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Bds4 Oral Surgery > Third molars > Flashcards

Third molars Flashcards

1
Q

what 2 nerves are in close proximity to mandibular third molars and where are they?

A

lingual nerve- close relationship to lingual plate in mandible and retro molar region
inferior alveolar nerve- close relation to M3M, anterior tooth at apex.

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2
Q

what guidelines are followed when considering third molar extraction?

A

NICE
SIGN
FDS, RCS 2020

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3
Q

what does the guidelines suggest with regards to removal of third molars?

A

discourages removal unless pathology (NICE and SIGN)
not removing impacted third molars puts off inevitable surgery, which could make it more complex (patient age, caries, complications etc) (FDS)

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4
Q

what type of radiograph should be taken pre-op?

A

OPT
CBCT if close relationship of M3M to IDC on OPT

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5
Q

what should be recorded from the OPT?

A

presence/ absence of disease
anatomy of M3M
depth of impaction
orientation of impaction
working distance
follicular width
periodontal status
relationship to maxillary antrum or inferior alveolar nerve canal.

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6
Q

why record he follicular width?

A

if follicular width is increased, there may be pathology eg dentigenous cyst

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7
Q

how is depth of impaction measured?

A

superficial= crown of 8 at level of crown of 7
moderate= in between
deep= crown of 8 a level of roots of 7

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8
Q

how is orientation of impaction measured?

A

measured against curve of spee
can be: horizontal, transverse, vertical, mesial, distal

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9
Q

what are the 3 main indications of close proximity of M3M to IDC? and the other 4 indications

A
  1. disruption of canal
  2. darkening of roots
  3. deflection of roots

also- narrowing of roots, dark and blind apex of root, diversion of canal, narrowing of canal

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10
Q

what are indications for third molar extraction? (11)

A

infection
cysts (dentigenous cyst from REE)
tumours/ part of cancer ressection
External inflammatory root resorption of 7
high risk of disease (mesio angular or horizontal impaction)
medical indications (to deem dentally fit)
accessibility to care
pt age
autotransplantation
GA

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11
Q

what are the treatment options for M3M?

A

referral
clinical review
extraction
extraction of maxillary third molar
coronectomy

operculectomy
surgical exposure
pre surgical ortho
autotransplantation

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12
Q

if making a referral, what should be included in the letter?

A

SBAR
situation
background
assesement
recommendation

include any photos or radiographs

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13
Q

what factors should be taking into account when assessing need for extraction?

A

current status of M3M- history, clinical exam, radiographs
patient age and medical status
risk of complications
patient access to care
opposing third molar status/ contralateral third molar - if undergoing GA

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14
Q

what should be explained to patient when discussing treatment options?

A

current status of M3M
risk status of patient and M3M
explain to pt that current symptoms and disease status may change over time and therefore, treatment options and risk of complications may also change with time.
discuss risks and possible complications of each of the treatment options.

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15
Q

How would you gain informed consent for surgical removal of M3M?

A

explain why this is the treatment of choice
decide on method of anaesthesia
explain the procedure- what to expect- is tooth likely to need sectioned, raising a flap, drilling bone, sutures etc
possible complications eg fracturing of adjacent teeth or restorations, jaw fracture in elderly
what to expect afterwards

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16
Q

what are the risks of M3M extraction?

A

pain, swelling, bleeding, bruising
jaw stiffness
infection
dry socket
nerve damage- temp (10-20%) or permanent (<1%) painful/ altered/ loss of sensation.
altered taste

17
Q

what is the order of procedure for surgical extraction of M3M?

A

anaesthesia, access, bone removal, tooth divison, debridement, suture, haemostasis, post op instructions (written and verbal)

18
Q

how is adequate access achieved?

A

buccal mucoperiosteal flap (+/- lingual flap)
to achieve maximum access with minimal trauma

19
Q

what are the principles of flap design

A
  1. use a scalpel in one continuous stroke and 90 degrees
  2. no sharp angles
  3. minimise trauma to dental papillae
  4. wider base than apex (greater blood supply)
  5. avoid vital structures
  6. keep tissues moist
  7. aim for healing by primary intention
  8. ensure flap margins and sutures are on sound bone
  9. do not close under tension (will lose blood supply)
  10. larger flaps heal just as quickly as smaller flaps
20
Q

how is the flap raised?

A

raise from base of relieving incision using warwick james to free the papilla.
reflect with periosteal elevator firmly on bone- ensure is full thickness.

21
Q

what is the purpose of retraction?

A

provides access ad protection of soft tissues

22
Q

what is used for retraction?

A

Howarths/ rake retractor/ minnesota

23
Q

what instrument is used for bone removal and why?

A

electrical straight hand piece with saline cooled bur.
used to prevent surgical emphysema and necrosis of bone

24
Q

from which aspect of the tooth is bone removed and in which direction?

A

bone is removed from the buccal aspect of tooth from mesial to distal of impaction

25
Q

what shape is bone removed in?

A

bone is removed to create a deep, narrow buccal gutter around crown

26
Q

What is pericoronitis?

A

Inflammation around the crown of a partially erupted tooth. Can cause food trapping under operculum and caries in adjacent 7

27
Q

When does crown calcification of third molars begin/ complete?

A

Begins at 7-9 years
Complete by age 18

28
Q

What is agenesis?

A

Missing third molar

29
Q

What is the treatment of pericoronitis?

A

Incision of localised periodontal abscess
+/- LA
Irrigation with warm saline (10-20ml syringe with blunt needle)

30
Q

What bacteria cause pericoronitis?

A

Anaerobic microbes eg streptococci/ actinomyces

31
Q

Which antibiotics are given for pericoronitis?

A

Metronidazole 200mg
1 tab 3x daily for 3 days

Not for pt on warfarin
Can’t drink alcohol

32
Q

What are some predisposing factors for pericoronitis?

A

Partial eruption
Vertical/ disto angular impaction
Opposing molar causing trauma to operculum
Poor OH

33
Q

What are the signs and symptoms of pericoronitis?

A

Pain
Swelling
Bad taste
Pus
Ulceration of operculum
Limited mouth opening
Dysphagia

34
Q

What is a coronectomy?

A

Alternative to surgical removal of entire tooth when there is an increased risk of IAN damage.

35
Q

When is coronectomy contraindicated?

A

Horizontal impaction
Apical pathology

36
Q

What are the indications for coronectomy?

A

Nerve lingual to M3M and absence of cortex between nerve and root
Likely to damage IAN during XLA

37
Q

What are the risks of coronectomy?

A

If root is mobilised during treatment, entire tooth must be removed
Leaving in roots could result in infection
Can get slow healing/ painful socket
Roots may migrate later and begin to erupt through mucosa and require future extraction.

38
Q

What is the procedure of coronectomy?

A

1.Flap design as necessary for access
2. Transaction of tooth 3-4mm below enamel
3. Elevate crown off without mobilising roots
4. Leave pulp in place
5. If necessary, further 3-4mm reduction below the alveolar crest
6. Irrigate socket
7. Primary closure of flap
8. Review 1-2 weeks.

Bds4 Oral Surgery (17 decks)

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