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Dental Tribune Middle East & Africa No. 5, 2016

Dental Tribune Middle East & Africa Edition | 5/2016 20 REFERRAL Wisdom Teeth in Adults. Strategy and Management Based on a Rare Case. Figure1 Figure4a Figure 6b: Hernia of the submandibular glandin theextractionsite. Figure2d Figure4b Figure 6c: 48, lingual and alveolar aspect andRetromolar triangle(2fragments). Figure3a Figure 5: 28, pericoronal cyst and polyp endo-antral. Figure7 Figure3b Figure 6a: Double osteotomy of the lin- gual tablewithultrasound. Figure3c Figure3d ByDr.Benoît Philippe,UAE Extractions of wisdom teeth in adultsareknowntohavesometimes certain peculiarities in particular an- kylosis and increased frequency of extensive cystic lesions favouring immediate or secondary iatrogenic fractures. Theobjectiveofthispublicationisto present, from a specimen case as per the size and two-sidedness of the ab- normalities noted, the thinking that preceded the surgical procedure and theexecutionofthesurgicalact. DiagnosisCircumstances The patient is an adult male aged 48, without specific medical and surgi- calhistory.Hewasreferredformedi- cal advice and possible surgical care withregardtohisasymptomaticim- pacted third molars. The clinical si- lence contrast with the radiographic tablefound. DentalPan Four (4) impacted third molars are highlighted. 38 is positioned along the dental pedicle, inverted and showsapericoronalcystinthevicin- ity of the dental nerve. 48 vertical is particularly low-located, its roots projecting on the area of the basilar border. 28 and 18 included high- located, show divergent roots posi- tioned in the sinus cavities. Radicu- lar ankylosis is objectified to the absence of periradicular radiolucent area.(Figure1) Scanner The computed tomography exami- nation specifies the diagnosis and confirms the surgical difficulty of theseextractions. At theMandible -38, in addition to its close proxim- ity to the dental pedicle it shows a pericoronal cyst in contact with the inferior alveolar nerve. Its crown, in- verted and extremely large stresses its retentive character (Figures 2a to 2d) 48, vertically positioned, is locat- ed on the lingual side of the inferior alveolar nerve; its roots contained in the lingual table. The apexes are located below the mylohyoid mus- cle in immediate contact with the submandibular gland and near "the facial artery that runs through the posterior superior part of the gland before turning around the bottom edge of the mandible" (1). 48 shows a pericoronal cyst developed mainly on the distal side of its crown. (Fig- ures3ato3d. At theMaxilla Two maxillary wisdom teeth high- positioned, leaning against the pterygo-tuberosital junctions and which endo-antral roots are diver- gent. 28 shows a very large intra- sinus lesion of liquid density, not visible in the dental panoramic, filling substantially all of the sinus cavity (Figures 4a and 4b). Although asymptomatic and despite a signifi- cant risk of intraoperative and post- operative complications in such a context, the extraction of mandibu- lar wisdom teeth and the extraction of the left maxillary wisdom tooth are confirmed. Indeed, as regards 38 and 48, the inevitable development of bone defects (cystic lesions) inevi- tablyexposesto: -Amandibularfracture - An infectious decompensation re- quiring urgent extraction (with an increased risk of intraoperative com- plications due to low accessibility generated by the trismus accompa- nyingtheinfection), - The progressive and fatal destruc- tionoftheinferioralveolarnerve(we note on the right and on the left the disappearance of the bony canal in thevicinityofthepericoronalcysts. The existence of adhesions between the cystic envelope and the pedicles fosters (besides the risk of bleeding) nervetraumas(Figures3dand2d). Concerning 28, the subtotal devel- opment of the endo-antral cystic lesion exposes in a near future to a sudden infectious decompensation by complete blockage of the sinus. Because of the high risk of oro-antral communication, 18 clinically and ra- diologically asymptomatic is main- tained as it is (there is especially no endo-antralimage). Information and Informed Consent Strengthened The surgical indication is confirmed to the patient despite the absence of symptoms. The option of general anaesthesiaisselectedbecauseofthe difficultyofthesurgicalprocedure. Given the mandibular anatomical lesions and especially their bilateral nature, the information provided to thepatientinsistontheincreasedin- traoperative and postoperative risk of mandibular fracture and destruc- tionofthealveolarnervebydirecthit (section,burning)orindirecthit(tear in case of fracture). The information stresses the same way on the risk of direct or indirect hit of the lingual nerve itself particularly fragile and located in the immediate vicinity of the roots of 48. Because of the high- location of 28 and the divergence of its roots, the risk of oral sinus com- municationisclearlyindicated. SurgicalStrategy In order to perform the surgery in the best technical conditions (espe- cially in the absence of trismus as a result of an infectious decompensa- tion) it is recommended to perform these extractions "in cold situation" and in two times (high fracture risk). 38 and 28 are programmed in a first phase and 48 in a second phase to 6 months. Surgical Procedures and An- esthesia Inordertohavethebestaccessibility, theintubationisperformedusingan endonasalprobeduringbothsurger- ies. Concerning 38: several technical fea- turesareworthmentioning: - The route for the approach and the separation are expanded (the incision covers the entire sillon of 37 and the retromolar triangle and is completed by two long discharge incisions) - The use of ultrasound allows, due to ankylosis, an efficient cleavage be- tweenthedentaltissueandthebone tissue - The separation of the cystic lesion is performed using the micro raspa- toryontheflat. ClinicalCase Given the inflammatory adhesions, a special attention is given to the lowerpoleofthecysticlesion: - The enucleation of the pericoronal cyst is performed without any pull- ingonitsenvelope. Concerning 28, the sulcular incision spreads from 26 until the impacted tuberosity, completed by two wide vertical discharge incisions led until thebottomofthevestibule. The vestibular osteoctomy carried out using the piezosurgery, spreads overtheentireheightof28.Thecyst- ic lesion (polyp) is enucleated in full (Figure5). Concerning 48, despite a widened approach path (in 47, the vestibu- lar and lingual sulcular incision is extended from the distal surface of the tooth until the anterior edge of the ramus), the procedure is to keep intact the outer table and the basilar margin of the mandible. The extraction is performed through the lingual path. Careful subperiosteal separationconcernsthelingualtable with regard to 47 and the retromolar triangle. Amalleablebladetoprotect Figure2a Figure2b Figure2c the lingual nerve is gradually posi- tionedintheseparationspace. Thedoubleverticalosteotomyofthe lingual table framing 48 impacted is performed with ultrasound under heavy irrigation with refrigerated serum. A controlled fracture of the lingual bone flap made with Ob- wegeser raspatory will complete the procedure. 48 is lingually dislocated (Figures6ato6c). In addition to the systematic recom- mendations given to the patient, preoperative and postoperative in- formation insist particularly on the prevention of secondary mandibu- lar fracture (soft diet for 45 days) and onthepreventionoforo-antralcom- munication (sneezing mouth open and gentle nose blowing during 45 days). The histological analysis of the man- dibularlesionconfirmsthediagnosis ofcystswithMalpighiancoatingand eliminates any unusual or suspi- ciouselementofmalignancy. Postoperative, Medium Term Monitoring Apart from an acute painful episode on the right side that occurred dur- ing chewing on the third postopera- tive week (without occlusion disor- der or pathological radiographic image), no complication was noted andinparticularnofractureornerve symptoms (dental nerve, lingual nerve) in immediate post-operative and secondary postoperative period (due to scarring mechanisms in the vicinityofnervouspedicle). The panoramic shot of late medical supervision reveals a satisfactory bonehealing;inparticularthedisap- pearance of radiolucent images in 38 and48andtheabsenceof opacityin the left sinus cavity which is a proof ofagoodventilation(Figure7). Conclusion With impacted wisdom teeth in adults, the importance of anoma- lies (ectopia, ankylosis, cystic lacuna, nervous vicinity) imposes an in- creasedobligationtoprovidefurther information. Nevertheless, with le- sions having a possible risk of acute infectious decompensation, the preventive extraction in the absence ofinfectiouslockjawseemstoberec- ommended. The two-sidedness of the lesions imposes a two-step pro- cedure. Despite the implementation of a sequence and a suitable surgical technique, nervous or fracture com- plications are always possible due to adhesions, ankylosis and loss of pre- operative cystic and postoperative iatrogenicbonesubstances. References P. Kamina: “Précis d’Anatomie Clin- ique”,volumeII 2ndEditionMaloine 204302-303 Dr.Benoît Philippe MaxillofacialSurgery andStomatology Dr.Roze&Associates DentalClinic Villa747JumeirahBeachRoad UmmSuqeim2,Dubai,UAE Tel:+97143881313 Email:info@dradubai.com

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