Term Paper on "Third Mandibular Molar Extraction Complications of Impacted"

Term Paper 20 pages (6395 words) Sources: 1+

[EXCERPT] . . . .

Third Mandibular Molar Extraction

Complications of Impacted Wisdom Teeth Extraction Surgery

Types of Impacted Mandibular Third Molars

The third molars are often referred to as the "wisdom teeth." We have one set of mandibular and one set of maxillary third molars. They are some of last teeth to come in and usually arrive sometime between 17 and 25 years old. They are called "wisdom teeth" because the person is supposed to have gained some wisdom by that time ("What Are Wisdom Teeth?" 2009). Sometimes they do not come in as planned and will come in at an angle. When they do this, they can affect adjacent teeth. Most people have four, but sometimes a person can have more or less than average ("What Are Wisdom Teeth?" 2009). Impacted mandibular third molars are a common condition among young adults (Obiechina, Oji, & Fasola, 2001). Despite their common occurrence, few academic studies exist regarding their extraction and complications associated with the procedure.

Third molars can become impacted for a number of reasons. Insufficient musculo skeletal development of the mandible is the most common cause of impaction (Ma'aita, 2000). It can also because by a mismatch between the growth rates of the molar and the mandible (Ma'aita, 2000). The end result is that there is not enough room for the molars to grow and they begin to crowd the ramus (Ma'aita, 2000). Unerrupted third molars have been associated with the pathological development of a number of conditions. These include cystic lesions, neoplasms, pericoronitis, periodontitis, and root resorption (Ma'aita, 2000). In addition, the impacted molar can also cause harm to adjacent teeth (Ma'aita, 2000).

It is believed that third molars were used by our human ancestors for grinding plant material (Tiago, Pereira, & Francisco, 2006). It is postulated that our ancestors had larger jaws and more teeth than we do today (Tiago, Pereira, & Francisco, 2006). It is postulated that genetics are responsible for the development of wisdom teeth in many populations. However, some suggest that diet is closely linked to the formation of wisdom teeth in some populations (Tiago, Pereira, & Francisco, 2006). Various cultures differ in the percentage of persons that develop wisdom teeth. For instance, only 0.2% of Bantu develop wisdom teeth. Where nearly 100% of all Mexicans develop wisdom teeth (Tiago, Pereira, & Francisco, 2006). These differences are related to the PAX9 gene, perhaps in combination with other genes (Tiago, Pereira, & Francisco, 2006).

These factors help to explain why many wisdom teeth have to be removed. There is no longer room in the jaw for them. The fact that variations among different cultures exist in the development of wisdom teeth helps provide clues as to their use and the reasons why they do not always grow without incidence. If theories are correct and third molars are a genetic remnant of our ancient ancestors, then it explains why impaction occurs in many cases. The removal of wisdom teeth may not have been necessary for our ancient ancestors. However, today, we are faced with this nuisance.

Impaction occurs in several forms, mesio angular, horizontal, vertical, and disto angular (Mwaniki & Guthua, n.d.). Mesio angular means the tooth is angled toward the front of the mouth. Vertical impaction occurs when the tooth does not erupt fully through the gums. Disto angular impaction means the tooth is angled towards the back of the mouth. Horizontal impaction occurs when the tooth is angled a full 90% forward and begins to grow into the roots of the second molar.

The most common type of impaction is the messio angular, which was found to occur in 62.6% of patients in a Kenya study (Mwaniki & Guthua, n.d.). Horizontal occurred in 13%, vertical in 11.6%, and disto angular in 9.9% (Mwaniki & Guthua, n.d.). Other types of impactions represented the remainder (Mwaniki & Guthua, n.d.). In a study of Jordanian patients, only 43.4% were in the mesio-angular position (Ma'aita, 2000). In Mosul, a similar occurrence was found, with an incidence rate of 46% (Mohammad & Ismail, 2003). The results of these studies may indicate cultural differences in the development of impacted third molars.

The angle and depth of impaction are the key indicators as to the difficulty of the extraction procedure. Disto angular impactions in the maxilla are the easiest to extract. The most difficult are those that are extracted from the mandible. However, mesio angular impactions are the most difficult to extract in the maxilla and the easiest to extract in the mandible ((Hazza'a, Bataineh, & Odat, (2009).

The angle of impaction can be predictive as to any complications that may arise the development of pericoronitis is often associated with mesioangular and distoangular impactions (Hazza'a, Bataineh, & Odat, (2009). In some cases, a portion of the bone must be removed, if the tooth does not yield easily (Hazza'a, Bataineh, & Odat, (2009). Pell and Gregory developed a scale that is used to predict the difficult or potential for complications of a tooth extraction (Garcia, Sampedro, & Rey, 2000). One of the key factors, according to this scale is whether they are still completely encased in the jawbone. Bony impactions are more difficult to remove than those that are in soft tissue (Garcia, Sampedro, & Rey, 2000).

At timed the tooth erupts completely through the gum bed and the gum at the back of the wisdom tooth extends over the biting surface. This can be difficult to clean with a toothbrush (Garcia, Sampedro, & Rey, 2000). This type of impaction can be a common source of infection due to the accumulation of bacteria under the skin flap. This type of infection can cause considerable difficulties and can progress to a more serious infection. This type of infection can cause difficulty opening the mouth. Pain from this type of infection can affect the entire area and can run down the entire length of the jaw or the neck (Garcia, Sampedro, & Rey, 2000). Many times the skin flap must be removed. However, there is the potential for accidental severing of the nerve to the tongue in this procedure.

The Pell-Gregory scale has been used as the standard for estimating the difficulty of a procedure. However, the accuracy and reliability of this scale has come into question. It is now no longer considered to be the standard in risk assessment, particularly where mandibular molars are concerned. However, to date, nothing has been developed to replace it.

Oral surgeons know that certain molar extractions pose more difficulty than others. Many of these have already been discussed, such as the angle, depth, encasement in the jawbone and other factors. However, there are sometimes unforeseen factors that can have a negative impact on the ease of the procedure. For instance, advanced osteoporosis or other undiscovered conditions can have an impact on the ease of the extraction. Many of these factors are unforeseeable until the surgery is underway.

We are now familiar with the different types of simple impactions that can occur in the typical population of patients. Impactions, it left untreated can begin to crowd of affect the surrounding teeth. In some cases, a bony impaction can cause the mandible to break as the tooth attempts to push its way out. Another type of complication that can occur is when the root of the molar wraps around the alveolar nerve. When this occurs, as change in sensation on that side of the face can occur. This can be either temporary of permanent. However, this is a sensory nerve and does not affect the ability to move in any way.

There are very few cases where an impacted tooth can be allowed to remain. It is likely that at some time in the future, the impacted tooth will become problematic, either through damage to surrounding teeth, or through the onset of an infection. However, not all wisdom teeth become impacted. Standard practice is to remove all molars as a preventative measure to make certain that they do not become impacted in the future. However, this practice has become questionable in its ability to reduce the likelihood of impaction later in life.

A recent study used a longitudinal time study to examine the necessity of preventative removal of molars. The study found that there was not indication either way, as to whether this practice prevented overcrowded teeth in the future (the Cochrane Collaboration, 2005).It is clear that early removal of third molars is necessary when an impaction has already occurred. However, prophylactic removal of healthy wisdom teeth is a controversial practice. Some clinicians believe that this exposes the patient to undue risk for infection or damage to the interior alveolar nerve (Esposito, 2005).

Clinicians on both sides of the issue of prophylactic removal have excellent points. There is no clear direction in terms of prophylactic removal. Valid arguments exist on both sides of the argument. There are many factors present with individual patients that may affect the decision to perform prophylactic removal of healthy wisdom teeth. Every situation should be treated individually and the… READ MORE

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