1. Third molars 3-7-08

2. Maxillary Molars Sinus Proximity– Alternate Procedure Palatal root sitting close to the sinus Palatal root sitting close to the sinus Reflect a flap Reflect a flap Stryker bone off the buccal Stryker bone off the buccal Separate the buccal roots from the crown Separate the buccal roots from the crown Remove the palatal root with the crown Remove the palatal root with the crown Remove the buccal roots individually Remove the buccal roots individually

3. Review again

4. Mandibular Molars Divide the tooth buccolingually from the buccal furcation towards the lingual with a Stryker 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 ONLY go 2/3 of the way to the lingual plate Use elevator to split remaining tooth structure Use elevator to split remaining tooth structure WRITE IT DOWN in Post-op Notes WRITE IT DOWN in Post-op Notes Remove the root with less interference Remove the root with less interference Remove the mesial root if it has less curvature Remove the mesial root if it has less curvature Remove the interseptal bone to free the distal root Remove the interseptal bone to free the distal root

5. Geriatric Patients Bone characteristics Bone characteristics Dense Dense Inelastic Inelastic Roots tend to break more easily Roots tend to break more easily Prepare to surgically remove the tooth Prepare to surgically remove the tooth

6. Malposed teeth Mandibular premolars-displaced to the lingual very difficult Mandibular premolars-displaced to the lingual very difficult Procedure Procedure Reflect a flap Reflect a flap Make a window in the plate Make a window in the plate Tap the tooth to the lingual Tap the tooth to the lingual The lingual plate should break The lingual plate should break Remove tooth Remove tooth Should the buccal plate come out, don’t put it back Should the buccal plate come out, don’t put it back

7. Wisdom Teeth Reasons to keep the 3 rds Reasons to keep the 3 rds The patient can maintain cleanliness The patient can maintain cleanliness It actually functions in occlusion It actually functions in occlusion There is adequate attached gingiva There is adequate attached gingiva

8. Wisdom Teeth Asymptomatic wisdom teeth become problematic in the future Asymptomatic wisdom teeth become problematic in the future Get them out when they are younger Get them out when they are younger Lesser complications-less recovery time Lesser complications-less recovery time Remove when 1/3 of the root is formed Remove when 1/3 of the root is formed One anesthesia risk, one surgery, one swelling, one pain One anesthesia risk, one surgery, one swelling, one pain

9. Asymptomatic vs. Symptomatic Symptomatic- no brainer, git ‘em oudda der Symptomatic- no brainer, git ‘em oudda der Pericoronitis Pericoronitis Periodontitis Periodontitis Pathologic Resorption Pathologic Resorption Neoplasms Neoplasms Orthodontic Treatment Orthodontic Treatment Pre-Dentures Pre-Dentures Pain Pain Caries Caries

10. Pericoronitis You must have a portion of the crown in the oral cavity to actually call it pericoronitis You must have a portion of the crown in the oral cavity to actually call it pericoronitis Impacted teeth are “impacted,” duh 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) Patients with pericoronitis at time of extraction have higher potential for dry socket (loss of blood clot, causing excruciating pain post-op)

11. Pericoronitis If you do an operculectomy and don’t remove the tooth, it will grow back If you do an operculectomy and don’t remove the tooth, it will grow back (not the tooth) (not the tooth) Just get the tooth out Just get the tooth out

12. 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 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 If try to extract 3rd molars will have anesthesia problems while the patient is still infected in the acidic environment

13. Periodontitis Potential periodontal problem Potential periodontal problem Left alone, the third molar becomes decayed Left alone, the third molar becomes decayed The decay undermines the second molar creating a periodontal problem The decay undermines the second molar creating a periodontal problem Decay may extend to the second molar, reaching the pulp 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) You lose both the third and the second molar (It’s a lose, lose, lose situation)

14. Periodontitis

15. Pathologic Resorption The erupting third molar may resorb the second molar roots and surrounding bone The erupting third molar may resorb the second molar roots and surrounding bone

16. Neoplasms Dentigerous cyst Dentigerous cyst Keratocyst Keratocyst Ameloblastoma Ameloblastoma The most common cyst is the dentigerous cyst The most common cyst is the dentigerous cyst

17. Dentigerous Cysts Dentigerous cyst-associated with the crown of an impacted 3rd molar 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 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 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 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 Ameloblastoma, keratocysts-other neoplasms associated with the 3rd molar area and associated with the cyst/sac

18. Orthodontic Treatment 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.) 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 Orthodontic treatment-3rd molar resorbs 2nd molar Refer patients either before or after orthodontic treatment because hard to make flap, preferably before 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 Do not refer orthodontic patients during treatment because the wires and hooks make it difficult to make a flap

19. Pre-Denture 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 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 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 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

20. Pain, Caries Self-explanatory Self-explanatory

21. Jaw Fractures

22. Most common sites Fracture TypePrevalence Body30 - 40 % Angle25 - 31 % Condyle15 - 17 % Symphysis7 - 15 % Ramus3 - 9 % Alveolar2 - 4 % Coronoid process 1 - 2 %

23. Jaw Fractures 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 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

24. Lock & Key 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 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 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 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 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 Tooth can become necrotic, then get a non-union because infection is in the line of fracture Periodically watch the tooth for necrosis Periodically watch the tooth for necrosis

27. Reliable Patients On a reliable patient with a jaw fracture On a reliable patient with a jaw fracture 3rd molar is acting as a lock & key and keep the pieces from moving apart 3rd molar is acting as a lock & key and keep the pieces from moving apart Then can leave tooth in the line of fracture 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 Get the patient back in and xray every week or every other week, patient kept on antibiotics and watch for tooth necrosis

28. Non-reliable Patients 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 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 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 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 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