Management of 3rd molars Flashcards
what are the problems associated with 3rd molars?
- Abnormal position – cheek biting upper 8’s
- Caries, pulp and periapical pathology in the 2nd and 3rd molars
- Periodontal problems – especially pocketing around the 7
- Pericoronitis
- Resorption – internal, and external for 7\7
- Cyst formation (one coming from unerupted tooth is called deciduous cyst)
- Difficulty with OH and food packing (especially the distal of the 7 and the 8)
- Crowding of lower incisors!
- Often involved in line of mandibular fractures
- In the way of orthognathic surgery
- Potential risk in the future for vulnerable and medically compromised patients
what is pericorinitis?
- Inflammation in the soft tissues around the crown of a partially erupted tooth
- Caused by bacterial infection and/or trauma
- Most commonly cited reason for extraction of 8s
what are the symptoms of pericorinitis?
- Pain or discomfort
- Soft tissue swelling in the region of the partially erupted tooth
- Difficulty eating, swallowing or opening mouth
- Tenderness on closing if opposing tooth in contact with inflamed soft tissues
- Unpleasant taste or smell
- May feel unwell with pyrexia
- May be a recurring problem
how to manage pericorinitis?
Local measures:
* Irrigation beneath gum flap with:
* Saline, Chlorhexidine mouthwash (more commonly saline now due to allergy)
* Remove upper 8 if traumatic occlusion
- Advise HSMW / Chlorhexidine and analgesics
+/- - Antibiotics if spreading infection or compromised (Metronidazole, 400mg t.d.s gold standard)
- Drain pus if present
how are 3rd molar problems reviewed?
– Assess 3rd molar(s)
* Likely to erupt and be functional - monitor
* Unlikely to erupt – if problematic - consider removal, if not then leave and monitor
* Persistent, recurrent or severe problems – consider removal
how do you assess the degree of surgical difficulty with 3rd molar removal?
- Angulation/type of impaction
- Crown size, shape & pathology
- Root number, orientation & pathology (eg cysts, caries in 2nd molar)
- Surrounding bone
- Proximity to inferior dental canal
what used to be done but now isn’t according to NICE guidelines for 3rd molar removal?
prophylactic removal of 3rd molars
What do the NICE guidelines 2000 for pathology free 3rd molar teeth state?
- The standard programme of dental care by dental practitioners need be no different, in general, for pathology free impacted third molars
What do the NICE guidelines 2000 for surgical extraction of 3rd molars state?
Surgical removal of impacted third molars should be limited to patients with evidence of pathology. Such pathology includes:
- unrestorable caries
- non-treatable pulpal and/or periapical pathology
- cellulitis
- abscess and osteomyelitis
- internal/external resorption of the tooth or adjacent teeth
- fracture of tooth
- disease of follicle including cyst/tumour
- tooth/teeth impeding surgery or reconstructive jaw surgery
- when a tooth is involved in or within the field of tumour resection
what is stated by the NICE 2000 guidelines on 3rd molars regarding plaque and pericorinitis?
Plaque formation is a risk factor but is not in itself an indication for surgery.
The degree to which the severity or recurrence rate of pericoronitis should influence the decision for surgical removal of a third molar remains unclear. The evidence suggests that a first episode of pericoronitis, unless particularly severe, should not be considered an indication for surgery. Second or subsequent episodes should be considered the appropriate indication for surgery.
what are the types of impaction and how difficult are they to remove?
- Vertical
–-> easiest to extract, risk of pericoronitis - Mesio-angular
–-> more difficult, risk of food packing and caries in 2nd molar - Horizontal
–-> even more difficult, risk of food packing and caries in 2nd molar - Disto-angular
–-> very difficult, risk of pericoronitis - Transverse (crown facing buccally tooth lying flat)
–-> Tricky!!
what is the root patterns for 3rd molars?
- fused and conical (easiest)
- straight and separate
- pincer (difficult needs separation due to curvature of roots)
what are the treatment options for 3rd molar problems?
- Treatment options:
– Removal
– Observation
– Operculectomy
– Coronectomy
what is a Operculectomy?
An Operculectomy is a minor surgical procedure where the affected soft tissue/ the flap of gum over the wisdom tooth, is cut away, preventing further build-up of debris and plaque, and subsequent inflammation
what types of patients are selected for conorectomy’s?
- Close proximity to IAN
- No evidence of:
– Active infection
– Tooth Mobility
Avoid horizontal/severe mesioangular impactions - increased risk of IAN damage during sectioning
- Not indicated for co-morbidity patients e.g chemotherapy, diabetes, immunosupressed, (bisphosphonates?)
