Sách hướng dẫn chi tiết nhổ răng khôn, là sách gối đầu của các bác sĩ Tiểu phẫuPhẫu thuật trong miệng. Sách hướng dẫn chi tiết nhổ răng khôn, là sách gối đầu của các bác sĩ Tiểu phẫuPhẫu thuật trong miệng. Sách hướng dẫn chi tiết nhổ răng khôn, là sách gối đầu của các bác sĩ Tiểu phẫuPhẫu thuật trong miệng.
Clinical Success in Impacted Third Molar Extraction J.-M KORBENDAU D.D.S., M.S X KORBENDAU D.D.S Associate Professor Faculty of Dentistry University Paris 5, France Private practice Oral Surgery France Contributors J.-F ANDREANI M.D Maxillofacial Surgeon Paris, France C DUNGLAS D.D.S Qualified Orthodontist Assistant Professor Faculty of Dentistry University Paris 5, France Translation M.-P HIPPOLYTE Periodontist Assistant Professor University of Reims, France www.pdflobby.com Paris, Chicago, Berlin,Tokyo, Copenhagen, London, Milan, Barcelona, Istanbul, São Paulo, New Delhi, Moscow, Prague, and Warsaw www.pdflobby.com Jean-Marie KORBENDAU D.D.S., M.S Associate Professor Faculty of Dentistry University Paris 5, France Xavier KORBENDAU D.D.S Private practice Oral Surgery France Jean-Franỗois ANDREANI M.D Maxillofacial Surgeon Paris, France Christophe DUNGLAS D.D.S Qualified Orthodontist Assistant Professor Faculty of Dentistry University Paris 5, France First published in French in 2002 by Quintessence International, Paris L’extraction de la dent de sagesse © Quintessence International, 2003 11 bis, rue d’Aguesseau 75008 Paris France Some of the product names, patents, and registered designs referred to in this book are registered trademarks or proprietary names even though specific reference to this fact is not always made in text Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publishers that the product is in the public domain All rights reserved This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without www.pdflobby.com prior written permission of the publisher www.pdflobby.com Acknowledgments The computerized radiographic images and the CT examination presented in this textbook were provided by Drs Pascal Guinet, Alain Lacan, Philippe Katz and Danielle Pajoni We gratefully acknowledge their contribution and the quality of their documentation www.pdflobby.com Table of Contents Cover Table of Contents Third molar extraction: Why and when? Embryology and eruption of the third molars Developmental prognosis and eruption axis of the third molar Indications requiring the use of orthodontic techniques Third molar and DMD Therapeutic occlusion and third molars Relapse of anterior tooth crowding and its effect on the third molar Developmental anomalies Terminology The follicular cyst Pericoronitis Complications Spread of infection The mandibular third molar Selection of radiographic examinations Dental panoramic radiograph Periapical radiograph Computerized tomography Classification: Clinical aspects www.pdflobby.com The shape of the tooth The anatomic situation of the tooth Nerve block anesthesia: Technique and failure assessment Anesthesia of the inferior alveolar nerve Additional anesthesia Anesthetic procedures for the upper oral regions Surgical protocol: Basic principles Instrumentation Incision lines Elevation of a full-thickness flap Bone removal Sectioning the retained tooth Alveolar socket evaluation Suture Germectomy Indications for germectomy At what age should treatment start? Surgical protocol The mesially inclined third molar Radiographic interpretation Degree of surgical difficulty The horizontal third molar Radiographic interpretation Surgical protocol Degree of surgical difficulty 10 The vertical third molar Radiographic interpretation www.pdflobby.com Degree of surgical difficulty 11 The distally inclined third molar Radiographic interpretation Degree of surgical difficulty The maxillary third molar 12 The maxillary third molar: Examination and extraction Anatomic specificities Degree of surgical difficulty Anesthesia in the maxilla Surgical protocol 13 Patient management First appointment Surgical phase Postsurgical phase Management of the healing process References www.pdflobby.com Third molar extraction: Why and when? 10 www.pdflobby.com 12-18a Simple flap Ratio C crown-root, with a slight mesial inclination Impacted right maxillary third molar in a 16-year-old female patient The thickening of the follicular tissue facilitates extraction The alveolar wall of the second molar is not resorbed The intraosseous eruption has been interrupted, while root development is almost complete The radiograph does not indicate any existing palatal root Note the relationships between the tooth and the sinus 12-18b The starting point of the retromolar incision is diverted toward the buccal aspect in order to facilitate flap elevation The releasing incision is avoided if the operator has not planned extensive bone removal It may still be undertaken during surgery if necessary 12-18c After reflecting the intermolar gingival papilla, the clinician elevates the marginal gingiva using a blunt elevator, from front to rear The periosteum is carefully removed The bone table has become thin because of the thickening of the follicular tissue Crown exposure does not present any difficulty 191 www.pdflobby.com 12-18d The almost complete formation of diverging roots might have represented an unpredictable presurgical complication The tooth is retained despite a certain amount of crown mobility Distal exposure has been continued to avoid fracturing the tuberosity during tooth luxation 12-19a Triangular flap Ratio C crown-root, located in a high position on the gingiva Impacted right maxillary third molar in a 25-year-old female patient In order to remove some of the cortical bone, a large area of access is required Here, the clinician has made an anterior vertical releasing incision, extending from the bottom of the vestibule up to the gingival papilla between the premolar and the molar 12-19b The alveolar mucosa is held taut in a vertical direction to facilitate the perpendicular penetration of a no 15 blade into the bone The blade meets the center of the papilla, which covers the outer slope of the interdental septum In order to avoid gingival recession, it is preferable that the releasing incision does not cross the marginal gingiva, which lies on an avascular cementum surface 192 www.pdflobby.com 12-19c The rounded bur mounted on the handpiece used at low speed and with adequate irrigation is less aggressive and likely to cause less damage than the spindle-shaped bur, which has greater cutting ability, but is less safe for use on the soft tissues in the maxilla 12-19d Using the tip of a fine right elevator (Warwick or Cryer) or the narrow blade of an elevator positioned against the cementoenamel junction of the retained tooth, the clinician can displace the crown buccally and distally There should be no resistance to this luxation, and the tactile sense of the clinician is essential Any bony obstruction can be removed in more difficult cases 193 www.pdflobby.com Patient management First appointment Surgical phase Postsurgical phase Management of the healing process 194 www.pdflobby.com First appointment Patient interview In addition to the medical questionnaire that is systematically completed by the patient, the surgeon should ask the following questions: • Do you receive regular medical checkups? • Do you take medications on a regular basis? • Do you take aspirin? • Do you have allergic reactions? • Have you experienced spasms? Before deciding on the presurgical prescription, the patient’s medical history must be assessed for pericoronitis Clinical examination After extraoral and intraoral examination, the clinician will be able to provide all relevant information pertaining to the surgical phase It is essential to inform the patient of the possible risks if treatment is not carried out, as well as the risks inherent in the surgical treatment It is strongly advised to give the patient an informed consent form, which clearly explains the possible incidents and accidents that may occur during and after surgery This informed consent does not disengage the clinician’s responsibility in any case However, in case of litigation, it will prove that the patient had been fully informed of the risks; this is a (legal) forensic obligation Specific instructions prior to oral surgery The clinician should give an instruction form to the patient This form summarizes the presurgical precautions previously mentioned, as well as the postsurgical recommendations to limit inflammatory reactions and avoid complications Following is an example of the information to be provided Before surgery In order that your surgery—carried out under local anesthesia—can be performed under optimal conditions, you should observe the following recommendations: • Do not take any salicylic acid (aspirin and derivatives) during the 10 days preceding surgery 195 www.pdflobby.com • Take the prescribed medications • Avoid smoking and alcoholic drinks during the 12 hours preceding surgery • Eat normally during the hours preceding surgery After surgery In order to ensure rapid healing and to avoid complications, you must observe the following recommendations During the first 24 hours following surgery: • Immediately after surgery, keep biting on the gauze placed between your teeth at the site of the operation (Replace the gauze three times.) • Apply an ice pack as soon as possible to the surgical site for 15 minutes every half hour during the first hours following surgery This simple precaution will limit edema and bleeding • Take the prescribed medication, even if you feel no pain and observe no edema during the first few hours • Avoid hot food and drinks • Do not smoke • Avoid mouthrinses In the case of slight bleeding, you may rinse with cold water if necessary and then bite on one or two folded gauze pads placed on the wound • If you lie down, keep your head in a raised position During the first week following surgery: • If bleeding continues, rinse with cold water then bite on a gauze pad placed on the wound; the gauze pad should be renewed every 10 minutes Inform the surgeon • Brush your teeth using cold water but avoid the area of surgery • Take all medication for the exact period of time specified on the prescription Radiographic examination A standard presurgical radiograph is obtained routinely, but may be complemented with a CT scan where necessary Presurgical medication 196 www.pdflobby.com Analgesics A salicylate-free analgesic is given to the patient 30 minutes prior to surgery Antibiotics Antibiotics are prescribed in all cases where there is: • A general medical history of valvular heart diseases, diabetes, or kidney or immunologic pathologies • A local medical history of pericoronitis or radiolucent images suggesting some defect Anxiolytics Where the prescription of anxiolytics is deemed necessary, a restroom should be made available and the patient should be accompanied by two other people Surgical phase Patient care The surgical team must ensure that surgery will be carried out efficiently, but regardless of the quality of the surgical technique, the following points should always be emphasized: • Before surgery: It is essential to ensure that the patient (adolescent or adult) feels confident The success of the surgical phase, especially under local anesthesia, depends on the relationship between the clinician and the patient established at the first appointment Confidence in the clinician and the procedure is preferable to the prescription of anxiolytics • During surgery: The patient should be monitored continually, and premonitory signs of faintness must be detected immediately (eg, sweating, dyschromia, finger dysesthesia) • After surgery: The postsurgical instructions should be repeated The instruction form given to the patient at the first appointment should be explained once again Postsurgical phase 197 www.pdflobby.com Postsurgical medication Analgesics During the first 24 hours, analgesics are prescribed routinely; after this time, they are used only when required Antibiotics In the case of a significant medical history as described above or when a large area of bone has been exposed, antibiotics are systematically prescribed Anti-inflammatory medications It is essential that either steroidal or nonsteroidal anti-inflammatory agents should be prescribed to supplement the antibiotic prescription Mouthrinses Mouthrinses should only be used 24 hours after surgery Follow-up appointments The first follow-up appointment is usually planned for days after surgery Prior to this visit, the patient is expected to have strictly observed the postsurgical instructions in order to ensure rapid tissue healing and avoid complications Suture removal In cases where the patient suffers from anxiety, the clinician may use resorbing sutures (fast Vicryl), to overcome the fear of suture removal in many patients However, the cutting and removal of sutures is in most cases painless Nevertheless, it is essential to use sharp, pointed scissors and ensure that the sutures have been completely removed Remnants of suture material may lead to infection Healing times vary among patients; therefore, it is sometimes prudent to wait an additional days before suture removal Hygiene After suture removal, the patient will find it more comfortable to begin brushing the surgical site again using a surgical toothbrush During the 198 www.pdflobby.com weeks following surgery, patients are advised to complete the three daily brushings with two mouthrinses using a 0.2% chlorhexidine gluconate solution because a properly cleaned wound will heal much more rapidly Although cessation of smoking is mentioned in the postsurgical instruction form, the clinician should reemphasize the adverse effects of tobacco on soft tissue healing at each follow-up visit after surgery Management of the healing process Wound closure The clinician will be dealing with the following three possible situations Impaction After the tooth has been extracted and the socket cleaned, the flap is replaced in its original position The soft tissue and retromolar gingival regions are then sutured edge to edge and the anterior portion of the flap is carefully repositioned The first stage of the healing process can then take place Sutures may be removed week later This type of surgery is frequently undertaken in cases of germectomies or extractions carried out on young adults Partial impaction In the case of a partially impacted tooth, it is not possible to achieve a tight (hermetic) seal after extraction The mucosal portion of the incision is sutured edge to edge and the anterior sulcular extension is closed as previously described The gingival retromolar edges are trimmed and the lips of the wound joined using a tension-free suture above the socket The suture located against the distal aspect of the second molar is meant to protect the bone septum and the root surface of the tooth, which may have been exposed Attachment loss In the presence of periodontitis, the sulcular incision is replaced by an inner beveled incision The epithelial wall of the periodontal pocket is eliminated and the root surface is treated Extraction of the third molar is carried out at the same stage and the distal aspect of the second molar is carefully cleaned in order to facilitate the new attachment 199 www.pdflobby.com In these three cases, the clinician must check the periodontal environment of the (adjacent) molars during the overall tissue-healing process After a surgical separation, tissues will reattach The biologic repair process rebuilds the structural and functional integrity of the tissue concerned (Schroeder) The junctional epithelium regenerates, starting from the basal layer, in less than days In the supra-alveolar region, the root surfaces are lined with sectioned collagen fibers These tissue remnants allow reattachment of the fiber system (Shroeder) This is why the anterior portion of the flap must be compressed for a few minutes using a gauze pad following the suturing of the interdental papilla The clot must be reduced in order to achieve primary healing Healing of the alveolar ridge During the first week, granulation tissue replaces the clot As early as the second week, newly formed connective tissue appears at the bottom of the socket, and the bone trabeculae develop, starting from the socket walls After or weeks, the lamina dura can no longer be seen on a radiographic image The alveolar ridges (lingual and buccal) of the socket re-form and become rounded; however, it is at the distal root level of the second molar that a defect may occur at varying depths in the socket Numerous longitudinal studies have already pointed out the problem of healing in this region The conclusions of these studies have some influence on our treatment outcomes: • In most cases, extractions carried out before the age of 25 years not result in any bone loss after years of follow-up (Marmary et al; Kugelberg et al) • Conversely, intrabony pockets are more common among adult patients over the age of 25 years Therefore, the patient’s age is the most important factor in the ad integrum repair process • The proximity of the crown of the second molar to its root is not a pathological factor when the tooth is impacted and no proximal root resorption occurs If the tooth is impacted, the denuded root cementum surface is not contaminated by bacteria In ratio C crown-root situations, the surgical protocol for extraction must allow for the protection of the cementum and the residual interdental bone Tissue repair thus becomes the main concern 200 www.pdflobby.com • However, in cases where the retained tooth is no longer impacted, the bone crypt then communicates with the oral cavity, sometimes for several years This situation may thus lead to interdental bone resorption with subsequent cementum damage • In all cases, postsurgical follow-up and the practice of careful oral hygiene by the patient are essential in order to manage tissue repair, given that the bone, which resorbs during the first days of healing, recovers its initial presurgical level after about 10 weeks in patients younger than 25 years 201 www.pdflobby.com References Akinosi JO A new approach to the mandibular nerve block Br J Oral Surg 1977;15:83–87 Alling CC, Helfrick JF, Alling RD Impacted Teeth Philadelphia: Saunders, 1993 Asanami S, Kasazaki Y Expert Third Molar Extractions Tokyo: Quintessence, 1993 Björk A, Jensen E, Palling M Mandibular growth and third molar impaction Eur J Orthod 1956;32:164–167 Blakey GH, White RP Jr, Offenbacher S, Phillips C, Delano EO Clinical/biological outcomes of treatment for pericoronitis J Oral Maxillofac Surg 1996;54:1150–1160 Bremer G Measurements of special significance in connection with anesthesia of the inferior alveolar nerve Oral Surg 1952;5:966–988 Brickley M, Sheperd J, Mancini G Comparaison of clinical treatment decisions with US National Institutes of Health consensus indications for lower third molar removal Br Dent J 1993;175:102–105 Cahill DR, Marks SC Jr Tooth eruption: Evidence for the central role of the dental follicle J Oral Pathol 1980;9:189–200 Charon J, Joachin F, Sandelé P Parondontie clinique moderne—de la littérature la réalité Paris: CdP, 1995 Charron C Y a t-il une relation entre l’encombrement incisivo-canin et l’éruption de la troisième molaire? Orthod Fr 1977;48:217–222 Commissionat Y, Roisin-Chausson MH Lesions of inferior alveolar nerve during extraction of the wisdom teeth Rev Stomatol Chir Maxillofac 1995;96(6):385–391 Craig RM, Wescott WB, Correll RW A well-defined coronal radiolucent area involving an impacted third molar J Am Dent Assoc 1984;109:612–613 Darque F La dent de sagesse (Question mise en discussion) Orthod Fr 1989;60:375 Gaudy JF L’anesthésie maxillaire Real Clin 1991;2(1):33–49 Ginestet G Chirurgie stomatologique et maxillo-faciale Paris: Flammarion, 202 www.pdflobby.com 1963 Glosser JW, Campbell JH Pathologic change in soft tissues associated with radiophically normal third normal impaction Br J Oral Maxillofac Surg 1999;37:259–260 Gow Gates GEA Mandibular conduction anesthesia: A new technique using extraoral landmarks Oral Surg Oral Path Oral Med 1973,36:321–327 Halverson BA, Anderson WH 3rd The mandibular third molar position as a predictive criteria of risk for pericoronitis: A retrospective study Mil Med 1992;157(3):142–145 Howe GL Minor Oral Surgery, ed Bristol: Wright & Sons, 1971 Jouan E, Pajoni D Scanner dentaire in Scanner rayons X Paris: Masson, 2000 Kiesselbach JE, Chamberlain JG Clinical and anatomic observations on the relationship of the lingual nerve to the mandibular third molar J Oral Maxillofac Surg 1984;42:565–567 Korbendau JM, Guyomard F Chirurgie parodontale orthodontique Paris: CdP, 1998 Kugelberg CF, Ahlström U, Ericson S, Hugoson A, Kvint S Periodontal healing after impacted lower third molar surgery in adolescent and adults A prospective study Int J Oral Maxillofac Surg 1991;20:18–24 Lacan A Nouvelle imagerie dentaire Paris: CdP, 1993 Lee DK, Kim BJ The relation of pericoronitis to the position of the mandibular third molar [in Korean] Taehan Chikkwa Uisa Hyophoe Chi 1989; 27(2):201–209 Liedholm R, Knutsson K, Lysell L, Rohlin M Mandibular third molars: Oral surgeons’ assessment of the indications for removal Br J Oral Maxillofac Surg 1999;37:443–450 Lindhe J Clinical Periodontology and Implant Dentistry Copenhagen: Munksgaard, 1997 Lysel I, Rohlin M A study of indications used for removal of third molar Int J Oral Maxillofac Surg 1988;17:161–164 Madrid C, Caballero R, Duran D, Bru de Sala C L’anesthésie mandibulaire Real Clin 1991;2(1):51–68 Mailland M Techniques de radiologie dentaire Paris: Masson, 1987 203 www.pdflobby.com Main DM Follicular cyst of mandibular third molar teeth: Radiological evaluation enlargement Dentomaxillofac Radiol 1989;18(4):156–159 Marks SC Jr, Cahill DR Ultrastructure of alveolar bone during tooth eruption in the dog Am J Anat 1986;177:427–438 Marmary Y, Brayer L, Tzukert A, Feller L Alveolar bone repair following extraction of impacted mandibular third molars Oral Surg 1986;60:324– 326 Mozsary PG, Middleton RA Microsurgical reconstrution of the lingual nerve J Oral Surg 1984;42:415–418 NIH Consensus development conference for removal of third molars J Oral Surg 1980;38:235–236 Pajoni D La radiographie panoramique Lecture, pièges, limites Rev Odontostomatol (Paris) 1992;21:449–466 Parant M Petite chirurgie de la bouche, éd Paris: L’expansion, 1963 Pell GJ, Gregory GT Impacted mandibular third molars; Classification and modified technique for removal Dent Dig 1933;39:330 Punwutikorn J, Waikakul A, Ochareon P Symtoms of unerupted mandibular third molars Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87(3):305–310 Richardson ME The early developmental position of the lower third molar relative to certain jaw dimensions Angle Orthod 1970;40(3):226–230 Richardson ME Some aspects of lower third molar eruption Angle Orthod 1974;44(2):141–145 Richardson ME The relative effects of the extraction of various teeth on the development of mandibular third molars Trans Eur Orthod Soc 1975:79– 85 Richardson ME Pre-eruptive movements of the mandibular third molar Angle Orthod 1978;48(3):187–193 Richardson ME Late third molar genesis: Its significance in orthodontic treatment Angle Orthod 1980;50(2):121–128 Ricketts RM Bioprogressive therapy as an answer to orthodontic needs Am J Orthod 1970;3:241–257 Ricketts RM Studies leading to the practice of abortion of lower third molars Dent Clin North Am 1979;23:393–411 204 www.pdflobby.com Schroeder HE Biopathologie des structures orales Paris: CdP, 1987 Schulhof RJ Third molar and orthodontic diagnosis J Clin Orthod 1976;10:272–281 Sentilhes C Indications for wisdom tooth germectomy Rev Odontostomatol (Paris) 1988;17(3):199–209 Silling G Development and eruption of the mandibular third molar and its response to orthodontic therapy Angle Orthod 1973;43:271–278 Ten Cate AR Oral histology Development, Structure, and Function, ed St Louis: Mosby, 1984 Turley P, Chaconas S A computerized method of forecasting third molar space in the mandibular arch AADR Abstr 1985 Tweed C Clinical Orthodontics St Louis: Mosby, 1966:423 Van Der Linden FPGM Aspects théoriques et pratiques de l’encombrement de la denture humaine Rev Orthop Dento Faciale 1971;9:329–352 Van Der Linden FPGM Development of the Dentition Chicago: Quintessence, 1983 Winter GB, ed Principles of Exodontias As Applied to the Impacted Third Molar St Louis: American Medical Books, 1926 Worrall SF, Riden K, Haskell R, Corrigan AM UK National Third Molar project: The initial report Br J Oral Maxillofac Surg 1998;36:14–18 205 www.pdflobby.com ... difficulty 11 The distally inclined third molar Radiographic interpretation Degree of surgical difficulty The maxillary third molar 12 The maxillary third molar: Examination and extraction Anatomic... inclined impacted right mandibular third molar The alveolar wall of the second molar remains intact despite the condition of the third molar Note the fenestration of the lingual cortical bone in. .. of infection Acute pericoronitis may be the starting point for the spread of bacterial infection and inflammation, the clinical forms of which vary according to the condition of the third molar