Introduction
The risk assessment before surgery is crucial in the effectiveness of operational procedures especially, the wisdom teeth removal that falls under common dental surgery procedures. The third molars are called the wisdom teeth and are frequently removed due to impaction, crowding, or infection. However, despite its normalcy, the procedure may be followed by some severe side effects including nerve damage or excessive bleeding or infection. Consequently, detailed pre-operative assessment of candidates is critical to reduce such risks and improve patients’ outcomes.
Why Do Impacted Third Molars Poise Surgical Challenges?
You might have commonly heard of the wisdom tooth or the third molar extractions. Whether due to impaction in the wrong direction or because of the discrepancies resulting in incomplete eruption or lack of space available in the oral cavity for the third molars, it is hence important that the dental or maxillofacial surgeon addresses this issue through pre-surgical planning. Though third molar extractions are indeed common surgeries. These surgical procedures should be ideally planned in advance and then executed according to the scientific evidence presentable to the operating dentist, as every patient's considerations would vary based on local and systemic factors.
The pre-operative assessment of third molars is so important before extraction because the dentist or maxillofacial surgeon can estimate the possible difficulties in the elimination of third molars which remains one of the major surgical challenges. Also, there tends to be a significant link according to current dental research between the level of complications or difficulty encountered by the dentist or operating oral surgeon for surgical removal of lower third molars specifically (in comparison to upper third molars) as these are influenced by many anatomic variables and possible post-operative swelling or common inflammatory complications such as delayed wound healing. Further in overweight patients, dental surgeons may face the common issue of accessibility or surgical approach to the third molars because of the herniation of the cheek or the difficulty with retraction methods.
What Are the Different Preoperative Risk Assessment and Evaluation Factors?
This is pivotal in deciding the technique to be adopted and also gives the operator an insight into the possible post-operative complications and how best to handle them.
1. Depth of Impaction: Research studies have demonstrated that the greater the depth of impaction of the maxillary or upper third molar, or wisdom tooth, there can be definitely higher the possibility of surgically inducing an oroantral perforation or making an unnecessary communication that creates post-operative complications.
A deeper impaction of the wisdom tooth also usually requires the surgeon to eliminate a larger amount of bone to deliver the third molar out safely. During this process, there would be likely damage to the lining of the maxillary sinus, where the posterior tooth roots are closed during the operative procedure. Hence, the current recommendation for all dentists or oral surgeons ideally is to depend on the cone-beam computed tomogram, which is the new age advanced 3D (three-dimensional) radiographic modality to measure the approximate proximity, preoperatively in between the roots of the maxillary third molar to the maxillary sinus floor.
2. Presence of Pathological Process or Phenomenon: Post-operative wisdom tooth complications are certain when the tooth is associated with an in-depth pathological process in the alveolar bone that needs elimination. In such infected cases of wisdom teeth, where odontoma, cementoblastomas, common periapical pathologies, or even radicular cysts may be the case in the wisdom tooth, there would further be a lot of bone resorption, owing to which the surgeon needs to preoperatively assess and extract the tooth in a minimally invasive and less traumatic way or surgical method (atraumatic extraction). Hence, the presence of pathologies or the identification rather before surgery can help the dentist or surgeon decipher possible post-operative complications and decide on the right surgical technique. The use of panoramic (OPG), or ideally CT (computed tomography), CBCT (cone beam computed tomography), or multidetector CT would be useful in these cases.
As wisdom tooth infections or pericoronitis represent more than nearly half of the surgical cases in dentistry or in maxillofacial surgery, it Is important to avert associated pericoronitis or common post-operative infections such as alveolitis, sinus-based pathologies, or jaw bone infections. Hence there is a need for the operating dentist or surgeon to consider all the above-enlisted factors ideally before surgical elimination of the wisdom tooth to avoid these complications.
3. Orientation of the Impacted Tooth: Surgical challenges commonly encountered by oral surgeons or dentists are when there is a greater deviation of the impacted tooth, from the course of the vertical alignment. This factor needs to be considered before tooth extraction to reduce surgical difficulties.
4. Arch-Space Tooth-Size Related Discrepancies: This can be an important variable that is associated with eruption perspective to retromolar space available for the tooth. By assessment of the space, the operating dentist would know the right surgical technique to adopt pre-operatively.
5. Root Morphology and Number of Roots: Surgical challenges would be significant to the dental operator when there is only limited root development for the wisdom tooth or the tooth had either divergent or complete roots. To reduce chair time and improve patient compliance, surgeons commonly attempt sectioning of a tooth to attain mobility of the wisdom tooth before its elimination because the fragmentation allows scope for reducing the retention areas, directly facilitating the elimination of the tooth and also preserving the adjacent bone without damage to any adjacent anatomical structures.
6. Proximity of the Alveolar Nerve: This is perhaps the most important variable associated with lower wisdom tooth extractions. The relation should be clearly assessed by the operating dentist or surgeon prior to the extraction, in between the mandibular canal and the tooth roots. As radiographic imaging may not always yield reliable results or show an accurate description of the same, cone beam CT or multidetector CT scan is ideally suggested in order to assess the position of the canal and the distance of vital nerve structures from the impacted tooth.
Conclusion
It is noted that the greater the impaction or the angulation associated with upper or lower wisdom tooth or third molars, the higher the surgical challenges encountered by the dentist, with patients as well being unable to comply with home care oral hygiene regimens for such teeth. Further, as these can cause severe pain, infection, and localized swelling (pericoronitis), these impacted teeth can be eliminated by thorough pre-surgical assessment.
