Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Course Outline
Part I: To Remove or Not to Remove 1. Development 2. Wisdom teeth as an asset 3. Wisdom teeth as a liability 4. Alternatives to removal 5. Timing of removal
Course Outline
Part II: Treatment Approach 1. Assessing the difficulty of removal 2. Patient counseling and preparation 3. Anesthesia 4. Instrumentation 5. Technique
Course Outline
Part III: Management of Infected Teeth
Course Outline
Part IV: It Aint Over Till Its Over 1. Complications 2. Post-operative care 3. Documentation
Development
Initial calcification
Occurs as early as 7yrs, more typically age 9.
Crown Mineralization
Usually completed by age 12 to 14.
Root Formation
Usually half-formed by age 16.
Root Completion
Fully formed roots with open apices are usually present by age 18.
Eruption
Most teeth that will erupt are erupted by age 20. 95% of all teeth that will erupt are erupted by age 24. A limited number of third molars appear to erupt, at least to some degree, in young adults.
Evaluating Risk:Benefit
Evaluating Risk:Benefit
Since Risk of retention and Benefit of removal are essentially the same concept, these terms may be combined. Since Benefit of retention essentially = 0, the equation may be simplified:
Evaluating Risk:Benefit
You must consider 2 separate assets of each risk and each benefit: 1. Magnitude of risk or benefit 2. Probability of risk or benefit
Magnitude
Is it major or minor? Does it require hospitalization? Is it permanent? Does it affect your daily routine? If so, for how long?
Probability
The most overlooked aspect of most consultations. Fortunately most real bad outcomes are real uncommon What is the likelihood of certain problems? How much does treatment alter this likelihood?
Risk:Benefit
Are erupted 3rds more or less subject to disease? Are erupted 3rds more or less beneficial?
Benefits of 3rds
Functional occlusion what is this? Is it any different than just occlusion? Is all occlusion functional? Is all functional occlusion important? If so, is it all equally important? Without evaluating questions such as these, how can you determine the true benefit of 3rds?
Tooth Transplantation
Under ideal conditions, 27 oral surgeons transplanted 291 teeth: 5-yr survival rate: 76.2% 10-yr survival rate 59.6%
Schwartz O, Bergman P, Klausen B: Resorption of autotransplanted teeth. A retrospective study of 291 transplantations over a period of 25 years. Int J Oral Surg 1985;14:245-258.
Conclusion
3rd molars provide no proven functional benefit and no obvious esthetic benefit. Rarely, they may provide a treatment option that, at best, is third-line treatment.
Augmentation: Conclusion
It wont improve your outcome. It will undoubtedly increase your infection rate Why would you want to augment this area anyway?
nd 2
Problem #3
rd 3
Molar Caries
Problem #3
rd 3
Molar Caries
Problem #4
nd 2
Molar Caries
Problem #5 - Infection
Can turn an elective procedure into an urgent or emergent situation Unscheduled loss of work Increased pain and healing time Compromise of adjacent teeth Compromise of patients systemic health
Infection
Types of Infection
1. 2. 3. 4. 5. Simple dental caries and periodontal disease Pericoronitis Abscess Cellulitis Abscess extension into adjacent fascial spaces 5. Abscess spread to distant sites 6. Recurrent infections 7. Infections resistant to initial local and systemic treatment measures
Pericoronitis
Pericoronitis
A failure of preventive measures A failure of early recognition, or a failure to seek proper treatment A step along the pathway of infection Pericoronitis should be a warning sign that initiates immediate and aggressive treatment with careful observation.
Problem #6 - Resorption
Problem #7 - Supereruption
Problem #8 - Cysts
Dentigerous Cyst
Dentigerous Cyst
Types of Cysts
Follicular cyst (Dentigerous Cyst) OKC (Odontogenic Keratocyst) Ameloblastoma (several varieties) Not all radiolucencies are cysts! - Lymphoma - Myeloma - Metastatic carcinoma
Without the radiolucency, would you have recommended removal? Is the removal of this better or worse with the radiolucency?
Cysts
Cysts themselves are not catastrophic the problem is that we dont know exactly what they are until they are histopathologically examined which necessitates removal. All cysts result in bone loss. Some cysts recur more than others.
Problem #9 - Tumors
Benign vs. malignant Odontogenic vs. non-odontogenic Primary vs. secondary Each of these factors has important treatment
implications.
Tumors
Immediate Pre-extraction
Immediate Post-extraction
3 Days Post-extraction
8 Days Post-extraction
Alternatives to Removal
1. 2. 3. 4. 5. Restoration Periodontal therapy Operculectomy Removal of another tooth No treatment
Bone removal will be necessary. Is it better to remove this 3rd molar or wait?
Removing
rd 3
Molar Germs
Bjornland T, Haanaes HR, Lind PO, Zachrisson B: Removal of third molar tooth germs: study of complications. Int J Oral Maxillofac Surg 1987;16:385-390. Half as much postop pain medication was required One third quicker procedure Well-tolerated with local anesthesia
Age 7-11:
rd 3
Molars
Age 7-11:
rd 3
Molars
Age 7-11:
rd 3
Molars
Age 12 -14
Crown mineralization progresses Distance of lower 3rds from ridge crest increases Lower 3rds become more difficult to remove Upper 3rds may still be quite difficult Psychologically, many patients may be less prepared at this age.
Age 12 -14
Age 12 -14
Age 12 -14
Age 15-18
Root formation has begun and may progress to near completion. Most patients are psychologically accepting of surgery at this age. Most studies agree that complication rates are least in this age range.
Age 15-18
Age 15-18
The follicle allows for relatively easy removal once the tooth is accessed. No PDL is present there is no attachment of the tooth to bone. The portion of the follicle deep to the forming roots acts as a safety zone between the tooth and the nerve.
Age 15-18
The periphery of the deepest mineralized tooth surface may be quite sharp, allowing laceration of the neurovascular bundle if it too is housed within the follicular space. The tooth may spin and be difficult to stabilize while sectioning and elevating.
Age 15-18
Age 15-18
Age 15-18
Age 19-22
Root development is not always complete during this period, making it still a favorable time for 3rd molar removal.
Age 22-35
Nearly all patients in this age group will have fully developed 3rd molar roots this potential advantage is lost. The bone still has a good ratio of elastic collagen matrix to mineral content, usually simplifying removal and even more frequently improving most parameters of healing. Most of these patients are healthy.
Age 35-45
Most patients are still ASA I or II The mineral content of the mandible increases during this time. Many 3rd molars must be removed during this time for therapeutic reasons.
Over Age 45
The complication rate is highest in this group. The incidence of nerve injury is highest in this group and recovery is the poorest. Even routine healing tends to be prolonged and associated with increased morbidity. Patient health may be compromised.