Surgical Removal ofSurgical Removal ofWisdom TeethWisdom Teeth

Dr Hazem AlDr Hazem Al--AhmadAhmadBDS, MSc (Lon), F.D.S. R.C.S.(Eng)BDS, MSc (Lon), F.D.S. R.C.S.(Eng)

Associate Professor, Dental SchoolAssociate Professor, Dental SchoolUniversity Of JordanUniversity Of Jordan

PREVALENCEPREVALENCEOne studyOne study –– 1717% of patients over% of patients over 2020 year oldyear old2222% maxillary third molars% maxillary third molars1818% mandibular third molars% mandibular third molars00..99% maxillary canines% maxillary caninesmandibular premolarsmandibular premolarsmandibular caninesmandibular caninesmaxillary premolarsmaxillary premolarsmaxillary central incisorsmaxillary central incisorsmaxillary lateral incisorsmaxillary lateral incisors

PREVALENCEPREVALENCEOne studyOne study –– 1717% of patients over% of patients over 2020 year oldyear old2222% maxillary third molars% maxillary third molars1818% mandibular third molars% mandibular third molars00..99% maxillary canines% maxillary caninesmandibular premolarsmandibular premolarsmandibular caninesmandibular caninesmaxillary premolarsmaxillary premolarsmaxillary central incisorsmaxillary central incisorsmaxillary lateral incisorsmaxillary lateral incisors

ETIOLOGYETIOLOGY Differential root growth between theDifferential root growth between the

mesial and the distal roots.mesial and the distal roots. The relation of the bony arch lengthThe relation of the bony arch length

to the sum of the mesiodistal widthsto the sum of the mesiodistal widthsof the teeth in the archof the teeth in the arch

Retarded maturation of the thirdRetarded maturation of the thirdmolarmolar

ETIOLOGYETIOLOGY Differential root growth between theDifferential root growth between the

mesial and the distal roots.mesial and the distal roots. The relation of the bony arch lengthThe relation of the bony arch length

to the sum of the mesiodistal widthsto the sum of the mesiodistal widthsof the teeth in the archof the teeth in the arch

Retarded maturation of the thirdRetarded maturation of the thirdmolarmolar

Clinical ExaminationClinical Examination

The patient attitudeThe patient attitude -- Type ofType ofanaesthesia and/or sedationanaesthesia and/or sedation

Age and general fitnessAge and general fitness The presence of facial swelling andThe presence of facial swelling and

enlarged, tender, lymph nodes.enlarged, tender, lymph nodes. Surgical accessSurgical access -- inspection of theinspection of the

mouth.mouth. The health of theThe health of the 11st andst and 22nd molarsnd molars

The patient attitudeThe patient attitude -- Type ofType ofanaesthesia and/or sedationanaesthesia and/or sedation

Age and general fitnessAge and general fitness The presence of facial swelling andThe presence of facial swelling and

enlarged, tender, lymph nodes.enlarged, tender, lymph nodes. Surgical accessSurgical access -- inspection of theinspection of the

mouth.mouth. The health of theThe health of the 11st andst and 22nd molarsnd molars

Clinical ExaminationClinical Examination

Soft tissues over the wisdomSoft tissues over the wisdom --activeactivepericoronitis, pus beneath the gumpericoronitis, pus beneath the gumflap.flap.

The position and condition of theThe position and condition of theupperupper 33rd molar.rd molar.

Possible future use as a denture orPossible future use as a denture orbridge abutment.bridge abutment.

Soft tissues over the wisdomSoft tissues over the wisdom --activeactivepericoronitis, pus beneath the gumpericoronitis, pus beneath the gumflap.flap.

The position and condition of theThe position and condition of theupperupper 33rd molar.rd molar.

Possible future use as a denture orPossible future use as a denture orbridge abutment.bridge abutment.

Classification systems forClassification systems forimpacted teeth:impacted teeth:Angulation:Angulation: mesiomesio--angularangular verticalvertical distodisto--angularangular horizontalhorizontal

Angulation:Angulation: mesiomesio--angularangular verticalvertical distodisto--angularangular horizontalhorizontal

Classification systems forClassification systems forimpacted teeth:impacted teeth: Relationship to anterior border ofRelationship to anterior border of

ramus: Pell and Gregory classesramus: Pell and Gregory classes 11,,22andand 33::

Class I: MClass I: M--D diameter of crown isD diameter of crown istotally anterior to ant border of ramustotally anterior to ant border of ramus

Class II: one half of crown is coveredClass II: one half of crown is coveredby ramusby ramus

Class III: tooth completely within theClass III: tooth completely within theramusramus

Relationship to anterior border ofRelationship to anterior border oframus: Pell and Gregory classesramus: Pell and Gregory classes 11,,22andand 33::

Class I: MClass I: M--D diameter of crown isD diameter of crown istotally anterior to ant border of ramustotally anterior to ant border of ramus

Class II: one half of crown is coveredClass II: one half of crown is coveredby ramusby ramus

Class III: tooth completely within theClass III: tooth completely within theramusramus

Classification systems forClassification systems forimpacted teeth:impacted teeth: Relationship to occlusal plane:Relationship to occlusal plane: Pell andPell and

Gregory classes A , B and C:Gregory classes A , B and C: Class A: occlusal surface is level (or nearly)Class A: occlusal surface is level (or nearly)

with occlusal plane ofwith occlusal plane of 22ndnd molarmolar Class B: occlusal surface between occlusalClass B: occlusal surface between occlusal

plane and cervical lineplane and cervical line Class C: occlusal surface below cervical lineClass C: occlusal surface below cervical line

Relationship to occlusal plane:Relationship to occlusal plane: Pell andPell andGregory classes A , B and C:Gregory classes A , B and C:

Class A: occlusal surface is level (or nearly)Class A: occlusal surface is level (or nearly)with occlusal plane ofwith occlusal plane of 22ndnd molarmolar

Class B: occlusal surface between occlusalClass B: occlusal surface between occlusalplane and cervical lineplane and cervical line

Class C: occlusal surface below cervical lineClass C: occlusal surface below cervical line

Radiological AssessmentRadiological Assessment

1.1. The Orientation of the ToothThe Orientation of the Tooth2.2. The Depth of the ToothThe Depth of the Tooth3.3. The Degree of Impaction of theThe Degree of Impaction of the

ToothTooth4.4. Root ShapeRoot Shape5.5. Bone Removal to Form a Path ofBone Removal to Form a Path of

ElevationElevation

1.1. The Orientation of the ToothThe Orientation of the Tooth2.2. The Depth of the ToothThe Depth of the Tooth3.3. The Degree of Impaction of theThe Degree of Impaction of the

ToothTooth4.4. Root ShapeRoot Shape5.5. Bone Removal to Form a Path ofBone Removal to Form a Path of

ElevationElevation

66. Bone Removal to Permit Application. Bone Removal to Permit Applicationof Elevatorsof Elevators

77. Bone Density. Bone Density88. The Relationship to the Inferior. The Relationship to the Inferior

Dental CanalDental Canal

AssessmentAssessment

AssessmentAssessment

To Remove or Not to RemoveTo Remove or Not to RemoveTo Remove or Not to RemoveTo Remove or Not to Remove

PericoronitisPericoronitis Food packing between the crown ofFood packing between the crown of

the impacted tooth and the secondthe impacted tooth and the secondmolarmolar -- caries. In later lifecaries. In later life --periodontal diseaseperiodontal disease

Suppuration around a buried tooth.Suppuration around a buried tooth. OrthodontistsOrthodontists -- imbrication of theimbrication of the

anterior teeth, orthodonticanterior teeth, orthodonticmovement of molars distally,movement of molars distally,orthognathic surgery.orthognathic surgery.

PericoronitisPericoronitis Food packing between the crown ofFood packing between the crown of

the impacted tooth and the secondthe impacted tooth and the secondmolarmolar -- caries. In later lifecaries. In later life --periodontal diseaseperiodontal disease

Suppuration around a buried tooth.Suppuration around a buried tooth. OrthodontistsOrthodontists -- imbrication of theimbrication of the

anterior teeth, orthodonticanterior teeth, orthodonticmovement of molars distally,movement of molars distally,orthognathic surgery.orthognathic surgery.

KeratocystKeratocyst Dentigerous cystDentigerous cyst AmeloblastomaAmeloblastoma Prevention of jaw fracturePrevention of jaw fracture -- sportssports Resorption of alveolar bone (loss ofResorption of alveolar bone (loss of

molars with age)molars with age) Unexplained painUnexplained pain

KeratocystKeratocyst Dentigerous cystDentigerous cyst AmeloblastomaAmeloblastoma Prevention of jaw fracturePrevention of jaw fracture -- sportssports Resorption of alveolar bone (loss ofResorption of alveolar bone (loss of

molars with age)molars with age) Unexplained painUnexplained pain

CaseCase 11

CaseCase 11

CaseCase 22

CaseCase 22

CaseCase 22

CaseCase 22

CaseCase 22

Contraindications forContraindications forremoval:removal: Extremes of ageExtremes of age Compromised medical statusCompromised medical status Surgical damage to adjacentSurgical damage to adjacent

structuresstructures

Extremes of ageExtremes of age Compromised medical statusCompromised medical status Surgical damage to adjacentSurgical damage to adjacent

structuresstructures

Part IIPart II

Basic stepsBasic steps

Reflecting adequate flaps forReflecting adequate flaps foraccessibiltyaccessibilty

a.a. Envelope flapEnvelope flapb.b. ThreeThree--cornered flap / Triangular flapcornered flap / Triangular flap(maxillary / mandibular teeth)(maxillary / mandibular teeth)

Reflecting adequate flaps forReflecting adequate flaps foraccessibiltyaccessibilty

a.a. Envelope flapEnvelope flapb.b. ThreeThree--cornered flap / Triangular flapcornered flap / Triangular flap(maxillary / mandibular teeth)(maxillary / mandibular teeth)

Basic stepsBasic steps

Removal of overlying boneRemoval of overlying bonea.a. Chisel / drillChisel / drillb.b. Lingual aspectLingual aspectc.c. Maxillary/ mandibular teethMaxillary/ mandibular teeth

Removal of overlying boneRemoval of overlying bonea.a. Chisel / drillChisel / drillb.b. Lingual aspectLingual aspectc.c. Maxillary/ mandibular teethMaxillary/ mandibular teeth

Basic stepsBasic steps

Sectioning the toothSectioning the tootha.a. chisel/bur (chisel/bur (33//44 of tooth)of tooth)b.b. Angulation of impactionAngulation of impaction

Sectioning the toothSectioning the tootha.a. chisel/bur (chisel/bur (33//44 of tooth)of tooth)b.b. Angulation of impactionAngulation of impaction

MesioangularMesioangular

Least difficultLeast difficult Distal half of theDistal half of the

crown is sectionedcrown is sectioned

Least difficultLeast difficult Distal half of theDistal half of the

crown is sectionedcrown is sectioned

Horizontal impactionHorizontal impaction

Bone removalBone removal Divide crown fromDivide crown from

rootsroots

Vertical impactionVertical impaction

Bone removalBone removal More accessMore access

neededneeded

distoangulardistoangular

Most difficultMost difficult Bone removalBone removal Crown sectioningCrown sectioning

Most difficultMost difficult Bone removalBone removal Crown sectioningCrown sectioning

Imacted maxillary teethImacted maxillary teeth

Rarely sectionedRarely sectioned No chiselNo chisel Rarely sectionedRarely sectioned No chiselNo chisel

Basic stepsBasic steps

Delivery with elevatorDelivery with elevator No luxationNo luxation No excessive forceNo excessive force(maxillary and mandibular teeth)(maxillary and mandibular teeth)

Delivery with elevatorDelivery with elevator No luxationNo luxation No excessive forceNo excessive force(maxillary and mandibular teeth)(maxillary and mandibular teeth)

Debridement of woundDebridement of wound

Remove bone chips and debrisRemove bone chips and debris Irrigate with salineIrrigate with saline Smooth sharp edgesSmooth sharp edges Primary closurePrimary closure

Remove bone chips and debrisRemove bone chips and debris Irrigate with salineIrrigate with saline Smooth sharp edgesSmooth sharp edges Primary closurePrimary closure

PostPost--operative careoperative care

Pain and anxiety controlPain and anxiety control SteroidsSteroids AntibioticsAntibiotics swellingswelling

Pain and anxiety controlPain and anxiety control SteroidsSteroids AntibioticsAntibiotics swellingswelling

ComplicationsComplicationsComplicationsComplications

complicationscomplications

PreventionPreventionIntraoperative:Intraoperative: Soft tissue injuriesSoft tissue injuries Injuries to oseous structuresInjuries to oseous structures Oroantral comunicationsOroantral comunications Fractures of the mandibleFractures of the mandible Injuries to adjacent teethInjuries to adjacent teeth Complications with the tooth being extractedComplications with the tooth being extracted Injuries to adjacent structuresInjuries to adjacent structures

PreventionPreventionIntraoperative:Intraoperative: Soft tissue injuriesSoft tissue injuries Injuries to oseous structuresInjuries to oseous structures Oroantral comunicationsOroantral comunications Fractures of the mandibleFractures of the mandible Injuries to adjacent teethInjuries to adjacent teeth Complications with the tooth being extractedComplications with the tooth being extracted Injuries to adjacent structuresInjuries to adjacent structures

Postoperative complications:Postoperative complications: BleedingBleeding Delayed healing and infectionDelayed healing and infection

Postoperative complications:Postoperative complications: BleedingBleeding Delayed healing and infectionDelayed healing and infection

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