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MOS Lecture Slides > Assessment and management of un-erupted teeth > Flashcards

Assessment and management of un-erupted teeth Flashcards

1
Q

Outline reasons why a tooth might be missing

A
  • congenital absence- hypodontia
  • tooth may be unerupted- delayed
  • tooth may be impacted
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2
Q

Define unerupted

A

an unerupted toot is one which fails to erupt within the expected time

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3
Q

When is a tooth considered to be unerupted?

A

if the tooth has failed to erupt 1 year after the normal eruption time

it must be investigated at this point

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4
Q

What is an impaction?

A

it occurs when there is prevention of complete eruption into a normal functional position of a tooth

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5
Q

Outline possible causes of impaction

A
  • lack of space in the arch
  • obstruction by another tooth
  • development in an abnormal position
  1. discrepancy in jaw- tooth size- genetic and environmental
  2. retained deciduous tooth
  3. impaction against supernumerary teeth
  4. root dilaceration
  5. natural or traumatic displacement of tooth germ
  6. congenital absence
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6
Q

Supernumerary teeth are most commonly present in the ______ arch

A

maxillary

they are most commonly present around the centre line, causing impaction of the lateral incisors or canines

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7
Q

Outline rare causes of unerupted or missing teeth

A
  • transposition
  • impaction against cysts or odontomes
  • radiotherapy
  • hypothyroidism
  • cleido-cranial dystosis
  • failure of root formation (this is cause by a failure in the bell phase of formation)
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8
Q

Outline common unerupted teeth

A
  • canines
  • third molars
  • second premolars
  • supernumaries
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9
Q

Unerupted teeth are more common in ______ teeth

A

in lower teeth compared to uppers

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10
Q

What is a consequence of late eruption?

A

space loss

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11
Q

Lower development of the mandibular lamina is more fragile. True or false

A

true

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12
Q

What is the combined width of the 4s and 5s ?

A

6mm

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13
Q

What is the combined width of Ds and Es?

A

10 mm

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14
Q

Outline some important information to gather for unerupted teeth

A

[ be aware of normal eruption date for unerupted tooth]
* dental age vs chronological age
* date when deciduous predecessor was lost
* trauma/infection/early extraction of deciduous predecessor history
* family history- congenitally missing
* age- bone density

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15
Q

What should be included in the clinical examination for the assessment of missing/unerupted teeth?

A
  • dental status- caries/perio/restorations present
  • any active infection- sinus, swelling, lymphadenopathy, pyrexia
  • buccal/lingual/palatal bony expansions - egg shell crackling
  • retroclined or proclined teeth adjacent to suspected erupted tooth
  • mobility or vitality of adjacent teeth
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16
Q

What are the standard radiological views for viewing unerupted or missing teeth?

A
  • OPT
  • Periapical
  • standard midline occlusal
  • lower true occlusal
    *
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17
Q

What is the use of CBCT for the assessment of lower 8s?

A
  • relationship to the 7
  • relationship to neighbouring structures such as the IAN canal/mandibular canal
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18
Q

What should your assessment include following radiograph of an unerupted tooth?

A
  • crown shape and size
  • root morphology- size, shape and state of development
  • tooth position- buccal/lingual/palatal, in line with arch, horizontal across arch
  • amount of bone overlaying the crown of the tooth
  1. relationship to vital structures
  2. relationship to adjacent tooth roots
  3. presence of root resorption
  4. size of follicle
  5. density of surrounding bone
  6. associated pathology-cysts, supernumerary
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19
Q

What can help guide maxillary canine eruption

A

mesial grooves of the upper 4s?

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20
Q

What is tooth transposition?

A

it is an interchange of two permanent teeth located at the same quadrant of the dental arch

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21
Q

Outline 5 management options for a transposed tooth

A
  • leave
  • extract
  • surgical exposure and repositioning
  • surgical exposure and orthodontic repositioning
  • transplant it
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22
Q

What factors can influence the choice of management of an unerupted tooth?

A
  • risks vs benefits
  • patients wishes
  • dental status
  • medical status
  • orthodontic opinion

*

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23
Q

% of people between the ages of 20-30 will have one impacted molar

A

70%

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24
Q

How are impacted molars classified?

A
  • degree of eruption
  • angulation and position
  • root morphology
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25
Q

What are the degrees of eruption ?

A
  • erupted
  • partially erupted
  • unerupted
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26
Q

What are the most common angulations and positions of impacted molars?

A
  • vertical
  • mesioangular
  • distoangular
  • horizontal

(can also be aberrant)
can also be in transverse position- buccal or lingual

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27
Q

What angulation/position often causes a plaque trap?

A

horizontal

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28
Q

According the the Archer and Kruger classification of impacted molars, transposition-horizontal means…

A

pointing toward the buccal

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29
Q

What are the possibilities for impacted 8 morphology?

A
  • fused or conical
  • two roots
  • multiple roots
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30
Q

What are the options for treatment of impacted 8s?

A
  • leave
  • remove (NICE guidelines)
  • coronectomy
  • transplant
  • orthodontically reposition
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31
Q

What should the patient be made aware of if the impacted 8 is pkanned to be left in situ?

A
  • resorption
  • caries
  • cyst formation
  • eruption under denture
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32
Q

Why might dentures stimulate eruption of impacted 8s?

A

Dentures caue low grade inflammation which causes bone resorption

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33
Q

How must impacted 8s be managed if left in situ?

A

they must be reviewed radiologically

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34
Q

What are the indications for the removal of impacted 8s?

A
  • infection
  • caries
  • pulpal/periapical pathology
  • periodontal disease
  • orthodontics
  • resorption
  • pain
  • follicle pathology
  • fracture of tooth/crown/bone
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35
Q

How can an impacted tooth lead to bone fracture?

A

development of cyst underneath the impacted 8 causes fragility of the bone

thus the bone is more prone to bone fracture

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36
Q

When should impacted 8s be removed if an osteotomy is to be performed? Why is this?

A
  • they should be removed 6 months before the osteotomy surgery
  • if the wisdom teeth is removed at the time of the osteotomy it will leave a void in the bone; no bony contact means that there will be no healing
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37
Q

An osteotomy requires ______ cuts through the rami

A

sagittal

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38
Q

According to NICE guidelines, extractions of impacted 8s can be indicated if the restorability of the 7 is compromised. True or false

A

true

39
Q

What types of infection are associated with impacted 8s?

A
  • caries/perio
  • pericoronitis
  • cellulitis
  • abscess
  • abscess extension into adjacent fascial spaces
40
Q

What is the 3rd most common cause of therapeutic 3rd molar removal/

A

pericoronitis

41
Q

What risks are associated with supraeruption of an 8?

A

aspiration pneumonia risk

42
Q

Outline the types of cysts

A
  • follicular/dentigerous cyst
  • odontogenic keratocyst (OKC)
  • ameloblastoma (several varieties)
43
Q

Give examples of radiolucencies that are not cysts

A
  • lymphoma
  • myeloma
  • metastatic carcinoma
44
Q

Outline important classifications of intraoral tumours

A
  • benign vs malignant
  • odontogenic vs non odontohgenic
  • primary vs secondary
45
Q

Odontogenic cysts are related to …

A

the tooth formation process

46
Q

What is the potential benefit of removing 8s in orthodontic treatment ?

A
  • prevent loss of post- retention stability
  • allows distalisation of 2nd molars (space gaining by moving molars posteriorly)
47
Q

What acronym can be used to aid radiographic assessment of impacted 8s ?

A
  • angulation
  • root morphology
  • margin of bone
  • height of tooth in bone
  • ID canal
  • trabeculation of bone
48
Q

What is the function of Winters Lines classification?

A

the provide an assessment of the difficulty of the extraction of mandibular first molars

it is used to determine the angulation of the impacted 3rd molar

49
Q

What should you radiographic assessment for M3Ms include?

A
  1. third molar crown and root form
  2. angulation of long axis to occlusal plane
  3. depth- they standard point of application to root of the second molar
  4. second molar-crown and roots, caries status
  5. ID canal
  6. distal bone level
  7. ID nerve assessment
50
Q

Outline the potential associations between the roots of M3M and the ID nerve/ID canal

A
  • seperate
  • grooved
  • perforated
51
Q

What are the stages of operation sequence of M3M removal?

A
  • mucoperiosteal flap
  • lingual retraction (controversial) - risk of lingual nerve damage
  • bone removal
  • sectioning if necessary
  • elevation of crown and roots
  • debridement
  • haemostasis
  • wound closure
52
Q

The distal incision for M3M removal should extend up to … (name the structure)

A

the external oblique ridge

(it is much more buccally placed thatpeople think)

53
Q

What are the POI that can be given following M3M removal?

A
  • pain - adequate analgesia should be provided
  • swelling- increases for up to 48 hours
  • bruising- appears after 48 hours
  • trismus- can last up to 7 days
  • soft diet
  • fluid and rest
54
Q

What complications can arise following M3M removal?

A
  • haemorrhage
  • haematomas
  • infection
  • damage to adjacent structures
  • displacemet of tooth
  • jaw fracture
  • temp/permanent ID/lingual nerve damage
55
Q

What radiographic views can be used to determine the position of impacted canines?

A
  • verical occlusal (maxilla)
  • parallax periapicals (using SLOB)
  • lower true occlusal in the mandible
  • two views at 90 degrees e.g. OPT and bisecting angle periapical
  • OPT in maxilla?
56
Q

Suggest a reason for the loss of resolution when using vertex occlusal radiographs to view impacted canines

A
  • scatter of the beam occurs due to lots of penetration of tissue
57
Q

What are the caveats associated with vertex occlusal radiographs?

A
  • long exposure time
  • direct irradiation to the lens of the eye
  • risk of irradiation of the gonads
58
Q

Define the term “parallax”

A

parallax is the apparent displacement of an object due to different positions of the observer
-SLOB

59
Q

What principle underlies the use of parallax periapicals?

A
  • if 2 objects are in a different plane and are viewed in different positions then the objects appear to move relative to each other
60
Q

What does SLOB stand for?

A

same lingual
opposite buccal

61
Q

What can you conclude if an unerupted tooth is not seen to more with the tube? What is a consequence of this?

A

its is likely that the tooth lies in line of the arch

occlusal views are then useful for the location of the unerupted tooth

62
Q

What is the major caveat associated with the bisecting angle periapical technique?

A

it is not reproducible

63
Q

What are some causes of unerupted maxillary canines?

A
  • long path of insertion
  • erupts after the upper lateral and upper first premolar
64
Q

Outline situations where it is appropriate to leave the unerupted maxillary canine in situ?

A
  • tooth is asymptomatic and its extraction may loosen or damage the adjacent teeth
  • no infection
  • no progressive widening of the follicular space
  • no resorption of adjacent roots
  • patient happy with aesthetics
  • no bridge work is planned to fill the space

tooth should be kept under annual review

65
Q

Outline a potential treatments for impacted maxillary canines

A
  • interceptive treatment- extraction of deciduous canines
  • surgical removal
  • surgical exposure and orthodontic repositioning
  • surgical repositioning
66
Q

Briefly outline the process of a surgical removal of buccally impacted canine

A
  • 2 or 3 sided flap depending on access requiremtns
  • bone removal with bur- guttering
  • tooth elevated with or without sectioning
  • debridement
  • closure
  • [bone wax can be placed to prevent defect being present]
67
Q

Briefly outline the process of a surgical removal of palatally impacted canine

A
  • incision from 4/5 region to contralateral 2
  • can use warwick james elevator to elevate papillae
  • use haworths periosteal elevator to raise the flap
  • bone removal
  • divide tooth if necessary
  • elevation + root elevation
  • debridement
  • closure
68
Q

Incisive papillae are heavily innervated therefore they have the potential for …

A

pain

69
Q

What risks are associated with the surgical removal of impacted canines?

A
  • damage to adjacent teeth or roots
  • post operative mobility of anteriors- particularly laterals
  • bleeding
  • swelling
  • infection
70
Q

What are the criteria required for the consideration of surgical exposure and repositioning of unerupted maxillary canines?

A
  • [following orthodontic assessment:]
  • adequate room in arch to accomodate tooth; may need to be created
  • if potential path of eruptuon is obstructed
  • when eruption is complete, the apex of the tooth should be as near normal angulation as possible
  • exposure of the crown is carried out as close as possible to the normal time of eruption
71
Q

Outline the operative procedure for surgical exposure and repositioning of an impacted canine (closed exposure)

A
  • raise flap- buccal or palatal
  • carefully remove bone to expose whole of crown and tip
  • attach bracket and gold chain
  • reposition flap, leaving chain protruding in the mouth
  • suture
  • orthodontist begins traction after 2 weeks

the chain is left protruding in the palate then after 2 weeks the orthodontist applies traction to the chain to pull the canine down and out of the gums

  • when the tooth is erupted a bracket is then attached and brought into the arch

it is a closed exposure because the chain is left hanging in the palate and the flap covers the teeth again

72
Q

Outline the operative procedure for surgical exposure and repositioning of an impacted canine (open exposure)

A
  • raise flap
  • remove bone to expose crown and tip
  • cut window in mucosa directly over the crown
  • place whiteheads varnish pack or dressing plate with coepack
  • removed 2 weeks later and bracket is applied
73
Q

Following pack removal in the open exposure technique, how long does the palate take to heal?

A

2 weeks

74
Q

What does surgical repositioning of an unerupte maxillary canine involve?

A

the displaced tooth is rotated or tilted about its apex

75
Q

What is limitation of the surgical repositioning technique

A

the tooth cannot be rotated more than a few degrees

76
Q

What are the requirements of the surgical repositioning technique ?

A
  • adequate space for canine in its correct position
  • substantial surgical slill to remove just the right amount of bone without damaging canine root
  • a good reason why orthodontic approach cannot be used
77
Q

When is surgical transplantation indicated?

A

when orthodontic repositioning is not possible due to severe malposition of the tooth

78
Q

What is the optimum condition required for surgical transplantations ?

A

on teeth with open apex as it increases chance of revascularisation

79
Q

Outline the operative procedure for a surgical transplantation of impacted canines

A
  • construction of splint e.g. vacuum formed
  • establish there is enough space in arch to accomodate canine
  • if deciduous teeth present, extract
  • raise flap and carefully remove bone (retain bone for bone graft?)
  • carefully extract tooth and suspent in patients own serum
  • create an artificial socket with a bur
  • place canine in socket- take care not to handle the roots
  • cement splint into position and leave for 6 weeks
  • remove splint and perform RCT if needed
  • review radiographically at least annually
80
Q

What is the prognosis of surgical transplantations?

A

10 years

81
Q

Unerupted mandibular canines are more common than unerupte maxillary canines . True or false

A

false

82
Q

What treatment options are provided for unerupted manidbular canines?

A

usually extracted for orthodontic or aesthetic reasons

83
Q

What variation of unerupted mandibular canines is the most difficult?

A

lower canines deep to the apices of the lower incisors

84
Q

What are the causes of unerupted lower premolars?

A
  • congenital absence
  • early loss of deciduous 2nd molar (Es)
85
Q

What are the treatment options for unerupted lower premolars

A
  • interceptive treatment
  • surgical removal
  • surgical exposure and orthodontic repositioning
  • surgical repositioning
86
Q

Outline the operative procedure for the removal of an unerupted lower premolar

A
  • adequate flap (usually buccal)
  • protection of mental nerve
  • bone removal
  • if lingual possible, knock through with couplands
  • section crown
  • debridement
  • closure
87
Q

Outline the cause of submerging deciduous molars

A
  • retention in lower/upper arch is usually due to ankylosis
  • as adjacent permanent teeth erupt they stimularte vertical alveolar development
  • this leaves the tooth partially or completely buried in the jaw and wedged between adjacent teeth
88
Q

How are submerging deciduous molars removed?

A

standard flap procedure

89
Q

Supernumeraries are primarily found in the ________ region. Give an example

A

premaxillary region

mesiodens

90
Q

What is a mesiodens?

A

supernumerary located in the midline
it is frequently palatal to the upper cental incisors

91
Q

Supernumeraries can be unilateral/bilateral, single or multiple. True or false

A

true

92
Q

What is the consequence of supernumeraries ?

A
  • rotation, spacing and malposition of one or more maxillary permanent incisors
  • occassionally responsible for dentigerious cyst formation
93
Q

Removal of supernumeraties depends on …

A

the accurate location

MOS Lecture Slides (7 decks)

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