Impaction of 3rd Molar Today we will start with impacted teeth management we talk last lecture about complicated

exodontia its different from the impacted teeth in general whats the difference between impacted teeth and unerupted teeth? ,,every impacted tooth is unerupted tooth but not every unerupted tooth is an impacted one pt 15 years old he has a missing canine we take RG and find the canine # its called here impacted of course but the same kid when he was 9 years old and he has no permanent canine its un erupted Indication of removal of the impacted teeth In the past American dentists used to take the wisdoms out whether the case indicates extraction or not, for personal gains to take money from their patients, on the other hand British were honest in dealing with their patients so they put specific guidelines (medical indications to take .)wisdoms out NICE Stands for National institute for clinical excellence they are Belonging to the Ministry of Health they are responsible for putting these guidelines . :The indications are Evidence of pathology include un restorable caries not treatable pulpal or periapical pathology abcess,osteomilitis internal and external resorption of the tooth or adjacent teeth fracture of the tooth diseases of follicle and tumor Wisdom tooth is one of normal dentition of normal human being if they have no problem or no future problem you will never touch them A tooth that is involved in osteomylitis (sclerosing osteomylitis Chronic focal sclerosing osteomyelitis is a periapical lesion that involves reactive osteogenesis evoked by chronic inflammation of the dental pulp. In most cases, this lesion develops in the mandibular molar region in response to a low-grade infection of the pulp that results from a deep carious lesion.

A case is presented in which incomplete tooth fracture was the apparent cause of this type of periapical pathosis Gum Infection (Pericoronitis) its an infection in the soft tissues that surround partially erupted wisdom tooth mainly in the mandibular 3rd molars When a wisdom tooth is partially erupted, food and bacteria collect under the gum causing a local infection. This may result in bad breath, pain, swelling and trismus (inability to open the mouth fully). The infection can spread to involve the cheek and neck. Once the initial episode occurs, each subsequent attack becomes more frequent and more severe. The patient come to you complaining from swelling in his mouth this is what we called MILD PERICORONITIS. After that the swelling gets bigger and a limitation in mouth opening starts to appear this is what we called MODERAT PERICORONITIS ,when there is severe trismus and signs and symptoms of infection redness ,malaise ,pain that gradually increase till it reaches to its severe stage This is called SEVERE PERICORONITIS ,now here the infection starts to convert itself to an abscess which is problem because this abscess can go through the spaces, like submassetric space because this space is closed by both massetric and buccinators muscles, it diffuse to the sulcus near 6or 7 which we called migratory abscess of pericoronitis .Now how do we manage this case ,if its mild we can just irrigate under the operculum its the soft tissue that covers partially erupted tooth by using( hydrogen peroxide(extra information)),and OHI, there is no need to give antibiotic because there is no signs of systemic involvement ,in moderate and sever we need to give antibiotic the eventual solution is extraction of the tooth but according to NICE guideline pericoronitis is considered as indication for extraction if it comes twice or more than twice a year, but after the episode of pericoronitis is resolved not immediately

Caries, here we dont treat wisdoms conservatively like other teeth , extraction takes the priority here wisdom has no rule in grinding 80% of grinding happened in second molars

As a cause of periodontal disease (prevention of perio disease) to the . adjacent tooth (7), when the tooth is Lying on the adjacent tooth it can cause pocketing . molar and eruption capacity when the root are still small . *This is colored photograph showing part of dentition, most probably in the mandible for posterior teeth, and there is partially impacted tooth, most probably its a wisdom. The 4th indication for taking wisdom out is "root resorption of 2
nd

molar"; when wisdom move it hits the 7 causing resorption, and this led
to restorable 7, so before damaging of 7 we should take that wisdom out. Cyst and tumor: Any pathology around any tooth in the dentition ,,its indication to take the tooth with the pathology out. -Prosthetic reasons: eg; edentulous patient have impacted wisdoms , if the patient construct a denture over those wisdoms,, later on due to resorption process of alveolar bone the wisdoms will exposed,, in order to do definitive management to such patient we should take those wisdoms out for prosthetic rehabilitation.

-Orthodontic reasons: In evidence base science it's never right to consider that the wisdom tooth always must extract in any ortho treatment ,,,,"wisdom has nothing to do with crowding". # some orthodontist claim that third molars can cause late lower anterior teeth crowding and that is never right.

-Socio economic reasons: Patient can afford taking wisdom out and just to avoid any expected complications that may impede their work or the patient social life and business.

Pic; Cropped OPG, showing the left part, showing a big sort of radiolucency extending from the upper ramus up from coronoid process down to the 7 area, and there is a wisdom which is dislodged inferiorly due to the pathology is this indication to take the wisdom out? Definitely,, with the pathology. - Unexplained facial pain(debatable): patient has emerged wisdoms absolutely fine, there is no any problem with them, we refer him to check his ear, TMJ, and all was fine,, so we refer him to extract the wisdoms. And there is a percentage found that they become better(12%). So when we have unexplained facial pain, be excluded any other possible causes of that pain, and still there is the wisdom, there is a weak indication to take that wisdom out.

-Prevention of fracture: -Also weak indication-, if the tooth was impacted and located at the angle of the mandible -occupying a very critical part of mandible- and the patient dont have strong mandible, so any minimal nocked it will lead to fracture. *So it might be indication in some cases like patient doing sports(kickboxing).

-Previously attending extraction: Patient is referral from other dentist to u as surgeon have to complete the extraction due to any problem with him( wisdom fracture).

Contraindications to take the wisdom out:

1-Extreme age: 16 yo or 90 yo(, he may have medical problems ,his mandible will be so thin so in those patient we have to weigh things carefully in our mind before taking wisdom out. 2-Compromised patient: like systemic diseases or bleeding problems ,local factor like radiotherapy or a patient who has a tumor, now if the operator is intending to take the tumor out we remove the tooth that is involved in that tumor, but in a case that the patient has a tumor in the Neck and the tumor is expanding to the mandible there is no definitive management to this patient we Shouldnt mess with them as we may cause transferring of the tumor from side to side, so if the patient was medically compromised we should think twicely. 3-Potential damage to adjacent vital structure: ID and lingual nerve.

Now moving to operative assessment related to patient itself

-First of all we need to do history and examination(general assessment) #According to examination we should consider: age, personality(in assessing wisdom surgery-how cooperative the patient is and if the patient from the beginning is frightened his pain threshold will be very low, so you as a surgeon has to decide whether to do it under sedation with local anesthesia or under GA).

Then,, local assessment(related to the tooth itself):

access; how to reach the tooth, U assess the position of the tooth, the accessibility and the depth of the wisdom. * make sure the width of mouth opening is appropriate for such a procedure (rima oris).

we have classifications(PELL and GREGORY): ****PELL and GREGORY put a classification for wisdom teeth it applies for upper and lower, they made 2 types of classes ,class1,2,3and class A,B,C, class A,B,C it applies for upper and lower, class 1,2,3 it applies only for lower wisdoms. Class I: the tooth is completely anterior to the anterior border of the ramus. Class II: the tooth not completely anterior not completely posterior to anterior border of the ramus. Class III: completely posterior to the anterior border of the ramus.

Soo; calss 1,2,3 is part of access assessment.

The other classification to PELL and GREGORY: class A, B, C. due to the depth. -In regarding to the 7,, how the wisdom is high; in the same level(A), between the level of 7 and the bone(B), below the level of crown of the 7(C).

Q: wisdom anterior of the remus and its impaction between the occlusal table of the 7 and the bone,, what is the classification according to PELL and GREGORY? -class I B.

Winters classification
#horizontal, mesioangular, vertical, distoangular *Obliquity; how the angulation of the tooth is, to the lingual or buccal side of the mandible( most of the wisdom is lingualy angulate). . -2 lines one on the long axis of the wisdom and one on the 7, and see the relation between each other: 1- right angel between line of the wisdom and the line of the7 ,,, horizontal.

2-The angel more obtuse,, mesioangular.

3-The lines just parallel,, vertical.

4-More to the other side,, distoangular.

Number and shape of the roots:

Why the numbers and shapes of the roots important for the assessment? Because its affect my expect, it will be easy or difficult. -If the roots of wisdom divergent,, it will not talking out easily. -Bone classification, for the elevator,, wisdom as other teeth, use coblant elevator, straight elevator, we must make sure that we apply the elevator to the mesiobuccal to tooth I want to extract(45 degree) except in distoangular we apply the elevator distobuccal. *Here we should think about need of suctioning. -Tooth impaction; in general horizontal or mesioangular need shedding, the tooth most affect 2nd molar. -If the tooth is impacted for any sort of impaction it might need surgical intervention depends on situation in site of separation, but generally when the tooth horizontally impacted definitely need surgery intervention to take it out,,, and in some situation we need to cut the tooth in separation-suctioning of the tooth-. -Crown size; if the impacted wisdom has big crown,, that make the operation more difficult. -Shape and the root of the 2nd molar; sometimes interceptivepatient with poor prognosis of the 7 in chronological age that guide me to extract the 7 to permit the 8 to take over the place of 7 ,, so we didn't need at that time to take the wisdom out because the 7 with poor prognosis. -Contexture; if the bone was osteoporotic,, so we should be very cautious to not fracture the bone upon surgery itself.

Relation to ID:
-TRAM LINES: 2 lines of ID canal on Xray. The tooth may be: 1- away from ID.

2-superimposed. 3-curving or connecting to the foramen. ----------------------------------

-Anesthesia: full loss of sensation, absence of all sensory modalities( ID

block). -Hypoesthesia: reduction in sensation, still feel sensation. -Paresthesia: is abnormal sensation, there is something going wrong in sensation. -Dysesthesia: unpleasant sensation they feel like electric shock after surgical procedure abnormal sense of touch. -Hyperalgesia: increase response to stimulus which Is normally painful but the patient has sensation of severe pain. -Allodynia: is suggested for pain after stimulation which is not normally painful(its very difficult patient to anastatis).

DONE by: asma'a almawas & Heba Radaideh