Management of extraction impacted 3rd molar tooth

Management of extraction impacted 3rd molar tooth

1.Definitions & Terminology

2.Indications

3.Advisable & non advisable

4.Clinical assessment

5.Radiological evaluation

6.When should unerupted 3rd molars be removed

7.Anesthetic surgical area

8.Clinical management

9.Follow up

10.Common complications associated with treatment

11.Serious complications associated with treatment

12.Unsuccessful outcome

13.references

Definitions & terminology

•Third molar emergence normally occurs between 18-24 years but eruption is not uncommon outside these limits:

•However one or more third molars fail to develop in approximately 1:4 adults.

•An unerupted tooth is a tooth lying within the jaws, entirely covered by soft tissue, and partially or completely covered by bone.

•A partially erupted tooth is a tooth that has failed to erupt fully into a normal position. The term implies that the tooth is partly visible or in communication with the oral cavity.

•An impacted tooth is a tooth which is prevented from completely erupting into a normal functional position. This may be due to lack of space, obstruction by another tooth, or an abnormal eruption path.

Indications:

•Strong indications:

1.episodes of infection such as pericoronitis, cellulitis, abscess formation; or untreatable pulpal/periapical pathology.

2.periodontal disease due to the position of the third molar and its association with the second molar tooth.

3.dentigerous cyst formation or other related oral pathology.

4.external resorption of the third molar or of the second molar where this would appear to be caused by the third molar.

•Other indications:

1.In cases of fracture of the mandible in the third molar region or for a tooth involved in tumor resection.

2.An unerupted third molar in an atrophic mandible.

3.Atypical pain from an unerupted third molar is a most unusual situation and it is essential to avoid any confusion with TMJ or muscle dysfunction before considering removal.

4.An acute exacerbation of symptoms occurring while the patient is on a waiting list for surgery may be managed by extraction of the opposing maxillary third molar.

Advisable & non advisable:

•Advisable:

1.In patients who are experiencing or have experienced significant infection associated with unerupted or impacted third molar teeth.

2.In patients with predisposing risk factors whose occupation or lifestyle precludes ready access to dental care.

3.In patients with a medical condition when the risk of retention outweighs the potential complications associated with removal of third molars (e.g. prior to radiotherapy or cardiac surgery).

4.In patients who have agreed to a tooth transplant procedure, orthognathic surgery, or other relevant local surgical procedure.

5.Where a general anaesthetic is to be administered for the removal of at least one third molar ,consideration should be given to the simultaneous removal of the opposing or contralateral third molars when the risks of retention and a further general anaesthetic outweigh the risks associated with their removal.

•Not advisable:

1.In patients whose third molars would be judged to erupt successfully and have a functional role in the dentition.

2.In patients whose medical history renders the removal an unacceptable risk to the overall health of the patient or where the risk exceeds the benefit.

3.In patients with deeply impacted third molars with no history or evidence of pertinent local or systemic pathology.

4.In patients where the risk of surgical complications is judged to be unacceptably high, or where fracture of an atrophic mandible may occur.

5.Where the surgical removal of a single third molar tooth is planned under local anaesthesia the simultaneous extraction of asymptomatic contralateral teeth should not normally be undertaken.

Clinical assessment:

A complete examination should include assessment of:

1.the eruption status of the third molar.

2. the presence of local infection.

3.caries in, or resorption of, the third molar and the adjacent tooth.

4.periodontal status.

5. orientation and relationship of the tooth to the inferior dental canal.

6.occlusal relationship.

7.temporomandibular joint function.

8.regional lymph nodes.

9.Any associated pathology should be noted.

•The following signs have been demonstrated to be associated with a significantly increased risk of nerve injury during third molar surgery:

1.diversion of the inferior dental canal

2. darkening of the root where crossed by the canal.

3. interruption of the white lines of the canal.

Radiological evaluation:

•The purpose of a careful radiological evaluation is to complement the clinical examination by providing additional information about the third molar, the related teeth and anatomical features, and the surrounding bone:

•The following information should be noted in relation to lower third molars:

1.the type and orientation of impaction and the access to the tooth.

2. the crown size and condition.

3. the root number and morphology, including the presence of apical hooks.

4. the alveolar bone level, including the depth and the point of elevation and density.

5. the follicular width.

6. the periodontal status, together with that of the adjacent tooth.

7. The relationship or proximity of upper third molars to the maxillary antrum and of lower third.

8.molars to the inferior dental canal.

When should unerupted 3rd molar be removed:

Anesthesia:

•Methods of anesthesia include local anesthesia, local anesthesia with intravenous sedation, and general anesthesia. It is common practice to use local anesthesia in general anesthesia cases to improve field of vision and cardio protection.

•In general dental practice, the former two methods are considered appropriate, but still require suitable facilities to be available.

•General anesthesia may be needed for complex and lengthy procedures but it must be recognized that local anesthesia carries less risk.

• Recent General Dental Council guidance emphasizes that general anesthesia is a procedure which is never without risk and that ?in assessing the needs of an individual patient, due regard should be given to all aspects of behavioral management and anxiety control before deciding to prescribe or to proceed with treatment under general anesthesia.

•The operation itself:

•General anaesthesia may be needed for complex and lengthy operations, but local anaesthesia carries less risk of complications.

• swelling often occur following third molar surgery, but usually go within two weeks.

• Other common complications of third molar surgery include bleeding, minor infection, and damage to the adjacent teeth.

•After the operation :

•doctor or dentist will advise how to look after the operation, e.g. with hot salty mouthwashes; and what painkillers to take, e.g. paracetamol or ibuprofen.

•There is no evidence to suggest that antibiotics should routinely be prescribed following third molar removal, but they may be needed in some cases.

•Before leaving, the patient should know how to contact the surgeon in case of emergency. A review appointment may be arranged, but this is not always necessarily.

Clinical management:

•At the time of the operation, the patient should know:         

• How to contact the surgeon in case of emergency

• How to look after their mouth postoperatively

• Possible complications and side effects of the operation in general and any problems specific to the operation undertaken.

• Any drug therapy required

• Whether a review appointment is required and if so, when That postoperatively the referring practitioner will receive a letter detailing the treatment undertaken.

•prior to surgery interim measures may include systemic antibiotic administration,

•chlorohexidine mouth rinses, local dressing and lavage.

•The whole tooth should be removed and wound toilet completed. Any suspected pathological material should be sent for a histopathology report.

•Resorbable sutures may be used at any time but in particular where no review is planned.

• in severe cases where there is acute infection at the time of operation, significant bone removal, or prolonged operation, antibiotics should not be withheld.

•Preoperative steroids should be considered (unless contraindicated) where there is a risk of significant postoperative swelling.

Clinical steps for extraction lower 3^rd molar:

•side of the wisdom tooth using a copious amount of saline irrigation. Depending on the position, the third molar is split using a tungsten fissure bur.

•bone window technique for the extraction of impacted lower third molars. To facilitate the extraction of the 

Anesthesia:

•Methods of anesthesia include local anesthesia, local anesthesia with intravenous sedation, and general anesthesia. It is common practice to use local anesthesia in general anesthesia cases to improve field of vision and cardio protection.

•In general dental practice, the former two methods are considered appropriate, but still require suitable facilities to be available.

•General anesthesia may be needed for complex and lengthy procedures but it must be recognized that local anesthesia carries less risk.

• Recent General Dental Council guidance emphasizes that general anesthesia is a procedure which is never without risk and that ?in assessing the needs of an individual patient, due regard should be given to all aspects of behavioral management and anxiety control before deciding to prescribe or to proceed with treatment under general anesthesia.

•The operation itself:

•General anaesthesia may be needed for complex and lengthy operations, but local anaesthesia carries less risk of complications.

• swelling often occur following third molar surgery, but usually go within two weeks.

• Other common complications of third molar surgery include bleeding, minor infection, and damage to the adjacent teeth.

•After the operation :

•doctor or dentist will advise how to look after the operation, e.g. with hot salty mouthwashes; and what painkillers to take, e.g. paracetamol or ibuprofen.

•There is no evidence to suggest that antibiotics should routinely be prescribed following third molar removal, but they may be needed in some cases.

•Before leaving, the patient should know how to contact the surgeon in case of emergency. A review appointment may be arranged, but this is not always necessarily.

Clinical management:

•At the time of the operation, the patient should know:         

• How to contact the surgeon in case of emergency

• How to look after their mouth postoperatively

• Possible complications and side effects of the operation in general and any problems specific to the operation undertaken.

• Any drug therapy required

• Whether a review appointment is required and if so, when That postoperatively the referring practitioner will receive a letter detailing the treatment undertaken.

•prior to surgery interim measures may include systemic antibiotic administration,

•chlorohexidine mouth rinses, local dressing and lavage.

•The whole tooth should be removed and wound toilet completed. Any suspected pathological material should be sent for a histopathology report.

•Resorbable sutures may be used at any time but in particular where no review is planned.

• in severe cases where there is acute infection at the time of operation, significant bone removal, or prolonged operation, antibiotics should not be withheld.

•Preoperative steroids should be considered (unless contraindicated) where there is a risk of significant postoperative swelling.

Clinical steps for extraction lower 3^rd molar:

•side of the wisdom tooth using a copious amount of saline irrigation. Depending on the position, the third molar is split using a tungsten fissure bur.

•bone window technique for the extraction of impacted lower third molars. To facilitate the extraction of the crown, roots or the complete molar, a small ostectomy in the form of a window can be made in the vestibular cortical, approaching the extraction through the resultant mesial space.

•It is very important not to damage the distal root of the second molar when creating the window.

•A straight elevator is introduced through the window, pushing the mesial root upwards to dislodge it.

•

•By creating a bony bridge, disto-buccal to the second molar, the soft tissue is prevented from collapsing.

•

•On minimizing the ostectomy and preventing soft tissue collapse the formation of a periodontal pocket in the distal root of the second molar is avoided.

•

•The alveolus is inspected and curettaged for granulation tissue, followed by copious saline irrigation and completion with the usual suture procedure.

•the classic envelope flap with a sulcular incision from the first to the second molar and a distal relieving incision to the mandibular ramus was used

•the other third molars were extracted after preparation of a modified triangular flap first similarly described by Szmyd.

• Wound healing was controlled on the first postoperative day, as well as 1 and 2 weeks after surgery.

Bone window tech.

•technique:

•This technique creates a small bone window that allows the  extraction of deep impacted third molars. By creating a bony bridge disto-buccal of the lower second molar, we prevent soft tissue collapse and help to avoid periodontal pockets on the second molar distal side. In using this technique we intend to minimize the time required for the ostectomy, postoperative pain, swelling and trismus, and periodontal risks to the second molar

•Results: The overall result was a total of 33% wound dehiscence. In the envelope-flap group, wound dehiscence's developed in 57% of the cases. This represents a relative risk ratio of 5.67, with a 95% CI from 1.852 to 12.336. With the modified triangular-flap technique, only 10% of the wounds gaped during wound healing.

•Conclusion: flap design in lower 3^rd molar influences primary wound healing.

Follow up:

•A review appointment is required:

•Where non-resorbable sutures have been placed.

• Where complications arise.

•At the patients or surgeons request.

 A discharge letter should always be sent to the referring clinician.

•How to look after their mouth postoperatively.

• Possible complications and side effects of the operation in general and any problems specific to the operation undertaken.

•Any drug therapy required.

• Whether a review appointment is required and if so, when

• That the referring practitioner will receive a letter postoperatively.

Common complication:

• Haemorrhage:

 Haemorrhage must be controlled at the time of surgery. Soft tissue bleeding may require haemostatic agents, bipolar diathermy and/or sutures. Occasionally a small amount of bone wax is necessary to control bleeding from bone, but this must be used with caution. Haematoma formation outwith the socket can occur and may require drainage.

• Ecchymosis:

 Patients should be informed that bruising is common and self-limiting and will usually resolve within two weeks of surgery.

Where signs of systemic involvement are present (pyrexia, regional lymphadenopathy) antibiotics should always be prescribed.

•Alveolar osteitis (dry socket) may occur in c. 20% of patients, particularly in those who smoke.

•Irrigation with saline (or chlorohexidine 0.2%) and/or placement of an obtundent, such as proprietary iodoform based medication, usually reduces the pain.

•Retention of root fragment:

• When a retained root fragment gives rise to symptoms it should be removed.

•Any infection should be controlled prior to surgical exploration.

•Wound dehiscence:

• Where wound dehiscence occurs without the development of pain and infection, patients should be advised to continue wound toilet, e.g. hot salty ,mouthwashes and socket syringing.

• Damage to adjacent teeth:

• Patients should be told about damage to adjacent teeth at the time of surgery or, if under sedation or generalanaesthetic, when they are fully conscious

• Periodontal health:

•The periodontium distal to the mandibular second molar may be affected by removal of an impacted third molar. Early removal of mesio-angular horizontal impacted third molars is associated with better periodontal health.