When are there strong indications for the removal of 3rd molars according to NICE guidelines ?
- recurrent episodes of infection such as pericoronitis, cellulitis, abscess formation or untreatable pulpal/periapical pathology
- caries in the third molar and tooth unlikely to be restored
- caries in 2nd molar which is unrestorable without removal of 3rd molar
- periodontal diseas due to position of 3rd molar and associatio with the 2nd molar tooth
- dentigerous cyst formation or related oral pathology
- external resorption of the 3rd molar or 2nd molar where it appears to be caused by the third molar
When is the removal of unerupted and impacted molars advisable according to NICE guidelines?
- significant infection associated with unerupted or impacted 3rd molar teeth
- patients with predisposing risk factors whose occupation or lifestle precludes ready access to dental care (e.g. astronauts, submarine engineers)
- in patients with a medical condition when the risk outweighs the associated removal of 3rd molars e.g. prior to radiotherapy or cardiac surgery
- patients who have agreed to tooth transplant procedure, orthognathic surgery or other relevant local surgical procedures
- where GA is to be administered for the remobval of at least one 3rd molar; consideration should be given to simultaneous removal of contralateral 3rd molars
Outline other indications for removal of 3rd molars
- autogenous transplantation to a first molar socket (first molar is lost)
- in cases of fracture of the mandible in the 3rd molar
- 3rd molar involved in tumour resection
- unerupted 3rd molar in atrophic mandible
- prophylactic removal of partially erupted 3rd molar
- atypical pain from unerupted 3rd molar
- partially erupted or unerupted third molar, close to the alveolar surface prior to denture construction or close to planned implant
What differential diagnoses for atypical pain in the 3rd molar region must you rule out before considering removal?
- TMJ pain
- muscle dysfunction
Following radiographic examination, what information should be noted with regards to characteristics of the 3rd molar?
- type and orientation of impaction and access to the tooth e.g. distinction between vertical and disto-angular orientation may affect surgical approach with regards to requirements for bone removal
- crown size and condition
- root number and morphology; including presence of apical hooks
- alveolar bone level; including depth and point of elevation and density
- follicular width
- periodontal status, together with that of adjacent tooth
- relationship or proximity of upper 3rd molars to maxillary sinus and lower 3rd molars to mandibular canal
What interim measures can be taking in preparation of surgical removal of 3rd molars to mitigate post-operative complications?
- systemic antibiotic administration
- chlorhexidine mouth rinses
- operculectomy
- local dressing
- Lavage
When is it particularly important to use resorbable sutures?
where no review is planned
When are antibiotics appropriate for the management of 3rd molar removals ?
- acute infection at time of operation
- significant bone removal
- prolonged operation
When should pre-operative steroids be considered for use ?
when there is risk of significant post-operative swelling
(antiinflammatory effects of steroids)
Where there are signs of systemic involvement, __________ should be prescribed
pyrexia
lymphadenopathy
Antibiotics
What does wound dehiscence refer to?
this occurs when a cut made during surgery re-opens
What are patients advised to do in the occurence of wound dehiscence in the absence of pain or infection?
continue wound toilet e.g. hot salty mouthwashes and sicket syringing
Outline serious complicatons associated with 3rd molar removals
- fracture of mandible
- fracture of tuberosity
- OAC
- broken instrument
- complete transection of lingual or inferior alveolar nerves
- late recognition of nerve damage
When are review appointments following 3rd molar extractions required?
- when non-resorbable sutures have been placed
- where complications arise
- at patients or surgeons request
A discharge letter is always sent to the referring clinician. What should it include ?
- how to look after mouth post-operatively
- possible complications and side effects
- any problems specific to the operation undertakken
- any drug therapy required
- whether a review appt is required
Prevalece of unerupted 3rd molars vary widely. What is the prevalence influenced by?
- age
- gender
- ethinicity
Define the meaning of an unerupted tooth
a tooth lying within the jaws, entirely covered by soft tissue, and partially or completely covered by bone
Define the term “ partially erupted tooth”
tooth that has failed to erupt fully into a normal position.
this term implies the tooth is partly visible and in communication with the oral cavity
What is an impacted tooth?
tooth that is prevented from completely erupting into a normal functional position
What are the potential cause of an impaction?
- lack of space
- obstruction by another tooth
- abnormal eruption path
Upper 3rd molars are more likely to erupt compared to their lower counterparts. True or false
True
When are 3rd molar removals NOT advisable?
- 3rd molars that have erupted successfully and have a functional role in the dentition
- patients whose medical history renders the removal an unacceptable risk to overall health of the patient
- in patients where there is planned single third molar removal under LA; there should be no simultaneous removal of asymptomatic contalateral 3rd molars
What kind of orthoghathic surgery is it appropiate for 3rd molars to be extracted?
sagittal split osteotomy
Why is the removal of 3rd molars acceptable/indicated in cases of fracture of the mandible in the 3rd molar region ?
this is because the presence of a tooth in a fracture line increases the risk of infection in some cases especially when the tooth has been displaced or rendered non-vital
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Oral and Facial Pain95
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Fascial Spaces66
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White Patches62
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Pre-cancerous lesions57
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Treatment Planning18
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Biopsy38
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Oral Biopsies 279
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Suturing60
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Surgical Technique44
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Mouth Cancer Referral GUIDELINES for dentists8
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Wound Healing119
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Haemostasis65
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SDCEP Bisphosphonates guidelines30
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PRADAXA11
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Diabetes Mellitus107
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Analgesics in MOS 1111
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Analgesics in MOS 279
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Analgesics in MOS 394
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SCD Acquired bleeding disorders87
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Bleeding disorders seen in the dental practice72
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Warfarin guidance33
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Management of palatally ectopic canines41
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Impacted Canines 263
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Management of patients with 3rd molars24
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Nerve Damage and 3rd Molar removal83
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M3Ms, CBCT, Coronectomy45
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Coronectomy22
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Treatment Planning for M3M34
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NICE guidelines for M3Ms3
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SIGN guidelines38
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Articaine28
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LA risks52
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Drug interactions with LA45
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Failure of LA 166
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Failure of LA 269
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Neurological Complications56
