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Wisdom Tooth Wisdom. Demystifying the Past And Planning for the Future. Ted Fields, DDS, PhD. Course Outline. Part I: 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. Course Outline.

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wisdom tooth wisdom

Wisdom Tooth Wisdom

Demystifying the Past

And

Planning for the Future

Ted Fields, DDS, PhD

course outline
Course Outline

Part I: 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

course outline3
Course Outline

Part II: Treatment Approach

  • Assessing the difficulty of removal
  • Patient counseling and preparation
  • Anesthesia
  • Instrumentation
  • Technique
course outline4
Course Outline

Part III:

Management of Infected Teeth

course outline5
Course Outline

Part IV: It Ain’t Over Till It’s Over

  • Complications
  • Post-operative care
  • Documentation
the difficulty in understanding 3 rd molars
The Difficulty in Understanding 3rd Molars
  • European third molar surgery is much different than that in the U.S.
  • Lingual fracture technique
  • Different instrumentation
  • Different economic influences on dental care
the difficulty in understanding 3 rd molars7
The Difficulty in Understanding 3rd Molars

2. Many research papers of the past 20 years set out to prove or disprove old ideas – many of which themselves are outdated.

  • Will the 3rd molar erupt?
  • Is there enough arch length for eruption?
  • Does removal of the 3rd molar compromise the 2nd molar?
the difficulty in understanding 3 rd molars8
The Difficulty in Understanding 3rd Molars
  • Much of the developmental literature is written from an orthodontic viewpoint.
  • There is an outcome bias towards younger individuals (what is the result in a 16-yr-old?)
  • The 3rd molar is judged in relation to orthodontic needs, rather than the patient’s overall needs.
the difficulty in understanding 3 rd molars9
The Difficulty in Understanding 3rd Molars

4. Many changes in technology have been totally neglected.

  • Implants
  • Electric handpieces
  • Antibiotics
  • Hemostatic agents
  • Bone augmentation materials
the difficulty in understanding 3 rd molars10
The Difficulty in Understanding 3rd Molars
  • The topic is not covered in any depth in most dental schools.
  • Knowing when it is in the patient’s best interest to remove 3rd molars is a judgment that requires detailed knowledge of the risks and benefits associated with tooth retention and with tooth removal.
initial calcification
Initial calcification
  • Occurs as early as 7yrs, more typically age 9.
crown mineralization
Crown Mineralization
  • Usually completed by age 12 to 14.
root formation
Root Formation
  • Usually half-formed by age 16.
root completion
Root Completion
  • Fully formed roots with open apices are usually present by age 18.
eruption
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.
predicting eruption who cares
Predicting Eruption – Who Cares?
  • Does it matter if a wisdom tooth erupts?
  • Does it matter when a wisdom tooth erupts?
the key issue
The Key Issue

Does it affect the

Risk:Benefit Ratio?

evaluating risk benefit20
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:
evaluating risk benefit21
Evaluating Risk:Benefit

You must consider 2 separate assets of each risk and each benefit:

  • Magnitude of risk or benefit
  • Probability of risk or benefit
magnitude
Magnitude
  • Is it major or minor?
  • Does it require hospitalization?
  • Is it permanent?
  • Does it affect your daily routine? If so, for how long?
probability
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?
the difficulty of accurate risk benefit assessment
The Difficulty of Accurate Risk:Benefit Assessment
  • The literature is not very complete or very helpful. Complication rates vary widely. Different people view these complications very differently (complication doesn’t always equal perception of the complication)

Ogden GR, Bissias E, Ruta DA, Ogston S: Quality of life following third molar removal: a patient versus professional perspective. Br Dent J 1998;185:407410.

the difficulty of accurate risk benefit assessment25
The Difficulty of Accurate Risk:Benefit Assessment

2. The wide variety of different complications and the wide range in the incidences of each potential complication result in a complex body of data to assimilate.

risk benefit
Risk:Benefit
  • Are erupted 3rds more or less subject to disease?
  • Are erupted 3rds more or less beneficial?
what impacts treatment
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.”
benefits of 3rds
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 part ii
Benefits of 3rds – Part II
  • Orthodontic repositioning to replace missing or grossly compromised 1st molars
  • Transplantation – poor long-term survival
  • With dental implants, these are rarely reasonable treatment alternatives.
tooth transplantation
Tooth Transplantation
  • Under ideal conditions, 27 oral surgeons transplanted 291 teeth:
  • 5-yr survival rate: 76.2%
  • 10-yr survival rate 59.6%

Schwartz O, Bergman P, Klausen B: Resorption of autotransplanted teeth. A retrospective study of 291 transplantations over a period of 25 years. Int J Oral Surg 1985;14:245-258.

conclusion
Conclusion
  • 3rd molars provide no proven functional benefit and no obvious esthetic benefit.
  • Rarely, they may provide a treatment option that, at best, is third-line treatment.
what impacts treatment34
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.
problem 1 soft tissue
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
problem 2 periodontal compromise
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.
bone loss distal to the 2 nd molar
Bone Loss Distalto the 2nd Molar
  • 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

bone loss distal to the 2 nd molar38
Bone Loss Distalto the 2nd Molar
  • 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

augmentation with freeze dried bone or bone substitutes
Augmentation with Freeze-Dried Bone or Bone Substitutes
  • Why?
  • There is no independent evidence of benefit
  • Why graft a contaminated site?
  • Why graft a site you can’t close primarily?
  • Your goal is to maintain bone height on the distal of the 2nd molar without pocket formation, not to augment potential defects more posteriorly.
augmentation conclusion
Augmentation: Conclusion
  • It won’t improve your outcome.
  • It will undoubtedly increase your infection rate
  • Why would you want to augment this area anyway?
problem 2 periodontal compromise46
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.
how do you treat missing 2 nd molars
How Do You Treat Missing2nd 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 2 nd molar dilemma
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.

problem 5 infection
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
types of infection
Simple dental caries and periodontal disease

Pericoronitis

Abscess

Cellulitis

Abscess extension into adjacent fascial spaces

5. Abscess spread to distant sites

Recurrent infections

Infections resistant to initial local and systemic treatment measures

Types of Infection
pericoronitis
Pericoronitis

The most common cause of therapeutic 3rd molar removal.

pericoronitis69
Pericoronitis
  • A failure of preventive measures
  • A failure of early recognition, or a failure to seek proper treatment
  • A step along the pathway of infection
  • Pericoronitis should be a warning sign that initiates immediate and aggressive treatment with careful observation.
problem 8 cysts
Problem #8 - Cysts

Dentigerous

Cyst

slide74

Supernumerary

4th Molar

Dentigerous Cyst

types of cysts
Types of Cysts
  • Follicular cyst (Dentigerous Cyst)
  • OKC (Odontogenic Keratocyst)
  • Ameloblastoma (several varieties)
  • Not all radiolucencies are cysts!

- Lymphoma

- Myeloma

- Metastatic carcinoma

slide77

Without the radiolucency, would you have recommended removal?

Is the removal of this better or worse with the radiolucency?

cysts a few facts
Cysts – A Few Facts
  • May be prevented by early removal – when normal dental follicle is still evident.
  • The pericoronal pocket, or residual follicle, is responsible for most cystic pathology.
  • All cystic tissues should be removed and biopsied.
cysts
Cysts
  • Cysts themselves are not catastrophic – the problem is that we don’t know exactly what they are until they are histopathologically examined – which necessitates removal.
  • All cysts result in bone loss.
  • Some cysts recur more than others.
treatment of large cysts
Treatment of Large Cysts
  • Aspirate first – rule out vascular lesions
  • Consider decompression (only after biospy confirmed diagnosis)
  • Consider marsupialization
  • Consider bone grafting
  • Consider possibility of mandible fracture
  • Consider extensive followup
problem 9 tumors
Problem #9 - Tumors
  • Benign vs. malignant
  • Odontogenic vs. non-odontogenic
  • Primary vs. secondary
  • Each of these factors has important treatment implications.
problem 12 orthodontics
Problem #12 - Orthodontics
  • Prevent loss of post-retention stability
  • Allow distalization of 2nd molars
  • These are controversial indications
alternatives to removal

Alternatives to Removal

Restoration

Periodontal therapy

Operculectomy

Removal of another tooth

No treatment

timing removal of 3rds

Timing Removal of 3rds

When is the best time for prophylactic removal?

age 7 11 mandibular 3rds
Age 7-11: Mandibular 3rds
  • Germs are first visible during this time
  • They usually appear in a superficial location close to the alveolar crest
  • After age 11, they are located deeper in the mandible
age 7 11 mandibular 3rds106
Age 7-11: Mandibular 3rds

Very close to ridge crest. Minimal if any bone removal will be needed.

age 7 11 mandibular 3rds107
Age 7-11: Mandibular 3rds
  • Mineralization is either not present or only mineralized cusps are evident
  • Remove requires a flap and minimal, if any, bone removal
  • Psychological factors and parental support should be carefully evaluated on a case by case basis
age 7 11 mandibular 3rds108
Age 7-11: Mandibular 3rds

Close to, but not at, ridge crest. Some bone removal will be needed.

age 7 11 mandibular 3rds109
Age 7-11: Mandibular 3rds

Bone removal will be necessary. Is it better to remove this 3rd molar or wait?

age 7 11 mandibular 3rds110
Age 7-11: Mandibular 3rds
  • There has been less published about removal of thirds at this age than at other ages, so intervention at this time tends to be more controversial
  • Much of the controversy has traditionally revolved around the difficulty in predicting eruption and arch length – probably not valid
removing 3 rd molar germs
Removing 3rd Molar Germs
  • Bjornland T, Haanaes HR, Lind PO, Zachrisson B: Removal of third molar tooth germs: study of complications. Int J Oral Maxillofac Surg 1987;16:385-390.
  • Half as much postop pain medication was required
  • One third quicker procedure
  • Well-tolerated with local anesthesia
age 7 11 maxillary 3rds
Age 7-11: Maxillary 3rds
  • These teeth tend to be high in the maxilla
  • Their small size can make them difficult to locate
  • Their size and location can increase the risk of injury to the developing 2nd molar
  • Increased operating time and frustration
  • Increased postop edema and discomfort
age 7 11 conclusion
Age 7-11: Conclusion
  • Lower 3rds are often very simple, upper 3rd are almost always very difficult and pose risk to the 2nd molars
  • In older individuals, 90% of the morbidity is from removal of the lower 3rds
  • Early removal may obviate the need for any sedation at any time
  • Psychological evaluation is critical
age 12 14
Age 12 -14
  • Crown mineralization progresses
  • Distance of lower 3rds from ridge crest increases
  • Lower 3rds become more difficult to remove
  • Upper 3rds may still be quite difficult
  • Psychologically, many patients may be less prepared at this age.
age 15 18
Age 15-18
  • Root formation has begun and may progress to near completion.
  • Most patients are psychologically accepting of surgery at this age.
  • Most studies agree that complication rates are least in this age range.
age 15 18124
Age 15-18
  • The follicle allows for relatively easy removal once the tooth is accessed.
  • No PDL is present – there is no attachment of the tooth to bone.
  • The portion of the follicle deep to the forming roots acts as a safety zone between the tooth and the nerve.
age 15 18125
Age 15-18
  • The periphery of the deepest mineralized tooth surface may be quite sharp, allowing laceration of the neurovascular bundle if it too is housed within the follicular space.
  • The tooth may spin and be difficult to stabilize while sectioning and elevating.
age 19 22
Age 19-22
  • Root development is not always complete during this period, making it still a favorable time for 3rd molar removal.
age 22 35
Age 22-35
  • Nearly all patients in this age group will have fully developed 3rd molar roots – this potential advantage is lost.
  • The bone still has a good ratio of elastic collagen matrix to mineral content, usually simplifying removal and even more frequently improving most parameters of healing.
  • Most of these patients are healthy.
age 35 45
Age 35-45
  • Most patients are still ASA I or II
  • The mineral content of the mandible increases during this time.
  • Many 3rd molars must be removed during this time for therapeutic reasons.
over age 45
Over Age 45
  • The complication rate is highest in this group.
  • The incidence of nerve injury is highest in this group – and recovery is the poorest.
  • Even routine healing tends to be prolonged and associated with increased morbidity.
  • Patient health may be compromised.
with increasing age
With Increasing Age
  • Narrowing of PDL and pericoronal space
  • Thickening of cortical bone
  • Increased risk of infection, bone loss, and other pathoses
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

Advantages of Early Removal