Evidence-­‐Based  Management    of  Third  Molar  Teeth

Disclaimer	   The	  informa,on	
  depicted	
  in	
  this	  slide	
  presenta,on	
  is	
  intended	
  for	
  educa,onal	
  purposes	
  only	  to	
  help	  health	
  care	  professionals	
  be6er	  understand	
  the	
  evidence-­‐based	  management	
  and	
  treatment	
  of	
  third	
  molar	  teeth.	
  It	
  is	
  not	
  meant	  as	
  professional	
  advice	
  as	
  all	  therapeu,c	
  decisions	
  remain	
  the	  responsibility	
  of	
  individual	
  prac,,oners.	
  The	
  opinions	
  expressed	
  and	
  statements	
  made	  on	
  this	  Evidence-­‐based	
  Third	
  Molar	
  PowerPoint	  Presenta,on	
  are	
  those	  of	
  the	  presenters	
  and	  do	
  not	
  imply	
  endorsements	
  by	
  or	
  oﬃcial	
  policy	
  of	
  the	  AAOMS	
  unless	  speciﬁcally	
  stated	
  otherwise.	
  AAOMS	
  makes	  no	
  representa,on	
  or	
  warranty	
  with	  respect	
  to	
  the	
  material	
  contained	
  within.	
  As	
  with	  all	
  clinical	
  materials,	
  these	  slides	  reﬂect	
  the	
  science	
  at	
  the	  ,me	  of	
  their	
  development.	
  They	  should	
  be	
  used	  with	  the	
  clear	  understanding	
  that	  con,nued	
  research	
  and	
  prac,ce	
  may	  result	
  in	
  new	
  knowledge	
  or	
  recommenda,ons.	
  They	  are	  not	
  intended	
  to	
  set	
  any	
  standards	
  of	
  care,	  and	  they	  cannot	  be	
  subs,tuted	
  for	  individual	
  professional	
  judgment	
  brought	  to	
  each	  clinical	
  situa,on.	
  For	
  assistance	  concerning	
  the	
  use	  of	
  this	  presenta,on	
  and	
  development	
  of	
  any	  personal	
  disclaimers	
  to	
  accompany	
  this	  presenta,on,	
  fellows	
  and	
  members	
  need	  to	
  consult	
  their	
  own	
  a6orneys	
  locally.	
  

  
  

Impacted  third  molars
Wisdom	  teeth,	
  or	
  third	
  molars,	
  are	
  located	
  at	
  the	
  back	
  of	
  
the	
  mouth.	
  They	  are	  the	
  last	  adult	
  teeth	  to	
  erupt,	
  or	
  enter	  the	
  mouth.	
  Most	  people	  have	  four	  wisdom	
  teeth,	
  
two	
  on	
  the	
  top,	
  two	  on	  the	
  bo6om.	
  	
  Third	
  molars	
  are	  considered	
  to	
  be	
  “impacted”	
  when	  they	
  don't	
  have	  enough	
  room	  to	
  emerge	
  or	
  grow	  normally.	
  	  Examples  of  impacted  third  molars⇑!

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Examples  of  impacted  third  molars
⇑!

⇑!

⇑!

Examples  of  impacted  third  molars⇑!

Examples  of  impacted  third  molars

⇑!
⇑!

⇑!

⇑
!

Examples  of  a  common  dilemma16-­‐year-­‐old	
  female	
  with	  4	
  asymptoma,c	
  and	
  unerupted	
  M3s.	
  	
  

	
  
	
  

⇒!
⇒!

!
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⇒!
⇒!

	
  

Organization Name!

Problems  associated  with    impacted  third  molars§ Infec,on,	
  	  § Damage	
  to	
  neighboring	
  teeth	  and	
  ,ssues,	  	  § Tooth	
  decay,	  	  § Periodontal	
  disease,	  § Receding	
  gums,	  	  § Loosened	
  teeth,	  	  § Bone	  loss,	  	  § Tooth	
  loss,	  § Jaw	  weakening,	
  	  § Development	
  of	
  associated	
  cysts	
  and	
  tumors,	
  and	  § Interference	
  with	  needed	
  dental	  treatments.	
  

	
  

Problems  associated  with    malposi?oned  third  molars
Ectopic	
  posi,oning	
  due	  to	
  supra-­‐erup,on:	
  	
  

⇐!

Problems  associated  with    impacted  third  molars
Third	
  molar	
  interference	
  with	  ﬁxed	  prosthe,c	
  (crown)	
  treatment	
  plan:	
  	
  

⇑!

Problems  associated  with    impacted  third  molars
Retained	
  third	
  molar	
  tooth	  interference	
  with	  removable	
  prosthe,c	
  treatment	
  plans:	
  ⇒!

Problems  associated  with    impacted  third  molars
Impacted	
  third	
  molar	
  interference	
  with	  erup,on	
  of	
  adjacent	
  second	  molar	
  and	
  orthodon,c	
  tooth	  movement:	
  Problems  associated  with    impacted  third  molars	   	
  Impacted	
  third	
  molar	  in	
  the	
  line	  of	
  fracture:	  	  Problems  associated  with    impacted  third  molars
Cysts	
  and	
  Tumors	
  Bilateral	
  Mandibular	
  Den,gerous	
  Cyst	  “Asymptoma?c”  versus  “Disease-­‐Free”§ “Asymptoma,c”	
  does	  not	
  mean	  “Disease	
  Free”	  § Even	
  third	
  molars	
  that	  have	  erupted	
  into	  the	
  mouth	
  in	
  a	
  
normal,	
  upright	
  posi,on	
  may	  not	  be	
  problem-­‐free.	
  	  § Their	
  loca,on	
  in	
  the	
  back	  of	
  the	
  mouth	  makes	  them	
  extremely	
  diﬃcult	  to	
  keep	  clean.	
  	  § Bacteria	
  that	  cause	  periodontal	
  disease	
  may	
  exist	
  
in	
  	
  
and	
  around	
  asymptoma,c	
  third	
  molars,	
  leading	
  to	
  damage	  before	
  symptoms	
  appear.	
  	  § Pathology	
  is	
  always	
  present	
  before	
  symptoms	
  appear.	
  § Once	
  damage	
  has	
  occurred,	
  it	
  is	
  not	
  always	
  treatable.	
  	  Addi?onal  risks§ Bacteria	
  may	  contribute	
  to	
  systemic	
  health	
  problems,	
  including:	
  § diabetes,	  	  § heart	
  disease,	  	  § kidney	
  disease,	
  and	  	
  § other	
  health	
  problems.	
  	
  § Studies	
  have	  found	
  that	  periodontal	
  disease	  in	
  expectant	
  mothers	
  may	  be	
  associated	
  with	  a	
  greater	
  likelihood	
  of	
  preterm	
  and	
  low	
  birthweight	
  babies.	
  Research  has  also  shown  a  rela?onship  between  the  presence  of  wisdom  teeth  and  the  progression  of  periodontal  disease.
§ White	  RP,	
  Oﬀenbacher	
  S,	
  et.al.	
  Chronic	  oral	  inﬂamma,on	
  and	  the	
  progression	
  of	
  periodontal	  pathology	
  in	
  the	
  third	
  molar	  region.	
  J	
  Oral	  Maxillofac	  Surg.	
  64:880,	
  2006	
  25%  of  wisdom  teeth  pa?ents  who  perceive  themselves  as  asymptoma?c  actually  already  have  inﬂammatory  periodontal  disease.
§ Blakey	
  GH,	
  Marciani	
  RD,	
  Haug	
  RH,	
  et.al:	  Periodontal	  pathology	
  associated	
  with	  asymptoma,c	
  third	
  molars;	
  Journal	
  of	
  Oral	  and	  Maxillofacial	
  Surgery.	
  2001;60:1227-­‐1233	
  The  role  of  age  in  third  molar  surgery§ Young	
  adult	
  wisdom	
  teeth	  have	  incomplete	
  root	  systems	
  § Surgery	
  less	  complicated	  	  § Healing	
  process	
  quicker.	
  	
  

12	
  years	
  14	
  years	
  17	
  years	
  24	
  years	
  No	
  one	
  can	  predict	
  when	
  third	
  molar	  complica,ons	
  will	  occur,	  but	
  when	
  they	  do,	  the	
  circumstances	
  can	  be	
  much	  more	  painful	  and	  the	
  teeth	  more	  diﬃcult	  to	
  treat.	
  Morbidity	
  associated	
  with	  surgical	
  management	
  of	
  third	  molar	
  teeth,	
  as	
  well	  as	
  the	
  risk	  of	
  complica=ons,	
  has	  been	
  shown	  to	
  increase	
  with	  age.	
  	  § Bui	  CH,	
  Selodin	
  EB,	
  Dodson	
  TB.	
  Types,	
  frequencies	
  and	
  risk	  factors	
  for	
  complica,ons	
  aeer	  third	
  molar	
  extrac,on.	
  J	
  Oral	  Maxillofac	
  Surg	
  .	
  61:	
  1379,	
  2003	  	
  § Bouloux	  GF,	  Steed	
  MB,	
  and	  Perciaccante	
  VJ.	  Complica,ons	
  of	
  third	
  molar	
  surgery.	
  Oral	  and	  Maxillofacial	
  Surgery	
  Clinics	
  of	  North	
  America.	
  19:117-­‐128,	
  2007	  § Marciani	
  RD.	  Third	
  molar	  removal:	
  An	
  overview	
  of	
  indica,ons,	
  imaging,	
  evalua,on,	
  and	
  assessment	
  of	
  risk..	
  Oral	  and	
  Maxillofacial	
  Surgery	
  Clinics	
  of	
  North	  America.	
  19:1-­‐13,	
  2007	
  The	
  risk	  of	
  future	
  disease	
  requiring	
  removal	
  of	
  retained	
  wisdom	  teeth	  in	
  asymptoma=c	
  pa=ents	
  who	
  retain	
  their	
  wisdom	  teeth,	
  exceeds	
  70%	
  aEer	
  18	
  years	
  of	
  follow-­‐up.	
  	  § Venta	
  I,	
  Ylipaavalniemi	
  P,	
  Turtola	
  L:	
  	
  Clinical	
  outcome	
  of	
  third	
  molars	
  in	
  adults	
  followed	
  during	
  18	
  years.	
  J	
  Oral	  Maxillofac	
  Surg.	
  62:182,	
  2004	
  
	
  

20	
  years	
  aEer	  UK	
  adopts	  the	
  “Na=onal	
  Ins=tute	
  of	
  Clinical	
  Excellence”	
  (NICE)	
  guidelines,	
  volume	
  of	
  third	
  molar	
  surgeries	
  decrease,	
  with	  a	
  corresponding	
  increase	  in	
  mean	
  age	
  for	
  surgical	
  admissions	  and	  an	
  increase	
  in	
  	
  “caries”	
  and	
  “pericoroni=s”	
  as	
  e=ologic	
  factors.

§ Renton	
  T,	
  Al-­‐Haboubi	
  M,	
  Pau	  A,	  Shepherd	
  J,	
  Gallagher	
  JE:	
  What	  has	  been	
  the	
  United	
  Kingdom’s	
  experience	  with	
  reten,on	
  of	
  third	
  molars?	
  J	
  Oral	  Maxillofac	
  Surg.	
  70:48-­‐57,	
  2012,	
  Suppl	
  1	
  

  

Reten=on	
  of	
  third	
  molars	
  is	
  associated	
  with	  increased	
  risk	  of	
  second	
  molar	
  pathology	
  in	
  middle-­‐aged	
  and	
  older	  	
  adult	
  men.	
  § Nunn,	
  ME,	  et	
  al.	
  Retained	
  Asymptoma,c	
  Third	  Molars	  and	
  Risk	  for	
  Second	  Molar	
  Pathology.	
  Nunn	  et	
  al.	
  J	
  
DENT	
  RES	
  published	
  online	
  16	
  October	
  2013.	
  Evidence-­‐based  management  of    third  molars
Every	
  den,st	
  and	
  dental	
  specialist	
  should	  understand	
  the	
  importance	
  of	
  evidence-­‐based	
  management	
  of	
  third	  molar	
  teeth	  and	
  oﬃce-­‐based	
  anesthesia	
  in	
  the	
  dental	
  oﬃce.	
  	
  	
  	
  

What  is  evidence-­‐based  management?
A	
  systema,c	
  approach	
  to	
  clinical	
  problem	
  solving	
  which	  allows	  the	
  integra,on	
  of	
  the	  best	  available	
  SCIENTIFIC	
  evidence	
  with	  clinical	
  exper,se	
  and	
  pa,ent	
  values.	
  
	
  
	
  
	
  
	
  

(Sacke6	
  DL,	  Strauss	
  SE,	
  Richardson	
  WS,et	
  al.	
  Evidence-­‐based	
  medicine:	
  
how	
  to	
  prac,ce	
  and	
  teach	  EBM.	
  London:	
  Churchill-­‐Livingstone,	  2000)	
  

	
  
	
  

Evidence-­‐Based  Clinical    Decision-­‐Making  (EBCD)§ Apply	
  per,nent	
  data	  to	
  each	  individual	
  case	  § Cri,cally	
  weigh	
  the	
  treatment	
  op,ons	
  § Choose	
  the	  best	  course	
  of	
  ac,on	
  for	  the	
  pa,ent	
  Evalua?ng  third  molars  for  surgery§ Every	
  pa,ent	
  and	
  every	
  case	  is	
  unique.	
  § Decisions	
  regarding	
  surgery	
  must	  consider:	  § Careful	  examina,on	
  of	
  your	  mouth;	
  § Radiographic	
  examina,on	
  involving	
  x-­‐rays	
  or	
  a	
  CT-­‐
scan;	
  and	  § Consulta,on	
  between	
  pa,ent,	
  den,st	
  and	
  oral	  and	  maxillofacial	
  surgeon	
  with	  a	
  balanced	
  discussion	
  of	
  
the	
  beneﬁts	
  and	
  risks	
  of	
  reten,on	
  versus	
  beneﬁts	
  and	
  risks	
  of	
  opera,ve	
  management.	
  Available  op?ons§ Depending	
  on	
  the	  results	
  of	
  the	
  dental	
  examina,on,	
  the	
  OMS	  may:	  § Extract	
  the	
  complete	
  tooth;	
  § Par,ally	
  remove	
  the	
  tooth;	
  or	  § Ac,ve	
  Surveillance	
  -­‐	  Observe	
  the	
  tooth	  over	  ,me	
  for	  changes	
  in	
  condi,on.	
  What  is  “par?al  removal?”
Par,al	  removal	
  of	
  third	
  molars,	
  or	
  “Coronectomy,”	
  is	
  a	
  
surgical	
  procedure	
  that	  removes	
  the	
  crown	
  of	
  the	
  tooth	  and	
  leaves	  the	
  root	  and	
  associated	
  nerve	  complex.	
  §May	  be	
  performed	
  when	  removing	  the	
  en,re	
  tooth	  might	
  damage	
  the	
  nerve,	
  poten,ally	
  causing	
  facial	
  numbness.	
  	
  Pogrel,	
  MA,	  Lee,	
  JS,	
  Muﬀ,	
  DF:	
  Coronectomy:	
  A	
  Technique	
  to	
  Protect	  the	  Inferior	
  Alveolar	  Nerve.	
  J	
  Oral	  Maxillofac	
  Surg.	
  1447-­‐1452,	
  2004	  When  must  third  molars  be    surgically  removed?
§ In	
  general,	  dental	
  professionals	
  agree	
  that	  third	
  molars	
  should	  be	
  removed	
  whenever	
  there	  is	
  evidence	  that	  predicts:	  § Periodontal	
  disease,	  	  § Cavi,es	
  that	  cannot	  be	
  restored,	  	  § Infec,ons,	  	  § Cysts	
  or	
  tumors,	
  and/or	
  § Damage	
  to	
  neighboring	
  teeth.	
  	
  Removal	
  of	
  wisdom	
  teeth	  is	
  always	
  appropriate	
  “where	
  there	  is	
  evidence	
  of	
  pathological	
  changes	
  such	  as	
  infec,on,	
  non-­‐
restorable	
  carious	
  lesions,	
  cysts,	
  tumors,	
  and	
  damage	  to	
  adjacent	
  teeth.”	
  
	
  
	
  
(American	
  Public	
  Health	
  Associa,on	
  (APHA)	
  Statement	
  on	
  Wisdom	
  Teeth,	
  2008)	
  	
  Under  what  circumstances  may  third  molars  be  retained?
Third	
  molars	
  may	  not	
  require	
  surgery	
  if	
  they	  are:	  	
  § Completely	
  erupted	
  and	
  func,onal,	  	  § Painless,	  	
  § Free	  of	
  cavi,es,	
  	
  § Disease-­‐free,	
  and	  	
  § In	  a	
  posi,on	
  that	  can	  be	
  kept	  clean	
  and	
  healthy.	
  	  AAOMS  Third  Molar  Posi?on  Statement§ All	
  pa,ents	
  with	  impacted	
  teeth	  should	
  be	
  carefully	
  evaluated	
  
by	
  a	
  qualiﬁed	
  den,st.	
  	
  Predicated	
  on	
  the	  best	  evidence-­‐based	
  data,	
  impacted	
  teeth	
  that	  demonstrate	
  pathology,	
  or	
  are	
  at	
  
high	
  risk	  of	
  developing	
  pathology,	
  should	
  be	
  surgically	
  managed.	
  	  In	  the	
  absence	
  of	
  pathology	
  or	
  signiﬁcant	  risk	  of	
  pathology,	
  ac,ve	
  clinical	
  and	  radiographic	
  surveillance	
  is	
  indicated.	
  § All	  third	
  molar	  teeth	  should	
  be	  managed	
  deliberately	
  using	
  an	
  evidence-­‐based	
  approach.	
  	
  Appropriate	
  management	
  of	
  third	  molar	
  teeth	  may	  include	
  removal,	
  par,al	
  removal	
  or	
  reten,on,	
  followed	
  by	
  ac,ve	
  clinical	
  and	  radiographic	
  surveillance	
  to	
  
make	
  sure	  that	  pathology	
  does	  not	
  develop.	
  AAOMS  Third  Molar  Posi?on  Statement§ The	  absence	
  of	
  symptoms	
  does	  not	
  necessarily	
  mean	  the	
  absence	
  of	
  disease.	
  § All	  third	
  molar	  teeth	  should	
  be	  managed	
  by	
  a	
  qualiﬁed	
  den,st.	
  	
  Oral	  and	
  maxillofacial	
  surgeons	
  surgically	
  manage	  acute,	
  chronic	
  and	
  poten,al	
  pathological	
  condi,ons	
  of	
  third	
  molar	  teeth.	
  § Third	
  molar	
  therapy	
  is	
  an	
  evidence-­‐based	
  treatment	
  paradigm.	
  	
  It	
  includes	
  radiographic	
  surveillance	
  to	
  assess	
  tooth	  posi,on,	
  pathology	
  and	  possible	
  need	  for	  removal.	
  	
  All	
  third	
  molars	
  that	  are	
  retained	
  require	
  periodic	  follow-­‐up.	
  Deliberate  management  of  third  molar  
teeth
The	
  Oral	  and	  Maxillofacial	
  Surgeon	  has	  the	
  most	  extensive	
  educa,on	
  and	  training	
  for	
  appropriate	
  third	  molar	  management.	
  	
  This	  includes:	  § Removal	
  	  § Par,al	
  removal	
  	
  § Reten,on	
  with	  ac,ve	
  surveillance	  	
  Case  Reports  

A	
  32	
  year-­‐old	
  physician	  presented	
  with	  bilateral	
  jaw	
  pain	  that	
  started	  one	
  week	  previously.	
  	
  Prior	  to	
  this	  episode,	
  he	
  
was	
  completely	
  asymptoma,c.	
  Examina,on	
  revealed	
  malposed	
  and	
  impacted	
  third	
  molar	  teeth	
  with	  gross	
  caries	
  involving	
  teeth	
  #s	
  17,	
  18,	  31	  and	
  32.	  

Carious  mandibular  second  and  third  molar  teeth

⇑
!

⇑

!

A	
  39	
  year-­‐old	
  female	
  pa,ent	
  is	
  evaluated	
  prior	  to	
  crown	
  replacement	
  at	
  the	
  lower	  lee	
  second	
  molar	
  tooth	
  #18.	
  !
⇑	   This	
  39	
  year	  old	
  female	
  pa,ent	
  is	
  scheduled	
  for	
  replacement	
  of	
  crown	
  #18.	
  	
  The	
  impacted	
  third	
  molar	  teeth	  should	
  ﬁrst	  be	
  appropriately	
  managed.	
  An	
  otherwise	
  healthy	
  63	
  year-­‐old	
  male	  pa,ent	
  (also	
  a	
  physician)	
  presented	
  to	
  the	
  oﬃce	  with	  complaints	
  of	
  pain	
  and	
  swelling	
  associated	
  with	  the	  area	  of	
  the	  mandibular	
  lee	
  third	  molar	
  tooth	
  #17.	
  	
  Clinical	
  examina,on	
  revealed	
  recurrent	
  caries,	  pericoroni,s	
  and	  a	
  mesial	
  periodontal	
  probing	
  depth	  of	
  8mm.	
  	  Periodontal  bone  loss  and  pericoroni?s  

⇑!

An	
  otherwise	
  healthy	
  25	
  year-­‐old	
  male	  pa,ent	  presented	
  to	
  the	  hospital	
  emergency	
  department	
  with	  complaints	
  of	
  severe	
  pain	  and	
  swelling	
  of	
  the	
  lee	
  face	  and	
  neck,	
  trismus,	
  and	
  diﬃculty	
  swallowing,	
  speaking	
  and	
  breathing.	
  	
  Clinical	
  examina,on	
  and	  a	  CT	
  scan	
  showed	
  an	
  abscessed	
  lower	  lee	
  wisdom	
  tooth	
  with	  infec,on	
  of	
  the	
  lee	
  submandibular,	
  masseteric,	
  medial	
  pterygoid	
  and	
  sublingual	
  spaces.	
  	  A	  shie	  of	
  the	
  airway	
  to	
  the	
  right	
  was	
  beginning	
  on	
  the	  CT	  scan.	
  	
  Laboratory	
  values	
  were	  consistent	
  with	  acute	
  infec,on.	
  	
  Abscessed  mandibular    leS  third  molar  toothCoronal  CT  scan  of  odontogenic  infec?on

Clinical examination revealed severe soft tissue cellulitis!

Although  the  radiology  report  for  the  CT  scan  showed  “soS  ?ssue  swelling  [celluli?s]”  with,  “No  evidence  of  abscess  forma?on,”  copious  pus  was  produced  upon  surgical  incision  and  drainage  of  the  infec?on.  

	
  An	
  80	
  year-­‐old	
  female	
  seen	  at	
  a	
  local	  hospital	
  with	  a	
  right	
  facial	
  infec,on	
  underwent	
  emergent	
  incision	
  and	
  drainage	
  by	
  an	
  ENT	
  surgeon	
  who	
  placed	
  her	  on	
  an,bio,cs	
  and	
  referred	
  her	  to	
  the	  OMS.	
  	
  When	  ﬁrst	  seen	  by	
  the	  OMS,	
  she	  was	
  infected	
  and	  in	
  severe	
  pain.	
  	
  Clinical	
  and	  radiographic	
  evalua,on	
  revealed	
  a	
  severely	
  atrophic	
  mandible	
  with	  a	
  grossly	
  carious	
  impacted	
  mandibular	
  right	
  third	
  molar	
  tooth	
  with	  an	
  associated	
  radiolucency	
  (odontogenic	
  cyst).	
  	
  Atrophic  mandible  with  carious  impacted  right  third  molar  tooth  #32  and  cyst

Postopera?ve  radiograph  following  removal  of  tooth  #32  and  associated  cyst

A	
  42	
  year-­‐old	
  male	  experienced	
  pain	
  and	
  swelling	
  associated	
  with	  his	
  right	  mandibular	
  wisdom	
  tooth	
  that	  was	  consistent	
  with	  pericoroni,s.	
  His	
  symptoma,c	
  lee	
  maxillary	
  and	  mandibular	
  wisdom	
  teeth	  were	  unevennully	
  removed	
  when	  he	
  was	  18	  years-­‐old.	
  Clinical	
  and	  radiographic	  evalua,on	
  revealed	
  probing	
  depths	
  >7mm	  and	  a	
  pericoronal	
  radiolucency	
  (den,gerous	
  cyst)	
  at	
  tooth	
  #32.	
  	
  Mandibular  right  third  molar  tooth  #32  with  pericoroni?s  and  den?gerous  cyst

Periopera?ve  boney  defect  right  posterior  mandibleOdontogenic  cyst

A	
  66	
  year-­‐old	
  female	
  experienced	
  mild	  intermi6ent	
  pain	  associated	
  with	  her	  previously	
  asymptoma,c	
  lee	  mandibular	
  “wisdom”	
  tooth.	
  	
  Clinical	
  and	  radiographic	
  evalua,on	
  revealed	
  a	
  large	  pericoronal	
  radiolucency	  (Den,gerous	
  Cyst)	
  at	
  impacted	
  tooth	
  #17.	
  	
  LeS  mandibular  den?gerous  cyst

Bilateral  odontogenic  cysts

A	
  47	
  year-­‐old	
  male	  experienced	
  pain	
  and	
  swelling	
  associated	  with	
  his	
  lee	  mandibular	
  wisdom	
  tooth.	
  Clinical	
  and	  radiographic	  evalua,on	
  revealed	
  a	
  large	  pericoronal	
  radiolucency	
  (den,gerous	
  cyst)	
  at	
  tooth	
  #17,	
  a	
  smaller	
  pericoronal	
  radiolucency	  (den,gerous	
  cyst)	
  at	
  tooth	
  #32,	
  and	
  carious	
  mandibular	
  second	
  molar	  teeth.	
  	  Bilateral  mandibular  den?gerous  cysts

Odontogenic  tumor/KCOT

A	
  27	
  year-­‐old	
  pa,ent	
  was	
  referred	
  by	
  his	
  general	
  den,st	
  for	  evalua,on	
  and	
  treatment	
  of	
  a	
  lesion	  of	
  the	
  lee	  mandible.	
  He	
  had	
  undergone	
  removal	
  of	
  his	
  asymptoma,c	
  “wisdom	
  teeth”	
  with	  another	  den,st	
  seven	
  years	
  previously.	
  The	
  panoramic	
  radiograph	
  revealed	
  a	
  unilocular	
  radiolucency	
  consistent	
  with	  a	
  large	
  residual	
  cyst.	
  However,	
  clinical	
  examina,on	
  revealed	
  boney	  expansion	
  sugges,ve	
  of	
  a	
  more	  aggressive	  process.	
  A	
  Cone	  Beam	  CT	
  scan	
  showed	
  erosion	
  through	
  the	
  buccal	
  and	
  lingual	
  plates.	
  Surgical	
  excision	
  of	
  the	
  lesion	  combined	
  with	  aggressive	  manual	  and	
  rotary	
  cure6age	
  was	
  followed	
  by	
  applica,on	
  of	
  Carnoy’s	
  solu,on.	
  Pathologic	  diagnosis	
  revealed	
  a	
  Keratocys,c	
  Odontogenic	  Tumor	
  (KCOT)	
  of	
  the	
  lee	  mandible.	
  	
  	
  	
  	
  	
  	
  	
  

Panoramic  radiograph  showing  lesion    of  leS  mandibleCone  beam  CT  in  panoramic  view  showing  KCOT  of  leS  mandibleCone  beam  CT  in  coronal  view  showing  KCOT  of  leS  mandibleCone  beam  CT  in  topographical  3D  view  showing  KCOT  of  leS  mandibleCone  beam  CT  in  topographical  3D  view  showing  KCOT  of  leS  mandibleCone  beam  CT  in  topographical  3D  view  showing  KCOT  of  leS  mandible⇓!

One-­‐year  postopera?ve  panoramic  radiograph  of  mandible  shows  no  recurrence  following  KCOT  removal⇒!

Odontogenic  tumor  A	
  completely	
  asymptoma,c	
  17	
  year-­‐old	
  pa,ent	
  was	
  referred	
  by	
  
her	
  orthodon,st	
  for	
  removal	
  of	
  her	
  third	
  molar	  teeth	  and	  evalua,on	
  of	
  a	
  mixed	  radiopacity/radiolucency	
  of	
  her	
  lee	
  posterior	
  maxilla	
  (odontoma	
  with	  unicys,c	
  amelloblastoma).	
  	
  Cone  beam  CT  scan  of  odontoma  and  ameloblastoma  of  leS  maxilla  in  panoramic  view⇑!

Cone  beam  CT  scan  of  odontoma  and  ameloblastoma  of  leS  maxilla  in  coronal  view

Cone  beam  CT  scan  of  odontoma  and  ameloblastoma  of  leS  maxilla  3D  view  from  below

Cone  beam  CT  scan  of  odontoma  and  ameloblastoma  of  leS  maxilla  3D  view  from  above  ⇑!
⇑!

Odontoma  with  unicys?c  ameloblastoma

For  more  informa?on,  please  see  the  AAOMS  Advocacy  White  Paper  on  Evidence-­‐
Based        Third  Molar  Surgery