peri-operative management of impacted third molars [autosaved]
DESCRIPTION
PRESENTATION ON MANAGEMENT OF IMPACTED WISDOM TEETHTRANSCRIPT
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Peri-operative Management of Impacted Third Molars
Dr Chamara Atukorala MD Consultant Oral and Maxillofacial Surgeon
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Definition
Prevalence
Indications for Surgical removal, /Guidelines
Investigations and Diagnosis
Classification
Surgical management
Assessment
Planning
Execution
Post op Management
Complications and their Management
Medico-legal Background
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Definition
Prevalence
Indications for Surgical removal, /Guidelines
Investigations and Diagnosis
Classification
Surgical management
Assessment
Planning
Execution
Post op Management
Complications and their Management
Medico-legal Background
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Impacted tooth is a one that has not erupted to its functional position in the occlusion and does not show clinical or radiological features indicating
that it may erupt.
Causes
Angulation
Hard or soft tissue obstruction
Pathological lesions
Lack of space
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Definition
Prevalence
Indications for Surgical removal, /Guidelines
Investigations and Diagnosis
Classification
Surgical management
Assessment
Planning
Execution
Post op Management
Complications and their Management
Medico-legal Background
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The management of asymptomatic, disease-free ITM
is controversial, the best evidence currently available
neither supports nor refutes extraction .
(Symptomatic ITM?)
Available Guidelines
Local- None
Foreign NICE
AAOMS
What is a Guideline ?
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Guidance
1.1 The practice of prophylactic removal of pathology-free ITM should be discontinued .
1.2 The standard routine programme of dental need be no different.
1.3 Surgical removal of ITM should be limited to patients with evidence of pathology. Such pathology includes unrestorable caries, non-treatable pulpal and/or periapical pathology, cellulitis, abcess and osteomyelitis, internal/external resorption of the tooth or adjacent teeth, fracture of tooth, disease of follicle including cyst/tumour, tooth/teeth impeding surgery or reconstructive jaw surgery, and when a tooth is involved in or within the field of tumour resection.
1.4 The evidence suggests that a first episode of pericoronitis, unless particularly severe, should not be considered an indication for surgery.
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The Guidelines boil down to waiting for some pathology to develop, (such as decay in the wisdom tooth or the
adjacent tooth, gum disease around the wisdom tooth,infection around the tooth crown, cellulitis, abscess and including cyst / tumour,tooth / teeth
impeding surgery or reconstructive jaw surgery )
Why Do British Practice This ?
This is regarded by some as supervised neglect.
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The American Association of Oral & Maxillofacial Surgeons (AAOMS), the professional organization representing more than 8,500 OMF surgeons in the USA .
Asymptomatic does not mean Disease Free Pathology is always present before symptoms appear. Once damage has occurred, it is not always treatable
25% of wisdom teeth patients who perceive themselves as asymptomatic actually already have inflammatory periodontal disease. Blakey GH, Marciani RD, Haug RH, et.al: Periodontal pathology associated with asymptomatic third molars; Journal of Oral and Maxillofacial Surgery. 2001;60:1227-1233
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The risk of future disease requiring removal of retained wisdom teeth in
asymptomatic patients who retain their wisdom teeth, exceeds 70% after 18 years of follow-up. Venta I, Ylipaavalniemi P, Turtola L: Clinical outcome of third molars in adults followed during 18 years. J Oral Maxillofac Surg. 62:182, 2004
20 years after UK adopts the National Institute of Clinical Excellence
(NICE) guidelines, volume of third molar surgeries decrease, with a corresponding increase in mean age for surgical admissions and an increase in caries and pericoronitis as etiologic factors. Renton T, Al-Haboubi M, Pau A, Shepherd J, Gallagher JE: What has been the United Kingdoms experience with retention of third molars? J Oral Maxillofac Surg. 70:48-57, 2012, Suppl 1
Retention of third molars is associated with increased risk of second
molar pathology in middle-aged and older adult men. Nunn, ME, et al. Retained Asymptomatic Third Molars and Risk for Second Molar Pathology. Nunn et al. J DENT RES published online 16 October 2013.
AAOMS firmly supports the surgical management of erupted and impacted third molar teeth, even if the teeth are asymptomatic, if there is presence or reasonable potential that pathology may occur caused by
or related to the third molar teeth. November 10, 2011
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Indications for removal of ITM identified in the Parameters and Pathways published by the AAOMS include
1. Pain , 2. Carious tooth , 3. Pericoronitis
4. Facilitation of the management of progression of periodontal disease
5. Nontreatable pulpal or periapical lesion
6. Acute and/or chronic infection (e.g., cellulitis, abscess)
7. Ectopic position (malposition, supraeruption, traumatic occlusion)
8. Abnormalities of tooth size or shape precluding normal function
9. Facilitation of prosthetic rehabilitation
10. Facilitation of orthodontic tooth movement and promotion of stability of
the dental occlusion
11. Tooth in the line of fracture complicating fracture management
12. Tooth involved in surgical treatment of associated cysts and tumors
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13. Tooth interfering with orthognathic /or reconstructive surgery
14. Preventive or prophylactic removal, when indicated, for patients with medical
or surgical conditions or treatments (e.g., organ transplants, alloplastic implants,
bisphosphonate therapy, chemotherapy, radiation therapy)
15. Clinical findings of pulp exposure by dental caries
16. Clinical findings of fractured tooth or teeth Impacted tooth
18. Internal or external resorption of tooth or adjacent teeth
19. Patients informed refusal of nonsurgical treatment options
20. Anatomic position causing potential damage to adjacent teeth
21. Use of the third molar as a donor tooth for tooth transplant
22. Tooth impeding the normal eruption of an adjacent tooth
23. Resorption of an adjacent tooth
24. Pathology associated with the tooth follicle
25. Abnormality of size or shape precluding normal function
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When managing a patient with asymptomatic, disease-free ITM, one must carefully review the risks and benefits of extraction or retention, and
heavily weight the patients treatment preference.
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A strong indication for removal of impacted third molar should be complemented with a strong contraindication to its retention
Mercier P., Precious D., Risk and benefits of removal of impacted third molars, IJOMS 21:17, 1992.
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Definition
Prevalence
Indications for Surgical removal, /Guidelines
Investigations and Diagnosis
Classification
Surgical management
Assessment
Planning
Execution
Post op Management
Complications and their Management
Medico-legal Background
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Radiological Investigations
Radiographs Intra Oral
IOPA
Occlusal views
Extra Oral
DPT (OPG)
Lateral Oblique Views
CT Cone Beam CT
Conventional CT
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Radiological Assessment Helps In
Classification of the ITM
Localisation and orientation of the ITM
Assessment of the crown and root morphology of the ITM
Assessment of the ramal bone cover
Assessment of the second molar tooth and its root morphology
Relationship of the ID canal to the roots of ITM
Associated pathological lesions with the ITM
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Definition
Prevalence
Indications for Surgical removal, /Guidelines
Investigations and Diagnosis
Classification
Surgical management
Assessment
Planning
Execution
Post op Management
Complications and their Management
Medico-legal Background
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Systematic classification of the position of Impacted Third molar ( ITM) teeth helps in
Assessing the best possible path of removal of the
ITM
Managing difficulties encountered during removal
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Prediction of operative difficulty before the extraction of ITM allows a design of treatment that minimises the risk of complications.
Both radiological and clinical information must be taken into account.
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Classification of Impacted Mandibular 3rd Molars
1. ADA-AAOMS Classification
2. Nature of the overlying tissues
3. Winters Classification
4. Pell & Gregorys Classification
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ADA-AAOMS Classification
Impacted tooth-with overlying soft tissue.
Impacted tooth-Partial bony impaction.
Impacted tooth-complete bony impaction .
Impacted tooth-complete bony impaction with unusual
surgical complications.
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Nature of the overlying tissues
Soft Tissue Impaction. is usually the easiest of type of impacted tooth to remove.
Hard Tissue ('Bony') Impaction.
Partial Bony. The superficial portion of the tooth is
covered only by soft tissue but the height of the tooth's contour is below the level of the surrounding alveolar bone.
Complete Bony. The tooth is completely encased in bone so that when the gingiva is cut and reflected back, the tooth is not seen. These are often the most difficult tooth to remove
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Winter's Classification
Mesioangular - 45%
Vertical - 40%
Horizontal - 10%
Distoangular 5%
Inverted
Bucco-version
Linguo-version
Transverse
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Pell & Gregory's Classification
Based on the relationship between the ITM to the ramus of the mandible (lower jaw) and the 2nd molar (based on the space
available distal to the 2nd molar).
Class A. The highest portion of impacted 3rd molar is on a level with or above the occlusal plane.
Class B. The highest portion of impacted 3rd molar is below the
occlusal plane but above the cervical line of the of 2nd molar.
Class C. The highest portion of impacted 3rd molar is below the cervical line of the of 2nd molar.
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Definition
Prevalence
Indications for Surgical removal, /Guidelines
Investigations and Diagnosis
Classification
Surgical management
Assessment
Planning
Execution
Post op Management
Complications and their Management
Medico-legal Background
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Assessment
Case history General medical status of the patient ( Fitness to undergo ITM surgery)
Extra oral examination Mouth opening and TMJ Facial form, mental nerve functioning
Intra oral Surgical site ITM in question
Assessment of the degree of difficulty of the ITM surgery
Assess the radiological features
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Assessment of the degree of difficulty of the surgery
WAR (Winters) Lines
WHARFEs ASSESSMENT by McGregor (1985)
PEDERSONS DIFFICULTY INDEX
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Category
Score
1. Winters classification
Horizontal Distoangular Mesioangular
Vertical
2 2 1 0 2. Height of mandible
1-30mm 31-34mm 35-39mm
0 1 2 3. Angulation of 3
rd molar
1 - 50 60 - 69 70 -79 80 - 89
90+
0 1 2 3 4
4. Root shape
Complex Favourable curvature
Unfavourable curvature
1 2 3 5. Follicles
Normal
Possibly enlarged Enlarged
0 1 2 6. Exit (Path of exit)
Space available
Distal cusp covered Mesial cusp covered Both cusp covered
0 1 2 3
Total
33
WHARFEs ASSESSMENT by McGregor (1985)
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PEDERSONS DIFFICULTY INDEX
Very difficult : 7 to 10 Moderataly difficult: 5 to 7 Minimally difficult : 3 to 4
Scoring
Mesio angular 1
Horizontal 2
Vertical 3
Distoangular 4
Level A 1
Level B 2
Level C 3
Class I 1
Class II 2
Class III 3
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Radiological features indicating a close association between IAN and ITM
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If the ID nerve is closely associated indicating a high risk of injury ; best is to assess using advanced imaging methods
Cone Beam CT
Conventional CT
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Important Anatomical Structures
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Definition
Prevalence
Indications for Surgical removal, /Guidelines
Investigations and Diagnosis
Classification
Surgical management
Assessment
Planning
Execution
Post op Management
Complications and their Management
Medico-legal Background
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ITM Management options
*Observation and periodic review
*Surgery
**Conventional
***Intra Oral
****Buccal Approach
****Lingual Split Technique
****BSSO
***Extra Oral Approach
**Coronectomy
** Staged Removal
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Planning
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Observation and periodic review
For patients who elect retention, the frequency of follow ups should be designed to match the symptoms or
disease associated with ITM
( physical and radiographic examination every 12 to 24 months by a health care professional trained to evaluate
third molars.)
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Surgery
Set up of care
LA +/- sedation
GA
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Definition
Prevalence
Indications for Surgical removal, /Guidelines
Investigations and Diagnosis
Classification
Surgical management
Assessment
Planning
Execution
Post op Management
Complications and their Management
Medico-legal Background
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Steps In Surgical Removal (Buccal Access)
Anesthesia
Incision and mucoperiosteal flap design and flap
reflection
Removal of bone
Sectioning of tooth/roots
Elevation/Extraction
Wound debridement and smoothening of bone
Achieve Haemostasis
Wound closure, Analgesics
Postoperative follow-up
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Principles of flap design
Adaquate access
Viability of the flap ( Base> top)
Avoid vital structures
Plan ease of repositioning
Ability to extend if the need arises
Clean incisions
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Types of flap designs
Envelope flap L- shaped incision Bayonet shaped incision Triangular shaped incision Wards incision and Modified Wards incision. Comma shaped incision. S -shaped incision Szmyd and modified Szmyd incision
Berwicks tongue shape flap.
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Wards incision
Modified Wards
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Envelop flap Incision Not to be extended too distally- Bleeding from buccal vessels &
other arteries
Postoperative trismus temporalis muscle damage
Herniation of buccal fat pad Damage to lingual nerve (lingual
extention)
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Triangular shaped Incision
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Bone Removal
Bone belongs to the patient
and tooth belongs to the
dentist
Minimize the amount of bone removal as possible
Instead section the tooth and deliver in pieces
Excessive bone removal results in poor healing and bone defect.
High risk of alveolar osteitis, post op pain and trismus.
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Once the soft tissue is elevated and retracted, the surgeon must make a judgment concerning the amount of bone to be removed.
Bone must be removed in an atraumatic, aseptic, and nonheat-producing technique, with as little bone removed and damaged as possible.
The amount of bone that must be removed varies with the depth of impaction, the morphology of roots, and the angulation of tooth.
No bone should be removed from lingual aspect so as to protect the lingual nerve from injury.
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Bone removal - Moore & Gillbes Collar Technique
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Tooth Division
Rationale of tooth sectioning is to create
a space into which impacted tooth can be
displaced & thence removed.
Tooth is sectioned in various ways depending on the type &
degree of impaction.
Tooth is sectioned of the way
towards the lingual aspect. A straight elevator is inserted
into the slot made by the bur and rotated to split the tooth
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Extra Oral Approach
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SSO
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Coronectomy
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Coronectomy
What is it ?
Indications
Technique
Post op Mx
Follow up
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Staged Removal
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Debridement of Wound & Closure
Thorough debridement of the socket by Periapical curettage.
Remove the follicle of the ITM.
Smoothening of sharp bony margins by Bone file / burs.
Thorough irrigation of the socket Betadine solution + Saline .
Initial wound closure is achieved by placing 1stsuture just
distal to 2ndmolar, sufficient number of sutures to get a
proper closure.
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Definition
Prevalence
Indications for Surgical removal, /Guidelines
Investigations and Diagnosis
Classification
Surgical management
Assessment
Planning
Execution
Post op Management
Complications and their Management
Medico-legal Background
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Post Operative Instructions
Pressure pack , Ice application
Soft diet 1st two days
1st dose of analgesic should be taken before the
anesthetic effect of LA wears off.
Avoid strenuous exercises for 1st 24 hrs.
Avoid gargling / spitting / smoking / drinking
with straw.
Warm water saline gargling after 24 hrs + mouth
wash regularly thereafter.
Suture removal on 5th POD.
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Antibiotics ?
Steroids?
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Definition
Prevalence
Indications for Surgical removal, /Guidelines
Investigations and Diagnosis
Classification
Surgical management
Assessment
Planning
Execution
Post op Management
Complications and their Management
Medico-legal Background
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Complications and their Management
Intra Operative
1. During incision a. Injury to facial artery b. Injury to lingual nerve c. Hemorrhage careful history
2. During bone removal a. Damage to second molar b. Slipping of bur into soft tissue & causing injury c. Extra oral/ mucosal burns d. Fracture of the mandible when using chisel & mallet e. Subcutaneous emphysema
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3. During elevation or tooth removal
a. Luxation of neighbouring tooth/
fractured restoration
b. Soft tissue injury due to slipping of elevator
c. Injury to inferior alveolar neurovascular bundle
d. Fracture of mandible
e. Forcing tooth root into submandibular space or
inferior alveolar nerve canal
f. Breakage of instruments
g. TMJ Dislocation careful history
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Post-operative complications Immediate
- Hemorrhage
- Pain
- Edema
- Drug reaction
Delayed
- Alveolitis
- Infection
- Trismus
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From Medico-legal point of view to avoid getting in to problems.
Make correct decisions Get patient actively involved in decision making INFORMED CONSENT Proper investigations Correct treatment. Manage complications Communicate with the patient Be nice to your patient