Surgical Removal of Wisdom Teeth: Techniqueclinicaljude.yolasite.com/resources/wisdom teeth...
Transcript of Surgical Removal of Wisdom Teeth: Techniqueclinicaljude.yolasite.com/resources/wisdom teeth...
Surgical Removal ofSurgical Removal ofWisdom TeethWisdom Teeth
Dr Hazem AlDr Hazem Al--AhmadAhmadBDS, MSc (Lon), F.D.S. R.C.S.(Eng)BDS, MSc (Lon), F.D.S. R.C.S.(Eng)
Associate Professor, Dental SchoolAssociate Professor, Dental SchoolUniversity Of JordanUniversity Of Jordan
PREVALENCEPREVALENCEOne studyOne study –– 1717% of patients over% of patients over 2020 year oldyear old2222% maxillary third molars% maxillary third molars1818% mandibular third molars% mandibular third molars00..99% maxillary canines% maxillary caninesmandibular premolarsmandibular premolarsmandibular caninesmandibular caninesmaxillary premolarsmaxillary premolarsmaxillary central incisorsmaxillary central incisorsmaxillary lateral incisorsmaxillary lateral incisors
PREVALENCEPREVALENCEOne studyOne study –– 1717% of patients over% of patients over 2020 year oldyear old2222% maxillary third molars% maxillary third molars1818% mandibular third molars% mandibular third molars00..99% maxillary canines% maxillary caninesmandibular premolarsmandibular premolarsmandibular caninesmandibular caninesmaxillary premolarsmaxillary premolarsmaxillary central incisorsmaxillary central incisorsmaxillary lateral incisorsmaxillary lateral incisors
ETIOLOGYETIOLOGY Differential root growth between theDifferential root growth between the
mesial and the distal roots.mesial and the distal roots. The relation of the bony arch lengthThe relation of the bony arch length
to the sum of the mesiodistal widthsto the sum of the mesiodistal widthsof the teeth in the archof the teeth in the arch
Retarded maturation of the thirdRetarded maturation of the thirdmolarmolar
ETIOLOGYETIOLOGY Differential root growth between theDifferential root growth between the
mesial and the distal roots.mesial and the distal roots. The relation of the bony arch lengthThe relation of the bony arch length
to the sum of the mesiodistal widthsto the sum of the mesiodistal widthsof the teeth in the archof the teeth in the arch
Retarded maturation of the thirdRetarded maturation of the thirdmolarmolar
Clinical ExaminationClinical Examination
The patient attitudeThe patient attitude -- Type ofType ofanaesthesia and/or sedationanaesthesia and/or sedation
Age and general fitnessAge and general fitness The presence of facial swelling andThe presence of facial swelling and
enlarged, tender, lymph nodes.enlarged, tender, lymph nodes. Surgical accessSurgical access -- inspection of theinspection of the
mouth.mouth. The health of theThe health of the 11st andst and 22nd molarsnd molars
The patient attitudeThe patient attitude -- Type ofType ofanaesthesia and/or sedationanaesthesia and/or sedation
Age and general fitnessAge and general fitness The presence of facial swelling andThe presence of facial swelling and
enlarged, tender, lymph nodes.enlarged, tender, lymph nodes. Surgical accessSurgical access -- inspection of theinspection of the
mouth.mouth. The health of theThe health of the 11st andst and 22nd molarsnd molars
Clinical ExaminationClinical Examination
Soft tissues over the wisdomSoft tissues over the wisdom --activeactivepericoronitis, pus beneath the gumpericoronitis, pus beneath the gumflap.flap.
The position and condition of theThe position and condition of theupperupper 33rd molar.rd molar.
Possible future use as a denture orPossible future use as a denture orbridge abutment.bridge abutment.
Soft tissues over the wisdomSoft tissues over the wisdom --activeactivepericoronitis, pus beneath the gumpericoronitis, pus beneath the gumflap.flap.
The position and condition of theThe position and condition of theupperupper 33rd molar.rd molar.
Possible future use as a denture orPossible future use as a denture orbridge abutment.bridge abutment.
Classification systems forClassification systems forimpacted teeth:impacted teeth:Angulation:Angulation: mesiomesio--angularangular verticalvertical distodisto--angularangular horizontalhorizontal
Angulation:Angulation: mesiomesio--angularangular verticalvertical distodisto--angularangular horizontalhorizontal
Classification systems forClassification systems forimpacted teeth:impacted teeth: Relationship to anterior border ofRelationship to anterior border of
ramus: Pell and Gregory classesramus: Pell and Gregory classes 11,,22andand 33::
Class I: MClass I: M--D diameter of crown isD diameter of crown istotally anterior to ant border of ramustotally anterior to ant border of ramus
Class II: one half of crown is coveredClass II: one half of crown is coveredby ramusby ramus
Class III: tooth completely within theClass III: tooth completely within theramusramus
Relationship to anterior border ofRelationship to anterior border oframus: Pell and Gregory classesramus: Pell and Gregory classes 11,,22andand 33::
Class I: MClass I: M--D diameter of crown isD diameter of crown istotally anterior to ant border of ramustotally anterior to ant border of ramus
Class II: one half of crown is coveredClass II: one half of crown is coveredby ramusby ramus
Class III: tooth completely within theClass III: tooth completely within theramusramus
Classification systems forClassification systems forimpacted teeth:impacted teeth: Relationship to occlusal plane:Relationship to occlusal plane: Pell andPell and
Gregory classes A , B and C:Gregory classes A , B and C: Class A: occlusal surface is level (or nearly)Class A: occlusal surface is level (or nearly)
with occlusal plane ofwith occlusal plane of 22ndnd molarmolar Class B: occlusal surface between occlusalClass B: occlusal surface between occlusal
plane and cervical lineplane and cervical line Class C: occlusal surface below cervical lineClass C: occlusal surface below cervical line
Relationship to occlusal plane:Relationship to occlusal plane: Pell andPell andGregory classes A , B and C:Gregory classes A , B and C:
Class A: occlusal surface is level (or nearly)Class A: occlusal surface is level (or nearly)with occlusal plane ofwith occlusal plane of 22ndnd molarmolar
Class B: occlusal surface between occlusalClass B: occlusal surface between occlusalplane and cervical lineplane and cervical line
Class C: occlusal surface below cervical lineClass C: occlusal surface below cervical line
Radiological AssessmentRadiological Assessment
1.1. The Orientation of the ToothThe Orientation of the Tooth2.2. The Depth of the ToothThe Depth of the Tooth3.3. The Degree of Impaction of theThe Degree of Impaction of the
ToothTooth4.4. Root ShapeRoot Shape5.5. Bone Removal to Form a Path ofBone Removal to Form a Path of
ElevationElevation
1.1. The Orientation of the ToothThe Orientation of the Tooth2.2. The Depth of the ToothThe Depth of the Tooth3.3. The Degree of Impaction of theThe Degree of Impaction of the
ToothTooth4.4. Root ShapeRoot Shape5.5. Bone Removal to Form a Path ofBone Removal to Form a Path of
ElevationElevation
66. Bone Removal to Permit Application. Bone Removal to Permit Applicationof Elevatorsof Elevators
77. Bone Density. Bone Density88. The Relationship to the Inferior. The Relationship to the Inferior
Dental CanalDental Canal
AssessmentAssessment
AssessmentAssessment
To Remove or Not to RemoveTo Remove or Not to RemoveTo Remove or Not to RemoveTo Remove or Not to Remove
PericoronitisPericoronitis Food packing between the crown ofFood packing between the crown of
the impacted tooth and the secondthe impacted tooth and the secondmolarmolar -- caries. In later lifecaries. In later life --periodontal diseaseperiodontal disease
Suppuration around a buried tooth.Suppuration around a buried tooth. OrthodontistsOrthodontists -- imbrication of theimbrication of the
anterior teeth, orthodonticanterior teeth, orthodonticmovement of molars distally,movement of molars distally,orthognathic surgery.orthognathic surgery.
PericoronitisPericoronitis Food packing between the crown ofFood packing between the crown of
the impacted tooth and the secondthe impacted tooth and the secondmolarmolar -- caries. In later lifecaries. In later life --periodontal diseaseperiodontal disease
Suppuration around a buried tooth.Suppuration around a buried tooth. OrthodontistsOrthodontists -- imbrication of theimbrication of the
anterior teeth, orthodonticanterior teeth, orthodonticmovement of molars distally,movement of molars distally,orthognathic surgery.orthognathic surgery.
KeratocystKeratocyst Dentigerous cystDentigerous cyst AmeloblastomaAmeloblastoma Prevention of jaw fracturePrevention of jaw fracture -- sportssports Resorption of alveolar bone (loss ofResorption of alveolar bone (loss of
molars with age)molars with age) Unexplained painUnexplained pain
KeratocystKeratocyst Dentigerous cystDentigerous cyst AmeloblastomaAmeloblastoma Prevention of jaw fracturePrevention of jaw fracture -- sportssports Resorption of alveolar bone (loss ofResorption of alveolar bone (loss of
molars with age)molars with age) Unexplained painUnexplained pain
CaseCase 11
CaseCase 11
CaseCase 22
CaseCase 22
CaseCase 22
CaseCase 22
CaseCase 22
Contraindications forContraindications forremoval:removal: Extremes of ageExtremes of age Compromised medical statusCompromised medical status Surgical damage to adjacentSurgical damage to adjacent
structuresstructures
Extremes of ageExtremes of age Compromised medical statusCompromised medical status Surgical damage to adjacentSurgical damage to adjacent
structuresstructures
Part IIPart II
Basic stepsBasic steps
Reflecting adequate flaps forReflecting adequate flaps foraccessibiltyaccessibilty
a.a. Envelope flapEnvelope flapb.b. ThreeThree--cornered flap / Triangular flapcornered flap / Triangular flap(maxillary / mandibular teeth)(maxillary / mandibular teeth)
Reflecting adequate flaps forReflecting adequate flaps foraccessibiltyaccessibilty
a.a. Envelope flapEnvelope flapb.b. ThreeThree--cornered flap / Triangular flapcornered flap / Triangular flap(maxillary / mandibular teeth)(maxillary / mandibular teeth)
Basic stepsBasic steps
Removal of overlying boneRemoval of overlying bonea.a. Chisel / drillChisel / drillb.b. Lingual aspectLingual aspectc.c. Maxillary/ mandibular teethMaxillary/ mandibular teeth
Removal of overlying boneRemoval of overlying bonea.a. Chisel / drillChisel / drillb.b. Lingual aspectLingual aspectc.c. Maxillary/ mandibular teethMaxillary/ mandibular teeth
Basic stepsBasic steps
Sectioning the toothSectioning the tootha.a. chisel/bur (chisel/bur (33//44 of tooth)of tooth)b.b. Angulation of impactionAngulation of impaction
Sectioning the toothSectioning the tootha.a. chisel/bur (chisel/bur (33//44 of tooth)of tooth)b.b. Angulation of impactionAngulation of impaction
MesioangularMesioangular
Least difficultLeast difficult Distal half of theDistal half of the
crown is sectionedcrown is sectioned
Least difficultLeast difficult Distal half of theDistal half of the
crown is sectionedcrown is sectioned
Horizontal impactionHorizontal impaction
Bone removalBone removal Divide crown fromDivide crown from
rootsroots
Vertical impactionVertical impaction
Bone removalBone removal More accessMore access
neededneeded
distoangulardistoangular
Most difficultMost difficult Bone removalBone removal Crown sectioningCrown sectioning
Most difficultMost difficult Bone removalBone removal Crown sectioningCrown sectioning
Imacted maxillary teethImacted maxillary teeth
Rarely sectionedRarely sectioned No chiselNo chisel Rarely sectionedRarely sectioned No chiselNo chisel
Basic stepsBasic steps
Delivery with elevatorDelivery with elevator No luxationNo luxation No excessive forceNo excessive force(maxillary and mandibular teeth)(maxillary and mandibular teeth)
Delivery with elevatorDelivery with elevator No luxationNo luxation No excessive forceNo excessive force(maxillary and mandibular teeth)(maxillary and mandibular teeth)
Debridement of woundDebridement of wound
Remove bone chips and debrisRemove bone chips and debris Irrigate with salineIrrigate with saline Smooth sharp edgesSmooth sharp edges Primary closurePrimary closure
Remove bone chips and debrisRemove bone chips and debris Irrigate with salineIrrigate with saline Smooth sharp edgesSmooth sharp edges Primary closurePrimary closure
PostPost--operative careoperative care
Pain and anxiety controlPain and anxiety control SteroidsSteroids AntibioticsAntibiotics swellingswelling
Pain and anxiety controlPain and anxiety control SteroidsSteroids AntibioticsAntibiotics swellingswelling
ComplicationsComplicationsComplicationsComplications
complicationscomplications
PreventionPreventionIntraoperative:Intraoperative: Soft tissue injuriesSoft tissue injuries Injuries to oseous structuresInjuries to oseous structures Oroantral comunicationsOroantral comunications Fractures of the mandibleFractures of the mandible Injuries to adjacent teethInjuries to adjacent teeth Complications with the tooth being extractedComplications with the tooth being extracted Injuries to adjacent structuresInjuries to adjacent structures
PreventionPreventionIntraoperative:Intraoperative: Soft tissue injuriesSoft tissue injuries Injuries to oseous structuresInjuries to oseous structures Oroantral comunicationsOroantral comunications Fractures of the mandibleFractures of the mandible Injuries to adjacent teethInjuries to adjacent teeth Complications with the tooth being extractedComplications with the tooth being extracted Injuries to adjacent structuresInjuries to adjacent structures
Postoperative complications:Postoperative complications: BleedingBleeding Delayed healing and infectionDelayed healing and infection
Postoperative complications:Postoperative complications: BleedingBleeding Delayed healing and infectionDelayed healing and infection
Thank youThank you