Third molar assessment

Question 1

1. Impacted 3rd molars are Developmental anomaly. So, why might we have mandibular/maxillary impacted 3rd molars?

Answer 1

a. Due to obstruction in their eruption path
b. Or pathology
c. Or lack of physical space
d. Ectopic position of the tooth

Question 2

2. What is the average eruption completion of 3rd molars?

Answer 2

a. The average eruption completion is at 20 years, but can be up to 25 years

Question 3

3. what are the 3 different types of impaction?

Answer 3

a. Partially erupted and partially covered by soft tissues.
b. Unerupted and completely covered by soft tissues
c. Unerupted and covered by bone and soft tissue.

Question 4

4. What are the categories of third molar impaction according to the tooth position?

Answer 4

a. Mesio-angualr
b. Disto-angular
c. Vertical
d. Horizontal
e. Transverse

Question 5

5. Classification of third molar according to the position of impaction – what is the most common type of impaction?

Answer 5

a. Mesio-angular

Question 6

6. What is the most difficult type of impaction? Describe it

Answer 6

a. Disto-angular – where the third molar is leaning distally into the ramus

Question 7

7. What does the term vertical impaction means?

Answer 7

a. Normal eruption but, impacted in the coronal surface by something like soft tissue or bone

Question 8

8. What does the term transverse impaction mean?

Answer 8

a. The crown towards the buccal and the roots toward the palatal side or the other way round and in the radiograph, they look like a big ball

Question 9

9. List the different impactions with their average percentage of those reported.

Answer 9

a. Vertical – 61.8%
b. Mesio-angular – 25.5%
c. Disto-angular – 6.7%
d. Horizontal – 4%

Question 10

10. Differentiate between the meaning of signs and symptoms

Answer 10

a. Symptom means an indication of disease noticed by a patient. For example, Pain, swelling, restricted mouth opening, bad breath, difficulty chewing.
b. Sign means observations by a health professional indicating disease or disorder. For example, BOP, pathological pocket depth, tenderness on palaption, radiographic signs.

Question 11

11. In which arch you most commonly see 3rd molar problems?

Answer 11

a. Lower arch (mandibular 3rd molars)

Question 12

12. What are the reasons behind 3rd molars extractions/ or why 3rd molars can cause problem?

Answer 12

a. CYSTS / PATHOLOGY
b. PERI-APICAL DISEASE
c. ABSCESS
d. RECURRENT PERICORONITIS – which is the most common one
e. UNRESTORABLE CARIES – in the 8 itself not in the adjacent tooth
f. ORTHOGNATHIC SURGERY
g. MALIGNANT TUMOUR
h. TRAUMA INFECTION

Question 13

13. What is pericoronitis?

Answer 13

a. An infection of the soft tissue around the crown of a partially impacted tooth, usually caused by normal oral flora.

Question 14

14. What are the underlying causes of pericoronitis?

Answer 14

a. Compromised host defences (e.g. URTI, medication)
b. Minor trauma from opposing maxillary dentition (operculum)
c. Food trapping under the operculum
d. Bacterial infection - Strep and Anaerobes
e. Poor OH

Question 15

15. What are the symptoms of pericoronitis?

Answer 15

a. Pain
b. Halitosis
c. Swelling
d. Erythema
e. Bad taste

Question 16

16. What does systemic signs mean? And what systemic signs can we have of untreated pericoronitis?

Answer 16

a. Systemic signs mean not localised and spread into the body
b. Systemic signs of pericoronitis are:
- Trismus
- Pyrexia
- Lymphadenopathy
- Malaise
- Dysphagia

Question 17

17. Where can the dental infection spread to in the face?

Answer 17

a. It can spread from the tooth to facial spaces (we need to know more about facial spaces)

Question 18

18. Why submandibular/ submental abscess can be problematic?

Answer 18

a. Pushes the tongue up  difficulty to swallow
b. Compress trachea  cannot swallow their saliva  lose their airways
c. Difficult to drain
d. Cannot put patient to sleep
e. Cannot open their mouth
f. Needs to put nasal tube while they are awake

Question 19

19. Is the treatment for tonsilitis the same as treatment for dental infection?

Answer 19

a. No, they are different (we use different antibiotics)

Question 20

20. List the steps that you would follow if you have patient coming with pain.

Answer 20

a. History (patient’s own words, use SOCRATES for pain history)
b. Clinical examination (extra-oral + intra-oral with a focus on the area in questions) (what are your findings?)
c. Formulate a differential diagnosis (Surgical Sieve)
d. Request relevant investigations to confirm your diagnosis (vitality testing, imaging) – radiographs need to be diagnostic and acceptable
i. Appropriate radiographic interpretation is used in combination with clinical information and other tests to formulate diagnosis + treatment plan
e. Confirm diagnosis – Ensure that you exclude other causes for the patients’ symptoms
f. Discuss with patient and formulate a treatment plan (discuss pros and cons of options)
g. Must discuss warnings with the patient and risks (Montgomery Consent)

Question 21

21. If a patient complains of pain of unerupted third molar, would it be possible that the main cause is that wisdom tooth if it was associated with pathology?

Answer 21

a. It is rare for third molars to cause symptoms if they are unerupted, even with associated pathology. You must consider other causes for the patients’ pain such as temporo-mandibular joint dysfunction.

Question 22

22. When do we use antibiotics in case of pericoronitis?

Answer 22

a. If there is systemic involvement

Question 23

23. What is the initial management of a patient comes with pericoronitis and present with no systemic features. e.g., Pain, Halitosis, Swelling, Erythema or Bad taste and there is no indication of systemic involvement?

Answer 23

a. Treat the patient with local measures:
i. irrigation with warm saline – (patients to use a monoject TM syringe if possible)
ii. hydrogen peroxide
b. Regular analgesia – NSAID / Paracetamol (check contra-indications and interactions)
c. irrigate with warm water and table salt in home
d. Caution with chlorhexidine

Question 24

24. What does trismus mean?

Answer 24

a. restricted mouth opening where normal mouth opening is about 3 cm but this varies between people

Question 25

25. What does pyrexia men?

Answer 25

a. Fever and the normal temperature is 37

Question 26

26. What does dysphagia mean?

Answer 26

a. difficulty to swallow

Question 27

27. what is the initial management of a patient with pericoronitis that has spread systemically where there is a sign of systemic involvement (active infection) e.g., Trismus, Pyrexia, Lymphadenopathy, Malaise or Dysphagia?

Answer 27

We would do 3 things: a. Local measures: Irrigation with Warm Saline Hydrogen Peroxide b. Analagesia c. Metronidazole 200mg TDS for 3/7 or Amoxicillin 500mg TDS for 3/7

Question 28

28. Is metronidazole a very strong antibiotic drug for pericoronitis? Why?

Answer 28

a. No, metronidazole is specific only for anaerobic bacteria. And pericoronitis is mixed infection.

Question 29

29. Give an example of strong antibiotic that would you use to manage pericoronitis infection? Justify your answer.

Answer 29

a. Amoxicillin as it is broad spectrum antibiotic. And pericoronitis is mixed infection

Question 30

30. What antibiotic would you use in case of having strong infection due to pericoronitis?

Answer 30

a. If it is very strong infection, you can give both antibiotics (amoxicillin and metronidazole) together

Question 31

31. What does TDS mean?

Answer 31

a. 3 times a day

Question 32

32. What does 3/7 mean?

Answer 32

a. for 3 days

Question 33

33. Why do we try to reduce the time we give the patient antibiotics?

Answer 33

a. to avoid the risk of resistance and antibiotics side effects

Question 34

34. what are the indications for the third molar removal according to the NICE guidelines?

Answer 34

a. Unrestorable caries (of the 8 not the adjacent tooth) b. Non-treatable pulpal and/or periapical pathology c. Cellulitis d. Abscess e. Osteomyelitis f. Internal/external resorption of the third molar or adjacent tooth g. Fracture of tooth h. Disease of the follicle (inc cyst/tumour) i. Tooth/teeth impeding surgery or reconstructive jaw surgery (e.g. orthognathic / trauma) j. Tooth involved in surgical resection field for tumour

Question 35

35. What will happen if we have caries in the distal surface of a 7 that is adjacent to an impacted third molar and according to the NICE guidelines the wisdom tooth is not indicated to be removed? Does removing the 7 helps in moving the 8?

Answer 35

a. If you left that wisdom tooth, the 7 would probably have a short life span because you will not be able to clean that, and that caries would progress b. Removing the 7 will not help in moving the 8 to the position of the 7 (this is not possible, it will never, erupt to the position of the 7 (will move just a little bit))

Question 36

36. What will happen if the patient left untreated from the local infection?

Answer 36

a. It will progress and lead to more serious consequences (systemic involvement)

Question 37

37. What are the consequences of dental infections?

Answer 37

a. There are potential routes of spread through the facial spaces. (you need to have an appreciation of the spaces and consequences of infections in such areas)

Question 38

38. What factors must we consider prior to removal of coronectomy of third molars?

Answer 38

a. patient factors b. surgical factors.

Question 39

39. What are the patient factors?

Answer 39

a. Age b. Social History c. Medical History d. Drug History e. BMI f. Ethnicity g. Capacity

Question 40

40. What are the surgical factors?

Answer 40

a. The third molar itself b. Periodontal Status c. Surgical Anatomy d. Systemic factors e. Mouth opening f. Adjacent structures g. Associated pathology h. TMJ status i. Occlusal relationship j. The operator

Question 41

41. How could the age of the patient impact on the third molar removal surgery (coronectomy)?

Answer 41

a. Complexity: Increased complication over the age of 25/ Increased age  mandibular third molar extractions would be more complicated b. Mental health: With increased age we see more mental health issues which will impact on surgery e.g., dementia, alzheimers, parkinsons, post stroke IHD c. Bone quality: Bone get harder with older ages d. Medical complexity e. Caries: Retained carious teeth (inc third molars) + more carious teeth

Question 42

42. What MH and Drug history do we need to consider when planning to remove the coronectomy of third molars?

Answer 42

a. Medical History: Considerations for those with co-morbidities should be accounted for e.g ischaemic heart disease, stroke, diabetes, mental health issues. b. Medications: e.g anti-platelets, anticoagulants, steroids, bisphosphonates, Antibiotic Prophylaxis and other biologics should be taken into consideration. i. Immunosuppressant can cause issues with healing ii. Patients with bisphosphonate are at risk of MRONJ

Question 43

43. Can patient’s BMI interfere with third molar surgery? Justify your answer

Answer 43

a. Yes, people with higher BMI have problems with small airways and short necks therefore, cause access problem b. Also, they might have other co-morbidities that are associated with obesity such as diabetes are associated with a high BMI. Such diseases are also associated with cardiovascular disease. Do not treat such conditions in isolation.

Question 44

44. What fact do you know about people with red hair regard to third molar surgery? What might you consider in this case?

Answer 44

a. Fact: if you have a bright red hair you bleed more (genetics) and your pain threshold is very low b. So, they might bleed more and need more analgesia

Question 45

45. What are the special investigations that you would use to assess third molar?

Answer 45

a. Radiographs b. We don’t very often do vitality test for third molars

Question 46

46. List acceptable reasons to request a radiograph imaging:

Answer 46

a. Presence of caries b. Condition of existing restorations c. Alveolar bone levels d. Root morphology e. Morphology of pulp chamber f. Signs of periodontal pathology g. Position of unerupted teeth or retained roots h. Other pathology of the jaws i. Form and quality of edentulous ridge and underlying bone j. Boundaries of relevant anatomical features

Question 47

47. Give a brief about PA radiographs

Answer 47

a. Intra-oral technique – An intra-oral technique which can often be difficult with regards to mandibular and maxillary third molars. Often reliant upon good technique and a co-operative patient. b. Shows individual teeth & apical area and gives detailed information of the root formation, hard tissues and any associated pathology.

Question 48

48. What can we investigate with PA image?

Answer 48

a. Detection of apical inflammation / infection b. Assessment of the periodontal status c. Post trauma d. ?un-erupted teeth e. Root morphology f. During endodontics g. Apical surgery h. Apical pathology i. Implants post op

Question 49

49. What are the cons of PA image?

Answer 49

a. Technique sensitive b. Gag reflex c. Edentulous alveolar ridge d. Children e. Co-operation

Question 50

50. What is the most common reason in oral surgery for taking periapical image?

Answer 50

a. post implant placement

Question 51

51. what images are most likely to be taken in oral surgery clinic?

Answer 51

a. OPT and Cone Beam CT scans

Question 52

52. What are the acceptable reasons for taking Tomography (orthopantomogram – OPT/OPG)?

Answer 52

a. Bony lesion / unerupted tooth not visible on IO radiograph b. Grossly neglected mouth c. Periodontal bone support assessment +/- PA’s d. Assessment of third molars before surgery (not routine) e. Orthodontic assessment f. Trauma g. Antral disease h. Destrictive disease of the articular surfgace of TMJ i. Vertical alveolar bone height and anatomy assessment for implants

Question 53

53. Is third molar assessment a reason to take OPT?

Answer 53

a. if the patient came in for pericoronitis of first episode treat it clinically do not necessarily to take OPT. b. if you think there is something else going on and it is the second or third episode and you are thinking of removing them then take OPT

Question 54

54. why sectional tomography might be appropriate in some cases?

Answer 54

a. As we need to adhere to ALARA principle where sectional tomogram may be appropriate which means ‘’ avoiding exposure to radiation that does not have a direct benefit to you, even if the dose is small’’

Question 55

55. Give a brief about 3-D imaging Cone Beam CT

Answer 55

a. Digital technique that enables 3D analysis of area in question, particularly useful for third molars in both jaws with regards to local anatomy such as the inferior alveolar nerve canal, accessory canals and associated pathology. b. All CBCT’s must be justified demonstrating that the benefits outweigh the risks of the image, and that the image should potentially add new information to aid patient management. Routine use of CBCT is not advised and is unacceptable practice. c. Additional training is required for requesting and interpreting CBCT images (level 1 and 2 respectively) which should be completed in addition to the IRMER training as a postgraduate. d. CBCT should not be selected unless the history and clinical examination have been performed, ‘routine’ imaging is unacceptable practice. e. Thin slices with variable thickness <1mm f. Can be viewed in all planes Eliminates superimposition g. High contrast resolution h. CBCT reduction in dose Short scan time i. High resolution Interactive software Issues with artefacts

Question 56

56. How to report radiographic image?

Answer 56

a. You must use a systematic process b. A knowledge of normal radiographic anatomy is fundamental to reporting and recognition of abnormal findings. c. Key areas to focus on are: i. Teeth ii. Apical Tissues iii. Periodontal Tissues iv. Body and ramus of mandible v. Other structures d. If an abnormal finding is discovered, then a simple mnemonic of ‘S.T.O.P.’ can be used

Question 57

57. How to report specific lesion from a radiograph?

Answer 57

Describe systematically: a. Site/ anatomical position b. Size c. Shape d. Outline e. Relative radiodensity and internal structure f. Effect on adjacent structures g. Time present, if known

Question 58

58. What is mnemonic of ‘S.T.O.P.’?

Answer 58

a. If an abnormal finding is discovered in the radiograph, then mnemonic of ‘S.T.O.P can be used. i. S – Site ii. T – Translucency iii. O – Outline iv. P – Previous imaging, if possible, to compare with previous imaging

Question 59

59. What radiographical finding are considered as red flag?

Answer 59

a. Loss of symmetry and apparent soft tissue mass b. Distorted anatomy – displacement of teeth with no obvious cause c. Bony erosions – irregular borders d. Teeth floating in air – correlate with clinical finding

Question 60

60. What do we need to consider when assessing 3rd molars radiographically?

Answer 60

a. Relationship to vital structures b. Configuration of the roots c. Condition of the surrounding bone

Question 61

61. What are the key (adjacent) anatomical structures in relation to third molars?

Answer 61

a. Maxillary antrum and tuberosity b. Inferior alveolar nerve and associated vessels Lingual nerve c. Mylohyoid nerve d. Long buccal nerve

Question 62

62. What does the facial nerve branch that runs with the lingual nerve called? And what does it supply?

Answer 62

a. chorda tympani b. it supplies a little bit of taste

Question 63

63. What knowledge regard the nerves do we need to know to worn the patient?

Answer 63

a. We need to know what each nerve supply so we can worn the patient of the risks of the surgery.

Question 64

64. What does the Facial nerve supply?

Answer 64

a. It supplies the muscles of the facial expression

Question 65

65. Does trigeminal nerve supply facial expression?

Answer 65

a. It supplies sensation but, it doesn’t supply the muscles of facial expression

Question 66

66. Where is the ID nerve located? and what does it supply?

Answer 66

a. Inferior alveolar nerve runs through the lingula into the mandible and supplies the sensation to all of the lower teeth and the gingiva and exists through the mental foramen (usually between the apices of the premolars but not always). That terminal branch supplies the sensation to your lip and the skin of the chin b. The mandibular canal is present on radiographic imaging, and often can be in close association with the apices of the mandibular teeth.

Question 67

67. What does the mylohyoid nerve supply?

Answer 67

the mylohyoid nerve supplies a tiny bit of the skin, little part of the chin

Question 68

68. What does the lingual nerve supply?

Answer 68

a. the lingual nerve supplies the sensation of the tongue

Question 69

69. What does the long buccal supply?

Answer 69

a. It supplies little bit of buccal soft tissues sensation

Question 70

70. What does the ID canal contain?

Answer 70

a. Inferior alveolar artery – likely posterior/postero-lateral to nerve b. Inferior alveolar vein – no pattern, can be 2 veins, lateral to the bone c. Inferior alveolar nerve – likely anterior to the vessel

Question 71

71. What happen if the operator hits the inferior alveolar artery?

Answer 71

a. There would be a bit if arterial bleed, spurt but it’s minimal and it will stop with pressure

Question 72

72. What happen if the operator hits the inferior alveolar vein?

Answer 72

a. you will get blood but again will stop with the pressure.

Question 73

73. What problem might you face when you hit vessel and want to put pressure to stop the bleeding?

Answer 73

a. you don’t want to compress the nerve as you might cause nerve injury

Question 74

74. does the ‘lingula’ (the little tongue) has 1 shape only in all people?

Answer 74

a. there are variety of shapes [triangular, truncated, nodular etc) where about 25% of people got prominent lingula and it is thought that has relation to the success rate of IAN Block

Question 75

75. what are the signs on plain film imaging which suggest a close/intimate relationship between the canal and the third molar? (high-risk)

Answer 75

a. Deviation of the canal b. Narrowing of the canal c. Periapical radiolucent area d. Narrowing of the roots e. Darkening of the roots f. Curving of the roots g. Loss of the lamina dura h. Interruptions of the white lines i. Dark and bifid apex of the root

Question 76

76. With these signs the damage of the inferior alveolar nerve is expected to be higher. What could you consider in this case?

Answer 76

a. would consider carrying a CBCT scan

Question 77

77. Explain what Deflection of the root means?

Answer 77

a. If the roots appear deflected as they hit the superior boarder of the canal

Question 78

78. Explain what Narrowing of the roots means?

Answer 78

a. As they are close to the canal they’ve pinched almost around

Question 79

79. Explain what Darkening of the roots

Answer 79

a. Once the roots are in the canal or appears to be in the canal, the root apices are darker

Question 80

80. What does bifid apex of the root

Answer 80

a. Bifid (i.e. like 2 apices)

Question 81

81. Does inferior alveolar nerve have branches?

Answer 81

a. there have been many studies about different branches of the inferior alveolar nerve. So, sometimes there isn’t just one canal, we get accessory canals, retromolar canals and sometimes you only see them on CT and sometimes you cannot see them at all

Question 82

82. What do we need to look at regarding the configuration of the roots of the third molar?

Answer 82

a. Number of roots b. Curvature of roots c. Degree of root divergence d. Size & shape of roots i. bulbous, conical, long, short, hooked e. Other i. root resorption, caries, anyklosis

Question 83

83. What do we need to consider when look at the condition of the surrounding bone in terms of the third molar removal surgery assessment?

Answer 83

a. Density determines difficulty b. Radiographs often unreliable c. Age is a good determinant

Question 84

84. Compare between the surrounding bone condition of 2 different age categories:

Answer 84

a. < 18 yo: Less dense, Pliable, Expands Bends, Easier to cut / expand b. >35 yo: Much denser bone, Decreased flexibility, Decreased ability to expand, More bone removal required, Higher risk of #

Question 85

85. What are the PREDICTIVE FACTOR of difficulty of surgery that dictate amount of bone required to be removed

Answer 85

a. Alveolar bone level b. Tooth position c. Application depth d. Point of elevation

Question 86

86. What can increase the risk of complications?

Answer 86

a. Underlying systemic disease b. Age c. Anatomical position of tooth and root morphology d. Local anatomical relationships e. Status of adjacent teeth f. Access g. Patient co-operation / compliance h. Bone density i. Ankylosis j. Infection k. Pathology

Question 87

87. Can the maxillary third molar extractions be an issue?

Answer 87

a. It could be an issue but, 95% of the time are straightforward

Question 88

88. What are the possible problems with this third molar removal?

Answer 88

a. OAC – oral-antral communication b. Fracturing maxillary tuberosity which also can cause OAC. Behind that there are very big vessels (e.g. hitting the branch of maxillary artery)

Question 89

89. What are the adjacent anatomical structures of the maxillary third molars that we need to be aware of?

Answer 89

a. The antrum b. Tuberosity

Question 90

90. What should you do If you took the tooth out and the tuberosity looks big and it’s bleeding?

Answer 90

a. the best thing is to put it straight back

Question 91

91. what should you do If the soft palate starts to move, when you are moving the tooth or tears?

Answer 91

you need to stop

Question 92

92. What other complication can result with maxillary third molar removal other than breaking the tuberosity and causing OAC?

Answer 92

a. You can push the tooth hard and it disappear as it’s gone into the antrum

Question 93

93. What does the consent need to include?

Answer 93

a. It must include standard surgical warnings: i. Pain, Swelling, Bleeding, Bruising, Infection, Sutures, TMJ, A.O. Damage, OAC, Fracture, and Medical

Question 94

94. What are the specific warnings for mandibular third molar surgery? If you are taking mandibular third molar you must worn the patient about:

Answer 94

a. Inferior alveolar nerve b. Lingual Nerve c. Chorda Tympani d. Loss or altered sensation (often a painful sensation) which can be temporary or permanent to the lower lip, skin of the chin, gums of the teeth, lower teeth and tongue and taste. e. The altered sensation can be painful similar to neuralgia or a 'tingling' sensation f. >2% permanent but if high risk can be up to 10% - specific to individual >5% temporary – if it is there after 6 months then it is permanent g. Stiff jaw because they might get TMJ pain h. Trismus i. Time off work j. Significant swelling and bruising which can spread to the neck / chest k. Rarely hospital admission requiring treatment

Question 95

95. What are the risks and complications of the third molar surgery that need to be listed in the consent?

Answer 95

a. Stiff Jaw, Nerves, Sinus b. Pain, Swelling, Bleeding, Bruising, Infection, Dry socket, and Damage to adjacent teeth

Question 96

96. What are the trigeminal nerve branches?

Answer 96

a. Ophthalmic (V1) b. Maxillary (V2) c. Mandibular (V3)

Question 97

97. Is there any difference between the risks of surgical extraction undertaken under LA/ GA? Justify your answer.

Answer 97

a. The likelihood of swelling, infection and nerve injury is much greater with junior dentist and under GA than LA because people are less carful during GA than LA as the patient is not responsive

Question 98

98. What do you need to do if you have seen signs indicating that the patient is at high risk group?

Answer 98

a. If there are increased risk signs on imaging discuss with patient might be b. SHOW the patient the image and use pictorial representation c. CONSIDER their individual risk factors d. AND your experience

Question 99

99. What are the possible treatment options of third molars?

Answer 99

a. Conservative Management / monitor b. Operculectomy c. Complete extraction of third molar d. Coronectomy of third molar

Question 100

100. What can you provide with Conservative +/- review or monitor treatment option?

Answer 100

a. Review at appropriate intervals, patient to come back if deteriorates If specialist can discharge back to GDP for monitoring. b. Useful to give patients written information which includes advice

Question 101

101. What is operculectomy? Give a brief.

Answer 101

a. Mandibular third molars which are partially erupted, and food is getting trapped in the operculum – removal of the operculum may improve symptoms. This does not always relieve the symptoms sufficiently. b. Extraction of the opposing maxillary third molar c. As with patients suffering with the operculum, it is acceptable to remove the opposing maxillary third molar if this is likely to be non-functional and carries a low risk of complications. You should remember the specific risks relating to extraction of maxillary third molars which can include fracture of the maxillary tuberosity, which could lead to oro-antral communication

Question 102

102. What is coronectomy? Give a brief.

Answer 102

a. Intentional removal of only the crown (all the enamel) of the third molar reduces the likelihood of nerve injury in those which are high risk. An awareness of this procedure is required at undergraduate level and the procedure is technique sensitive and not all patients are suitable for the procedure. b. Although the technique has its place, it is contentious and starting to become recognised as an appropriate alternative to reduce the risk of nerve injury. c. Patient selection, (as is additional training) key to success, non-compromised patients with good healing potential, ideally teeth which are healthy and no intra-pulpal pathology. d. Patients should also be warned about the risks of the procedure, including that if the roots become mobile during the procedure they must be removed, the risk of post-operative infection and/or alveolar osteitis, potential for re-operation rate (0-2%), root migration rate (13-33%) and how technique sensitive it is.

Question 103

/103. What is the technique for third molar removal?

Answer 103

a. Local anaesthesia i. Maxillary third molars: Buccal and palatal infiltrations (lidocaine or articaine) ii. Mandibular third molars: Inferior alveolar, lingual and long buccal nerve blocks (lidocaine) OR Inferior alveolar, lingual and buccal infiltrations (articaine) b. LA + Intra venous sedation (conscious sedation) i. Patient ii. Procedure c. LA + GA i. Patient ii. Procedure iii. Risks