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Why might wisdom teeth become impacted ?
Last teeth to develop ^UBAbVvzk
Lack of space
Irregularity in position - most likely to become ectopic
Density of overlying and surrounding bone
What symptoms might a patient complain about?
Pain
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Impaction types
Soft tissue impaction
Bony impaction - Partial
Bony Impaction Complete
Winters Classification
Third molars classiified based on their inclination compared to the long axis of the 2nd molar
Vertical
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Pell and Gregory Classificatoin
Archers Classification of upper 3s
Complications with lower 3s
displacement of the root or tooth
You have to section the tooth, meaning parts of the root can dissapear in the submandibular area!
There have been cases were roots or teeths are displaced and may need to be accessed extra-orally, p/ts can even lose salivary glands
Dry socket/ Alveolar Ostitis
Bony defects distal to the 2nd molar
Periodontal defect distal to the 2nd molar
IAN/ Lingual damage
Sometimes instruments are put down into the lingual suclus to push soft tissues away, but the process of retracting can stretch the lingual nerve and cause paresthesia
This is still a big debate in oral surgery!!
Tips to look out for
Darkening of the roots
Interruption of radiopaque line (loss of corticated border)
Diversion of the ID canal/ Narrowing of ID canal
Dark and bifid apex
Complications of upper 3’s
Oroantral communication
Displacement into adjacent anatomical spaces
Fracture of the maxillary tuberosity
Root Fracture
Assessment of OA communication is difficult from PA/s OPGs due to projection
CBCT is the best
For example: Sinus can invaginate between the root, or sit palatal to everything and it will show an overlap
Darkening of the root is a big hint that there is a change in radiodensity/smt happening here
Breaking of the cortical border is also a good indicator
Pathology associated with 3rd molars
Pericoronitis
Symptoms include:
- Erythema -Swelling -Suppuration -Radiating pain to FOM, ear or throat
If you see pericoronitis, rub it down the sulucs and try to get discharge out: this tells you that its chronic
Management
Flushing around the tooth/flap with saline
Antibiotics (if we are thinking of a spreading infection)
remove opposing tooth as trauma from the upper exacerbates
Remove the impacted tooth
Operculectomy (not really advised unless for very short term relief)
Peridontitis
Caries
Tumours
ameloblastoma, okc, odontogenic fibroma, squamous cell carincoma
Cysts
Dentigerous cysts are the most common
Local and deep space infection
Root Resorption
Indications for removal
Ongoing pain
Infection : either single severe or repeat mild
Caries
cysts/tumours
resoprtion of the roots of the 2nd molars
If it is going to be in a surgical field
orthognathic surgery
ORIF
As part of an orthodontic treatment plan
Management of 3rd molars
Removal
General Principles :
- Flap
- Troguh
- Section -Elevate -irrigate -close (generally takes between 5-20 minutes)
Coronectomy
Procedure involves:
- Flap
- Section off the crown , 2-4 mm below the cej
- Removal of all residual enamel
- MUST NOT mobilise roots
Works well for people at high risk of nerve injury/ social factors like singers and instrument players
Risk of failure and root migration
Active surviellance
- Monitor Perio pocketing
- Surveillance of OPG periodically