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ORTHOdontics
PGI
_____________________________________________________________________________________________________________________
CONTROVERSIES IN TREATMENT PLANNING: THE THIRD MOLAR DEBATE
INCLUDES:
DEBATE OF GERMECTOMY VS. LATE REMOVAL
______________________________________________________________________________
FACULTY: Felipe Rezk-Lega, DDS.
Goals: This series of lectures should enable the first year residents to:
1. Be acquainted with the current controversies regarding the removal of partially/totally
molars.
2. Be aware of the epidemiology of the third molars impaction.
3. Recognize the etiological factors of third molars impactions and complications.
In the management of impacted mandibular third molars (mostly), two conflicting
Routine prophylactic removal vs. conservative management.
4. Be able to assess the risk / benefit conditions.
5. Understand the consensus regarding their removal for orthodontic, pathological and
purposes is also emphasized.
impacted
third
views are opposed:
ectopic
Objectives: At the end of this series, the residents should know:
1. The potential factors leading to third molar impactions.
2. The space availability and the probable risk factors for impaction.
3. The current data on space availability subsequent to premolar extractions as well as the scientific facts in relation to
mandibular incisor crowding.
4. The different sequelae resulting from third molar impaction on surrounding hard and soft structures.
5. The conflicting opinions with their respective arguments.
6. The risk / benefit situation and the consequent management plan.
7. The established rationale for removal.
_____________________________________________________________________________________________________________________
COURSE DURATION AND SCOPE: This
course is part of a course on controversies in treatment planning scheduled for the first year residents. It is given in January on a Thursday at a 1.5-hour session
between 10:00 a.m. and 11:30 a.m. This lecture presents the influence of the third molars on orthodontic treatment, and the controversies about theirremoval.
POLICY ON EXAMINATIONS: Evaluation of residents is done upon class participation. If unsatisfactory, written examination deemed necessary by the course
director and program director will be scheduled.
THE THIRD MOLAR DEBATE: GERMECTOMY VS. LATE REMOVAL
__________________________________________________________________________________________
SUMMARY OUTLINE
- EPIDEMIOLOGY OF M3 AND M3 THIRD IMPACTION
- ETIOLOGY OF M3 IMPACTION
- M3 IMPACTION SEQUELAE
- MAXILLARY THIRD MOLAR
COURSE OUTLINE
1. EPIDEMIOLOGY OF MANDIBULAR (M3) AND MAXILLARY (M3) THIRD
MOLAR IMPACTION
2. ETIOLOGY OF M3 IMPACTION
A. Posterior crowding
a. Narrow vs. wide alveolar shelves
b. Distal M3 crown dimension
c. Insufficient A/P mandibular growth
d. Vertical condylar growth direction
e. Eruption direction of the dentition
f. Arch length discrepancy (ALD)
g. Abrasive diet?
h. Interproximal attrition and wear
i. Mesial migration of dentition
B. Initial M3 angulation
a. Mesio-distal
b. Bucco-lingual
C. Ectopic M3 position
D. Obstruction in pathway of eruption
a. Odontomas and supernumerary teeth
b. Posterior crowding & non-extraction orthodontic treatment
c. Distalization mechanics (HG, LB...)
c1. 2nd molar interference
c2. Cysts and tumors
c3. Bony obstacle in ascending ramus
E. Calcification stage / physical maturity
a. Late mineralization
b. Early physical maturity
F. Ethnic differences?
a. Increase with racial combinations
b. Disharmonies in jaw / inherited tooth sizes
3. M3 IMPACTION SEQUELAE
A. Pre-Eruptive caries & pulpitis
B. Caries & pericoronaritis
C. M2 Periodontal complications
D. M3 risk index
E. Interference on M2
a. M2 Retention
b. M2 Resorption
F. Post-operative complications
G. Systemic infection
4. MAXILLARY THIRD MOLAR
A. Regional anatomy of M3
B. Etiology of M3*
a. Restricted posterior space
b. Initial ectopic position M3
c. Obstruction in pathway of eruption
C. Problem management
D. Comparative arguments
E. Orthodontic indications
Consensus Facts
a. Lower incisor crowding???
b. Posterior crowding & non-extraction orthodontic treatment
c. Orthodontic / orthognathic surgery
F. Concluding remarks
Rationale M3 Removal
a. Orthodontic / orthognathic surgery
b. Ectopic impactions
c. Pathology (symptomatic)
REFERENCES
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Andreasen JO, Petersen JK, Laskin DM. Textbook and Color Atlas of Tooth Impactions. Munksgaard 1997.
Song F, O'Meara S, Wilson P, Golder S, Kleijnen J. The effectiveness and cost-effectiveness of prophylactic removal of wisdom teeth. Health Technol
Assess 2000; 4(15):1-55.
Song F, Landes DP, Glenny AM, Sheldon TA. Prophylactic removal of impacted third molars: an assessment of published reviews. Br Dent J. 1997
;182(9):339-46.
Chiapasco M, Crescentini M, Romanoni G. Germectomy or delayed removal of mandibular impacted third molars: the relationship between age and
incidence of complications. J Oral Maxillofac Surg 1995; 53(4): 418-22; discussion 422-3.
Bishara SE. Third molars: a dilemma! Or is it? Am J Orthod Dentofacial Orthop 1999; 115(6):628-33.
Richardson ME. Prophylactic extraction of lower third molars: setting the record straight. Am J Orthod Dentofacial Orthop. 1999; 115(1):17A-18A.
Hicks EP. Third molar management: a case against routine removal in adolescent and young adult orthodontic patients. J Oral Maxillofac Surg 1999;
57(7):831-6.
Beeman CS. Third molar management: a case for routine removal in adolescent and young adult orthodontic patients. J Oral Maxillofac Surg 1999;
57(7):824-30.
Ricketts RM, Turley P, Chaconas S, Schulhof RJ. Third molar enucleation: diagnosis and technique. J Calif Dent Assoc 1976; 4(4):52-7.
Lindqvist B, Thilander B. Extraction of third molars in cases of anticipated crowding in the lower jaw. Am J Orthod 1982; 81:130-9.
Southard TE, Southard KA, Weeda LW. Mesial force from unerupted third molars. Am J Orthod Dentofacial Orthop 1991; 99:220-5.
Lysell L, Roblin M. A study of indications used for removal of mandibular third molars. Int J Oral Maxillo Surg 1988; 17:161-4.
Southard TE, Southard KA, Weeda LW. Mesial force from unerupted third molars. Am J Orthod Dentofacial Orthop 1991; 99:220-5.
Ades AG, Joondeph DR, Little RM, Chapko MK. A long-term study of the relationship of third molars to changes in the mandibular dental arch. Am J
Orthod Dentofacial Orthop 1990; 97:323-35.
Removal of Third Molars. NIH Consens Statement 1979 Nov 28-30; 2(11):65-68.
Report on a workshop on the management of patients with third molar teeth. J Oral Maxillo Surg 1994; 52:1102-12.
ORTHOdontics
PGI
_____________________________________________________________________________________________________________________
CONTROVERSIES IN TREATMENT PLANNING: APERTOGNATHIA
INCLUDES :
ALTERNATIVES IN THE GROWING VS. ADULT PATIENT
_____________________________________________________________________________________________________________________
FACULTY:
Felipe Rezk-Lega, DDS.
Goals: This series of lectures should enable first year residents to:
1. Review the different treatment approaches of open bite malocclusions in both growing and adult patients.
2. Be familiar with the etiologic factors commonly attributed to the development of openbite.
These include an unfavorable growth pattern, functional disturbances, and dental eruption problems.
3. Know that, with proper management, growth modification can be achieved, avoiding the ultimate treatment alternative of
orthognathic surgery.
4. Be aware of specific options that will be illustrated through case reports including long-term retention records along with
recommendations for long term stability.
Objectives: Upon completion of this course, residents will be able to:
1. Assess the potential factors leading to the development of an open bite not omitting to check for airway obstruction and its
related breathing pattern.
2. Differentiate between a dental open bite and that aggravated by a skeletal dysplasia.
3. Recognize the ideal timing for treatment and identify the proper mechanics, i.e., control of the vertical dimension in the
growing patient.
4. Emphasize on long term patient cooperation, even in the retention years.
5. Assess the probable causes for relapse.
_____________________________________________________________________________________________________________________
COURSE DURATION AND SCOPE: This
course is part of a course on controversies in treatment planning scheduled for the first year residents. It is given in January on a Thursday at a 1.5-hour session
between 10:00 a.m. and 11:30 a.m. This lecture imparts information about the possible alternative treatments of the openbite, going from orthopedic intervention
to surgical correction.
POLICY ON EXAMINATIONS: Evaluation of residents is done upon class participation. If unsatisfactory, written examination deemed necessary by the course
director and program director will be scheduled.
APERTOGNATHIA: TREATMENT ALTERNATIVES IN THE GROWING VS. ADULT PATIENT
SUMMARY OUTLINE
- DEFINITION
- ETIOLOGY
- TREATMENT ALTERNATIVES
A. Growing patients
B. Adults
- CLINICAL CASES
- CONCLUDING REMARKS
- SEARCH FOR “UNUSUAL SUSPECTS”
- TAKE HOME MESSAGE
- CUSTOMIZED RETENTION PROTOCOL
__________________________________________________________________________________________
COURSE OUTLINE
1. DEFINITION
A. Open bite, absence of dental contacts in the vertical plane
B. Vertical dysplasia
C. Dental and/or skeletal
D. All malocclusions
E. Developmental stage
2. ETIOLOGY
A. Functional influences (environmental factors)
B. Eruption disturbances
C. Growth patterns
D. Muscular dysfunction
3. TREATMENT ALTERNATIVES
A. Growing patients
a. Primary and early mixed dentition
a1. Spontaneous closure
a2. Habit breaker appliance
a3. Anterior brackets and elastics
b. Late mixed / Permanent dentition : Skeletal dysplasia
b1. Orthopedic / Orthodontic
b2. Posterior dental eruption “control”
b2.1.
High-pull headgear
b2.2.
Vertical-pull chincup
b2.3.
Functional appliances
b2.4.
Bite blocks (posteriors)
b2.5.
Combination 1&3
b2.6.
Magnets
b2.7.
MEAW
b2.8.
Miniscrews…
B. Adults
a. Mild problems
Orthodontic extrusion
b. Severe problems
b1. Surgery
b2. Orthodontic camouflage
4. CLINICAL CASES
5. CONCLUDING REMARKS
A. Primary & early mixed dentition: No treatment … except!!!
Habit elimination
B. Late mixed / permanent dentition: Skeletal involvement
Control eruption of posterior dentition is key
6. SEARCH FOR “UNUSUAL SUSPECTS”
A. Upper airway obstruction (tonsils & adenoids)
B. Tongue posture & peri-oral musculature
C. Unfavorable growth pattern
7. TAKE HOME MESSAGE
A. Etiology
a. Inherited factors (genetic)
b. Environmental influences
c. Eruption disturbances
B. Clinical features
a. No vertical overlap (dentition)
b. Excessive posterior eruption
c. Insufficient anterior eruption ???
d. Skeletal involvement
e. Excessive anterior facial height
f. Narrow maxilla
g. All malocclusions
8. CUSTOMIZED PROLONGED RETENTION PROTOCOL
Compromised end results
SUGGESTED READING AND REFERENCES
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Proffit WR and Fields HW Jr. The Etiology of Orthodontic Problems. Chapter 5. Contemporary Orthodontics. 3rd edition, Mosby 2000.
Fields, HW et al. Relationship between vertical dentofacial morphology and respiration in adolescents. Am J Orthod Dentofacial Orthop 1991;99:147-54.
Solow B, Kreiborg S. Soft-tissue stretching: a possible control factor in craniofacial morphogenesis. Scand J Dent Res 1977 Sep; 85(6):505-67.
Warren DW, Spalding PM. Dentofacial morphology and breathing: a century of controversy. In Melsen B, ed. Controversies in orthodontics, Berlin:
Quintessence-Verlage, 1990.
Fields HW, Proffit WR, Nixon WL, Phillips C, Stanek E. Facial pattern differences in long-faced children and adults. Am J Orthod Dentofacial Orthop
1984; 85:217-23.
Ung N, Koenig J, Shapiro PA, Shapiro G, Trask G. A quantitative assessment of respiratory patterns and their effects on dentofacial development. Am J
Orthod Dentofacial Orthop 1990; 98:523-32.
Proffit WR. Equilibrium theory revisited: Factors influencing position of the teeth. Angle Orthod 1978; 48:175-86.
Kim YH et al. Stability of anterior openbite correction with multiloop edgewise archwire therapy: A cephalometric follow-up study. Am J Orthod
Dentofacial Orthop. 2000 Jul; 118(1):43-54.
Frankel R. Lip seal training in the treatment of skeletal open bite. Eur J Orthod. 1980; 2(4):219-28.
Audiovisual References
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Proffit WR. Open Bite: Current Concepts. American Association of Orthodontists. John Valentine Mershon Memorial Lecture 1997.
McNamara JA. Vertical Dementia. American Association of Orthodontists. John Valentine Mershon Memorial Lecture 2002.
Shapiro P. Stability of Open Bite Treatment. International Symposium on Early Orthodontic Treatment 2002.
Joondeph DR, Bloomquist D. Open Bite Closure with Mandibular Osteotomy. Advances in Orthodontics & Dentofacial Surgery 2004.