Parameters of Care Dentoalveolar Surgery 2012

Parameters of Care:
Clinical Practice Guidelines

for Oral and Maxillofacial Surgery
(AAOMS ParCare 2012)
DENTOALVEOLAR SURGERY
Copyright 2012 by the American Association of Oral and Maxillofacial Surgeons.
This document may not be copied or reproduced
without the express written permission of the
American Association of Oral and Maxillofacial Surgeions.
All rights reserved.
J Oral Maxillofac Surg
70:e50-e71, 2012, Suppl 3
THIS SECTION IS 1 OF 11 CLINICAL SECTIONS INCLUDED IN AAOMS
PARCARE 2012, WHICH IS VIEWED AS A LIVING DOCUMENT APPLICABLE
TO THE PRACTICE OF ORAL AND MAXILLOFACIAL SURGERY. IT WILL BE UPDATED
AT DESIGNATED INTERVALS TO REFLECT NEW INFORMATION CONCERNING THE
PRACTICE OF ORAL AND MAXILLOFACIAL SURGERY.
e50
INTRODUCTION
Dentoalveolar surgery encompasses those surgical procedures that involve teeth and supporting structures associated
with the oral cavity. This section includes the management of: odontogenic infections; erupted, unerupted, and impacted
teeth; third molars; periradicular pathology; and the revision, reduction, and excision of deformities and defects of the
dentoalveolar complex. Implant surgery, traumatic injuries, pathologic conditions, and reconstructive surgery that are
applicable to the dentoalveolar complex are not included. These topics are addressed in the chapters Dental and
Craniomaxillofacial Implant Surgery, Trauma Surgery, Diagnosis and Management of Pathological Conditions, and
Reconstructive Surgery, respectively. The subject of osteomyelitis is included in the Diagnosis and Management of
Pathological Conditions chapter.
An understanding of basic surgical principles, as well as an awareness and appreciation of the extent of the biomedical
literature, is necessary for the proper interpretation and appreciation of the Dentoalveolar Surgery section.
In the future, signicant advances will occur in biomaterials, diagnostic techniques, and management modalities, and
each will make an impact on the achievement of favorable outcomes. Such potential for change requires that this
document remain dynamic, updated, and revised to include valid new information applicable to patient care.
GENERAL CRITERIA, PARAMETERS, AND CONSIDERATIONS FOR
INFORMED CONSENT: All surgery must be preceded by the patients or legal guardians consent, unless an
emergent situation dictates otherwise. These circumstances should be documented in the patients record. Informed
consent is obtained after the patient or the legal guardian has been informed of the indications for the procedure(s), the
goals of treatment, the known benets and risks of the procedure(s), the factors that may affect the risk, the treatment
options, and the favorable outcomes.
PERIOPERATIVE ANTIBIOTIC THERAPY: In certain circumstances, the use of antimicrobial rinses and systemic
antibiotics may be indicated to prevent infections related to surgery. The decision to employ prophylactic perioperative
antibiotics is at the discretion of the treating surgeon and should be based on the patients clinical condition as well as
other comorbidities which may be present.
USE OF IMAGING MODALITIES: Imaging modalities may include panoramic radiograph, periapical and/or
occlusal radiographs, maxillary and/or mandibular radiographs, computed tomography, cone beam computed tomog-
raphy, positron emission tomography, positron emission tomography/computed tomography, and magnetic resonance
imaging. In determining studies to be performed for imaging purposes, principles of ALARA (as low as reasonably
achievable) should be followed.
DOCUMENTATION: The AAOMS ParCare 2012 includes documentation of objective ndings, diagnoses, and
patient management interventions. The ultimate judgment regarding the appropriateness of any specic procedure must
be made by the individual surgeon in light of the circumstances presented by each patient. Understandably, there may
be good clinical reasons to deviate from these parameters. When a surgeon chooses to deviate from an applicable
parameter based on the circumstances of a particular patient, he/she is well advised to note in the patients record the
reason for the procedure followed. Moreover, it should be understood that adherence to the parameters does not
guarantee a favorable outcome.
GENERAL THERAPEUTIC GOALS FOR DENTOALVEOLAR SURGERY:
A. Elimination of acute and/or chronic infection
B. Limitation or elimination of pain
C. Restored anatomical form
D. Restored masticatory function
E. As an adjunct or to facilitate other restorative procedures
F. Preserved vital structures
G. Limited period of disability
H. Elimination of existing pathology
I. Appropriate understanding by patient (family) of treatment options and acceptance of treatment plan
J. Appropriate understanding and acceptance by patient (family) of favorable outcomes and known risks and
complications
AAOMS ParCare 2012 e51
Dentoalveolar Surgery
K. Prevention of future expected problems (planned radiation therapy, bisphosphonate therapy, or radiation to the
jaws)
L. Prophylactic treatment when access to care is expected to be limited in the future (eg, military service, service in
third world country)
GENERAL FACTORS AFFECTING RISK DURING DENTOALVEOLAR SURGERY: Certain general factors
will affect the outcome of dentoalveolar surgery. These severity factors increase the risk and the potential for known
complications.
A. Presence of acute and/or chronic infection
B. Presence of coexisting major systemic disease (eg, disease that increases a patients American Society of
Anesthesiologists classication to II, III, or IV) as detailed in the Patient Assessment chapter
C. Age of patient
D. Presence of local or systemic conditions that may interfere with the normal healing process and subsequent tissue
homeostasis (eg, diabetes mellitus, chronic renal disease, liver disease, blood disorder, steroid therapy, immu-
nosuppression, malnutrition, bisphosphonate therapy)
E. Degree of patient and/or family understanding of the etiology and natural course of the condition or disorder and
therapeutic goals and acceptance of the proposed treatment
F. Presence of behavioral, psychological, neurologic, and/or psychiatric disorders, including habits (eg, substance
abuse, including tobacco and alcohol), seizure disorders, self-mutilation that may affect surgery, healing, and/or
response to therapy
G. Degree of patients and/or familys cooperation with and/or adherence to preoperative and postoperative
instructions and follow-up
H. Location of branches of cranial nerves
I. Location of adjacent teeth and adjacent dental restorations
J. Presence of associated or adjacent pathologic conditions
K. History of or ongoing treatment with radiation, bisphosphonate therapy, or chemotherapy
L. History of temporomandibular joint disease or disorder
M. History of myofascial pain
N. Limited access to oral cavity (eg, trismus, neurologic disorders, inadequate oral orice)
O. Patient decisions regarding regulatory and/or third party rules concerning access to care, indicated therapy, drugs,
devices, and/or materials
GENERAL FAVORABLE THERAPEUTIC OUTCOMES FOR DENTOALVEOLAR SURGERY:
A. Absence of acute and/or chronic infection
B. Absence of pain
C. Uncomplicated healing of surgical sites
D. Restored and/or improved form and function
E. Limited period of disability
F. Reduced susceptibility to pathologic conditions
G. Restoration, retention, and function of previously diseased tooth or teeth
H. Absence of neurologic dysfunction (sensory)
I. Improved host defenses
J. Patient (family) acceptance of procedure and understanding of outcomes
GENERAL KNOWN RISKS AND COMPLICATIONS FOR DENTOALVEOLAR SURGERY:
A. Unexpected or prolonged pain, swelling, hemorrhage, trismus
B. Prolonged period of disability
C. Symptoms of temporomandibular joint disease or disorder
D. Symptoms of myofascial pain
E. Osteomyelitis (also see the Osteomyelitis section in the Diagnosis and Management of Pathological Conditions
chapter)
F. Osteoradionecrosis
G. Osteonecrosis of the jaws
H. Postoperative wound infection
I. Unplanned admission to emergency care facility or hospital after surgery
e52 AAOMS ParCare 2012
Comment and Exception: Planned admission should be documented in the patients record before
surgery.
J. Unplanned intubation during the perioperative period
Comment and Exception: Planned intubation should be documented in the patients record before
surgery.
K. Reintubation after surgery or the necessity for a surgically created airway after surgery (for airway impairment)
L. Unplanned need for parenteral drugs and uids
Comment and Exception: Procedures where long-term parenteral drugs and/or uids are anticipated as
part of the original treatment plan should be documented in the patients record before surgery.
M. Failure to meet proscribed discharge criteria within 6 hours of elective surgery
Comment and Exception: Anticipated delays in discharge should be documented preoperatively.
N. Facial and/or trigeminal nerve dysfunction after surgery (eg, anesthesia, paresthesia of the lips, teeth, chin, or
tongue)
Comment and Exception: When postoperative nerve dysfunction is a known risk, anticipated decits
should be documented in the patients record before surgery (eg, trigeminal nerve dysfunction after
removal of a third molar documented to be close to nerves).
O. Maxillary or mandibular fracture during or after surgery
Comment and Exception: A fractured bone that may be a sequela to surgery should be documented in
the patients record before surgery.
P. Unplanned Caldwell-Luc, bronchoscopy, or other exploratory procedures associated with surgery
Q. Dental injury and/or damage to adjacent dental restorations during surgery
Comment and Exception: When the likelihood of dental injury is possible, it should be documented in
the patients record before surgery.
R. Ocular injury during surgery
S. Unanticipated tissue loss or damage to adjacent vital structures
T. Repeat Oral and/or Maxillofacial Surgery
Comment and Exception: Staged procedures that are part of the original treatment plan should be
documented before the initial procedure.
U. Core temperature of greater than 101F during the rst 72 hours
V. Presence of foreign body after surgery
Comment and Exception: Implanted materials that are anticipated as a normal course of the surgical
procedures should be documented in the patient record.
W. Unplanned transfusion(s) of blood or blood components during or after surgery
X. Compromised airway
Y. Adverse systemic sequelae (eg, septicemia, endocarditis)
Z. Respiratory and cardiac arrest
AA. Death
Comment and Exception: Admissions for terminal care must be documented.
SPECIAL CONSIDERATIONS FOR PEDIATRIC
Management of odontogenic infections; erupted, unerupted, and impacted teeth; third molars; periradicular pathology;
and defects of the dentoalveolar structures is similar in children and adults. However, certain age- and developmental-
dependent variables must be considered.
Informed consent must be obtained from a parent or guardian with legal authority and should include the child as soon
as he/she is old enough to understand the procedure, risks, and benets. It is especially important to have detailed
information related to who will be taking the child home after the procedure. This is absolutely mandatory in the case
of separated parents.
Maxillofacial infections in children vary according to age and development. In children younger than 5 years, it is
more common to have upper face (orbit, soft tissue over maxilla or zygoma) infections of nonodontogenic etiology
accompanied by systemic sepsis. Also, there is a more frequent association with sinusitis and otitis in upper face
infections. In children older than 5 years, lower face infections are more commonly of odontogenic origin. Nonodon-
togenic infections may require broad-spectrum intravenous antibiotics and hydration; odontogenic infections require
antibiotics, hydration, drainage, and treatment of the underlying dental problem as indicated.
Behavioral management of the child requiring a dentoalveolar procedure is determined by the patients age and stage of
psychological development. It is important to take enough time with the parent and child to appreciate the behavioral status
and make a reasonable judgment on management regarding the use of local anesthesia, sedation, or general anesthesia.
The nature of the dentoalveolar procedure to be performed is greatly affected by the childs age. For example, the
most common impacted tooth for extraction in children is the mesiodens compared with the third molar in adults.
Neonatal or natal teeth are not uncommon and are frequently indicated for removal due to lack of alveolar bone support,
poor root development, associated mobility, and aspiration risk. Neonatal teeth represent the early arrival of the primary
dentition, so parents need be counseled regarding the anticipated dental decit when these have been removed.
Riga-Fede disease, a chronic, nonhealing ulceration of the midline ventral aspect of the tongue in infants, is due to the
presence of newly erupted mandibular primary incisors. Simple smoothing of the incisal edges will usually sufce, but
on occasion these teeth will require removal to avoid failure to thrive situations. Children who have late mixed
dentition or early adult dentition often require exposure of impacted canines during orthodontic treatment. Timing of
surgery is important in children. In general, consideration should be given to waiting until the incisors adjacent to an
impacted mesiodens have at least two-thirds root development so that extraction will present less risk to the developing
teeth but still allow spontaneous eruption of the incisors. This general principle may be applied to extraction of any
impacted supernumerary teeth. Trauma and avulsion of teeth is common in children, and management is governed by
the fact that open apices are associated with a better prognosis than the same injury in adults.
Space maintenance is a frequent need following removal of teeth in children. The surgeon should recommend that
appropriate consultation with, or referral to, the primary care dental provider or orthodontist be accomplished to address
this need.
Ankyloglossia release and labial frenectomy, when indicated, are ideally performed in children before detrimental
effects occur. Lingual frenectomy, when indicated, is considered early for optimizing speech development. It is
important to recognize that recurrent ranulae may be confused with lymphatic malformations of the oor of the mouth.
Finally, hemangiomas can be seen on the alveolus in infants. These need to be differentiated from eruption cysts.
Hemangiomas may undergo a rapid growth phase in the rst year of life but then regress spontaneously. Eruption cysts
resolve with eruption of the tooth.
ODONTOGENIC INFECTIONS
Also see the Osteomyelitis section in the Diagnosis and Management of Pathological Conditions chapter.
I. Indications for Therapy for Odontogenic Infections
May include one or more of the following:
A. Clinical or physical ndings
1. Pain
2. Swelling
3. Soft tissue induration
4. Erythema
5. Lymphadenitis
6. Trismus
7. Purulence
8. Fistula
9. Nonvital pulp of tooth
10. Carious tooth
11. Fractured tooth
12. Tooth mobility
13. Fetor
14. Malaise
15. Fever
16. Chills
17. Diaphoresis
ODONTOGENIC INFECTIONS (continued)
18. Dyspnea
19. Dysphagia
20. Altered function
21. Altered sensation
22. Soft tissue necrosis (eg, necrotizing fasciitis)
23. Systemic sepsis
24. Disseminated infection (eg, prosthetic cardiac valve)
B. Diagnostic imaging ndings
1. Dental caries
2. Periodontal bone loss
3. Fractured tooth or tooth root
4. Internal resorption or external resorption of tooth
5. Periapical radiolucency (eg, osteolytic process)
6. Widening of periodontal ligament space
7. Sclerosis or reactive bone
8. Osteolytic area (eg, cystic, bone radiolucency, or degeneration not associated with a tooth)
9. Antral wall destruction or thickening
10. Gas spaces in soft tissue
11. Soft tissue mass, uid loculation, and/or abscess cavity
C. Laboratory ndings
1. Abnormal complete blood cell count, differential count, sedimentation rate, serum electrolytes, glucose,
arterial blood gas
2. Positive microbiologic culture (eg, blood, purulence)
3. Positive Gram stain
4. Elevated temperature
II. Specic Therapeutic Goals for Odontogenic Infections
The goal of therapy is to restore form and/or function. However, risk factors and potential complications may
preclude complete restoration of form and/or function.
A. Presence of a general therapeutic goal, as listed in the section entitled General Criteria, Parameters, and
Considerations for Dentoalveolar Surgery
B. Prevention of recurrence
III. Specic Factors Affecting Outcomes From Odontogenic Infections
Severity factors that increase risk and the potential for known complications:
A. Presence of a general factor affecting risk, as listed in the section entitled General Criteria, Parameters, and
B. Extent of infection (eg, localized, diffuse)
C. Direction and/or rate of extension of infection
D. Presence of impending airway obstruction
E. Susceptibility of organism to antibiotics
F. Virulence of organism
G. Presence of generalized periodontitis
H. Presence of inadequate oral hygiene
I. Presence of dental crowding or malocclusion
J. Proximity to contiguous structures
K. Presence of foreign bodies or implanted materials
L. Dental management objectives that are altered and/or adversely affected by therapy
IV. Indicated Therapeutic Parameters for Odontogenic Infection
The presurgical assessment includes, at a minimum, a history and both a clinical and an imaging evaluation. Also
see the Patient Assessment chapter.
The following procedures for the management of odontogenic infections are not listed in order of preference:
ODONTOGENIC INFECTIONS (continued)
A. Establishment of airway (intubation, emergency tracheostomy, cricothyroidotomy), if compromised
B. Elimination of source (removal of tooth, endodontic treatment, periodontal therapy, etc)
C. Incision and drainage (intraorally and/or extraorally of the maxillofacial region)
D. Aspiration
E. Pain control
F. Irrigation and debridement
G. Identication of organism (eg, Gram stain, aerobic and anaerobic organism culture and sensitivity testing,
culture acid-fast bacilli and fungi) when indicated
H. Assessment and support of host defenses (eg, local measures, antipyretics, nutritional support, and hydration,
hyperbaric oxygen treatment)
I. Antimicrobial therapeutic management, if indicated (systemic or local therapy)
J. Assessment and management of systemic involvement (eg, sepsis)
K. Assessment and management of coexisting systemic disease (eg, diabetes mellitus)
L. Instructions for posttreatment care and follow-up
V. Outcome Assessment Indices for Odontogenic Infections
Indices are used by the specialty to assess aggregate outcomes of care. Outcomes are assessed through clinical
evaluation and may include an imaging evaluation.
A. Favorable therapeutic outcomes
1. General favorable therapeutic outcomes, as listed in the section entitled General Criteria, Parameters,
and Considerations for Dentoalveolar Surgery
2. Absence of local or systemic signs and/or symptoms of infection
3. Absence of unanticipated tissue loss
4. Restored form and function
5. Improved host defenses
6. Limited period of disability
B. Known risks and complications associated with therapy
1. Presence of a general known risk and/or complication, as listed in the section entitled General Criteria,
Parameters, and Considerations for Dentoalveolar Surgery
2. Persistence or extension of infection (intracranial extension, eg, sinusitis, cavernous sinus thrombosis,
osteomyelitis, mediastinitis)
3. Airway impairment
4. Tissue loss or damage to adjacent vital structures
5. Adverse systemic sequelae (eg, septicemia, endocarditis), which could lead to organ failure and death
6. Adverse drugs reactions or interaction with existing therapeutic drug regimens
7. Facial, neck scarring, or keloid formation with need for secondary revision surgery
8. Nerve injury secondary to the infection or the surgical intervention
9. Fracture of the maxilla or mandible
10. Onset or exacerbation of symptom(s) related to the temporomandibular joint (TMJ) and surrounding
structures
ERUPTED TEETH
I. Indications for Therapy for Erupted Teeth
A. Pain
B. Clinical or imaging ndings of:
1. Dental caries
2. Periodontal disease
3. Periapical pathology
4. Nonrestorable tooth
5. Split tooth
ERUPTED TEETH (continued)
6. Tooth mobility
7. Internal or external resorption of tooth
8. Infection
9. Severe anomaly of the crown/root precluding prosthetic/restoration treatment
10. Traumatic injuries to tooth
C. Loss of pulp vitality
D. Ectopic position (eg, malposition, supraeruption, traumatic occlusion), which may cause damage to other teeth
E. Adjunct to prosthetic rehabilitation or implant placement
F. Orthodontic considerations (eg, arch length/tooth size discrepancies, interceptive extractions to obtain func-
tional occlusion, ankylosis)
G. Teeth in line of mandibular or maxillary osseous fracture (eg, fractured teeth, abscessed teeth, periodontally
involved teeth)
H. Teeth associated with pathologic lesions
I. Medical or surgical condition or treatment (eg, organ transplantation, chemotherapy, radiation therapy,
placement of prosthetic heart valves, prosthetic joints, bisphosphonate administration, joint replacement) for
which removal of teeth is prophylactic
J. Prevention of injury (eg, natal teeth in nursing mother, psychiatric or motor disorder)
K. Patient refusal of appropriate endodontic and/or periodontal therapy or appropriate surgical exposure to aid
orthodontic treatment.
II. Specic Therapeutic Goals for Erupted Teeth
B. Prevention of pathology
C. Improved aesthetics
D. Optimization of occlusion
E. Optimization of prosthetic rehabilitation
F. Optimization of healing of osseous fractures
G. Maintenance of functional teeth
H. Enhanced orthodontic results
I. Normal eruption pattern of teeth
J. Healthy oral and maxillofacial environment for patient undergoing head and neck radiation therapy
K. Healthy oral and maxillofacial environment for patient undergoing systemic therapy (eg, chemotherapy,
bisphosphonate drugs, organ transplantation, or heart valve replacement)
L. Elimination of hard and/or soft tissue pathology
M. Optimize implant placement
III. Specic Factors Affecting Risk for Erupted Teeth
B. Presence of associated pathologic disease
C. Presence of acute and/or chronic infection
D. Existing active dental, endodontic, or periodontal diseases
E. Presence of adjacent tooth or teeth
F. Presence of extensive dental caries
G. Presence of large restoration in adjacent teeth
H. Presence of associated jaw fracture
I. Size and density of supporting bone (eg, maxilla, mandible)
J. History of endodontic therapy
K. Relationship of tooth or teeth to maxillary antrum
L. Approximation of tooth or teeth to inferior alveolar nerve, lingual nerve, mental nerve, maxillary sinus, or other
signicant structures
M. Root anatomy (eg, size, shape, number, dilaceration, divergence)
N. Root-to-crown ratio
O. Accessibility (eg, compromised by ectopic eruption or positioning of adjacent teeth)
P. Limited access to oral cavity (eg, trismus, inadequate oral orice)
IV. Indicated Therapeutic Parameters for Erupted Teeth
The presurgical assessment includes, as a minimum, a history and both a clinical and an imaging evaluation. Also
see the Patient Assessment chapter.
The following procedures for the management of erupted teeth are not listed in order of preference:
A. Incision, drainage, and medical management of acute infection (see the Odontogenic Infections section for
indicated therapeutic parameters)
B. Endodontic therapy
1. Nonsurgical
2. Periapical surgery
C. Hemisection of tooth or root amputation
D. Periodontal surgery
1. Mucogingival surgery
2. Alveolar/osseous surgery
3. Grafting procedures (eg, soft and/or hard tissue, autogenous, alloplastic)
4. Crown lengthening procedures
5. Guided tissue augmentation
E. Dental extraction
1. Simple
2. Surgical including root amputation
3. Concomitant augmentation with alloplastic or autogenous graft to maintain alveolar form and function
F. Observation
G. Instructions for posttreatment care and follow-up
V. Outcome Assessment Indices for Erupted Teeth
evaluation.
1. General favorable therapeutic outcomes, as listed in the sections entitled General Criteria, Parameters
and Considerations for Dentoalveolar Surgery and Special Considerations for Dentoalveolar Surgery
2. Maintenance of previously diseased teeth
3. Improved aesthetics
4. Improved function and occlusion
2. Acute and/or chronic infection
3. Alveolar osteitis
4. Injury to adjacent teeth and/or hard and/or soft tissue
5. Damage to adjacent restorations
6. Presence of foreign body in surgical site
7. Presence of portion of tooth intentionally left in alveolus
8. Presence of portion of tooth unintentionally left in alveolus
9. Presence of unattached bone fragment intentionally or unintentionally left in surgical site
10. Mandibular and/or maxillary fractures
11. Condition that requires unplanned additional surgery (eg, incision and drainage, curettage)
12. Oroantral and/or nasal stula formation
13. Displacement of tooth, tooth fragments, or foreign bodies into adjacent anatomical sites (eg, airway,
gastrointestinal tract, maxillary sinus, inferior alveolar canal, contiguous soft tissues)
14. Persistent or new pathology (eg, recurrent or residual cyst or tumor)
15. Osteonecrosis related to systemic bisphosphonate therapy
16. Persistent exposure of alveolar bone
17. Acute and/or chronic osteomyelitis
18. Damage to lingual or inferior alveolar nerve
19. Onset or exacerbation of symptom(s) related to the temporomandibular joint (TMJ) and surrounding structures
UNERUPTED AND IMPACTED TEETH (OTHER THAN THIRD MOLARS)
An impacted tooth is one that cannot erupt into normal position or function; it is considered to be pathologic.
I. Indications for Therapy for Unerupted and Impacted Teeth (Other Than Third Molars)
A. Pain
B. Clinical ndings of:
1. Dental caries
2. Periodontal disease
3. Periapical pathology
4. Nonrestorable tooth
5. Internal or external resorption of tooth or adjacent teeth
6. Infection
7. Failure of the tooth to spontaneously erupt
8. Ectopic eruption of a tooth
C. Orthodontic abnormalities (eg, arch length/tooth size discrepancies, ankylosis)
D. Medical or surgical condition or treatment (eg, organ transplantation, chemotherapy, bisphosphonate therapy, radiation
therapy, placement of prosthetic heart valves, prosthetic joint replacement) for which removal of teeth is prophylactic
E. Adjunct to prosthetic rehabilitation
F. Teeth in line of osseous fracture
G. Pathology associated with tooth follicle (eg, cysts, tumors)
H. Teeth associated with pathologic lesions
I. Facilitation of management in trauma or orthognathic surgery
J. Insufcient space to accommodate erupting tooth or teeth
K. Traumatic injury to the tooth
L. Anatomical position causing potential damage to adjacent teeth
II. Specic Therapeutic Goals for Unerupted and Impacted Teeth (Other Than Third Molars)
B. Prevention or elimination of pathology
C. Optimization of prosthetic rehabilitation
D. Optimization of management and/or healing of jaw fractures
E. Optimization of orthodontic results
F. Healthy oral and maxillofacial environment for patient undergoing radiation therapy, chemotherapy, bispho-
sphonate therapy, organ transplantation, or placement of prosthetic heart valves
G. Prevention of complications in orthognathic surgery
III. Specic Factors Affecting Risk for Unerupted and Impacted Teeth (Other Than Third Molars)
(continued)
B. Presence of associated or adjacent pathology
C. Presence of acute and/or chronic infection
D. Size and density of supporting bone (eg, mandible, maxilla)
E. Anatomical relationships of tooth or teeth to:
1. Maxillary antrum and nasal cavity
2. Adjacent nerves
3. Adjacent teeth
4. Other signicant anatomical structures
5. Adjacent blood vessels
F. Anatomical position of tooth or teeth
G. Tooth root anatomy (eg, dilaceration, divergence, size, shape, number)
H. Presence of gemination or fusion with adjacent tooth
I. Status of adjacent teeth (eg, large restorations, fractured crown, terminal abutment for bridge)
J. Ankylosis of tooth or teeth
K. Presence of associated jaw fracture
L. Accessibility (eg, compromised by ectopic eruption or positioning of adjacent teeth)
M. Limited access to oral cavity (eg, trismus, inadequate oral orice)
N. History of radiation, chemotherapy, or bisphosphonate therapy
IV. Indicated Therapeutic Parameters for Unerupted and Impacted Teeth (Other Than Third Molars)
The presurgical assessment includes, as a minimum, a history and both a clinical and an imaging evaluation. See
also the Patient Assessment chapter.
The following procedures for the surgical management of unerupted and impacted teeth are not listed in order
of preference:
A. Surgical removal of tooth or teeth
B. Surgical exposure with or without placement of orthodontic attachments
C. Coronectomy
D. Surgical repositioning, reimplantation, or transplantation
E. Surgical periodontics
F. Surgical removal of associated cysts
G. Marsupialization of defects with secondary management of associated impacted teeth
H. Removal of associated neoplasms
I. Instructions for posttreatment care and follow-up
J. Interdental Corticotomy/Osteotomy to assist eruption
K. Observation
V. Outcome Assessment Indices for Unerupted and Impacted Teeth (Other Than Third Molars)
2. Absence of infection
3. Elimination of associated pathology (odontogenic cysts, neoplasms)
4. Orthodontic and/or prosthetic rehabilitation facilitated
(continued)
4. Injury to adjacent teeth and/or hard or soft tissues
5. Injury/damage to adjacent restorations
7. Presence of portion of tooth intentionally left in alveolus, requiring secondary treatment
9. Presence of unattached bone fragment intentionally or unintentionally left in alveolus
10. Devitalization, ankylosis, and/or internal or external resorption of surgically exposed or repositioned tooth
11. Mandibular and/or maxillary fracture
16. Bisphosphonate-related osteonecrosis or osteoradionecrosis
17. Acute or chronic osteomyelitis
structures
THIRD MOLARS
Given the following indications and the desire to achieve therapeutic goals, obtain positive outcomes, and avoid known
risks and complications, a decision should be made before the middle of the third decade to remove or continue to
observe third molars knowing that future treatment may be necessary based on the clinical situation. There is a growing
body of knowledge suggesting that the retention of third molars that are erupted or partially erupted contribute to a
higher incidence of periodontal disease. This persistent periodontal disease has both dental and medical consequences
for the host and therefore may be an indication for prophylactic removal.
An unerupted third molar is an embedded tooth that will probably erupt by the middle of the third decade.
An impacted third molar is so positioned that it will probably not erupt by the middle of the third decade and may
lead to disease with dental and medical consequences. To limit known risks and complications associated with surgery,
it is medically appropriate and surgically prudent to remove these impacted third molars before the middle of the third
decade and before complete root development. An impacted tooth with completed root formation that is totally covered
by bone in a patient beyond the third decade that does not meet the following indications for removal should be
monitored for change in position and/or development of disease, which may then indicate its removal.
I. Indications for Therapy for Third Molars
A. Erupted third molar tooth: an erupted tooth that is so positioned that the entire clinical crown is visible.
1. Pain
2. Carious tooth
3. Facilitation of the management of or limitation of progression of periodontal disease
4. Nontreatable pulpal or periapical lesion
5. Acute and/or chronic infection (eg, cellulitis, abscess)
6. Ectopic position (malposition, supraeruption, traumatic occlusion)
7. Abnormalities of tooth size or shape precluding normal function
8. Facilitation of prosthetic rehabilitation
9. Facilitation of orthodontic tooth movement and promotion of stability of the dental occlusion
10. Tooth in the line of fracture complicating fracture management
11. Tooth involved in surgical treatment of associated cysts and tumors
12. Tooth interfering with orthognathic and/or reconstructive surgery
THIRD MOLARS (continued)
13. Preventive or prophylactic removal, when indicated, for patients with medical or surgical conditions or
treatments (eg, organ transplants, alloplastic implants, bisphosphonate therapy, chemotherapy, radiation
therapy, prosthetic joint replacement)
14. Clinical ndings of pulp exposure by dental caries
15. Clinical ndings of fractured tooth or teeth
17. Patients informed refusal of nonsurgical treatment options
18. Anatomical position causing potential damage to adjacent teeth
B. Partially erupted third molar tooth: a partially erupted tooth that is so positioned that only a portion of the
clinical crown is visible.
1. Pain
2. Pericoronitis
3. Carious tooth
5. Nontreatable pulpal or periapical lesion
6. Acute and/or chronic infection (eg, cellulitis, abscess)
7. Ectopic position
10. Facilitation of orthodontic tooth movement and promotion of dental stability
11. Tooth impeding the normal eruption of an adjacent tooth
12. Tooth in the line of fracture
13. Tooth involved in tumor resection
14. Pathology associated with tooth (eg, cysts, neoplasms)
15. Preventive or prophylactic removal, when indicated, for patients with medical or surgical conditions or
treatments (eg, organ transplants, alloplastic implants, bisphosphonate therapy, chemotherapy, radiation
therapy)
16. Tooth interfering with orthognathic and/or reconstructive jaw surgery
19. Impacted tooth (as dened previously)
C. Unerupted/impacted third molar tooth: an unerupted/impacted tooth that has not penetrated through bone
and/or soft tissue and entered the oral cavity.
Consideration should be given to removal of an unerupted /impacted third molar by the third decade when
there is a high probability of disease or pathology and that the tooth will not erupt and when risks associated
with early removal are less than anticipated risks of later removal (eg, increased morbidity).
1. Pain
2. Pathology associated with tooth follicle (eg, cysts, tumors)
5. Resorption of adjacent tooth
6. Facilitation of orthodontic tooth movement and promotion of stability of the dental occlusion
8. Tooth impeding the normal eruption of an adjacent tooth
9. Tooth in the line of fracture
10. Tooth involved in tumor resection
11. Tooth interfering with orthognathic and/or reconstructive jaw surgery
12. Preventive or prophylactic tooth removal, when indicated, for patients with medical or surgical
conditions or treatments (eg, organ transplants, alloplastic implants, bisphosphonate therapy, chemo-
therapy, radiation therapy)
14. Pathology associated with the impacted tooth (odontogenic cysts, neoplasms)
16. Need for donor transplant or stem cell harvest
17. Facilitate harvesting of autologous graft
18. Impacted tooth (as dened previously)
D. Diagnostic imaging: a panoramic radiograph is recommended for management of third molars, although
periapical, maxillary, and/or mandibular radiographs and computed tomography may also be used. Indications
for cone beam computed tomography for routine third molar surgery should be documented before ordering
scans and follow the principles of ALARA (as low as reasonably achievable).
II. Specic Therapeutic Goals for Third Molar Removal
B. Prevention of pathology
C. Preservation of periodontal health of adjacent teeth
D. Optimization of prosthetic rehabilitation
E. Optimization of management and/or healing of jaw fractures
F. Optimization of orthodontic results
G. Aid in tumor resection
H. Healthy oral and maxillofacial environment for patient undergoing radiation therapy, chemotherapy, organ
transplantation, or placement of alloplastic implants
I. Prevention of complications in orthognathic surgery
III. Specic Factors Affecting Risk for Third Molar Removal
B. Size and density of supporting bone (eg, mandible, maxilla)
C. Anatomical relationships of tooth or teeth to:
2. Adjacent nerves
3. Adjacent teeth
4. Other signicant anatomical structures
D. Anatomical position of tooth
E. Tooth root anatomy (eg, dilaceration, divergence, size, shape, number)
F. Status of adjacent teeth (eg, large restorations, fractured crown, terminal abutment for bridge)
G. Ankylosis of tooth or teeth
H. Presence of associated jaw fracture
I. Accessibility (eg, compromised by ectopic eruption or positioning of adjacent teeth)
J. Limited access to oral cavity (eg, trismus, inadequate oral orice)
K. Patients informed refusal of nonsurgical treatment options
L. Systemic drugs such as bisphosphonates
M. Radiation therapy to surgical sites
IV. Indicated Therapeutic Parameters for Third Molar Removal
The presurgical assessment includes, at a minimum, a history and both a clinical and an imaging evaluation.
Radiographs are necessary to provide appropriate treatment planning and surgery, if indicated, for the third molar
patient. Growth and development of this region will impact the decision of frequency. Therefore timely radiographs are
necessary and ideally would be within one year of planned surgery. In a fully grown patient, the lms may be repeated
at a less frequent interval if no other clinical signs are present and a 2 year interval view may be sufcient. Observation
of pathology, advancing decay, periodontal issues may necessitate radiographs at a more frequent interval but should
always be dictated by the patients clinical presentation and the principles of ALARA. Indications for radiographs and
type of radiograph should be noted prior to ordering the study. See also the Patient Assessment chapter.
The following procedures for the management of third molars are not listed in order of preference:
A. Surgical removal of tooth or teeth
B. Surgical exposure
C. Surgical repositioning, reimplantation, or transplantation
D. Surgical periodontics
E. Endodontic therapy
F. Coronectomy
G. Marsupialization of associated soft tissue pathology with observation and possible secondary treatment
H. Observation in cases of unerupted teeth completely covered by bone that do not meet indications for surgery
I. Instructions for posttreatment care and follow-up
V. Outcome Assessment Indices for Third Molar Removal
Indices are used by the specialty to assess aggregate outcomes of care. Outcomes area assessed through clinical
4. Acute/chronic osteomyelitis
5. Injury to adjacent teeth and/or hard or soft tissues
7. Osteonecrosis, osteoradionecrosis
8. Presence of portion of tooth intentionally left in alveolus
10. Presence of bone fragments or sequestra in surgical site
11. Exposure of alveolar bone
12. Mandibular and/or maxillary fracture
structures
DEFORMITIES AND DEFECTS OF THE DENTOALVEOLAR COMPLEX
I. Indications for Therapy for Deformities and Defects of the Dentoalveolar Complex
A. Clinical ndings of osseous or soft tissue deformity or defects (eg, soft tissue abnormalities, exostosis, tori,
enlarged tuberosity)
B. Radiographic ndings of osseous defects
C. Infection, ulceration, and/or pain
D. Osteomyelitis
(continued)
E. Speech abnormality
F. Masticatory dysfunction
G. Dysphagia
H. Periodontal disease
I. Interference with prosthetic rehabilitation or orthodontic treatment
J. Diastema
K. Medical or surgical condition or treatment (eg, organ transplantation, chemotherapy, radiation therapy,
placement of prosthetic heart valves, prosthetic joints, bisphosphonate administration, joint replacement) for
which the correction of a dentoalveolar complex defect is prophylactic
L. Facilitate implant placement or subsequent implant restoration
II. Specic Therapeutic Goals for Deformities and Defects of the Dentoalveolar Complex
B. Absence of deformities and defects of the dentoalveolar complex
C. Retention of previously diseased tooth or teeth
D. Improved masticatory function
E. Improved appearance
F. Recovery to a degree that permits prosthetic rehabilitation or orthodontic treatment or placement of dental
implants
G. Improved speech
III. Specic Factors Affecting Risk for Deformities and Defects of the Dentoalveolar Complex
B. Anatomical location, size, and extent of defect or deformity
C. Anatomical relationships to:
2. Adjacent teeth, existing xed prosthesis, or dental implants
3. Adjacent nerves and other signicant anatomical structures
D. Acute or chronic sinus disease
E. Bisphosphonate or previous radiation therapy
IV. Indicated Therapeutic Parameters for Deformities and Defects of the Dentoalveolar Complex
The presurgical assessment includes, at a minimum, a history and both a clinical and an imaging evaluation. See
also the Patient Assessment chapter.
A. Surgical alteration, repair, graft, excision, reduction, or augmentation of hard and/or soft tissues, including but
not limited to:
1. Reduction of tuberosity brous and/or osseous reduction
2. Reduction or excision of exostosis, mandibular tori, or torus palatinus
3. Maxillary, mandibular, and lingual frenotomy, frenectomy, or frenoplasty
4. Corticotomy
5. Reconstruction, repair and/or revision of hard tissue defects
6. Distraction osteogenesis
7. Reconstruction, repair, and/or revision of soft tissue defects
8. Vestibuloplasty, including extension, soft tissue grafts, muscle reattachment, revision of soft tissue, and
management of hypertrophied or hyperplastic soft tissue
(continued)
9. Lowering of oor of mouth with or without skin or mucosal grafting
10. Alveoloplasty and/or alveolectomy
11. Destruction of lesions of the dentoalveolar structures
12. Mucogingival surgery
13. Soft and hard tissue recontouring
14. Oronasal, oroantral, or orocutaneous stula closure
15. Ridge preservation when implant placement is anticipated
16. Ridge preservation when implant placement is not anticipated
B. Instructions for posttreatment care and follow-up
V. Outcome Assessment Indices for Deformities and Defects of the Dentoalveolar Complex
1. General favorable therapeutic outcomes, as listed in the section entitled General Criteria, Parameters, and
2. Adequate soft and hard tissue base for prosthetic reconstruction and rehabilitation
3. Improved physiologic condition of supporting structures of teeth (eg, periodontium, alveolar bone)
4. Improved:
a. Mastication
b. Speech
c. Appearance
5. Relief from pain
6. Facilitated prosthetic reconstruction
7. Aided orthodontic treatment
8. Creation of an alveolar contour and volume of bone that will allow placement of dental implants
9. Absence of oral/antral communication
3. Unanticipated loss of hard and/or soft tissues
4. Condition that requires unplanned additional surgery
5. Failure to complete planned staged treatment (eg, insufcient bone for endosseous implants)
7. Nerve injury
8. Vascular injury
structures
SELECTED REFERENCES - DENTOALVEOLAR SURGERY
This list of selected references is intended only to acknowledge some of the sources of information drawn on in the
preparation of this document. Citation of the reference material is not meant to imply endorsement of any statement
contained in the reference material. The list is not an exhaustive compilation of information on the topic. Readers should
consult other sources to obtain a complete bibliography.
SPECIAL CONSIDERATIONS FOR PEDIATRIC DENTOALVEOLAR SURGERY
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