Third molar management

Question 1

summary for management

Answer 1

Question 2

what are the reason to remove third molars?

Answer 2

Unrestorable caries
Non-treatable pulpal and/or periapical pathology
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

Question 3

what are the different indications of removing third molars ?

Answer 3

Question 4

what are the therapeutic indications ?

Answer 4

Infection
pericoronitis (repeated)
oteomyelitis
osteonecrosis
osteoradionecrosis
Caries / induced caries
M3M | M2M
Peri-apical disease / pathology
Periodontal disease
Other
cysts, resorption, tumour

Question 5

what are the surgical indications ?

Answer 5

malignancy
othrognatic

Question 6

what are the risks of dental diseases?

Answer 6

Second molar
19% incidence of Distal Cervical Caries in M2M
with MA impacted MTM (42%)
Third molar

Question 7

what are the medical indications ?

Answer 7

Prevention of MRONJ
prior to commencement of biologics /
immunosuppressants
Pre-operative radiotherapy
Infective Endocarditis
Portal of infection

Question 8

what are the accessibly indications?

Answer 8

service personell (milltary personel)
long trips away occupation

Question 9

what are the pt age indications ?

Answer 9

consider their age

Question 10

what re the 4 tx options ?

Answer 10

Active Clinical Monitoring
Operculectomy
Complete Extraction of third molar
Coronectomy of third molar (rare in maxillary third molars)

Question 11

how do we clinically monitor pts ?

Answer 11

Risk vs benefit
Regular review
+/- appropriate radiographs
Symptom dependent
Shared decision making process with patient

Question 12

what are the risks of surgery

Answer 12

Pain
Swelling
Bleeding
Bruising
Infection
Dry Socket
Damage to adjacent teeth
Stiff / sore jaw / difficulty opening

Question 13

what are the specific risks for maxillary ?

Answer 13

Fractured tuberosity
Oro-antral communication
Displacement of tooth into antrum

Question 14

what re the specific risks of mandibular teeth?

Answer 14

Trigeminal Nerve – lingual & inferior alveolar
Temporary or permanent altered or loss of sensation to the
Lower lip, skin of the chin, gums of the lower teeth, the lower teeth, side of the tongue and some
taste.
The altered sensation can be painful similar to nerualgia or a ‘tingling’ sensation.

Question 15

when would do an opercultectomy ?

Answer 15

Food trapping
Trauma from opposing third molar
Pain, swelling, halitosis
Pericoronitis
Infection

Question 16

how do we do operculectomy ?

Answer 16

Local anaesthetic
Surgical removal of operculum
Enables effective local cleaning
Not always sucessful - grows back
Painful
Bleeding

Question 17

how do we surgically remove maxillary third molars ?

Answer 17

• can use a rectracter that is place don tuberosity to help with extraction
• we would raise flap and direct tooth in half or take crown off
• no air in drill to prevent surgical emphysema
• we use saline irrigation too

Question 18

how do we extract mesioangularl ?

Answer 18

Question 19

how do we extract horizontal tooth?

Answer 19

Question 20

how do we extract distoangular?

Answer 20

• MORE TRICKY

Question 21

why is depth of impaction important ?

Answer 21

• more lower the depth of impaction the more tricky to extract

Question 22

what is a coronectomy ? when do we do it?

Answer 22

Technique sensitive
Not a sliver bullet
“Removal of a crown from the roots of a tooth whilst leaving the roots intact”.
(partial tooth removal, partial odontectomy deliberate vital root retention)

Question 23

what are the contraindication of coronectomy ?

Answer 23

Infection
Mobile teeth
Caries into the pulp
Apical disease
Associated pathology
Pre-orthognathic surgery
Immunocompromised
Pre-radiotherapy
Active Clinical Monitoring
Operculectomy
Complete extraction
Coronectomy

• doesn’t mean we don’t so it but we need to be careful not to cause further infection

Question 24

what are some of the consideration of cornoectomy ?

Answer 24

No evidence for treatment of the exposed pulp of the tooth
Root should be left 3mm inferior to crest of bone
Late migration of the root fragement may occur
Operative site should be closed in tension free manner
Treat alveolar osteitis in same way
Post op considerable pain
Technique sensitive

Question 25

what can cause an increased risk of complication

Answer 25

Underlying systemic disease
Increased age
Infection
Anatomical position of tooth / root morphology
Local anatomical relations
Status of adjacent teeth
Reduced access
Dense bone
Lack of PDL space – ankylosis
Pathology
Poor patient cooperation / compliance