White Paper On Wisdom Teeth- Dr. Hamid Ryan Kazemi

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White Paper On Wisdom Teeth- Dr. Hamid Ryan Kazemi

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White paper on wisdom teeth published by AAOMS discussing current knowledge on wisdom teeth and treatment indications.

White paper on wisdom teeth published by AAOMS discussing current knowledge on wisdom teeth and treatment indications.

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  • 1. WHITE PAPER ON THIRD MOLAR DATA H. Ryan Kazemi, DMD Oral & Maxillofacial Surgery Bethesda, MD
  • 2. LOSE THE WISDOM
  • 3. LOSE THE WISDOM BUT STILL KEEP THE COMMON SENSE
  • 4. Can the course of an unerupted third molar be predicted? Hard tissue space: space/ crown width rations < 1 Radiographic monitoring Eruption does not imply health or adequate periodontal support Change in position even after age 25
  • 5. Periodontal Considerations Presence of Third molar Pan: 3-4% Bone loss and Root resorption PA: 24%-42% Probings Visible third molar >=5mm Disruption of of PDL, root resorption, pocket and LOA
  • 6. Periodontal Considerations Third molar Removal Loss of Attachment or Age <25 increase pocket depth Preoperative state Adversity predicted based on preop existence of intrabony defect, age, level off plaque control
  • 7. Periodontal Considerations Reduction in postop LOA Flap design, buccal window, GTR, approach....... No relationship between approach and minimizing LOA GTR helpful if there is pre-existing attachment loss Scaling / RP and plaque control help
  • 8. Periodontal Considerations Risk factors Visible third molars: Elevated levels of periodontitis and progressive Presence of pocket depths >=4-5 mm or bleeding on probing may be good predictors Third molars should be considered as a possible predictor of periodontitis due to direct association of periodontal disease, its progression, severity, and flora.
  • 9. Microflora Absence of symptoms does not indicated absence of disease or pathology Pathogenic bacteria exist around asymptomatic 3rds Periodontal disease as indicated by probings of >=4-5mm exists around asymptomatic 3rds Indicators of chronic inflammation exists in pockets Periodontal disease progresses in the absence of symptoms
  • 10. 3/2003 1/24/08
  • 11. Effect of age Symptomatology + Age pain (35.3%) swelling (21.7%) discomfort (3.6%) purulence (3%) ** increase with age
  • 12. Effect of age Periodontitis + Age >25 33% asympt perio defects <25 17% asympt perio defects 6793 patients, 52-74: 1.5 times the odds of having perio defect >5mm 5831 patients, 25-34 vs 18-24, 30% greater chance of periodontal defects
  • 13. Effect of age Caries + Age 342 subjects, mean age 73: increased caries 22-32 year-old: 3 years, increased caries 40% risk of caries in erupted thirds before end of third decade
  • 14. Effect of age Postoperative risks + Age Lower post op morbidity in younger patients All risks increased from <25 to 25-35, to >35 4004 patients: 1.5 times complications if >25, increasing through age 65 Perio defects twice as commonly (51%) in patients >26
  • 15. Effect of age Germectomy + Age (Roots one third or less developed) no nerve injuries no pocketing significantly lower morbidity
  • 16. Effect of age Presence of 3rds + Age increase in patients >40 needing 3rds ext eruption of 3rds in older patients is more frequent than may be thought 14-45 year olds found 51% of 312 late erupting thirds had perio disease in 2.2 year f/u
  • 17. Effect of age Presence of 3rds + Age Increase in presence of retained third molars: Periodontal defects Caries Post operative morbidity >25 Germectomy is recommended
  • 18. Orthodontics / Prosthodontics Crowding Asymptomatic impacted third molars under existing or planned removable prosthesis
  • 19. Imaging Techniques CT & IAN injury Sensitivity Specificity 93% 77% Panorex & IAN Sensitivity Specificity 70% 63% Sensitivity is the proportion of people that tested positive of all the positive people tested; that is (true positives) / (true positives + false negatives). It can be seen as the probability that the test is positive given that the patient is sick. The higher the sensitivity, the fewer real cases of diseases go undetected (or, in the case of the factory quality control, the fewer faulty products go to the market). Specificity is the proportion of people that tested negative of all the negative people tested; that is (true negatives) / (true negatives + false positives). As with sensitivity, it can be looked at as the probability that the test is negative given that the patient is not sick. The higher the specificity, the fewer healthy people are labeled as sick (or, in the factory case, the less money the factory loses by discarding good products instead of selling them). Role and indications of CT is unclear and evolving
  • 20. Coronectomy 5 papers in literature Partial root removal when intimate relationship between roots and IAN No standard of care with regard to this technique An alternative approach until more studies
  • 21. Socket protocol following extraction Age >26, perio defect, mesioangular impaction Predictable benefit to reconstruct defect at time of extraction
  • 22. Nerve damage IAN: 1-5% 1-7 days after surgery; 0.9%-low zero after 6 months Lingual Nerve: 0.4-1.5% 1-day after surgery; 0.5%-low zero after 6 months Long Buccal: No specific reports Mylohyoid nerve: 1.5% (lingual approaches) Spontaneous Recovery: 50-100%, IAN & Lingual
  • 23. Nerve damage Evaluation Mapping and photograph Light touch (von frey’s hairs)- A beta, pressure Two point discrimination- Larger myelinated Direction test: A alpha and A beta fibers Pinprick- A delta and C fibers
  • 24. Nerve damage Nerve repair 23 lingual nerves, earliest at 6 m: 50% with some recovery, Poor results with dysesthesia 63% good recovery in 19 with repair at 4.5 m 55 % recovery in 51 patients 92% in 32 nerves repaired at mean 4.5 m
  • 25. Nerve damage Nerve repair Timing: within 10 weeks of injury Lingual nerve: upto 47 months after injury with good results Repairs for dysesthesia carried a poorer prognosis whatever the timing of repair
  • 26. Nerve damage Rare incidences at least 50% recover spontaneously Nerve surgery between 4.5-7 months, over 50% show improvements Taste recovery can happen in case of lingual nerve repair
  • 27. Pearls Remove Third molars Do it early Conservative Surgery Risk assessment
  • 28. http://web.mac.com/hrkazemi/ToThePoint/Welcome.html
  • 29. www.facialart.com hkazemi@facialart.com