Presentation on theme: "Demystifying the Past And Planning for the Future"— Presentation transcript:
1Demystifying the Past And Planning for the Future Wisdom Tooth WisdomDemystifying the PastAndPlanning for the FutureTed Fields, DDS, PhD
2Part I: To Remove or Not to Remove Course OutlinePart I: To Remove or Not to Remove1. Development2. Wisdom teeth as an asset3. Wisdom teeth as a liability4. Alternatives to removal5. Timing of removal
3Part II: Treatment Approach Course OutlinePart II: Treatment ApproachAssessing the difficulty of removalPatient counseling and preparationAnesthesiaInstrumentationTechnique
4Management of Infected Teeth Course OutlinePart III:Management of Infected Teeth
5Part IV: It Ain’t Over Till It’s Over Course OutlinePart IV: It Ain’t Over Till It’s OverComplicationsPost-operative careDocumentation
6The Difficulty in Understanding 3rd Molars European third molar surgery is much different than that in the U.S.Lingual fracture techniqueDifferent instrumentationDifferent economic influences on dental care
7The Difficulty in Understanding 3rd 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 Many research papers of the past 20 years set out to prove or disprove old ideas – many of which themselves are outdated.Will the 3rd molar erupt?Is there enough arch length for eruption?Does removal of the 3rd molar compromise the 2nd molar?
8The Difficulty in Understanding 3rd Molars 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 3rd molar is judged in relation to orthodontic needs, rather than the patient’s overall needs.
9The Difficulty in Understanding 3rd Molars 4. Many changes in technology have been totally neglected.ImplantsElectric handpiecesAntibioticsHemostatic agentsBone augmentation materials
10The Difficulty in Understanding 3rd Molars The topic is not covered in any depth in most dental schools.Knowing when it is in the patient’s best interest to remove 3rd molars is a judgment that requires detailed knowledge of the risks and benefits associated with tooth retention and with tooth removal.
15Root CompletionFully formed roots with open apices are usually present by age 18.
16Eruption Most teeth that will erupt are erupted by age 20. 95% of all teeth that will erupt are erupted by age 24.A limited number of third molars appear to erupt, at least to some degree, in young adults.
17Predicting Eruption – Who Cares? Does it matter if a wisdom tooth erupts?Does it matter when a wisdom tooth erupts?
18The Key IssueDoes it affect theRisk:Benefit Ratio?
20Evaluating Risk:Benefit Since “Risk of retention” and “Benefit of removal” are essentially the same concept, these terms may be combined.Since “Benefit of retention” essentially = 0, the equation may be simplified:
21Evaluating Risk:Benefit You must consider 2 separate assets of each risk and each benefit:Magnitude of risk or benefitProbability of risk or benefit
22Magnitude Is it major or minor? Does it require hospitalization? Is it permanent?Does it affect your daily routine? If so, for how long?
23Probability The most overlooked aspect of most consultations. Fortunately most real bad outcomes are real uncommonWhat is the likelihood of certain problems? How much does treatment alter this likelihood?
24The Difficulty of Accurate Risk:Benefit Assessment The literature is not very complete or very helpful. Complication rates vary widely. Different people view these complications very differently (complication doesn’t always equal perception of the complication)Ogden GR, Bissias E, Ruta DA, Ogston S: Quality of life following third molar removal: a patient versus professional perspective. Br Dent J 1998;185:
25The Difficulty of Accurate Risk: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.
26Risk:Benefit Are erupted 3rds more or less subject to disease? Are erupted 3rds more or less beneficial?
28What Impacts Treatment? Eruption into occlusion should not be the sole criterion of usefulness.The issue is not “can you save it” but “should you save it.”
29Benefits of 3rds “Functional 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, how can you determine the true benefit of 3rds?
30Benefits of 3rds – Part II Orthodontic repositioning to replace missing or grossly compromised 1st molarsTransplantation – poor long-term survivalWith dental implants, these are rarely reasonable treatment alternatives.
31Tooth Transplantation Under ideal conditions, 27 oral surgeons transplanted 291 teeth:5-yr survival rate: 76.2%10-yr survival rate 59.6%Schwartz O, Bergman P, Klausen B: Resorption of autotransplanted teeth. A retrospective study of 291 transplantations over a period of 25 years. Int J Oral Surg 1985;14:
32Conclusion3rd 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.
34What Impacts Treatment? Failure of eruption should not be the sole criterion for removal.Successful eruption should not be the sole criterion for retention.Eruption is not always a “yes” or “no” proposition.
35Problem #1 – Soft TissueEven with adequate arch length and full eruption, 3rd molars are often surrounded by thin, unkeratinized, highly distensible lining mucosa of the buccal vestibule.Encourages pathogenic bacteria retentionPoorly withstands hygiene measures
36Problem #2 – Periodontal Compromise Bone loss distal to the 2rd molar after removal of the 3rd molar is controversial, at best. Even with some loss of bone, the result is stable and cleansable – the goal of periodontal therapy.
37Bone Loss Distal to the 2nd Molar A reduction in pocket depth with no change in bone height on the distal of the 2nd molar.Szmyd and HesterGroves and MooreGrondahl and Lekholm
38Bone Loss Distal to the 2nd Molar Alveolar bone crest healing distal to the 2nd molar is enhanced in younger patients with incompletely developed 3rd molar roots.Ash, Costich, and HaywardZiegler
39Augmentation with Freeze-Dried Bone or Bone Substitutes Why?There is no independent evidence of benefitWhy graft a contaminated site?Why graft a site you can’t close primarily?Your goal is to maintain bone height on the distal of the 2nd molar without pocket formation, not to augment potential defects more posteriorly.
40Augmentation: Conclusion It won’t improve your outcome.It will undoubtedly increase your infection rateWhy would you want to augment this area anyway?
46Problem #2 – Periodontal Compromise The role of pathogenic bacteria retention in 3rd molar pockets is unknown. How does this affect the rest of the dentition?Hygenic compromise of the 2nd molar can result in a difficult to restore situation if this tooth is lost.
51How Do You Treat Missing 2nd Molars? If the entire dentition is healthy and a mandibular 2nd molar needs extraction, what is the recommended treatment?Cantilevered abutment?Implant?Partial denture?Remove opposing tooth at same time?Nothing. Allow opposing tooth to supererupt.
52The Missing 2nd Molar Dilemma Your treatment plan for this scenario illustrates the value you place on 2nd molars.Most people will subconsciously do acost:benefit analysis and concludethat restoration is not necessary.
65Problem #5 - InfectionCan turn an elective procedure into an urgent or emergent situationUnscheduled loss of workIncreased pain and healing timeCompromise of adjacent teethCompromise of patient’s systemic health
67Types of Infection Simple dental caries and periodontal disease PericoronitisAbscessCellulitisAbscess extension into adjacent fascial spaces5. Abscess spread to distant sitesRecurrent infectionsInfections resistant to initial local and systemic treatment measures
68PericoronitisThe most common cause of therapeutic 3rd molar removal.
69Pericoronitis A failure of preventive measures A failure of early recognition, or a failure to seek proper treatmentA step along the pathway of infectionPericoronitis should be a warning sign that initiates immediate and aggressive treatment with careful observation.
80Cysts – A Few FactsMay be prevented by early removal – when normal dental follicle is still evident.The pericoronal pocket, or residual follicle, is responsible for most cystic pathology.All cystic tissues should be removed and biopsied.
81CystsCysts themselves are not catastrophic – the problem is that we don’t know exactly what they are until they are histopathologically examined – which necessitates removal.All cysts result in bone loss.Some cysts recur more than others.
82Treatment of Large Cysts Aspirate first – rule out vascular lesionsConsider decompression (only after biospy confirmed diagnosis)Consider marsupializationConsider bone graftingConsider possibility of mandible fractureConsider extensive followup
102Problem #12 - Orthodontics Prevent loss of post-retention stabilityAllow distalization of 2nd molarsThese are controversial indications
103Alternatives to Removal RestorationPeriodontal therapyOperculectomyRemoval of another toothNo treatment
104When is the best time for prophylactic removal? Timing Removal of 3rdsWhen is the best time for prophylactic removal?
105Age 7-11: Mandibular 3rds Germs are first visible during this time They usually appear in a superficial location close to the alveolar crestAfter age 11, they are located deeper in the mandible
106Age 7-11: Mandibular 3rdsVery close to ridge crest. Minimal if any bone removal will be needed.
107Age 7-11: Mandibular 3rdsMineralization is either not present or only mineralized cusps are evidentRemove requires a flap and minimal, if any, bone removalPsychological factors and parental support should be carefully evaluated on a case by case basis
108Age 7-11: Mandibular 3rdsClose to, but not at, ridge crest. Some bone removal will be needed.
109Age 7-11: Mandibular 3rdsBone removal will be necessary. Is it better to remove this 3rd molar or wait?
110Age 7-11: Mandibular 3rdsThere has been less published about removal of thirds at this age than at other ages, so intervention at this time tends to be more controversialMuch of the controversy has traditionally revolved around the difficulty in predicting eruption and arch length – probably not valid
111Removing 3rd Molar Germs Bjornland T, Haanaes HR, Lind PO, Zachrisson B: Removal of third molar tooth germs: study of complications. Int J Oral Maxillofac Surg 1987;16:Half as much postop pain medication was requiredOne third quicker procedureWell-tolerated with local anesthesia
112Age 7-11: Maxillary 3rds These teeth tend to be high in the maxilla Their small size can make them difficult to locateTheir size and location can increase the risk of injury to the developing 2nd molarIncreased operating time and frustrationIncreased postop edema and discomfort
117Age 7-11: ConclusionLower 3rds are often very simple, upper 3rd are almost always very difficult and pose risk to the 2nd molarsIn older individuals, 90% of the morbidity is from removal of the lower 3rdsEarly removal may obviate the need for any sedation at any timePsychological evaluation is critical
118Age 12 -14 Crown mineralization progresses Distance of lower 3rds from ridge crest increasesLower 3rds become more difficult to removeUpper 3rds may still be quite difficultPsychologically, many patients may be less prepared at this age.
122Age 15-18Root formation has begun and may progress to near completion.Most patients are psychologically accepting of surgery at this age.Most studies agree that complication rates are least in this age range.
124Age 15-18The follicle allows for relatively easy removal once the tooth is accessed.No PDL is present – there is no attachment of the tooth to bone.The portion of the follicle deep to the forming roots acts as a safety zone between the tooth and the nerve.
125Age 15-18The periphery of the deepest mineralized tooth surface may be quite sharp, allowing laceration of the neurovascular bundle if it too is housed within the follicular space.The tooth may spin and be difficult to stabilize while sectioning and elevating.
129Age 19-22Root development is not always complete during this period, making it still a favorable time for 3rd molar removal.
130Age 22-35Nearly all patients in this age group will have fully developed 3rd molar roots – this potential advantage is lost.The bone still has a good ratio of elastic collagen matrix to mineral content, usually simplifying removal and even more frequently improving most parameters of healing.Most of these patients are healthy.
131Age 35-45 Most patients are still ASA I or II The mineral content of the mandible increases during this time.Many 3rd molars must be removed during this time for therapeutic reasons.
132Over Age 45 The complication rate is highest in this group. The incidence of nerve injury is highest in this group – and recovery is the poorest.Even routine healing tends to be prolonged and associated with increased morbidity.Patient health may be compromised.
133With Increasing Age Narrowing of PDL and pericoronal space Thickening of cortical boneIncreased risk of infection, bone loss, and other pathoses
134Advantages of Early Removal Wide pericoronal spaceIncomplete root developmentStraight rootsAway from IANAway from sinusLess risk of infectionLess risk of fracturePatient more likely in good healthBetter chance for primary closureSmaller teeth require less bone removal