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BDS4 Oral Surgery > Third Molars > Flashcards

Third Molars Flashcards

1
Q

When does crown calcification of 3rd molars begin

A

7-10 years old

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2
Q

when is root calcification of 3rd molars complete

A

18-25 years

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3
Q

what is it called when a 3rd molar fails to develop

A

agenesis

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4
Q

if they are missing at the age of —- on a radiograph they almost always fail to develop

A

14

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5
Q

what does impacted mean

A

the tooth eruption is blocked (partial or full)

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6
Q

consequences of impaction

A
  • caries
  • pericoronitis
  • cyst formation
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7
Q

nerves at risk during 3rd molar surgery

A
  • IAN
  • Lingual nerve
  • nerve to mylohyoid
  • long buccal nerve
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8
Q

Where does the IAN derive from and what does it supply

A
  • mandibular branch of the trigeminal nerve
  • all mandibular teeth, skin of lower lip and chin on that side
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9
Q

Where does the lingual nerve derive from and what does it supply

A
  • branch of the mandibular division of the trigeminal nerve
  • anterior 2/3 dorsal and ventral mucosa of tongue
  • gives off a branch which supplies lingual gingiva of mouth
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10
Q

where does the lingual nerve lie

A

on the superior attachment of mylohyoid muscle

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11
Q

what does the lingual nerve have a close relationship to

A
  • lingual plate in the mandibular and retromolar area
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12
Q

NICE and SIGN guidelines for extraction of 3rd molars say…

A

therapeutic approach: only extract if there is pathology

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13
Q

FDS, RCS 2020 guidelines for extraction of 3rd molars say…

A

more holistic approach should be taken:
- by not removing impacted molars we’re just postponing inevitable surgery which could make tx more difficult at the time
- could affect 7
- patient likely older so increased complications

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14
Q

Therapeutic indications for extraction of 3rd molars

A
  • infection (most common)
  • cysts
  • tumours
  • external resorption of 7 or 8
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15
Q

additional indications for XLA of 3rd molars

A
  • surgical indications
  • high risk of disease
  • medical indications
  • accessibility - limited access
  • patient age
  • autotransplantation (rare)
  • GA
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16
Q

what is pericoronitis

A
  • inflammation around the crown of a PE tooth
  • food and debris gets trapped under the operculum resulting in inflammation or infection
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17
Q

signs and sypmtoms of pericoronitis

A
  • pain
  • swelling
  • bad taste
  • pus discharge
  • occlusal trauma to operculum
  • ulceration of operculum
  • evidence of cheek biting
  • foetor oris (?)
  • limited mouth opening
  • dysphagia
  • pyrexia
  • malaise
  • regional lymphadenopathy
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18
Q

Tx of pericoronitis

A
  • incision of localised pericoronal abscess if required
  • IDB depending on pain/patient
  • irrigation with warm saline or chlorhexidine mouthwash (10-20ml blunt syringe) under the operculum
  • extraction of upper 3rd molar if traumatising the operculum
  • pt instructed on frequent warm saline or chlorhexidine mouthwashes
  • advise on analgesia
  • instruct pt to keep fluid levels up and keep eating soft/ liquid diet if necessary
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19
Q

would you prescribe antibiotics for pericoronitis

A

no, unless more severe, systemically unwell, EO swelling, immunocompromised e.g. poorly controlled diabetes

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20
Q

when would you refer a pt to max fax or a and e

A
  • large EO swelling
  • systemically unwell
  • trismus
  • dysphagia
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21
Q

pre-disposing factors to pericoronitis

A
  • PE and vertical or distoangular impaction
  • opposing maxillary M3M or M2M causing mechanical trauma (recurrent infection)
  • URTIs and stress and fatigue
  • poor OH
  • insufficient space between the ascending ramus of the lower jaw and the distal aspect of the lower 7 (M2M)
  • white race
  • a full dentition
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22
Q

What to cover in history of 3rd molar issues e.g. pericoronitis

A
  • General apperance
  • Presenting complaint
  • HPC: how long, how many episodes, how often, severity, requirement for antibiotics?
  • MH: systemic enquiry, medications, allergies, previous hospitalisations inc srgery. Nb bleeding disorders, bisphosphonates, immunocompromised?
  • DH: history of extractions, dental anxiety, dental experience, regular OH
  • SH: smoking, alcohol, occupation, carer, support
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23
Q

EO assessment for e.g. pericoronitis

A
  • TMJ: need to rule out as the source of pain
  • limited mouth opening: increase in surgical difficulty
  • lymphadenopathy
  • facial asymmetry
  • mom
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24
Q

IO assessment for e.g. pericoronitiss

A
  • soft tissues
  • dentition
  • M2M: distance between M2M and ascending ramus ‘working space’
  • eruption status of M3Ms
  • condition of the remaining dentition
  • occlusion
  • OH
  • caries status
  • perio status
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25
Q

what radiograph would you take and why

A

OPT only if surgical intervention is being considered
- presence/absence of disease
- anatomy of 3M
- depth of impaction
- orientation of impaction
- working distance
- folliccular wideth
- periodontal status
- relationship/ proximity of upper 3Ms to max antrum and lower 3M to inferior dental canal
- any other associated pathoology

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26
Q

How would you assess a radiograph

A
  • interruption of white lines/lamina dura of the canal
  • darkening of the root where crossed by the canal
  • diversion/deflection of the IAN canal
  • deflection of root
  • narrowing of the IAN canal
  • narrowing of the root
  • dark and bifid root
  • juxta apical area
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27
Q

What radiograph signs are associated with a significantly increased risk of nerve injury during 3M surgery

A
  1. diversion of the inferior dental canal
  2. darkening of the root where crossed by the canal
  3. interuption of the white lines of the canal
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28
Q

Describe the IAN canal

A

Diversion/deflection of the inferior dental canal

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29
Q

Describe the IAN canal relationship

A

darkening of the root where crossed by the canal

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30
Q

describe the relationship to the IAN canal

A

interruptioni of the white lines/lamina dura of the canal

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31
Q

Describe the relationship to the IAN canal

A

deflection of root

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32
Q

Assess radiographically

A

narrowing of the inferiror dental canal

33
Q

assess radiographically

A

narrowing of the root

34
Q

assess radiographically

A

dark and bifid root (splits/divides over canal)

35
Q

assess radiographically

A

juxta apical area

36
Q

if an OPT suggests a close relationship between the 3rd molar and the inferior dental canal, what should you do

A

consider CBCT
- 3D, will trace ID canal

consider periapical
- caries detection

37
Q

What different angulations can be assessed radiographically

A
  • vertical
  • mesial (most common)
  • distal (harder to extract)
  • horizontal
  • transverse or aberrant
38
Q

what is the angulation of 3rd molars measured against

A

the curve of spee

39
Q

Angulation?

A

mesial

40
Q

Angulation?

A

horizontal

41
Q

Angulation?

A

distal

42
Q

Angulation?

A

vertical

43
Q

Angulation

A

transverse

44
Q

Angulation

A

aberrant

45
Q

why would we want to measure depth of a 3rd molar in relation to the 7

A

gives an indication of the amount of bone removal required

46
Q

if crown of 8 related to crown of 7

A

superficial depth

47
Q

if crown of 8 related to crown and root of 7

A

moderate depth

48
Q

if crown of 8 related to root of 7

A

deep depth

49
Q

assess radiographically

A

superficial distal impaction

50
Q

assess radiographically

A

horizontal moderate impaction

51
Q

what other radiographic finding is here of relevance to the 8

A

overhang of adj 7 restoration
- if comes off would need to temporise tooth and work on that later

52
Q

common GDP tx options for 3Ms

A
  • referral to OS or OMFs or specialist practice
  • clinical review
  • removal of M3M
  • extraction of maxillary 3rd molar
  • coronectomy
53
Q

FDS management of patients with mandibular 3rd molars (M3Ms)

A
54
Q

what methods of anaesthesia could you consider for 3rd molar surgery

A
  • LA alone
  • conscious sedation
  • GA

anxiety, behavioural/medical, tx complexity

55
Q

What to cover in consent process

A
  • pain
  • swelling
  • bruising
  • jaw stiffness/limited mouth opening
  • bleeding
  • infection
  • dry socket
  • explain procedure to pt
  • if a tooth is likely to be sectioned explain this
  • numbness or tinging of lower lip, chin and side of tongue
  • nerve damage
  • flap?
  • possible drilling
  • possible stitches
  • risk of restoration on a 7 fracturing
  • risk of jaw fracture if mandible is atrophic
56
Q

what are the different types of nerve damage a patient could get

A
  • numbness (anaesthesia)
  • tingling (paraesthesia)
  • pain/unpleasant sensation (dysaesthesia)
  • reduced sensation (hypoaesthesia)
  • heightened sensation (hyperaesthesia - check)
57
Q

how to structure a referral to e.g. a hospital

A
  • professional, courteous and appropriate
  • Situation e.g. this 23yr male presents with pain on LL8
  • Background e.g. HPC, pt has experienced 4 episodes of pericoronitis in the last year. The most recent was 2weeks ago and required course of amoxicillin
  • Assessment e.g. LL8 PE moderate mesial angular impaction, occulsal caries present. pt reports food packing and finding cleaning area very difficult, MH, SH, clinical exam
  • Recommendation e.g. my opinion of what should be done e.g. pt is keen for surgical removal of LL8 and I believe this is indicated in this case
58
Q

Basic principles in surgical removal of 3Ms

A
  • required when can’t be XLA with forceps alone
  • risk assessment (plan and medical history)
  • aseptic technique
  • minimal trauma to hard and soft tissues
  • consent (written and signed)
59
Q

Steps in surgical removal

A
  1. anaesthesia
  2. access
  3. bone removal as necessary
  4. tooth division as necessary (check apices)
  5. debridement
  6. suture
  7. achieve haemostasis
  8. post-op instructions (verbal and written)
60
Q

how is access gained

A

raising a buccal mucoperiosteal flap with scalpel

61
Q

instruments to reflect flap

A
  • mitchell’s trimmer
  • howarth’s periosteal elevator
  • ash periosteal elevator
  • curved warwick james elevator (to undermine dental papillae)
62
Q

what insruments retract operative field

A
  • howarth
  • rake retractor
  • minniesota retractor
63
Q

why is saline used in the handpiece for bone removal

A

to avoid necrosis of the bone
- air drive handpieces may lead to surgical emphysema

64
Q

what shape of gutter are you trying to create with bone removal

A

deep and narrow gutter around the crown of the 8 (buccal and distal aspect)

65
Q

what direction do you move the bur in and why when creating gutter

A

Distal to mesial
otherwise bur could go into tissues behind which contain lingual nerve

66
Q

why would you want to divide a tooth when removing

A

not enouch space to remove tooth out whole

67
Q

describe horizontal crown section of tooth

A
68
Q

describe vertical crown section of tooth

A
69
Q

Methods of debridement

A
70
Q

aims of suturing

A
  • reposition tissues
  • cover bone
  • prevent wound breakdown
  • achieve haemostasis
  • (+healing by primary intention?)
71
Q

draw a 3 sided flap

A
72
Q

draw a 2 sided/envelope flap

A
73
Q

give post- op instructions

A
74
Q

when would you do a coronectomy

A

when there appears to be an increased risk of IAN damage with surgical removal

75
Q

aim of coronectomy

A

to reduce the risk of IAN damage

76
Q

steps in a coronectomy

A

After:
- socket irrigated
- flap replaced
- follow up 1-2 weeks and 3-6 months

77
Q

warnings for patient with coronectomy

A
78
Q

how are upper 3rd molars removed

A
  • elevation only or elevation and forceps extraction. Flap can be raised if XLA not possible
  • straight or curved warwick james usually
  • forceps: bayonets
  • challenges: dense bone and limited mouth opening, PE, diverging roots possible, risk of fracture of tuberosity
  • support tuberosity with finger and thumb

BDS4 Oral Surgery (10 decks)

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