3rd molar assessment Flashcards
1
Q
What problems are associate with mesially impacted 3rd molar
A
- pericoronitis
- Dental caries
- Periodontal disease
- Distal caries in second molars
2
Q
What problems can third molars cause
A
Swelling
caries
pericoronitis
3
Q
What problems can third molars cause
A
Swelling
caries
pericoronitis
4
Q
What is pericoronitis
A
A partially erupted tooth covered by a large amount of soft tissue (operculum) that can get infected
5
Q
How can we treat pericoronitis
A
Clean the area
Extract the tooth
6
Q
What are the causes of pericoronitis
A
- Patients with compromised host defenses
- Minor trauma
- Food trapping under the operculum
- Bacterial infection
- Poor OH
7
Q
List the signs and symptoms of pericoronitis
A
- Pain
- Hallitosis
- Swelling
- Erythema
- Bad taste
8
Q
What can happen if pericoronitis is not treated
A
- Trismus
- Pyrexia
- Lymphadenopathy
- Malaise
- Dysphagia
9
Q
List some spaces in the head that can get infected in a patients with untreated pericoronitis
A
Submandibular space
sublingual spcae
buccal space
10
Q
What do we use to irrigate sockets
A
Saline
11
Q
What are the benefits of saline
A
Your body already makes it
it is easy for patients to make at home
12
Q
If we suspect systemic involvement following periocoronitis what should we do
A
Prescribe antibiotics
13
Q
Which antibiotics do we prescribe for systemic pericoronitis
A
- Metronidazole 200mg TDS for 3 days
- Amoxicillin 500mg TDS for 3 days
14
Q
Why can some third molars be impacted
A
Due to obstruction in their eruption path, pathology or lack of physical space
15
Q
List the different types of impaction
A
- Partially erupted and partially covered by soft tissues
- Unerupted and completely covered by soft tissue
- Unerupted and covered by bone and soft tissue
16
Q
How are third molars classified
A
Classified by the position of their impaction
17
Q
Name the different classifications of 3rd molar impaction
A
- mesioangular
- Horizontal
- Vertical
- Distoangular
18
Q
How common are Mesiodens angular 3rd molar impaction
A
25.5%
19
Q
How common are horizontal 3rd molar impactions
A
4%
20
Q
How common are vertical 3rd molar impaction
A
61.8%
21
Q
How common are distorting angular 3rd molar impactions
A
6.7%
22
Q
Talk through the guidance of extractions of wisdom teeth given by NICE
A
- Unrestorable caries
- Non treatable pulpal and or periapical caries
- Cellulitis
- Abscess
- Osteomyelitis
- Internal / External resorption of the tooth or adjacent teeth
- Fracture of tooth
- Disease of the follicle inc cyst/tumour
- Tooth / teeth impeding surgery
- Reconstructuve jaw surgery
- Tooth is involved in the field of tumour resection
23
Q
List some patient factors we must consider when assessing an oral surgery patient
A
- Age
- Social history
- Medical history
- BMI
- Ethnicity
- Capacity
24
Q
List some surgical facts we must consider when assessing an oral surgery patient
A
- The tooth itself
- Periodontal status
- Surgical anatomy
- Systemic
- Mouth opening
- Adjacent structures
- Associated pathology
- TMJ
- Occlusal relationship
- Surgeon skill
25
Why is it important to consider age when assessing an oral surgery patient
1. Medical complexity increases with age
2. Increased complications after 30 years
3. Mental health
4. Retained carious third molars are communion older patients
26
What drugs do we need to look out for when assessing an oral surgery patient
1. Anticoagulants
2. Steroids
3. Immunosuppressive
4. Biphosphonates
5. Antibiotics prophylaxis
27
Why do we need to consider BMI when assessing an oral surgery patent
Higher BMI linked with harder access and larger neck and oral cavity
medical considerations such as diabetes
Metabolism and healing may be different in patients with a higher BMI
28
Which structures do we need to check when doing an extra oral examination
1. Cervical lymphadenopathy
2. Mouth opening
3. TMJ
4. Facial symmetry
5. Facial swelling
6. Trigeminal nerve
29
What structures do we need to check when doing an intra oral examination
1. Soft tissues
2. hard tissues
3. Status of second molars
30
Why do ew need imaging when assessing third molars
1. Check for presence of caries
2. Conditions of existing restorations
3. Alveolar bone levels
4. Root morphology
5. Morphology of pulp chamber
6. Signs of periodontal pathology
7. Position of unerupted teeth or retained roots
8. Other pathology of the jaws
31
Which radiographs may we take to image third molars
1. Peri-apical Radiograph
2. Orthopantomogram
(sectional or full)
3. Cone Beam CT
32
Give some indications for a peri apical radiograph
1. Detection of apical inflammation/ infection
2. Assessment of periodontal status
3. Post trauma
4. Unerupted teeth
5. Root morphology
6. During Endodontics
7. Apical surgery
8. Apical pathology
9. Implants post op
33
What are the disadvantages of peri apical radiographs
1. Technique sensitive
2. Gag reflex
3. Edentulous alveolar ridge
4. Children
5. Co operation
34
Give some indications for an OPT
1. Gross neglect
2. Prior to general anaesthesia
3. Oral surgery
4. Orthodontics
5. TMJ
35
Describe what a CBCT can show us
1. Thin slices with variable thickness
2. Can be viewed in all planes
3. Eliminates super imposition
4. High contrast resolution
36
What are some benefits of CBCT
1. Reduction in dose
2. Short scan time
3. High resolution
4. Interactive software
37
What are some of the issues surrounding CBCT
Issues with artefacts
38
When might a CBCT be indicated
When conventional radiographs show a close relationship between the mandibular third molars and the inferior alveolar canal
39
What do we check to see if a radiogrpah is diagnostic quality
1. Contrast and density
2. Region of interest is clearly visible
3. Surrounding tissue is normal
4. No disotrtion
40
What should we do if we think we see something abnormal
S.T.O.P
Site
Translucency
Outline
Previous imaging
41
List some red flags we may see on a radiogrpah
1. Loss of symmetry
2. Apparent soft tissue mass
3. Distorted anatomy- displacement of teeth with no obvious cause
4. Teeth floating in air
5. Relevant medical history and clinical correlation
42
If you see a lesion on a radiogrpah what should your description include
1. Site or anatomical position
2. Size
3. Shape
4. Outline
5. Relative radiodensity and internal structure
6. Effect on a adjacent structures
7. Time present
43
Relationship with which adjacent structures is it important to assess when looking at a third molar
1. Maxillary antrum and tuberosity
2. Inferior alveolar nerve and associated vessels
3. Lingual nerves
4. Mylohyoid nerve
5. Long buccal nerve
44
List some signs on a plain film imaging which may suggest close/intimate relationship between the canal and the third molar
1. Super imposition of the inferior alveolar nerve canal and third molar
2. Diversion of the inferior alveolar nerve canal
3. Darkening of the root where it is crossed by the canal and the widening of the canal
4. Interruption of the white lines on the canal
5. Darkening o 5th eroots with associated widening of the canal
6. Juxta apical area
45
What is the inferior alveolar artery positioned in relation to the nerve
Likely posterior/ posterior lateral to the nerve
46
What do we look at regarding roots
1. Number of roots
2. Curvature of roots
3. Degree of root divergence
4. Size and shape of roots
5. Root resorption
6. Caries
47
Describe the most favourable type of roots
Fused or conical roots
48
How does the bone determine th difficulty of a third molar extraction
Bone density determines difficulty
49
Describe the bone in a patient under the age of 18
1. Less dense
2. Pliable
3. Expands
4. Bends
5. Easier to cut/ expand
50
Describe the bone in a patient OVER the age of 35
1. Much denser bone
2. Decreased flexibility
3. Decreased ability to expand
4. Much bone removal required
5. Higher risk of extraction
51
List the predictors of difficulty
1. Alveolar bone level
2. Tooth position
3. Application depth
4. Point of elevation
52
List some factors which increase risk of complication
1. Underlying systemic disease
2. Age
3. Anatomical position of tooth and root morphology
4. Local anatomical relationships
5. Status of adjacent teeth
6. Access
7. Patient co operation
8. Bone density
9. Infection
10. Pathology
11. Ankylosis
53
What are the risks associates with all patients undergoing surgery
1. Pain
2. Swelling
3. Bleeding
4. Bruising
5. Infection
6. Dry socket
7. Difficulty opening
8. Damage to adjacent teeth
54
Which cranial nerve causes the most issues during third molar surgery
The trigeminal nerve
55
Other than the branches of the trigmeinal nerve which other nerves cause problem in third surgery
Chroda tympani
56
Which branches of the trigmeinal nerve causes the most issues
The lingual nerve
The inferior alveolar nerve
57
When is the lingual nerve at risk
1. Durign the incision
2. Flap retraction
3. Lingual split procedure
4. Removal of fractured bone of socket
5. Tooth sectioning
6. Over aggressive removal of retained follicle
7. Deep suturing
8. Absent lingual plate
58
List some specific risks of mandibular third molar surgery
1. Temporary or permeant altered or loss or sensation to the lower lip, skin of the chin, gums of the lower teeth, lower teeth and taste
2. Truisms
3. Time off work
4. Significant swelling or bruising that can spread to the neck
5. Rarely but hospital admission may be required
59
List the 4 basic surgical principles
1. Good anaesthesia
2. Minimal trauma
3. Good planning
4. Anatomical knowledge
60
Why is it important we follow the 4 principles of basic surgery
1. Avoids physical and psychological stress
2. Reduction in pain
3. Lower risk of infection
4. Reduced swelling
5. Rapid healing
61
What is operculectomy
A surgical procedure to remove the affected soft tissue covering the partially erupted tooth
62
Why do we carry out operculectomy
To improve oral hygiene
63
Which tissues do we have to be careful of when carrying out third molar surgery
Periosteum
64
What does the periosteum contain
Cells responsible for bone remodelling
65
What must we preserve when carrying out 3rd molar surgery
Consider bone and preserve it as much as possible
66
What must we be careful of if we elevate the third molars
Could fracture the distal of the 7
67
What pre op can you give patients before third molar surgery
Pre op 400mg ibuprofen
68
What must we be careful of when carrying out this molar surgery
Make sure no air gets forced into soft tissues or sockets
no air rotors
69
What can happen if air gets forced into the soft tissues or sockets
Patient can develop surgical emphysema leadign to swelling of the face
70
Talk through the basic principles of flap design
1. Base wider than the free margin
2. Width of the base should be bigger than the length of the flap
3. Axial blood supply
4. Margins on sound bone
5. Preserve vital structures
6. Access
7. uncomplicated closure
71
When do we raise flaps
Usually in mandibular third molar XLA
72
What post operative care must we tell the patient
1. Expect the worst
2. Regular analgesia
3. No smoking or vaping for a week
4. Post op next day
5. Give written contact details to patient for advise and emergencies
73
What complications can arise with third molar surgery
1. LA
2. Damage to adjacent teeth
3. Extraction of th wrong tooth
4. Displacement of root/tooth fragment
5. Aspiration
6. Instrument fracture
7. Soft tissue damge
8. TMJ dislocation
9. Mandible fracture
10. Nerve damage
11. Fractured tuberosity
12. Burn
74
What is a coronectomy
Removal of the crown from the roots of a healthy tooth in healthy patients indicated to prevent inferior alveolar nerve damage in high risk patients
75
Give some guidelines regarding which teeth can have a coronectomy
1. Teeth with associated infection should be exclusded
2. Teeth are are mobile shoudl be excluded
76
What can happen in some coronectomys
1. Late migration of the root fragment may occur
2. leaving the retained root fragment at least 3mm inferior to the crest of the bone seems appropriate
77
List some contra indication for a coronectomy
1. Caries with pulpal invovlement
2. Apical disease
3. Mobility of roots
4. Association pathology
5. Pre orthographic surgery
6. Immunocompromsied
7. Pre radiotherapy
