_____________________________________________________ DCA03TM Third Molar Surgery, 5th Edition
Ludwig’s angina (bilateral involvement of all three mentioned spaces), can cause sepsis and spread to the neck and chest cavity, including the pericardial sac (An et al., 2022). General symptoms of infection because of bacteremia, such as malaise, fever, and headache, add to the clinical presentation of third molar–related infection. An anaerobic bacterial infection of a third molar with Peptostreptococcus and Actinomyces with beta- lactamase-producing species such as Prevotella , Fusobacterium nucleatum , Bacteroides , or other species often begins as acute pericoronitis, complicating the progression and treatment of the disease (Kwon and Serra, 2022; Huang et al., 2020). Under these circumstances, a quick and unfortunate evolution from a benign-looking pericoronal inflammation around the impacted wisdom tooth can lead to an aggressive and refractory bacterial infection that can extend into proximate muscle and fascial layers and can occasionally lead to death from severe intoxication and toxic shock, airway compromise, and other respiratory or systemic impairments (Kwon and Serra, 2022). The phrase “the tooth can kill” applies to these late and ful- minant complications of odontogenic infection in some cases.
There are many classifications of third molar impactions. Clinicians most commonly use a classification of impacted wisdom teeth based on the relative position of third molars to second molars. According to this classification, there are vertical, mesioangular, distoangular, horizontal, and inverted impactions of third molars (Choi et al, 2025). There is also a classification of third molars into lingual and buccal versions that stresses the projection of the roots toward the lingual cortex or buccal cortical plate. Another classification surgeons and insurance companies routinely use estimates the depth of the impaction and related difficulty of the surgery. It describes third molars with different degrees of “submergence” into the soft and hard tissues and includes full (complete) bone impaction, partial bone impac- tion, and soft tissue impaction. It is well accepted that full bony horizontal and distoangular impactions are among the most difficult third molar teeth to remove, given the obstruction of the overlying alveolar bone and the position of the ascending ramus of the mandible (Choi et al., 2025). RISKS AND COMPLICATIONS OF THIRD MOLAR EXTRACTION Any surgical procedure has inherent benefits and risks. The benefits of a particular surgery should be obvious and over- shadow the risks in order for the procedure to be recommended to patients. Although complications of third molar surgery are uncommon, they do occur and must be explained to every patient preoperatively. The patient must also be informed of the benefits and alternatives. In this way, the patient can make an informed decision to proceed or decline the procedure. As an acknowledgment of this understanding, an informed consent document should also be signed before the surgery. Risks of third molar surgery include postoperative infection (wound infection), bleeding, dry socket, sinus infection, oroantral communication, injury to the adjacent tooth, root fracture and displacement, neurosensory changes (numbness), and fracture of the mandible. Most postoperative complica- tions (e.g., bleeding, dry socket, postoperative infection) are minor and usually resolve with treatment within days or weeks. Some of these complications (e.g., neurosensory changes of the lingual and inferior alveolar nerves and oroantral [sinus] communications) can linger over weeks and months, and some may become permanent. Furthermore, the general status of the patient can signifi- cantly influence recovery from the surgery. A patient with an immunocompromised condition, such as a patient with HIV/ AIDS with neutropenia, that is, a neutrophil count <500 cells/ mm 3 , may be at an increased risk of developing postoperative infections. Prophylactic antibiotic therapy and postsurgical antibiotics may be indicated in these cases (Juras et al., 2024).
Self-Assessment Question 1
1. Difficulty in swallowing is known as: A) Apnea.
B) Dysgeusia. C) Dysphagia. D) Neuralgia.
CLASSIFICATION AND SURGICAL MANAGEMENT
One of the major considerations of wisdom tooth surgery and the decision to proceed or observe relates to the depth of impaction and position of the third molar relative to the surrounding important structures. Maxillary third molars, in general, are known to be less difficult extractions than mandibular extractions because the maxillary bone is less dense. Mandibular third molars are often more difficult teeth to remove because of an increased density of the surrounding bone, a lack of sufficient space between an ascending ramus and the erupted second molar, a deep and often abnormal tooth position (horizontal, reverse, angular impactions), and proximity of the nerve structures (inferior alveolar, lingual) and inferior border of the mandible (Trachoo et al., 2024). With age, bone density increases, making the extraction of an impacted wisdom tooth more difficult, with an increased potential for postsurgical complications (Jeyashree and Kumar, 2022). This situation, as well as the emerging evidence estab- lishing the connection between chronic dental inflammation and systemic conditions, has led to the development of a prophylactic philosophy of third molar extraction (Vranckx et al., 2021).
129
EliteLearning.com/Dental
Powered by FlippingBook