Third molars 3-7-08. Maxillary Molars Sinus Proximity– Alternate Procedure Palatal root sitting close to the sinus Palatal root sitting close to the sinus.

Third molarsThird molars3-7-083-7-08

Maxillary Molars Sinus Maxillary Molars Sinus Proximity– Alternate ProcedureProximity– Alternate Procedure

Palatal root sitting close to the sinusPalatal root sitting close to the sinus Reflect a flapReflect a flap Stryker bone off the buccalStryker bone off the buccal Separate the buccal roots from the Separate the buccal roots from the

crowncrown Remove the palatal root with the Remove the palatal root with the

crowncrown Remove the buccal roots Remove the buccal roots

individuallyindividually

Review againReview again

Mandibular MolarsMandibular Molars

Divide the tooth buccolingually from the Divide the tooth buccolingually from the buccal furcation towards the lingual with buccal furcation towards the lingual with a Strykera Stryker

ONLY go 2/3 of the way to the lingual ONLY go 2/3 of the way to the lingual plateplate

Use elevator to split remaining tooth Use elevator to split remaining tooth structurestructure

WRITE IT DOWN in Post-op NotesWRITE IT DOWN in Post-op Notes Remove the root with less interferenceRemove the root with less interference Remove the mesial root if it has less Remove the mesial root if it has less

curvaturecurvature Remove the interseptal bone to free the Remove the interseptal bone to free the

distal rootdistal root

Geriatric PatientsGeriatric Patients

Bone characteristicsBone characteristics DenseDense InelasticInelastic Roots tend to break more easilyRoots tend to break more easily Prepare to surgically remove the Prepare to surgically remove the

toothtooth

Malposed teethMalposed teeth

Mandibular premolars-displaced to the Mandibular premolars-displaced to the lingual very difficultlingual very difficult

ProcedureProcedure Reflect a flapReflect a flap Make a window in the plateMake a window in the plate Tap the tooth to the lingualTap the tooth to the lingual

The lingual plate should breakThe lingual plate should break Remove toothRemove tooth

Should the buccal plate come Should the buccal plate come out, don’t put it backout, don’t put it back

Wisdom TeethWisdom Teeth

Reasons to keep the 3Reasons to keep the 3rdsrds The patient can maintain The patient can maintain

cleanlinesscleanliness It actually functions in occlusionIt actually functions in occlusion There is adequate attached gingivaThere is adequate attached gingiva

Wisdom TeethWisdom Teeth

Asymptomatic wisdom teeth Asymptomatic wisdom teeth become problematic in the futurebecome problematic in the future

Get them out when they are Get them out when they are youngeryounger Lesser complications-less recovery Lesser complications-less recovery

timetime Remove when 1/3 of the root is Remove when 1/3 of the root is

formedformed One anesthesia risk, one surgery, One anesthesia risk, one surgery,

one swelling, one painone swelling, one pain

Asymptomatic vs. Asymptomatic vs. SymptomaticSymptomatic

Symptomatic- no brainer, git ‘em Symptomatic- no brainer, git ‘em oudda deroudda der PericoronitisPericoronitis PeriodontitisPeriodontitis Pathologic ResorptionPathologic Resorption NeoplasmsNeoplasms Orthodontic TreatmentOrthodontic Treatment Pre-DenturesPre-Dentures PainPain CariesCaries

PericoronitisPericoronitis

You You mustmust have a portion of the have a portion of the crown in the oral cavity to actually crown in the oral cavity to actually call it pericoronitiscall it pericoronitis

Impacted teeth are “impacted,” Impacted teeth are “impacted,” duhduh

Patients with pericoronitis at time Patients with pericoronitis at time of extraction have higher potential of extraction have higher potential for dry socket (loss of blood clot, for dry socket (loss of blood clot, causing excruciating pain post-op)causing excruciating pain post-op)

PericoronitisPericoronitis

If you do an operculectomy and If you do an operculectomy and don’t remove the tooth, it will don’t remove the tooth, it will grow backgrow back

(not the tooth)(not the tooth) Just get the tooth outJust get the tooth out

PericoronitisPericoronitis

Best treatment for full infection Best treatment for full infection of 3rd molars-I&D tooth, place of 3rd molars-I&D tooth, place patient on antibiotics, let things patient on antibiotics, let things calm down and take all four 3rd calm down and take all four 3rd molars out at one timemolars out at one time

If try to extract 3rd molars will If try to extract 3rd molars will have anesthesia problems while have anesthesia problems while the patient is still infected in the the patient is still infected in the acidic environment acidic environment

PeriodontitisPeriodontitis

Potential periodontal problemPotential periodontal problem Left alone, the third molar becomes Left alone, the third molar becomes

decayeddecayed The decay undermines the second The decay undermines the second

molar creating a periodontal problemmolar creating a periodontal problem Decay may extend to the second Decay may extend to the second

molar, reaching the pulpmolar, reaching the pulp You lose both the third and the You lose both the third and the

second molar (It’s a lose, lose, lose second molar (It’s a lose, lose, lose situation)situation)

PeriodontitisPeriodontitis

Pathologic ResorptionPathologic Resorption

The erupting third molar may The erupting third molar may resorb the second molar roots resorb the second molar roots and surrounding boneand surrounding bone

NeoplasmsNeoplasms

Dentigerous cystDentigerous cyst KeratocystKeratocyst AmeloblastomaAmeloblastoma

The most common cyst is the The most common cyst is the dentigerous cystdentigerous cyst

Dentigerous CystsDentigerous Cysts

Dentigerous cyst-associated with the crown Dentigerous cyst-associated with the crown of an impacted 3rd molarof an impacted 3rd molar

3rd molars left in the mouth, epithelial lining 3rd molars left in the mouth, epithelial lining in cyst can transform with timein cyst can transform with time

The epithelium can turn into squamous cell The epithelium can turn into squamous cell carcinoma, mucoepidermoid carcinoma, carcinoma, mucoepidermoid carcinoma, cyst can also get larger and largercyst can also get larger and larger

Pathologic fracture because the whole Pathologic fracture because the whole ramus is full with dentigerous cyst that has ramus is full with dentigerous cyst that has grown over timegrown over time

Ameloblastoma, keratocysts-other Ameloblastoma, keratocysts-other neoplasms associated with the 3rd molar neoplasms associated with the 3rd molar area and associated with the cyst/sacarea and associated with the cyst/sac

Orthodontic TreatmentOrthodontic Treatment

Most of the time, the arch is not large Most of the time, the arch is not large enough to accommodate third molars enough to accommodate third molars (i.e. we who are born without thirds are (i.e. we who are born without thirds are more evolved than those with thirds.)more evolved than those with thirds.)

Orthodontic treatment-3rd molar Orthodontic treatment-3rd molar resorbs 2nd molarresorbs 2nd molar

Refer patients either before or after Refer patients either before or after orthodontic treatment because hard to orthodontic treatment because hard to make flap, preferably beforemake flap, preferably before

Do not refer orthodontic patients during Do not refer orthodontic patients during treatment because the wires and hooks treatment because the wires and hooks make it difficult to make a flapmake it difficult to make a flap

Pre-DenturePre-Denture

Edentulous ridge,-nothing more Edentulous ridge,-nothing more embarrassing then making a denture for a embarrassing then making a denture for a patient & 6 months later denture doesn’t fit patient & 6 months later denture doesn’t fit because patient is “growing new teeth” in because patient is “growing new teeth” in mouthmouth

Missed the impacted 3rd molars-all teeth Missed the impacted 3rd molars-all teeth removed in mouth, but pano wasn’t taken to removed in mouth, but pano wasn’t taken to determine if there were impacted 3rd determine if there were impacted 3rd molarsmolars

If impacted 3rd molars close to the surface, If impacted 3rd molars close to the surface, with pressure/rubbing of the denture, the with pressure/rubbing of the denture, the little bit of bone that was over tooth is gone little bit of bone that was over tooth is gone & impacted 3rd molar may erupt into mouth& impacted 3rd molar may erupt into mouth

Pain, CariesPain, Caries

Self-explanatorySelf-explanatory

Jaw FracturesJaw Fractures

Most common sitesMost common sites

Fracture Type Prevalence

Body 30 - 40 %

Angle 25 - 31 %

Condyle 15 - 17 %

Symphysis 7 - 15 %

Ramus 3 - 9 %

Alveolar 2 - 4 %

Coronoid process1 - 2 %

Jaw FracturesJaw Fractures

Fractured mandible-most Fractured mandible-most common places for 3rd molars to common places for 3rd molars to fracture, 3rd molar sitting in the fracture, 3rd molar sitting in the angle, acts as a weak link & angle, acts as a weak link & undermines angular amount of undermines angular amount of bonebone

Lock & KeyLock & Key

3rd molar can act as lock & key, may keep the 3rd molar can act as lock & key, may keep the two pieces of jaw fractures together if have two pieces of jaw fractures together if have fracture through the crypt of the 3rd molar fracture through the crypt of the 3rd molar

Because of the way the 3rd molar sits, it keeps Because of the way the 3rd molar sits, it keeps two pieces of jaw fractures from pulling apart two pieces of jaw fractures from pulling apart and separatingand separating

Leave 3rd molar in place as fracture healsLeave 3rd molar in place as fracture heals Problem with this type of fracture-bacteria can Problem with this type of fracture-bacteria can

get into the fracture and around the tooth itself get into the fracture and around the tooth itself Tooth can become necrotic, then get a non-Tooth can become necrotic, then get a non-

union because infection is in the line of fractureunion because infection is in the line of fracture Periodically watch the tooth for necrosisPeriodically watch the tooth for necrosis

Reliable PatientsReliable Patients

On a reliable patient with a jaw fracture On a reliable patient with a jaw fracture 3rd molar is acting as a lock & key and 3rd molar is acting as a lock & key and

keep the pieces from moving apartkeep the pieces from moving apart Then can leave tooth in the line of Then can leave tooth in the line of

fracturefracture Get the patient back in and xray every Get the patient back in and xray every

week or every other week, patient kept week or every other week, patient kept on antibiotics and watch for tooth on antibiotics and watch for tooth necrosis necrosis

Non-reliable PatientsNon-reliable Patients

Highland-patients not reliable and do not come Highland-patients not reliable and do not come back for post-op; do not leave any tooth in the back for post-op; do not leave any tooth in the line of fracture at highland because tooth can line of fracture at highland because tooth can become infected, then get a nonunion/malunion become infected, then get a nonunion/malunion which creates a big problemwhich creates a big problem

If extract that 3rd molar, then disrupt that lock & If extract that 3rd molar, then disrupt that lock & key; end up with two pieces in different areaskey; end up with two pieces in different areas

Need to take patient to the operating room, make Need to take patient to the operating room, make an incision an incision underneath the mandibleunderneath the mandible, bring pieces , bring pieces back and wire it together because lost the 3rd back and wire it together because lost the 3rd molar that was acting as the lock & keymolar that was acting as the lock & key

If jaw fracture is open to the oral environment, If jaw fracture is open to the oral environment, prescribe antibiotics, if mucosa is intact and not prescribe antibiotics, if mucosa is intact and not exposed to oral environment, no need to exposed to oral environment, no need to prescribe antibioticsprescribe antibiotics