Wisdom Tooth Wisdom

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    Wisdom Tooth Wisdom

    Demystifying the Past

    And

    Planning for the Future

    Ted Fields, DDS, PhD

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    Course Outline

    Part I: To Remove or Not to Remove

    1. Development2. Wisdom teeth as an asset

    3. Wisdom teeth as a liability

    4. Alternatives to removal5. Timing of removal

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    Course Outline

    Part II: Treatment Approach

    1. Assessing the difficulty of removal2. Patient counseling and preparation

    3. Anesthesia

    4. Instrumentation5. Technique

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    Course Outline

    Part III:Management of Infected Teeth

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    Course Outline

    Part IV: It Aint Over Till Its Over

    1. Complications2. Post-operative care

    3. Documentation

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    The Difficulty inUnderstanding 3 rd Molars

    1. European third molar surgery is much

    different than that in the U.S.Lingual fracture techniqueDifferent instrumentation

    Different economic influences on dentalcare

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    The Difficulty inUnderstanding 3 rd Molars

    2. Many research papers of the past 20 years

    set out to prove or disprove old ideas many of which themselves are outdated.Will the 3 rd molar erupt?

    Is there enough arch length for eruption?Does removal of the 3 rd molar compromisethe 2 nd molar?

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    The Difficulty inUnderstanding 3 rd Molars

    3. Much of the developmental literature is

    written from an orthodontic viewpoint.There is an outcome bias towards younger individuals (what is the result in a 16-yr-old?)

    The 3 rd molar is judged in relation toorthodontic needs, rather than the patientsoverall needs.

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    The Difficulty inUnderstanding 3 rd Molars

    4. Many changes in technology have been

    totally neglected.ImplantsElectric handpiecesAntibioticsHemostatic agentsBone augmentation materials

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    The Difficulty inUnderstanding 3 rd Molars

    5. The topic is not covered in any depth inmost dental schools.Knowing when it is in the patients bestinterest to remove 3 rd molars is a judgmentthat requires detailed knowledge of therisks and benefits associated with toothretention and with tooth removal.

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    Development

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    Initial calcificationO ccurs as early as 7yrs, more typically age 9.

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    Crown Mineralization

    Usually completed by age 12 to 14.

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    Root FormationUsually half-formed by age 16.

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    RootC

    ompletionF ully formed roots with open apices are usually

    present by age 18.

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    Eruption

    Most teeth that will erupt are erupted by age

    20.95% of all teeth that will erupt are erupted byage 24.

    A limited number of third molars appear toerupt, at least to some degree, in youngadults.

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    Predicting Eruption Who Cares?

    Does it matter if a wisdom tooth erupts?

    Does it matter when awisdom tooth erupts?

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    The Key IssueDoes it affect the

    Risk:Benefit Ratio?

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    Evaluating Risk:Benefit

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    Evaluating Risk:BenefitYou must consider 2 separate assets of each

    risk and each benefit:

    1. Magnitude of risk or benefit

    2. Probability of risk or benefit

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    MagnitudeIs it major or minor?

    Does it require hospitalization?Is it permanent?Does it affect your daily routine? If so, for

    how long?

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    ProbabilityThe most overlooked aspect of most

    consultations.F ortunately most real bad outcomes are realuncommon

    What is the likelihood of certain problems?How much does treatment alter thislikelihood?

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    The Difficulty of AccurateRisk:Benefit Assessment

    1. The literature is not very complete or veryhelpful. Complication rates vary widely. Different

    people view these complications very differently(complication doesnt always equal perception of the complication)

    O gden GR, Bissias E, Ruta DA, O gston S: Quality of life following thirdmolar removal: a patient versus professional perspective. Br Dent J1998;185:407410.

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    The Difficulty of AccurateRisk:Benefit Assessment

    2. The wide variety of different complications

    and the wide range in the incidences of each potential complication result in a complex body of data to assimilate.

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    Risk:Benefit

    Are erupted 3rds more or less subject todisease?

    Are erupted 3rds more or less beneficial?

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    Wisdom Teeth as an Asset

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    What Impacts Treatment?

    Eruption into occlusion should not be

    the sole criterion of usefulness.The issue is not can you save it butshould you save it.

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    Benefits of 3rds F unctional occlusion what is this?

    Is it any different than just occlusion?Is all occlusion functional?Is all functional occlusion important? If so, is it all

    equally important?Without evaluating questions such as these, howcan you determine the true benefit of 3rds?

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    Benefits of 3rds Part II

    O rthodontic repositioning to replace missing

    or grossly compromised 1st

    molarsTransplantation poor long-term survivalWith dental implants, these are rarely

    reasonable treatment alternatives.

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    Tooth Transplantation

    Under ideal conditions, 27 oral surgeonstransplanted 291 teeth:5-yr survival rate: 76.2%10-yr survival rate 59.6%

    SchwartzO

    , Bergman P, Klausen B: Resorption of autotransplanted teeth. A retrospective study of 291transplantations over a period of 25 years. Int J O ral Surg1985;14:245-258.

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    Conclusion

    3rd molars provide no proven functional

    benefit and no obvious esthetic benefit.

    Rarely, they may provide a treatment option

    that, at best, is third-line treatment.

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    Wisdom Teeth as a Liability

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    What Impacts Treatment?

    F ailure of eruption should not be the sole criterionfor removal.

    Successful eruption should not be the sole criterionfor retention.

    Eruption is not always a yes or no proposition.

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    Problem #2 PeriodontalCompromise

    Bone loss distal to the 2 rd molar after removal of the 3 rd molar is controversial, at

    best. Even with some loss of bone, the resultis stable and cleansable the goal of

    periodontal therapy.

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    Bone Loss Distalto the 2 nd Molar

    A reduction in pocket depth with no change

    in bone height on the distal of the 2nd

    molar.

    Szmyd and Hester Groves and Moore

    Grondahl and Lekholm

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    Bone Loss Distal

    to the 2 nd Molar Alveolar bone crest healing distal to the 2 nd

    molar is enhanced in younger patients withincompletely developed 3 rd molar roots.

    Ash, Costich, and HaywardZiegler

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    Augmentation with F reeze-

    Dried Bone or Bone SubstitutesWhy?

    There is no independent evidence of benefitWhy graft a contaminated site?Why graft a site you cant close primarily?Your goal is to maintain bone height on the distal of the 2 nd molar without pocket formation, not toaugment potential defects more posteriorly.

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    Augmentation: Conclusion

    It wont improve your outcome.

    It will undoubtedly increase your infectionrateWhy would you want to augment this area

    anyway?

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    Measuring Bone Height

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    Problem #2 Periodontal

    CompromiseThe role of pathogenic bacteria retention in

    3rd

    molar pockets is unknown. How does thisaffect the rest of the dentition?

    Hygenic compromise of the 2nd

    molar canresult in a difficult to restore situation if thistooth is lost.

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    How Do You Treat Missing

    2nd Molars?If the entire dentition is healthy and a mandibular 2nd molar needs extraction, what is therecommended treatment?

    Cantilevered abutment?Implant?Partial denture?Remove opposing tooth at same time?

    Nothing. Allow opposing tooth to supererupt.

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    The Missing 2 nd Molar

    DilemmaYour treatment plan for this scenario

    illustrates the value you place on 2nd

    molars.

    Most people will subconsciously do a

    cost:benefit analysis and concludethat restoration is not necessary.

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    Problem #3 3 rd Molar Caries

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    Problem #3 3 rd Molar Caries

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    Problem #4 2 nd Molar Caries

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    Problem #5 - Infection

    Can turn an elective procedure into an urgent

    or emergent situationUnscheduled loss of work Increased pain and healing time

    Compromise of adjacent teethCompromise of patients systemic health

    f i

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    Infection

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    Types of Infection

    1. Simple dental caries and

    periodontal disease

    2. Pericoronitis

    3. Abscess

    4. Cellulitis

    5. Abscess extension into

    adjacent fascial spaces

    5. Abscess spread to distant

    sites6. Recurrent infections

    7. Infections resistant to

    initial local and systemictreatment measures

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    Pericoronitis

    A failure of preventive measures

    A failure of early recognition, or a failure toseek proper treatmentA step along the pathway of infection

    Pericoronitis should be a warning sign thatinitiates immediate and aggressive treatmentwith careful observation.

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    Problem #6 - Resorption

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    Problem #8 - Cysts

    DentigerousCyst

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    DentigerousCyst

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    Types of Cysts

    F ollicular cyst (Dentigerous Cyst)O KC ( O dontogenic Keratocyst)Ameloblastoma (several varieties)

    Not all radiolucencies are cysts!- Lymphoma- Myeloma- Metastatic carcinoma

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    Without theradiolucency, wouldyou haverecommendedremoval?

    Is the removal of this better or worsewith theradiolucency?

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    Cysts A F ew F acts

    May be prevented by early removal when

    normal dental follicle is still evident.The pericoronal pocket, or residual follicle, isresponsible for most cystic pathology.

    All cystic tissues should be removed and biopsied.

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    Cysts

    Cysts themselves are not catastrophic the problem is that we dont know exactly whatthey are until they are histopathologicallyexamined which necessitates removal.

    All cysts result in bone loss.Some cysts recur more than others.

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    Treatment of Large Cysts

    Aspirate first rule out vascular lesionsConsider decompression (only after biospyconfirmed diagnosis)Consider marsupializationConsider bone graftingConsider possibility of mandible fractureConsider extensive followup

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    Problem #9 - Tumors

    Benign vs. malignant

    O dontogenic vs. non-odontogenic

    Primary vs. secondary

    Each of these factors has important treatmentimplications.

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    Tumors

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    Problem #10 Risk of F racture

    Immediate Pre-extraction

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    Immediate Pre extraction

    Immediate Post extraction

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    Immediate Post-extraction

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    8 Days Post-extraction

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    8 Days Post-extraction

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    Problem #11 - F racture

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    Problem #12 - O rthodontics

    Prevent loss of post-retention stabilityAllow distalization of 2nd molars

    These are controversialindications

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    Alternatives to Removal

    1. Restoration2. Periodontal therapy3. O perculectomy4. Removal of another tooth5. No treatment

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    Timing Removal of 3rds

    When is the best time forprophylactic removal?

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    Age 7-11: Mandibular 3rds

    1. Germs are first visible during this time

    2. They usually appear in a superficiallocation close to the alveolar crest

    3. After age 11, they are located deeper in the

    mandible

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    Age 7-11: Mandibular 3rds

    Very close to ridge

    crest. Minimal if any bone removalwill be needed.

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    Age 7-11: Mandibular 3rds

    1. Mineralization is either not present or onlymineralized cusps are evident

    2. Remove requires a flap and minimal, if any, bone removal

    3. Psychological factors and parental supportshould be carefully evaluated on a case bycase basis

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    Age 7-11: Mandibular 3rds

    Close to, but not at,

    ridge crest. Some boneremoval will beneeded.

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    Age 7-11: Mandibular 3rds

    Bone removal will be necessary. Is it better to removethis 3 rd molar or wait?

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    Age 7-11: Mandibular 3rds

    There has been less published about removalof thirds at this age than at other ages, sointervention at this time tends to be morecontroversialMuch of the controversy has traditionallyrevolved around the difficulty in predictingeruption and arch length probably not valid

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    Removing 3 rd Molar Germs

    Bjornland T, Haanaes HR, Lind P O , Zachrisson B:Removal of third molar tooth germs: study of

    complications. Int J O ral Maxillofac Surg1987;16:385-390.

    Half as much postop pain medication was requiredO ne third quicker procedureWell-tolerated with local anesthesia

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    Age 7-11: Maxillary 3rds

    These teeth tend to be high in the maxillaTheir small size can make them difficult tolocateTheir size and location can increase the risk of injury to the developing 2 nd molar

    Increased operating time and frustrationIncreased postop edema and discomfort

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    Age 7-11: Maxillary 3rds

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    Age 7-11: 3 rd Molars

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    Age 7-11: 3 rd Molars

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    Age 7-11: 3 rd Molars

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    Age 12 -14

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    Age 12 -14

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    Age 12 -14

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    Age 15-18

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    Age 15-18

    The follicle allows for relatively easyremoval once the tooth is accessed.

    No PDL is present there is no attachmentof the tooth to bone.The portion of the follicle deep to theforming roots acts as a safety zone betweenthe tooth and the nerve.

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    Age 15-18

    The periphery of the deepest mineralizedtooth surface may be quite sharp, allowinglaceration of the neurovascular bundle if ittoo is housed within the follicular space.The tooth may spin and be difficult to

    stabilize while sectioning and elevating.

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    Age 15-18

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    Age 15-18

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    Age 15-18

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    Age 19-22

    Root development is not always completeduring this period, making it still a favorabletime for 3 rd molar removal.

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    Age 22-35

    Nearly all patients in this age group will have fullydeveloped 3 rd molar roots this potential advantage

    is lost.The bone still has a good ratio of elastic collagenmatrix to mineral content, usually simplifyingremoval and even more frequently improving most

    parameters of healing.Most of these patients are healthy.

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    Age 35-45

    Most patients are still ASA I or IIThe mineral content of the mandibleincreases during this time.Many 3 rd molars must be removed duringthis time for therapeutic reasons.

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    O ver Age 45

    The complication rate is highest in thisgroup.The incidence of nerve injury is highest inthis group and recovery is the poorest.Even routine healing tends to be prolongedand associated with increased morbidity.Patient health may be compromised.

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    With Increasing Age

    Narrowing of PDL and pericoronal spaceThickening of cortical boneIncreased risk of infection, bone loss, andother pathoses

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    Advantages of Early Removal

    Wide pericoronal spaceIncomplete rootdevelopmentStraight rootsAway from IAN

    Away from sinusLess risk of infection

    Less risk of fracturePatient more likely ingood healthBetter chance for

    primary closure

    Smaller teeth requireless bone removal