DCA03TM Third Molar Surgery, 5th Edition _____________________________________________________
INTRODUCTION Treatment philosophy toward the extraction of third molars (wisdom teeth) varies in different developed countries. It ranges from observation in many countries in Europe to a prophylactic removal approach in the U.S. A more proactive stance on often asymptomatic wisdom teeth extraction takes into consideration chronic inflammation that is related to the impacted wisdom teeth and its influence on the patient’s overall health; age of the patient; relative ease of early extraction (before full root development); difficulty of removal/type of impaction; and proximity to the inferior alveolar nerve, lingual nerve, and maxillary sinus. This approach is also often called preventive surgical treatment , and it can be done under local anesthesia, oral sedation with or without nitrous oxide inhalation sedation, or intravenous sedation, with the level of sedation corresponding to the nature of the surgery and the patient’s level of anxiety about the procedure. This basic-level course will provide a review of the classifica- tion of impactions of third molars in relation to their position relative to contiguous anatomical structures such as the second molar, the adjacent bone, and the oral mucosa, as well as the relative surgical difficulty associated with the extraction of impacted wisdom teeth. It will help general dentists determine if they have the surgical and patient management skills neces- sary to extract an impacted wisdom tooth in an atraumatic fashion while minimizing postsurgical complications such as trauma to the inferior alveolar nerve, the lingual nerve, and the maxillary sinus. The course highlights some of the com- mon surgical instruments and techniques employed for the extraction of impacted wisdom teeth. It is important to note, however, that the instrument selection and techniques described are not an exhaustive list and that each clinician must decide which are the most appropriate for the specific extraction for the patient. No surgical technique is without the potential for complications, and the most serious complications resulting from the extraction of wisdom teeth involve trauma to the inferior alveolar or lingual nerves, which can result in temporary or permanent adverse neurosensory changes. A discussion of the anatomical relationships between the inferior alveolar nerve and the lingual nerve relative to the roots of impacted mandibular wisdom teeth provides course participants with information about surgical neurosensory risks that must be discussed with the patient before the surgical procedure begins. This course will provide dental clinicians with empirical information about impacted wisdom teeth, the potential difficulty of their extraction, and postsurgical complications. Clinicians can use this information to deter- mine if their surgical expertise is at a high enough level for the extraction of an impacted wisdom tooth or if they should refer such patients to an oral surgeon.
CLINICAL PRESENTATION A change in diet and chewing efficiency over thousands of years has influenced the human stomatognathic musculoskeletal system. More refined food requires less effort in mastication and, over time, has led to a decrease in the strength of muscles used for mastication, an overall decline in jaw development, a reduction in density of the jawbone, and a reduction in the amount of chewing molar teeth need to grind food (Gkantidis et al., 2021). One of the obvious results of these developmental gnathologi- cal changes has been a decrease in space for all 32 teeth in the dentition, often leaving the last four third molars (wisdom teeth—teeth that erupt at the time of maturity or wisdom) sur- rounded by soft tissue and bone behind the second molars in the posterior quadrants of the jaws (retromolar areas). These impacted teeth that are “stuck” behind the second molars commonly become a source of food retention and difficulty with oral hygiene, causing signs and symptoms associated with impacted third molars. Most cases of impacted teeth result from a deficiency of adequate space in the dental arch, which prevents the unimpeded eruption of a third molar. Theories such as the orthodontic theory suggest that the disruptions of the developmental growth of the jaw and teeth or the Mende- lian theory which postulates that inherited discrepancies in the size of the jaw and teeth favor the impaction of the mandibular third molars (Adeola, et.al., 2023). The most common local signs and symptoms of impacted third molars are intermittent pain and swelling. Occasionally, difficulty with swallowing (dysphagia) also occurs. The initial symptoms often appear at the time of eruption, which occurs around ages 13 to 19 (earlier in girls, later in boys). The pain can disappear spontaneously with or without antibiotic treat- ment and often returns later. These symptoms arise from the difficulty of cleaning retained food underneath the pericoronal flap of gingival tissue behind the second molar. Deep pockets (often 10 mm or more) between impacted third and erupted second molars are a perfect environment for bacterial coloni- zation. Because of a lack of oxygen, the bacterial colonies in these deep periodontal pockets are predominantly composed of obligate and facultative anaerobic species, which can become aggressive and subsequently extend into adjacent spaces (Caymaz and Buhara, 2021). An inflammatory condition usually starts intraorally, with the pericoronal tissues redden- ing and swelling (pericoronitis), and then can spread to the adjacent tissues and become visible extraorally (cellulitis). The inflammation then quickly progresses into an infectious stage of a fluctuant infiltrate: An abscess. The symptoms can worsen quickly, within two to three days, if the infection spreads into the deep tissue planes. Odontogenic space infections, such as submandibular, submental, and sublingual infections, can result. A more dangerous local space infection, such as
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