesthesia or under GA .so take into account (personality and difficulty of the procedure). Local assessment related to the tooth itself.. 1. Access to the tooth and make sure the width of mouth opening is appropriate for such a procedure (rima oris in Latin) Now PELL and GREGORY put a classification for wisdom teeth it applies for upper and lower they made 2 types of classes ,class1,2,3and class A,B,C, class A,B,C it applies for upper and lower, class 1,2,3 it applies only for lower wisdoms .Now lets explain each type of these classes CLASS1: the tooth is found completely anterior to the anterior border of ramus of the mandible. CLASS2: the tooth is found in the middle, part of it is found anterior to the anterior border of the ramus and the other part is posterior to the anterior border of the ramus . CLASS3: The entire tooth is found posterior to the anterior border of the ramus .And here is a picture for these classes .

We will talk about class ABC later on.but you need to know that class 1,2,3 is part of access assessment Lets talk about classification according to Winter based on the inclination of the impacted wisdom tooth to the long axis of second molar..he created 3 lines (white line ,amber line, red line) they are not that specific but you should know about them . White Line The white line is drawn along the occlusal surfaces of the erupted mandibular molars & extended over the 3rd molar posteriorly. It indicates the difference in occlusal level of the 1st & 2nd molars & the 3rd molar. Amber Line The amber line represents the (height of the) bone level. The amber line is drawn from the surface of the bone on the distal aspect of the 3rd molar (or from the ascending ramus) to the crest of the inter-dental septum twixt the 1st & 2nd molars. This line denotes the margin of the alveolar bone covering the 3rd molar and gives some indication to the amount of bone that will need to be removed for the tooth to come out. Red Line

The red line is an imaginary line drawn perpendicular from the amber line to an imaginary point of application of an elevator. Usually, this is the cemento-enamel junction on the mesial aspect of the impacted tooth (unless, it is the disto-angular impacted tooth where the application point is the distal cemento-enamel junction). The red line indicates the amount of bone that will have to be removed before elevation of the tooth i.e. the depth of the tooth in the jaw & the difficulty encountered in removing the tooth as the red line become longer extraction become harder its not that much applicable.

Now the classification for Winters are (mesio-angular,distoangular, horizontal, vertical) ,to differentiate between them.. we draw a line on the long axis of the next-door tooth the 7 and a line on the long axis of the 8 and we check the angle between them. If the lines are parallel its vertical look at the picture..

 If the long axis of third molar is horizontal the angle will be 90 so its Horizontal..

Disto-Angular. The long axis of the 3rd molar is angled distally / posteriorly awayfrom the 2nd molar.

 Mesio-Angular. The impacted tooth is tilted toward the 2nd molar in a mesial direction.

2. Now the second assessment is according to the depth of the tooth inside the boneNow we apply Pell and Greogory classA,B,C Class A. The occlusal plane of the impacted tooth is at the same level as the occlusal plane of the 2nd molar. (The highest portion of impacted 3rd molar is on a level with or above the occlusal plane). Class B. The occlusal plane of the impacted tooth is between the occlusal

plane & the cervical margin of the 2nd molar. (The highest portion of impacted 3rd molar is below the occlusal plane but above the cervical line of the 2nd molar). Class C. The impacted tooth is below the cervical margin of the 2nd molar. (The highest portion of impacted 3rd molar is below the cervical line of the of 2nd molar). Note that its only the depth that is changing not the distance from the anterior border of the ramus as in Class1,2,3

Now whats about obliquityin general in.most of the cases third molar positioned lingual to the rest of the teeth. Buccal / Lingual Obliquity. In combination with the above, the tooth can be buccally (tilted towards the cheek) or lingually (tilted towards the tongue) impacted.we call it bucco or linguo-version tooth, look at the pictures below

3. You have also to asses number and shape of the roots . If we have a tooth with one root and its conical in shape we expect that the extraction is easy.. If we have a tooth with 3 roots and they are erratic we expect the extraction to be difficulthere we think of surgical extraction, we open a flap . Another thing to consider is the point of application when the tooth is mesioangular the POA is mesial and when its distoangular the POA is distal.. All of these we could specify them by the proper assessment of the tooth and Xrays Some time the problem is not the third molar it self but the problem is with the next-door tooth, so we afraid that there will be some sort of trauma to the next -door tooth so if you have amesioangular third molar adjacent to an overfilled 7 you may cause fracture to the filling or even the tooth it self so its better to do surgical extraction in this case so always check third molar and next door tooth .if you have

a third molar with a big crown and small root you may think its easy to remove it ,you are wrong its so difficult to extract it in non surgical procedure. And it will be more difficult to have a ball in socket when the tooth is not fully formed a follicle surrounds the crown so the tooth starts to rotate in its place when you try to remove it 4. Assess shape of the root If we have a second molar with a conical shape root and we put the elevator between 7and 8 to extract the 8 we will definitely extract the 7 because it will be easy to remove it due to the shape of its root 5. Assess bone texture for older people bone is much harder than younger age groups who have resilient bone texturein sclerotic bone its more difficult to take teeth out. . 6. Assess the tram line (skeet al7adeed) when you look at the x-ray you will find 2 lines for ID canal if they are away from the tooth we are in the safe side ,extraction will not affect the nerve . There is a study done in 1990 by Roods an Shehap in which they brought patients with wisdom teeth and they took X-rays for them, they started looking at the teeth in relation to the ID they found different situations. if there is radiolucecy on the root of the wisdom (at the apical third) if the ID canal is derooted as it change its direction . if one of the tram line at the region of the root of third molar disappeared either at the upper or the lower . if the root are straight and suddenly you notice deflection at the ID canal region . if the roots of the molar start as normal in shape when they arrive to the ID canal region they either appear constricted or flared . If any of these cases is noted the possibility of having numbness after extraction is higher.. One of the students asked about the diameter of ID canal I think?

The doctor answered that he doesnt have a specific number but its not less than 4mm. Now lets talk about some definitions related to this study .perforation, grooving,notching, Notching: the tooth has one root but it has a notch or a small opening at the end (apical third) this is where the ID canal enters and passes the tooth. Perforation: during the growth of teeth, part of it will grow above the canal and the other part under the canal it seems perforated . Its unlikely to see such cases, its used for academic reasons mainly, what I want you to know that if we have such these appearances or cases we think of surgical extraction, because when you do simple extraction you may do sectioning for the tooth in small pieces, always think before doing any thing I really tried hard looking for more obvious definitions of these terms, this is what I found according to radiographic appearance 1- Notching: Radiolucent band at the apex of the roots, a break in the continuity of the upper radio dense border, and narrowing at the expense of the top of the canal. 2- Grooving: Radiolucent band across the root above the apex, interruption of both superior and inferior borders of the canal and narrowing of the canal space. 3-. Perforation: Radiolucent band crossing the root above the apex with loss of both superior and inferior borders of the canal at the area where they cross the roots and constriction of the canal maximal in the middle of the root. This is perforation ..

. ( Notching, grooving and perforation were regrouped as true relation)

Lets talk about different terms of sensation .. Parasthesia of the lip and tongue Anesthesia full loss of sensation Hypoesthesia reduction in sensation still feel sensation Paresthesia is abnormal sensation there is something going wrong in sensation It is more generally
known as the feeling of "pins and needles

Dysesthesia : unpleasant sensation they feel like electric shock after surgical procedure abnormal sense of touch Hyperalgesia increase response to stimulus which may be caused by damage to nociceptors or peripheral nerves There is a third sensation I couldnt here it but it means that the patient feel pain spontaneously in the lips even without touching them,

The doctor showed a picture about Roods classification this is what I found.

. A, darkening of apex; B, reexion of apex; C, narrowing of apices; D, bid apices on canal; E, deviation of canal; F narrowing of canal; G island-shaped apex.

We can take wisdoms in three ways or under three sources of anesthesia Local anesthesia

 Local with sedation (nitrous oxide for children not as useful for the adult , midazolam,or we can ask the patient to take diazepame orally 5 mg the day before the surgery ,midazolam is more effective and have immediate action .the way we use, is determined by the patient personality and cooperation . But the question is why do we use local anesthesia for a patient to be treated under GA? For vasoconstriction and for Pre-emptive analgesia to anesthetize C-fibers which are responsible for pain transduction, so the patient will feel lesser pain after he wakes up The end of part 1 Done by: Bayan Mrayan Sorry for any mistake
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