wisdom of wisdoms .pdf
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This document discusses impacted and unerupted teeth, with a focus on impacted wisdom teeth. It provides information on: - The frequency of tooth impactions, with wisdom teeth and maxillary third molars being most common. - Factors to consider when deciding whether to remove impacted wisdom teeth, including development stages, potential risks like infection, and possible benefits like occlusion. - Surgical principles for removing impacted teeth, including flap design, suturing techniques, and managing complications like nerve injury. - Alternatives to surgical removal like restoration and the optimal timing for prophylactic removal of wisdom teeth between ages 15-18.
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wisdom of wisdoms .pdf
- 1. Copy Right 2020 Wisdom of wisdoms
- 3. Impacted teeth is a tooth that fails to erupt into its normal functioning position in the dental arch within the expected time. The term Unerupted includes both impacted teeth and teeth that are in the process of erupting.
- 4. Evidence-Based Dentistry Clinician’s Clinical Expertise Patient’s Needs and Preferences Assessment of Scientific Literature 1. mandibular 3rd molar 2. maxillary 3rd molar 3. maxillary cuspid 4. mandibular cuspid 5. Mandibular premolar 6. maxillary premolars 7. maxillary central and lateral incisiorors frequency of impaction
- 5. To Remove or Not to Remove 1. Development 2. Wisdom teeth as an asset 3. Wisdom teeth as a liability 4. Alternatives to removal 5. Timing of removal
- 6. Development ikassem@dr.com Initial calcification ■ Occurs as early as 7yrs, more typically age 9.
- 7. ikassem@dr.com Crown Mineralization ■ Usually completed by age 12 to 14. ikassem@dr.com Root Formation ■ Usually half-formed by age 16.
- 8. ikassem@dr.com Root Completion ■ Fully formed roots with open apices are usually present by age 18. Eruption ■ Most teeth that will erupt are erupted by age 20. ■ 95% of all teeth that will erupt are erupted by age 24. ■ A limited number of third molars appear to erupt, at least to some degree, in young adults.
- 9. Predicting Eruption – Who Cares? ■ Does it matter if a wisdom tooth erupts? ■ Does it matter when a wisdom tooth erupts?
- 10. ikassem@dr.com The Key Issue Does it affect the Risk:Benefit Ratio? ikassem@dr.com Evaluating Risk:Benefit
- 11. Evaluating Risk:Benefit ■ Since “Risk of retention” and “Benefit of removal” are essentially the same concept, these terms may be combined. ■ Since “Benefit of retention” essentially = 0, the equation may be simplified: Magnitude ■ Is it major or minor? ■ Does it require hospitalization? ■ Is it permanent? ■ Does it affect your daily routine? If so, for how long?
- 12. How Sick Is Patient? ■ Airway most important ■ Mental status ■ Swallowing/ Secretions ■ Trismus ■ Vital Signs ■ Speed of onset Treat? ■ Your office ■ Oral surgeon’s office (document referral) ■ Hospital
- 13. Probability ■ The most overlooked aspect of most consultations. ■ Fortunately most real bad outcomes are real uncommon ■ What is the likelihood of certain problems? How much does treatment alter this likelihood? Risk:Benefit ■ Are erupted 3rds more or less subject to disease? ■ Are erupted 3rds more or less beneficial?
- 14. Wisdom Teeth as an Asset What Impacts Treatment? ■ Eruption into occlusion should not be the sole criterion of usefulness. ■ The issue is not “can you save it” but “should you save it.”
- 15. Benefits of 3rds ■ “Functional occlusion” – what is this? ■ Is it any different than just “occlusion”? ■ Is all occlusion functional? ■ Is all functional occlusion important? If so, is it all equally important? ■ Without evaluating questions such as these, how can you determine the true benefit of 3rds? Benefits of 3rds ■ Orthodontic repositioning to replace missing or grossly compromised 1st molars ■ Transplantation – poor long-term survival ■ With dental implants, these are rarely reasonable treatment alternatives.
- 16. Wisdom Teeth as a Liability What Impacts Treatment? ■ Failure of eruption should not be the sole criterion for removal. ■ Successful eruption should not be the sole criterion for retention. ■ Eruption is not always a “yes” or “no” proposition.
- 17. Problem #1 – Soft Tissue ■ Even with adequate arch length and full eruption, 3rd molars are often surrounded by thin, unkeratinized, highly distensible lining mucosa of the buccal vestibule. ■ Encourages pathogenic bacteria retention ■ Poorly withstands hygiene measures
- 18. Problem #2 – Periodontal Compromise ■ Bone loss distal to the 2rd molar after removal of the 3rd molar is controversial, at best. Even with some loss of bone, the result is stable and cleansable – the goal of periodontal therapy. ■ A reduction in pocket depth with no change in bone height on the distal of the 2nd molar. Szmyd and Hester Groves and Moore Grondahl and Lekholm ■ Alveolar bone crest healing distal to the 2nd molar is enhanced in younger patients with incompletely developed 3rd molar roots. Ash, Costich, and Hayward Ziegler
- 20. Problem #2 – Periodontal Compromise ■ The role of pathogenic bacteria retention in 3rd molar pockets is unknown. How does this affect the rest of the dentition? ■ Hygenic compromise of the 2nd molar can result in a difficult to restore situation if this tooth is lost.
- 21. How Do You Treat Missing 2nd Molars? ■ If the entire dentition is healthy and a mandibular 2nd molar needs extraction, what is the recommended treatment? ■ Cantilevered abutment? ■ Implant? ■ Partial denture? ■ Remove opposing tooth at same time? ■ Nothing. Allow opposing tooth to supererupt. The Missing 2nd Molar Dilemma ■ Your treatment plan for this scenario illustrates the value you place on 2nd molars. ■ Most people will subconsciously do a cost:benefit analysis and conclude that restoration is not necessary.
- 22. Problem #3 – 3rd Molar Caries
- 23. Problem #4 – 2nd Molar Caries Happy birthday
- 24. Problem #5 - Infection ■ Can turn an elective procedure into an urgent or emergent situation ■ Unscheduled loss of work ■ Increased pain and healing time ■ Compromise of adjacent teeth ■ Compromise of patient’s systemic health Happy birthday
- 25. Types of Infection 1. Simple dental caries and periodontal disease 2. Pericoronitis 3. Abscess 4. Cellulitis 5. Abscess extension into adjacent fascial spaces 5. Abscess spread to distant sites 6. Recurrent infections 7. Infections resistant to initial local and systemic treatment measures The most common cause of therapeutic 3rd molar removal. Pericoronitis Happy birthday
- 26. Problem #6 - Resorption
- 27. Problem #7 - Supereruption
- 28. ikassem@dr.com Problem #8 - Cysts Dentigerous Cyst Dentigerous Cyst
- 30. Types of Cysts ■ Follicular cyst (Dentigerous Cyst) ■ OKC (Odontogenic Keratocyst) ■ Ameloblastoma (several varieties) ■ Not all radiolucencies are cysts! - Lymphoma - Myeloma - Metastatic carcinoma Without the radiolucency, would you have recommended removal? Is the removal of this better or worse with the radiolucency?
- 31. When would you recommend removal of this 3rd molar?
- 32. Problem #9 - Tumors ■ Benign vs. malignant ■ Odontogenic vs. non-odontogenic ■ Primary vs. secondary ■ Each of these factors has important treatment implications.
- 34. Problem #10 – Risk of Fracture ikassem@dr.com Immediate Pre-extraction
- 35. ikassem@dr.com Immediate Post-extraction 3 Days Post-extraction 8 Days Post-extraction
- 36. Problem #11 - Fracture
- 37. ikassem@dr.com
- 38. Problem #12 - Orthodontics ■ Prevent loss of post- retention stability ■ Allow distalization of 2nd molars ■ These are controversial indications
- 39. Alternatives to Removal 1. Restoration 2. Periodontal therapy 3. Operculectomy 4. Removal of another tooth 5. No treatment
- 40. Timing Removal of 3rds When is the best time for prophylactic removal? Age 15-18
- 41. Advantages of Early Removal ■ Wide pericoronal space ■ Incomplete root development ■ Straight roots ■ Away from IAN ■ Away from sinus ■ Less risk of infection ■ Less risk of fracture ■ Patient more likely in good health ■ Better chance for primary closure ■ Smaller teeth require less bone removal
- 42. Evaluation Mesioangular Vertical Distoangular Horizontal Inverted Transverse
- 43. Whinters lines
- 48. BASIC NECESSITIES FOR SURGERY ■ Adequate visibility (1) adequate access (2) Adequate light, and (3) a surgical field free of excess blood and other fluids. ■ Assistance Never operate through a keyhole
- 50. Incisions sharp blade of the proper size firm, continuous stroke vital structures blade held perpendicular to the epithelial surface. should be properly placed (attached gingiva, healthy bone)
- 52. Flap design
- 53. ikassem@dr.com
- 56. Types of Sutures ■ Absorbable or non-absorbable (natural or synthetic) ■ Monofilament or multifilament (braided) ■ Dyed or undyed ■ Sizes 3 to 12-0 (numbers alone indicate progressively larger sutures, whereas numbers followed by 0 indicate progressively smaller) ■ New antibacterial sutures ■ Degraded via inflammatory response – Vicryl – Monocryl – PDS – Chromic – Cat gut (natural) Absorbable Non-absorbable ■ Not biodegradable and permanent – Nylon (Ethilon) – Prolene – Stainless steel – Silk (natural, can break down over years)
- 57. Natural Suture ■ Biological ■ Cause inflammatory reaction – Catgut (connective from cow or sheep) – Silk (from silkworm fibers) – Chromic catgut Synthetic ■ Synthetic polymers ■ Do not cause inflammatory response – Nylon – Vicryl – Monocryl – PDS – Prolene ■ Single strand of suture material ■ Minimal tissue trauma ■ Smooth tying but more knots needed ■ Harder to handle due to memory ■ Examples: nylon, monocryl, prolene, PDS Multifilament (braided) ■ Fibers are braided or twisted together ■ More tissue resistance ■ Easier to handle ■ Fewer knots needed ■ Examples: vicryl, silk, chromic Monofilament
- 58. Suture Selection ■ Do not use dyed sutures on the skin ■ Use monofilament on the skin as multifilament harbor BACTERIA ■ Non-absorbable cause less scarring but must be removed ■ Plus sutures (staph, monocryl for E. coli, Klebsiella) ■ Location and layer, patient factors, strength, healing, site and availability Surgical Needles ■ Wide variety with different company’s naming systems ■ 2 basic configurations for curved needles – Cutting: cutting edge can cut through tough tissue, such as skin – Tapered: no cutting edge. For softer tissue inside the body
- 61. Simple Interrupted Suturing Rule of halves 1 1 1 3 2 Simple Interrupted Suturing Rule of halves
- 62. Suturing ■ The needle enters the skin with a 1/4-inch bite from the wound edge at 90 degrees – Visualize Erlenmeyer flask – Evert wound edges ▪ Because scars contract over time
- 64. Continous suture
- 65. mattress suture
- 66. ikassem@dr.com Nerve injury (1) neurapraxia (2) axonotmesis (3) neurotmesis Types of injury
- 67. Happy birthday
- 81. ]
- 86. Impacted Canine
- 87. ikassem@dr.com Tube-Shift Localization (Clark) SLOB Rule Same Lingual Opposite Buccal
- 88. ikassem@dr.com
- 89. ikassem@dr.com
- 110. Thank you •Islam Kassem • ikassem@dr.com • 00201222209842 • 002034810481 • 00201091472244 • 0097455118606 www.kmaxfacs.com