Third molar management Flashcards
summary for management
what are the reason to remove third molars?
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
what are the different indications of removing third molars ?
what are the therapeutic indications ?
Infection
pericoronitis (repeated)
oteomyelitis
osteonecrosis
osteoradionecrosis
Caries / induced caries
M3M | M2M
Peri-apical disease / pathology
Periodontal disease
Other
cysts, resorption, tumour
what are the surgical indications ?
malignancy
othrognatic
what are the risks of dental diseases?
Second molar
19% incidence of Distal Cervical Caries in M2M
with MA impacted MTM (42%)
Third molar
what are the medical indications ?
Prevention of MRONJ
prior to commencement of biologics /
immunosuppressants
Pre-operative radiotherapy
Infective Endocarditis
Portal of infection
what are the accessibly indications?
service personell (milltary personel)
long trips away occupation
what are the pt age indications ?
consider their age
what re the 4 tx options ?
Active Clinical Monitoring
Operculectomy
Complete Extraction of third molar
Coronectomy of third molar (rare in maxillary third molars)
how do we clinically monitor pts ?
Risk vs benefit
Regular review
+/- appropriate radiographs
Symptom dependent
Shared decision making process with patient
what are the risks of surgery
Pain
Swelling
Bleeding
Bruising
Infection
Dry Socket
Damage to adjacent teeth
Stiff / sore jaw / difficulty opening
what are the specific risks for maxillary ?
Fractured tuberosity
Oro-antral communication
Displacement of tooth into antrum
what re the specific risks of mandibular teeth?
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.
when would do an opercultectomy ?
Food trapping
Trauma from opposing third molar
Pain, swelling, halitosis
Pericoronitis
Infection
how do we do operculectomy ?
Local anaesthetic
Surgical removal of operculum
Enables effective local cleaning
Not always sucessful - grows back
Painful
Bleeding
how do we surgically remove maxillary third molars ?
- 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
how do we extract mesioangularl ?
how do we extract horizontal tooth?
how do we extract distoangular?
- MORE TRICKY
why is depth of impaction important ?
- more lower the depth of impaction the more tricky to extract
what is a coronectomy ? when do we do it?
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)
what are the contraindication of coronectomy ?
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
what are some of the consideration of cornoectomy ?
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
what can cause an increased risk of complication
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
