Transcript Third molars

Third molars
3-7-08
Maxillary Molars Sinus Proximity–
Alternate Procedure
Palatal root sitting close to the sinus
 Reflect a flap
 Stryker bone off the buccal
 Separate the buccal roots from the
crown
 Remove the palatal root with the
crown
 Remove the buccal roots individually
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Review again
Mandibular Molars
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Divide the tooth buccolingually from the
buccal furcation towards the lingual with a
Stryker
ONLY go 2/3 of the way to the lingual plate
Use elevator to split remaining tooth
structure
WRITE IT DOWN in Post-op Notes
Remove the root with less interference
Remove the mesial root if it has less
curvature
Remove the interseptal bone to free the
distal root
Geriatric Patients
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Bone characteristics
Dense
 Inelastic
 Roots tend to break more easily
 Prepare to surgically remove the tooth
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Malposed teeth
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Mandibular premolars-displaced to the lingual very
difficult
Procedure
Reflect a flap
 Make a window in the plate
 Tap the tooth to the lingual
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lingual plate should break
Remove tooth
Should the buccal plate come out,
don’t put it back
Wisdom Teeth
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Reasons to keep the 3rds
The patient can maintain cleanliness
 It actually functions in occlusion
 There is adequate attached gingiva
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Wisdom Teeth
Asymptomatic wisdom teeth become
problematic in the future
 Get them out when they are younger
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Lesser complications-less recovery time
Remove when 1/3 of the root is
formed
 One anesthesia risk, one surgery, one
swelling, one pain
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Asymptomatic vs. Symptomatic
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Symptomatic- no brainer, git ‘em oudda der
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Pericoronitis
Periodontitis
Pathologic Resorption
Neoplasms
Orthodontic Treatment
Pre-Dentures
Pain
Caries
Pericoronitis
You must have a portion of the
crown in the oral cavity to actually
call it pericoronitis
 Impacted teeth are “impacted,” duh
 Patients with pericoronitis at time of
extraction have higher potential for
dry socket (loss of blood clot, causing
excruciating pain post-op)
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Pericoronitis
If you do an operculectomy and don’t
remove the tooth, it will grow back
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 Just get the tooth out
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Pericoronitis
Best treatment for full infection of 3rd
molars-I&D tooth, place patient on
antibiotics, let things calm down and
take all four 3rd molars out at one
time
 If try to extract 3rd molars will have
anesthesia problems while the patient
is still infected in the acidic
environment
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Periodontitis
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Potential periodontal problem
Left alone, the third molar becomes
decayed
The decay undermines the second molar
creating a periodontal problem
Decay may extend to the second molar,
reaching the pulp
You lose both the third and the second
molar (It’s a lose, lose, lose situation)
Periodontitis
Pathologic Resorption
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The erupting third molar may resorb
the second molar roots and
surrounding bone
Neoplasms
Dentigerous cyst
 Keratocyst
 Ameloblastoma
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The most common cyst is the
dentigerous cyst
Dentigerous Cysts
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Dentigerous cyst-associated with the crown of an
impacted 3rd molar
3rd molars left in the mouth, epithelial lining in
cyst can transform with time
The epithelium can turn into squamous cell
carcinoma, mucoepidermoid carcinoma, cyst can
also get larger and larger
Pathologic fracture because the whole ramus is full
with dentigerous cyst that has grown over time
Ameloblastoma, keratocysts-other neoplasms
associated with the 3rd molar area and associated
with the cyst/sac
Orthodontic Treatment
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Most of the time, the arch is not large
enough to accommodate third molars (i.e.
we who are born without thirds are more
evolved than those with thirds.)
Orthodontic treatment-3rd molar resorbs
2nd molar
Refer patients either before or after
orthodontic treatment because hard to
make flap, preferably before
Do not refer orthodontic patients during
treatment because the wires and hooks
make it difficult to make a flap
Pre-Denture
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Edentulous ridge,-nothing more embarrassing then
making a denture for a patient & 6 months later
denture doesn’t fit because patient is “growing
new teeth” in mouth
Missed the impacted 3rd molars-all teeth removed
in mouth, but pano wasn’t taken to determine if
there were impacted 3rd molars
If impacted 3rd molars close to the surface, with
pressure/rubbing of the denture, the little bit of
bone that was over tooth is gone & impacted 3rd
molar may erupt into mouth
Pain, Caries
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Self-explanatory
Jaw Fractures
Most common sites
Fracture Type
Prevalence
Body
30 - 40 %
Angle
25 - 31 %
Condyle
15 - 17 %
Symphysis
7 - 15 %
Ramus
3-9%
Alveolar
2-4%
Coronoid process
1-2%
Jaw Fractures
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Fractured mandible-most common
places for 3rd molars to fracture, 3rd
molar sitting in the angle, acts as a
weak link & undermines angular
amount of bone
Lock & Key
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3rd molar can act as lock & key, may keep the two
pieces of jaw fractures together if have fracture
through the crypt of the 3rd molar
Because of the way the 3rd molar sits, it keeps
two pieces of jaw fractures from pulling apart and
separating
Leave 3rd molar in place as fracture heals
Problem with this type of fracture-bacteria can get
into the fracture and around the tooth itself
Tooth can become necrotic, then get a non-union
because infection is in the line of fracture
Periodically watch the tooth for necrosis
Reliable Patients
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On a reliable patient with a jaw fracture
3rd molar is acting as a lock & key and
keep the pieces from moving apart
Then can leave tooth in the line of fracture
Get the patient back in and xray every
week or every other week, patient kept on
antibiotics and watch for tooth necrosis
Non-reliable Patients
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Highland-patients not reliable and do not come
back for post-op; do not leave any tooth in the line
of fracture at highland because tooth can become
infected, then get a nonunion/malunion which
creates a big problem
If extract that 3rd molar, then disrupt that lock &
key; end up with two pieces in different areas
Need to take patient to the operating room, make
an incision underneath the mandible, bring pieces
back and wire it together because lost the 3rd
molar that was acting as the lock & key
If jaw fracture is open to the oral environment,
prescribe antibiotics, if mucosa is intact and not
exposed to oral environment, no need to prescribe
antibiotics