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ARTICLE FOR CPD POINTS                                                          Clinical1. ODONTOGENIC TUMOURS &          ...
Clinical                                     ARTICLE FOR CPD POINTS4. JAW & FACIAL INFECTIONS                             ...
Clinical                                     ARTICLE FOR CPD POINTSthis 31 year old female had her wis-               this...
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The benefits of specialist prophylactic wisdom tooth removal


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The benefits of specialist prophylactic wisdom tooth removal

  1. 1. ARTICLE FOR CPD POINTS Visit our website: for updated information on CPD Points on this article. Click on “articles”. ClinicalThe benefits ofspecialist prophylacticwisdom tooth removal ARTICLE FOR CPD POINTS By Dr Paul Lloyd G. Coceancig, Specialist oral & maxillofacial surgeon MB ChB (Otago) BDS Hons. (Sydney) MDS OMS (Otago) FRACDS Div.OMS Clinical W isdom teeth are a major cause of human morbidity and dental disease. Because of the multitude of problems that For the diseases they cause, medicine & dentistry has created their own specialty, oral & maxillofa- cial surgery, to deal with them in a way that mini- they cause, & also due to the high rates of surgi- mises risk & surgical complications. cal complications from their removal, most people Wisdom teeth are a major source of develop- will be referred to specialist oral & maxillofacial mental lesions of the jaws, particularly if they surgeons for the specific management of their wis- become impacted. infections are common, & den- dom teeth. tal disease such as caries or periodontal disease may affect the health & longevity of the forwardDr Paul Lloyd G. Prophylactic wisdom tooth removal second molars.Coceancig the human species has a complex evolutionary & Jaw-angle fractures following minor knocks social phylogeny. With increasing life span, & the during contact sports commonly involve impacted evolution of surgical science, disease prevention wisdom teeth. Jaw joint disease can develop, & & prophylactic surgical care for developmental or front teeth may become crowded as wisdom teeth vestigial organ disease in the young, & for occult attempt to erupt into a restricted arch; an expen- metabolic or tumour disease in the middle-aged, is sive situation especially if orthodontics needs to be increasing. repeated to realign the teeth. medicine is replete with examples of prophy- of the entire population, ~1% of people will lactic screening. Routine bowel colonoscopy, pap retain all their wisdom teeth over their lifetime. smears, breast screening, chest x-rays, eCG screen- Wisdom teeth are a major source of morbidity & ing, PsA assays & general blood tests are a part of jaw disease; dentists, specialist surgeons & ortho- every-day medical practice. Preventative medicine dontists will usually recommend their prophylac- extends life, & reduces the chance for debilitat- tic removal before they become a problem. ing & life threatening disease developing before it it is not logical preventative practice to clini- starts. cally advise for removal of impacted wisdom teeth dentistry is all about prevention as well. in only after they have caused problems. “Problems” childhood, 6 monthly checks with the dentist usually represents serious or co-morbid dental dis- for detection of early decay or gum disease is as ease for which treatment is usually complex, pro- important as adolescent orthodontics to establish longed and destructive. healthy & straight teeth for a life time of perfect Contrary to popular belief, wisdom teeth dental health. removal (only when performed by specialist oral & Wisdom teeth are a major cause of acute dental maxillofacial surgeons) can be comfortable & quick disease. the last teeth to develop, they often try to operations, with few if any side effects. Complica- erupt into an arch which has long since stopped tions of wisdom tooth removal does occur however growing. & you should carefully question your surgeon as to 3rd molars may have been useful for the short- their specialist oral surgical credentials. lived Homo erectus, or Australopithecus species. For You are assured that all specialist accredited the much longer lived Homo sapiens, wisdom teeth surgeons who belong to the Australian & New are vestigial; meaning for most people, they have Zealand Association of oral & maxillofacial sur- no function; however they can still cause trouble. geons (ANZAoms) actively maintain competency modern dentistry enables routine checks to make & learning in all facets of oral & maxillofacial sur- sure wisdom teeth are not developing problems. gery.44 Australasian Dentist
  2. 2. ARTICLE FOR CPD POINTS Clinical1. ODONTOGENIC TUMOURS & this 40 year old female presents withCYSTS intractable right sided jaw pain whilstthis patient was originally referred overseas. early return from her holidayby her orthodontist for a routine oPG leads to emergency dental review & diag-screening film at 18 years. A previous nosis of a deeply decayed second molarscreening film at 14 years showed early caused by the impacted wisdom tooth.developing wisdom teeth, without sign her dentist had never suggested removalof developing tumour. of the wisdom tooth, & instead has removed the 1st molar, where root tips are seen to remain. X-ray shows extent of decay into the backside surface of the second molar. The combination of decay & gross loss of distal alveolar bone necessitate removal of both teeth & replacement of both the 1st & 2nd molars with dental implants (after removal of retained roots & abscess tissue). Both of her 2nd molar problems would have been circumvented with early removal of the wisdom tooth. A 32 year old male presenting with local pain & deeply impacted lower right wis- dom tooth. his dentist had previously advised at 18 years of age to “remove it when you get problems.” Removal at 32 years will leave a significantImpacted wisdom tooth seen at base of jaw, gum & bonewith large odontogenic keratocyst occupying defect thatalmost entirety of right side of mandible. incompletelyComparison is made to normal left side; with heals, & whichpresence of a ‘normal’ impacted wisdom grossly affectstooth. the periodontal health & longevity of the forward 2nd molar. Current techniques of co-bone grafting (with wisdom tooth removal) can significantly2. DENTAL DISEASE improve the periodontal prognosis for theAFFECTING THE FORWARD 2nd molar.2nd MOLARthis 18 year old male presents for normalwisdom tooth assessment following com- 3. JAW FRACTURES CAUSED BYpletion of orthodontic treatment. Par- IMPACTED WISDOM TEETHtially erupted & horizontally impacted A 33 year old first grade Newcastlewisdom tooth (third molar) has caused Knights rugby league player fracturesdeep decay on distal (backside) surface of mandible five weeks before career end.forward second molar tooth. X-ray shows non-displaced fractured X-ray shows mandible, with crack propagation occurring impacted through deeply impacted left lower wisdom tooth wisdom tooth. Wisdom teeth cause notch causing plaque deformities at the angle of the jaw, making trap & deep the area decay on distal potentially (backside) vulnerable of forward to fracturesecond molar. After wisdom tooth removal, following smallsecond molar tooth is treated with a large knocks duringrestoration & root canal filling, reducing the contact of the tooth in an otherwise perfectspan of teeth. Australasian Dentist 45
  3. 3. Clinical ARTICLE FOR CPD POINTS4. JAW & FACIAL INFECTIONS quickly extend to involve the airway, whole 6. PROXIMAL STRUCTURESCAUSED BY IMPACTED neck & upper chest. SUCH AS THE INFERIORWISDOM TEETH DENTAL NERVE 5. ORTHODONTIC CROWDINGthis 55 year old male presents with CAUSED BY IMPACTED Normally the assessment of the relation-extensive swelling involving the right WISDOM TEETH ship of the inferior dental nerve (idN) islower jaw, & extending into the neck first made on oPG, & then where over-affecting swallowing & breathing. 1 lap is seen, by formal Ct scan. if oPGweek of intravenous antibiotics followed determines a surgical risk to the idN,before his wisdom teeth were removed Ct allows for a more precise determina-under general anaesthesia. tion of nerve relationships & proximity occasionally lower incisor teeth may Photo shows to tooth structures; from there a surgical imbricate (overlap), requiring repeat extent of swelling treatment plan can be safely formulated. on patient’s right orthodontics. imbrication often devel- occasionally the roots may curve under a side of neck & ops as impacted wisdom teeth attempt nerve trunk, or the nerve trunk can pass jaw; sometimes to erupt into the early adult dental arch. called ‘Ludwig’s between roots or within the tooth struc- Whilst wisdom tooth removal may pre- Angina’. Swelling ture itself; necessitating careful dissec- developed quickly vent development of imbrication, it does tion under direct visual magnification.over 24 hours; but left to develop, it can not reverse imbrication already caused. tooth removal before root development in ages 13-17 years minimises risks ofADVICE FOR PATIENTS SEEKING WISDOM TEETH REMOVAL dental roots invaginating or compromis- ing the main nerve trunk.Patients who seek wisdom teeth removal should know...1. They should accept specialist treatment only by specialists who are full members of the Aus- tralian & New Zealand Association of Oral & Maxillofacial Surgeons (ANZAOMS),2. Normally Oral & Maxillofacial Surgeons are both medical & dental specialists. Patients should ask for formal surgical credentials or proof that they are registered with both the NSW Dental & NSW Medical Boards as specialist oral & maxillofacial surgeons,3. They should consider that general dentists or dental surgeons who maintain hospital dental GA lists may only have indemnity insurance to provide general dentistry (e.g. fillings & simple X-rays of 16 year old extractions), & may not have professional indemnity coverage to provide routine oral surgical male compared to 25 services. year old male, showing relationship of root4. Only specialist Oral & Maxillofacial Surgeons offer the full range of coverage for specialist development to inferior Medicare & insurance rebates for treatment of a range of conditions that may co-exist with dental nerve (IDN). X-ray impacted wisdom teeth. of full developed tooth is further compared to extracted wisdom tooth showing5. Wisdom teeth either cause problems due to their impactions, or because of their partial erup- grooving of inferior alveolar nerve (IDN) tions through early to late adulthood. against the impacted wisdom tooth’s roots.6. Normally all developing or developed wisdom teeth will be advised for removal before they become a problem. 7. COMPLICATIONS OF WISDOM TOOTH REMOVAL BY7. In young people, a tooth’s roots have not totally formed, & bone surrounding the teeth is NON-SURGICAL SPECIALISTS softer. Early removal means there is less risk of damage to nerves, bone or other teeth, & full this 38 year old female had her lower left bone regeneration is possible. Bone regeneration potential lessens after ~25 years of age. wisdom tooth (presumably) removed 68. Impacted wisdom teeth can lead to jaw fractures, tumour or cyst development, orthodontic years previously during a three hour oper- crowding, local & regional swelling, neck infections, & destruction of the backside surface of ation with her general dentist/dental sur- the forward second molar tooth. geon. on-off left lower facial numbness9. Normally wisdom teeth are removed by specialist surgeons in order to guard against surgical has persisted over the years, & now her complications that commonly arise from untrained wisdom teeth removal. Only trained & left face is grossly swollen from infection registered surgical specialists are competent in the management of all possible surgical com- related to the retained wisdom tooth. plications arising from wisdom tooth surgery. X-ray shows10. Rates of surgical complications from specialist surgical practices are much lower when com- the presence of pared to general dental surgery practices that provide oral surgery; but complication rates are a decoronated never zero. You should carefully consider the advice of your surgeon before embarking on any wisdom tooth, surgical treatment plan recommended to you. with all the root structures11. Occasionally CT scans may be requested to formally identify local vital structures such as the remaining. The Inferior Dental Nerve (IDN), prior to removing your lower wisdom tooth. Only CTs requested by wisdom tooth a specialist dentists/surgeons attract Medicare rebates. is abscessed & now involves the inferior dental nerve. The retention of the wisdom12. Not all wisdom teeth should be removed by oral & maxillofacial surgeons. Simple wisdom tooth roots has also lead to local infection in teeth may be competently & safely removed by experienced dentists or dental surgeons the cheek and face, as well as caries distal to where only extraction forceps are required. Bone cutting & surgical tooth division implies a the lower second molar, & local periodontal complexity of care that should only be performed by surgical specialists. disease with bone loss.46 Australasian Dentist
  4. 4. Clinical ARTICLE FOR CPD POINTSthis 31 year old female had her wis- this 45 year old female had her impacted ing swallowing & general health. swell-dom tooth removed by a general dental lower right wisdom tooth removed by ing developed ~2 days following wisdomsurgeon who claimed to be a “specialist a dentist, with subsequent jaw fracture. tooth surgery (performed in a privateoral surgeon”. 3 hours after commenc- three operations later, multiple teeth hospital) by a general dentist/dental sur-ing removal, he gave up, sewed the have been removed, her jaw has had mul- geon providing “minor oral surgery”.surgical defect over & repaired the sur- tiple plating & bone graft procedures, & Photo showsgically-damaged forward 2nd molar. 4 her right lower face is completely numb. extensive leftweeks later, & in intractable pain she 15 years later the jaw is severely resorbed cheek swelling representingself presents to an oral & maxillofacial & weakened, & the patient has persisting focal infection,surgeon. Under GA, the remaining frag- complaint of chronic severe neuralgic type extendingment was safely removed away from the pain to her right chin & lower right lip. under eye &embedded inferior dental nerve. under left Right lower jaw jaw. 2 weeks Presenting x-ray shows of in-hospital IV antibiotics followed with specialist’s the presence successful resolution of all disease. u x-ray shows of 3 titanium terminal 3rd of plates, 14 screws, & Dr Paul Lloyd Getty COCEANCIG wisdom tooth MB ChB (Otago) BDS Hons. (Sydney) MDS OMS remaining a retention (Otago) FRACDS Div.OMS in intimate wire. There Following brief periods in emergency medicine contact with is complete and psychiatry, and after completing his full the inferior severance of the inferior dental nerve, surgical fellowship in the specialty (FRACDSdental nerve (which supplies lower lip & with local bone wasting & osteoporosis. OMS), Paul settled into private full time OMSchin sensation). Gross surgical bone loss is Reconstruction followed a jaw fracture practice in Newcastle. Paul has current visitingdemonstrated from a prolonged & abnormal secondary to wisdom tooth removal by a consultant appointments to Warners Bay,surgical event, as well as a poorly contoured general dentist. Toronto, and Newcastle Private Hospitals, andrestoration of the backside surface of the works with specific interest in reconstructive2nd molar. The 2nd molar now requires this 22 year old female presented with as well as orthognathic and corrective facialfurther root canal therapy. considerable left facial infection affect- surgery.Questions for CPD points1. At what ages are screening OPGs b. Reduction of surgical risk to inferior dental specialist prophylactic wisdom tooth recommended? nerve, by taking wisdom tooth before root removal?a. 3, 10, 17, 24, 34 years development allows for later (adult) surgi- a. Odontogenic lesionsb. 18mths, 6 years, 12, 18, 24 years cal compromise of this structure (the IDN) b. Jaw fracturesc. 7, 14, 21, 28 and every decade thereafter c. Quicker operation, fewer side effects, c. Tooth decay and periodontal diseased. Every decade of life beginning at 1 year of and faster recovery when performed by a affecting the forward 2nd molar age surgical specialist d. None of the above d. All of the above.2. At approximately what age would you 8. What techniques or situations are expect bone regeneration to not occur 5. What techniques are available for bone available to minimise nerve damage after wisdom tooth removal where loss regeneration after wisdom tooth when removing wisdom teeth? demonstrable pre-operative bone loss removal? a. Micro-surgical techniques is seen on OPG? a. None b. Pre-operative CT scanninga. 35 years b. Gortex membrane, and guided tissue c. Specialist surgical managementb. 25 years regeneration after the development of d. All of the abovec. 20 years a distal periodontal pocket followingd. 15 years wisdom tooth removal 9. What of the following lesions arise c. Hip graft to region secured with pin fixa- from wisdom teeth when left to treat-3. What investigation would you perform tion ment based on “you should only get if you were to see >50% overlap of the d. Mineral bone particulate with collagen them removed after you get a prob- inferior dental nerve to the roots of a membrane overlay lem.”? wisdom tooth on an OPG?a. A postero-anterior mandibular plain film 6. What is the most common complica- a. Caries or periodontal disease affecting theb. PA of the wisdom tooth region, with slight tion of wisdom tooth removal? distal surface of the forward second molar obliquity upwards a. swelling and post operative pain b. Large cystic or neoplastic lesions thatc. A rotational tomogram with cross-sec- b. fractured jaw affect the forward second molar, and tional capacity c. infection regional anatomy, including sinus, nerved. A CT scan d. inferior alveolar nerve or lingual nerve tissue, or osseous anatomy damage resulting in lip, chin or tongue c. Infections involving the buccal space,4. What advantages are there to early anaesthesia infra-temporal region, infra-orbital region, removal of wisdom teeth? sub mandibular region, and tissue planesa. Full bone regeneration of surgical defect 7. What of the following are compli- of the neck and mediastinum distal to forward second molar most likely cations that can be prevented by d. All of the above48 Australasian Dentist