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Third molars

Third molars. 3-7-08. Maxillary Molars Sinus Proximity– Alternate Procedure. Palatal root sitting close to the sinus Reflect a flap Stryker bone off the buccal Separate the buccal roots from the crown Remove the palatal root with the crown Remove the buccal roots individually.

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Third molars

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  1. Third molars 3-7-08

  2. Maxillary Molars Sinus Proximity– Alternate Procedure • Palatal root sitting close to the sinus • Reflect a flap • Stryker bone off the buccal • Separate the buccal roots from the crown • Remove the palatal root with the crown • 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 • ONLY go 2/3 of the way to the lingual plate • Use elevator to split remaining tooth structure • WRITE IT DOWN in Post-op Notes • Remove the root with less interference • Remove the mesial root if it has less curvature • Remove the interseptal bone to free the distal root

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

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

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

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

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

  10. Pericoronitis • You must have a portion of the crown in the oral cavity to actually call it pericoronitis • 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)

  11. Pericoronitis • If you do an operculectomy and don’t remove the tooth, it will grow back • (not the tooth) • 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 • 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 • Left alone, the third molar becomes decayed • The decay undermines the second molar creating a periodontal problem • 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)

  14. Periodontitis

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

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

  17. Dentigerous Cysts • 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 • 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 • 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.) • Orthodontic treatment-3rd molar resorbs 2nd molar • 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

  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 • 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

  20. Pain, Caries • Self-explanatory

  21. Jaw Fractures

  22. Most common sites

  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

  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 • 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 • 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 • Periodically watch the tooth for necrosis

  25. Reliable Patients • On a reliable patient with a jaw fracture • 3rd molar is acting as a lock & key and keep the pieces from moving apart • 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

  26. 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 • 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 • 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

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