LAop: Indications & Contraindications, Pericoronitis

Principles of management of impacted teeth
Chapter 9, Contemporary Oral and Maxillofacial Surgery, James R. Hupp

Indications for removal of impacted teeth
1. Prevention of periodontal disease
2. Prevention of caries
3. Prevention of pericoronitis

• Definition: Infection of soft tissue around crown of a partially impacted tooh usually caused by normal flora. Usually, bacteria and host defences maintain a delicate balance
• Causes:
  (a) When host defences are compromised (during minor illnesses, on immunocompromising drugs)
  (b) Following minor trauma from a upper 8
  (c) Food trap beneath operculum
• Treatment: Mechanical debridement of periodontal pocket under operculum with ChX/ saline irrigation
• Severity
  (a) Mild: Localised tissue swelling and soreness
  (b) Moderate: Large amount of tissue swelling being traumatised by upper 8? Remove upper 8 immediately + local irrigation for mandibular 8
  (c) Severe: Local swelling and pain, mild facial swelling, mild trismus resulting from inflammation extending into muscles of mastication, low-grade fever? Debride, irrigate, AB
  (d) Very severe: Serious fascial space infections. Trismus <20mm, fever, facial swelling, pain, malaise? Refer to OS; might admit for parenteral AB and careful monitoring
• Lower 8 should not be removed until s/s of pericoronitis have completely resolved due to increased incidence of post-op complications such as alveolar oestitis, post-op infection, more bleeding, slower healing
• About operculectomy: Painful, usually ineffective, soft tissue tends to recur

4. Prevention of root resorption
5. Impacted teeth under a dental prosthesis
6. Prevention of odontogenic cysts and tumours
7. Treatment of pain of unexplained origin
8. Prevention of jaw fractures
9. Facilitation of orthodontic treatment
10. Optimal periodontal healing

Contraindications for removal of impacted teeth
1. Age extremes:

• Bone becomes highly calcified, < flexible. > bone needs to be removed during surgery
• Slower healing
• If a tooth has been retained in alveolar process for many years without periodontal disease, caries or cystic degeneration, it is unlikely that these unfavourable sequelae would occur

2. Compromised medical status
3. Probable excessive damage to adjacent structures

General rules
1. All impacted teeth should be removed unless removal is contraindicated
2. Removal of impacted teeth becomes more difficult with advancing age due to increased bone density and compromising systemic diseases (slower healing)
3. Advantages of early removal

• Reduces post-op morbidity
• Better healing - both periodontal and nerve recovery
• Easier to remove as bone is less dense and root formation is incomplete

4. Best age to remove: When roots of teeth are 1/3 to 2/3 formed. Usually between 17-20yo. Average age of complete eruption is 20, but eruption may continue up to 25yo

• Root morphology
• Optimal time for removal: Root is 1/3 to 2/3 formed, with blunt ends
• If <1/3, tooth more difficult to remove because will roll around in socket like a marble
• Single, conical root or widely separated roots
• Curvature of roots
• Direction of root curvature: In a mesioangular impaction, roots curved gently in the distal direction following pathway of extraction can be removed without fracturing. But if roots are straight/curved mesially, the roots commonly fracture if tooth is not sectioned before extraction
• PDL space; the wider the PDL space, the easier to remove
• Size of follicular sac
• Density of surrounding bone. Optimal time for removal 18yo. >35yo = denser bone.
• Contact with mandibular second molar
• Relationship to IDN
• Nature of overlying tissue

5. Cut off age: Over 35yo and impacted tooth shows no signs of disease, should not be removed