A Task Force was convened by the American Association of Oral and Maxillofacial Surgeons in March 2007 to review the current literature with regard to selected aspects relating to third molars and their removal
Here are the conclusions of the final report named
WHITE PAPER ON THIRD MOLAR DATA
The Natural History of Third Molars
While it is not possible to predict eruption of third molars in all cases, adequate space
between the anterior border of the mandible and the distal of the mandibular second molar seems to be necessary to allow successful eruption to the occlusal plane Assessment of this space can be determined using a variety of radiographic techniques
However, eruption to the occlusal plane does not imply a good state of health particularly with respect to soft tissue support
Finally, third molars that remain impacted after the age of 25 may still change in position
Periodontal Considerations in Third Molar Removal
The presence of impacted third molars adversely affects the periodontium of adjacent second molars as reflected in disruption of the periodontal ligament, root resorption and pocket depth associated with loss of attachment
The removal of impacted third molars can negatively impact the periodontium of adjacent second molars
The preoperative existence of an intrabony defect, age of the patient, and level of plaque control may serve to predict adverse outcomes
No single surgical approach to the removal of third molars that will minimize loss of
periodontal attachment was identified
GTR and/or DBP may be beneficial in instances where there is evidence of significant
pre-existing attachment loss
Scaling, root planing, and plaque control have the potential to reduce post-operative loss of attachment
Further research is needed to clarify under what conditions GTR and/or DBP can
contribute to minimizing post-operative periodontal defects
The presence of visible third molars is associated with overall elevated levels of
periodontitis and that of immediately adjacent teeth
In the presence of visible third molars, periodontitis involving adjacent teeth is
progressive and only partially responsive to therapy
Here are the conclusions of the final report named
WHITE PAPER ON THIRD MOLAR DATA
The Natural History of Third Molars
While it is not possible to predict eruption of third molars in all cases, adequate space
between the anterior border of the mandible and the distal of the mandibular second molar seems to be necessary to allow successful eruption to the occlusal plane Assessment of this space can be determined using a variety of radiographic techniques
However, eruption to the occlusal plane does not imply a good state of health particularly with respect to soft tissue support
Finally, third molars that remain impacted after the age of 25 may still change in position
Periodontal Considerations in Third Molar Removal
The presence of impacted third molars adversely affects the periodontium of adjacent second molars as reflected in disruption of the periodontal ligament, root resorption and pocket depth associated with loss of attachment
The removal of impacted third molars can negatively impact the periodontium of adjacent second molars
The preoperative existence of an intrabony defect, age of the patient, and level of plaque control may serve to predict adverse outcomes
No single surgical approach to the removal of third molars that will minimize loss of
periodontal attachment was identified
GTR and/or DBP may be beneficial in instances where there is evidence of significant
pre-existing attachment loss
Scaling, root planing, and plaque control have the potential to reduce post-operative loss of attachment
Further research is needed to clarify under what conditions GTR and/or DBP can
contribute to minimizing post-operative periodontal defects
The presence of visible third molars is associated with overall elevated levels of
periodontitis and that of immediately adjacent teeth
In the presence of visible third molars, periodontitis involving adjacent teeth is
progressive and only partially responsive to therapy
The evaluation of a visible third molar for removal should include an assessment of the periodontium associated with both the third molar itself and that of adjacent teeth and include anatomical limitations to mechanical removal of plaque
The presence of pocket depths of 4-5 mm and/or bleeding on probing should be recognized as possible predictors of future progression of periodontitis
The association of overall increased disease severity in the presence of visible third
molars, the progressive nature of periodontitis involving non-third molars when third
molars are present, the relationship between visible third molars and bacteria associated with severe and refractory periodontitis, and the negative impact of visible third molars on treatment outcomes all lend support to the hypothesis that third molars should be considered as a possible predictor of periodontitis
Third molars should be included in studies of periodontal disease prevalence and
severity, and in studies assessing factors that may indicate an increased risk for
periodontal disease
The Microflora Around the Second and Third Molars
Data on microflora and asymptomatic disease in the third molar region show
Absence of symptoms does not indicate absence of disease or pathology
Pathogenic bacteria (red and orange complexes) in clinically significant numbers exist in and around asymptomatic third molars
Periodontal disease as indicated by probing depths > 4 mm exists in and around
asymptomatic third molars
Indicators of chronic inflammation exist in periodontal pockets in and around
asymptomatic third molars
Periodontal disease progresses in the absence of symptoms
The Effects of Age on Various Parameters Relating to Third Molars
Periodontal defects, as assessed by pocket depths, deteriorate with increasing age in the presence of retained third molars
Caries in erupted third molars increases in prevalence with increasing age
The incidence of postoperative morbidity following third molar removal is higher in
patients > 25 years
Germectomy may be associated with a lower incidence of postoperative morbidity
Orthodontic and Prosthodontic Considerations in Removal of Third Molars
Despite good intentions, we are not able to explain, predict, or prevent dental crowding, no matter what the cause
While it is likely that third molars play a role in the etiology of crowding, they are only one factor to consider in making a clinical decision about third molar management
Therefore, it is prudent for clinicians to educate patients that the cause of dental crowding is multi-factorial and, while third molars may play a significant role in
some patients, the current state of knowledge does not allow us to identify with accuracy who is at risk
The position and disposition of unerupted teeth has been found to be dynamic and
unpredictable
Therefore, the ultimate decision regarding the management of such teeth is best made by an expert clinician after clinical examination and review of factors such as the
age of the patient, position of the tooth, anticipated difficulty of removal, type of overlying prosthesis, and risks associated with removal
Current Imaging Techniques
The exact role and indications for CT imaging for the management of impacted third molars is unclear and evolving
Additional investigations are warranted to better understand and outline the parameters for effective use of CT imaging in the management of third molars
The Possible Role of Coronectomy (also known as partial tooth removal, partial
odontectomy or intentional root retention) in Third Molar Removal
When imaging suggested an intimate relationship between the roots of the lower third molar and the IAN and the tooth still needs to be removed, consideration should be given to coronectomy with retention of the portion of the roots associated with the IAN
Since there are only five papers in the literature describing more than single cases there is no standard of care with regard to this technique, and until more information is available this technique should be considered as an alternative only
The Role of Lingual Flap Elevation and Lingual Retraction in the Management of
Third Molars
Raising a lingual flap and the use of a lingual retractor for selected indications is felt to bean acceptable technique for removal of lower third molars
The periosteal elevator must remain subperiosteal at all times
A lingual retractor must be broad and without sharp edges so as to protect and not damage the lingual nerve
Should Anything Be Placed in the Socket Following Third Molar Removal
While non-resorbable and resorbable GTR, DBP, and platelet rich plasma (PRP) work in the setting of high-risk or near high-risk third molars, DBP is the simplest to use
Nerve Damage – Prevention, Evaluation and Management in Relation to Third Molars
Occasional damage to the inferior alveolar and lingual nerve occurs following third molar surgery
At least 50 percent of cases recover spontaneously
Attempts to standardize objective evaluation of nerve injuries have been unsuccessful
The results of nerve surgery are variable, but if carried out between 4.5 and 7 months over 50 percent of patients probably show improvement
Later repairs, up to 47 months post injury, can still show some recovery
It is possible that in some cases there may be some recovery of taste in the case of lingual nerve
The presence of pocket depths of 4-5 mm and/or bleeding on probing should be recognized as possible predictors of future progression of periodontitis
The association of overall increased disease severity in the presence of visible third
molars, the progressive nature of periodontitis involving non-third molars when third
molars are present, the relationship between visible third molars and bacteria associated with severe and refractory periodontitis, and the negative impact of visible third molars on treatment outcomes all lend support to the hypothesis that third molars should be considered as a possible predictor of periodontitis
Third molars should be included in studies of periodontal disease prevalence and
severity, and in studies assessing factors that may indicate an increased risk for
periodontal disease
The Microflora Around the Second and Third Molars
Data on microflora and asymptomatic disease in the third molar region show
Absence of symptoms does not indicate absence of disease or pathology
Pathogenic bacteria (red and orange complexes) in clinically significant numbers exist in and around asymptomatic third molars
Periodontal disease as indicated by probing depths > 4 mm exists in and around
asymptomatic third molars
Indicators of chronic inflammation exist in periodontal pockets in and around
asymptomatic third molars
Periodontal disease progresses in the absence of symptoms
The Effects of Age on Various Parameters Relating to Third Molars
Periodontal defects, as assessed by pocket depths, deteriorate with increasing age in the presence of retained third molars
Caries in erupted third molars increases in prevalence with increasing age
The incidence of postoperative morbidity following third molar removal is higher in
patients > 25 years
Germectomy may be associated with a lower incidence of postoperative morbidity
Orthodontic and Prosthodontic Considerations in Removal of Third Molars
Despite good intentions, we are not able to explain, predict, or prevent dental crowding, no matter what the cause
While it is likely that third molars play a role in the etiology of crowding, they are only one factor to consider in making a clinical decision about third molar management
Therefore, it is prudent for clinicians to educate patients that the cause of dental crowding is multi-factorial and, while third molars may play a significant role in
some patients, the current state of knowledge does not allow us to identify with accuracy who is at risk
The position and disposition of unerupted teeth has been found to be dynamic and
unpredictable
Therefore, the ultimate decision regarding the management of such teeth is best made by an expert clinician after clinical examination and review of factors such as the
age of the patient, position of the tooth, anticipated difficulty of removal, type of overlying prosthesis, and risks associated with removal
Current Imaging Techniques
The exact role and indications for CT imaging for the management of impacted third molars is unclear and evolving
Additional investigations are warranted to better understand and outline the parameters for effective use of CT imaging in the management of third molars
The Possible Role of Coronectomy (also known as partial tooth removal, partial
odontectomy or intentional root retention) in Third Molar Removal
When imaging suggested an intimate relationship between the roots of the lower third molar and the IAN and the tooth still needs to be removed, consideration should be given to coronectomy with retention of the portion of the roots associated with the IAN
Since there are only five papers in the literature describing more than single cases there is no standard of care with regard to this technique, and until more information is available this technique should be considered as an alternative only
The Role of Lingual Flap Elevation and Lingual Retraction in the Management of
Third Molars
Raising a lingual flap and the use of a lingual retractor for selected indications is felt to bean acceptable technique for removal of lower third molars
The periosteal elevator must remain subperiosteal at all times
A lingual retractor must be broad and without sharp edges so as to protect and not damage the lingual nerve
Should Anything Be Placed in the Socket Following Third Molar Removal
While non-resorbable and resorbable GTR, DBP, and platelet rich plasma (PRP) work in the setting of high-risk or near high-risk third molars, DBP is the simplest to use
Nerve Damage – Prevention, Evaluation and Management in Relation to Third Molars
Occasional damage to the inferior alveolar and lingual nerve occurs following third molar surgery
At least 50 percent of cases recover spontaneously
Attempts to standardize objective evaluation of nerve injuries have been unsuccessful
The results of nerve surgery are variable, but if carried out between 4.5 and 7 months over 50 percent of patients probably show improvement
Later repairs, up to 47 months post injury, can still show some recovery
It is possible that in some cases there may be some recovery of taste in the case of lingual nerve
repair
THE FULL PAPER IS AVAILABLE AT
Don't Worry at all , within one week to 10 days ,sweling & pain will go off & you will be OK ,but this's provided that you take our prescrbed ntibiotics & aantiedematouss & anti-inflammatory edications
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