Canine ImpactionDr. Amit T. Suryawanshi

Oral and Maxillofacial Surgeon Pune, India

Contact details :Email ID -

amitsuryawanshi999@gmail .comMobile No - 9405622455

Canine Impac t i on INTRODUCTIONINTRODUCTION FREQUENCY OF IMPACTIONFREQUENCY OF IMPACTION INCIDENCEINCIDENCE CLASSIFICATION CLASSIFICATION RISKS ASSOCIATED WITH IMPACTED TEETHRISKS ASSOCIATED WITH IMPACTED TEETH CAUSES OF DELAYED ERUPTION OF CUSPIDSCAUSES OF DELAYED ERUPTION OF CUSPIDS PREVENTION OF CANINE IMPACTIONPREVENTION OF CANINE IMPACTION INDICATIONSINDICATIONS CONTRA INDICATIONSCONTRA INDICATIONS DIAGNOSISDIAGNOSIS RADIOGRAPHIC INTERPRETATION RADIOGRAPHIC INTERPRETATION SURGICAL REMOVALSURGICAL REMOVAL POSTOPERATIVE TREATMENT , INSTRUCTIONS AND POSTOPERATIVE TREATMENT , INSTRUCTIONS AND

CARECARE COMPLICATIONSCOMPLICATIONS CAUSES FOR POOR PROGNOSISCAUSES FOR POOR PROGNOSIS

* INTRODUCTIONINTRODUCTION **

IMPORTANACE OF CUSPID

* FUNCTION

* OCCLUSION (Cuspid rise)

* ESTHETICS

* ARCH HARMONY AND INTEGRITY

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* * NORMAL CUSPID DEVELOPMENTNORMAL CUSPID DEVELOPMENT **

* Develops early - erupts* Develops early - erupts late (∼ age 11) * Occupies several areas during DevelopmentOccupies several areas during Development* Dental lamina develops lingual to Dental lamina develops lingual to

deciduous teeth, terminates apical to 1st deciduous teeth, terminates apical to 1st deciduous molar and bicuspiddeciduous molar and bicuspid

* Migrates anteriorly and inferiorlyMigrates anteriorly and inferiorly

*Almost never congenitally missing*Almost never congenitally missing

* DEFINITIONDEFINITION *

IMPACTED TOOTH :-• IMPACTED TOOTH THAT HAS FAILED TO ERUPT IMPACTED TOOTH THAT HAS FAILED TO ERUPT

COMPLETELY OR PARTIALLY TO ITS CORRECT COMPLETELY OR PARTIALLY TO ITS CORRECT POSITION IN THE DENTAL ARCH AND ITS ERUPTION POSITION IN THE DENTAL ARCH AND ITS ERUPTION POTENTIAL HAS BEEN LOST.POTENTIAL HAS BEEN LOST.

* THE WORD IMPACTION IS FROM LATIN WORD * THE WORD IMPACTION IS FROM LATIN WORD - “IMPACTUS”.

IMPACTION :-

* IMPACTION IS CESSATION OF ERUPTION OF A * IMPACTION IS CESSATION OF ERUPTION OF A TOOTH CAUSED BY A PHYSICALBARRIER OR TOOTH CAUSED BY A PHYSICALBARRIER OR ECTOPIC ECTOPIC POSITIONING OF A TOOTHPOSITIONING OF A TOOTH.

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*CAUSES OF IMPACTED TOOTH

- THERE ARE MAINLY TWO TYPES OF CAUSES OF IMPACTION OF TOOTH.

1) LOCAL CAUSES

2) SYSTEMIC CAUSES

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( 1 ) LOCAL CAUSES :-

* OBSTRUCTION FOR ERUPTION :- IRREGULARITY IN POSITION & PRESENCE OF AN ADJACENT TOOTH.- DENSITYOF OVERLYING & SURROUNDING BONE.

* LACK OF SPACE IN THE DENTAL ARCH :

- CROWDING, SUPERNUMERARY TEETH

* ANKYLOSIS OF PRIMARY & PERMANENT TEETH

* NON ABSORBING , OVER-RETAINED DECIDUOUS TEETH

* NON ABSORBING ALVEOLAR BONE

* ECTOPIC POSITION OF TOOTH BUD

* ASSOCIATED SOFT TISSUE OR BONY LESIONS

( 2 ) SYSTEMIC CAUSES :-

* PRENATAL CAUSES – HEREDITY

* POST NATAL CAUSES – RICKETS, ANAEMIA,TUBERCULOSIS , CONGINITAL SYPHILIS, MALNUTRITION

* ENDOCRINAL DISORDERS – OF - THYROID,

- PARATHYROID,

- PITUTARY GLANDS; like primary retention of teeth is seen due to lack of osteoclastic activity

* HEREDITARY- LINKED DISORDERS :

- Down syndrome

- Hurler’s syndrome

- Osteopetrosis

- Cleidocranial dysostosis

- Cleft palate etc.

*FREQUENCY OF IMPACTIONFREQUENCY OF IMPACTION *

FREQUENCY ORDER OF IMPACTED FREQUENCY ORDER OF IMPACTED TEETH TEETH NORMALLY OBSERVED NORMALLY OBSERVED AS FOLLOWSAS FOLLOWS :

1) MAXILLARY THIRD MOLAR 2) MANDIBULAR THIRD MOLAR 3) MAXILLARY CANINE 4) MANDIBULAR PREMOLAR 5) MANDIBULAR CANINE 6) MAXILLARY PREMOLAR 7) SUPERNUMERARY TEETH 8) MAXILLARY CENTRAL INCISOR 9) MAXILLARY LATERAL INCISOR

* INCIDENCE *

Grover and Lorton in 1985 - 5,000 Army recruits, maxillary canine most likely to be impacted after 3rd molars

Dachi and HowellDachi and Howell in1961 - 3,874 full-mouth in1961 - 3,874 full-mouth radiographs, 0.92% incidence of maxillary radiographs, 0.92% incidence of maxillary canine impactionscanine impactions

third molars, maxillary canines, mandibular third molars, maxillary canines, mandibular premolars, maxillary premolars, second molarspremolars, maxillary premolars, second molars

3:1 female to male, 3:1 female to male, 3: 1 palatal to labial maxillary cuspid impactions3: 1 palatal to labial maxillary cuspid impactions

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* INCIDENCE ,Continue..*

Lingual mandibular impactions much more common than labial

Maxillary impactions 20X more common than mandibular

Maxillary impactions 1% in general population, 2% in orthodontic population, 8% are impactions

Cuspid impactions occur in normal arch length and anodontia

* CLASSIFICATION *

* FIELD AND ACKERMAN(1935)

* Classification is based on the findings of FIELD AND ACKERMAN (1935).

Class-1 1.Maxillary Canines :

a.Labial Position(1).Crown in intimate relationship with incisors(2).Crown well above apices of incisors

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b. Palatal Position(1).Crown near surface in close relationship to roots of incisors.(2).Crown deeply embedded in close relationship to apices of incisors

C. Intermediate Position (1).Crown between lateral incisor and first premolar roots. (2).Crown above this teeth with crown labially placed and roots palatally place or vice versa .

D. Unusual Positions (1) In nasal or antral wall (2) In infraorbital region

( f – 3 )

F- a O.P.G. SHOWING UNUSUAL POSITION OF MAXILLARY IMPACTED CANINE

2.Mandibular canines :

a. Labial position ( f – 3 ) (1) Vertical (2) Oblique

(3) Horizontal

( f – 4 )

b. Unusual Position

(1) At inferior Border.(2) In mental protuberance.(3) Migrated to the opposite side.

F - b O.P.G. showing impacted mandibular canine

F - c O.P.G. showing impacted mandibular canine ( vertical )

*CALSSIFICATION OF IMPACTED MAXILLARY CANINE * ( V. KAPOOR )

CLASS I:- MAXILLARY CANINE IN PALATALPOSITION. - HORIZONTAL,

- VERTICAL & - ANGULATED.

CLASS II:- LABIALLY IMPACTED CANINE.- HORIZANTAL,- VERTICAL &- ANGULATED.

(IN THIS POSITION THE CORWN OF IMPACTED CANINE CAN BE IN INTIMATE RELATIONSHIP WITH THE INCISOR OR WELL ABOVE THE APICES OF INCISORS.)

CLASS III:- IMPACTED CANINE WITH CROWN ON THE PALATAL SIDE AND ROOT ON THE BUCCAL SIDE OR VICE VERSA.

CLASS IV : VERTICALLY IMPACTED CANINE BETWEEN LATERAL INCISOR & FIRST PREMOLAR

CLASS V : CANINE IMPACTED IN EDENTULOUS MAXILLA.

CLASS VI : MAXILLARY CANINE IN UNUSUAL POSITIONS.

e.g.

- in NASO- ANTRAL WALL or

- INFRAORBITAL MARGIN

* RISKS ASSOCIATED WITH

IMPACTED TEETH * Malocclusion and loss of arch lengthInfectionMalocclusion and loss of arch lengthInfection Dentigerous cysts or odontogenic tumorsDentigerous cysts or odontogenic tumors Root resorption of adjacent teethRoot resorption of adjacent teeth Maleruption of adjacent teethMaleruption of adjacent teeth Migration or loss of neighboring teethMigration or loss of neighboring teeth Resorption (internal, external) of the impacted Resorption (internal, external) of the impacted

toothtooth HeadacheHeadache NeuralgiaNeuralgia

* CAUSES OF DELAYED ERUPTION CAUSES OF DELAYED ERUPTION OF CUSPIDSOF CUSPIDS *

Arch length deficiencyArch length deficiency Ectopic position of toothEctopic position of tooth Malformed tooth, trauma, infectionMalformed tooth, trauma, infection Prolonged retention of deciduous teethProlonged retention of deciduous teeth Mechanical obstruction from supernumerary or Mechanical obstruction from supernumerary or

ectopic tooth, cyst, neoplasmectopic tooth, cyst, neoplasm Odontogenic tumorsOdontogenic tumors Nutritional deficiencies, genetic and endocrine Nutritional deficiencies, genetic and endocrine

abnormalities abnormalities Head and neck syndromesHead and neck syndromes Cleft lip and palateCleft lip and palate

* * PREVENTION OF CANINE PREVENTION OF CANINE IMPACTIONIMPACTION * *

Prevention - close observation for eruption Prevention - close observation for eruption patterns and early dental crowdingpatterns and early dental crowding

Some advocate extraction of deciduous canines Some advocate extraction of deciduous canines when impaction is suspected, as early as 8 y/o, when impaction is suspected, as early as 8 y/o, by age 11by age 11

Spontaneous eruption successful when canine is Spontaneous eruption successful when canine is distal to the midline of the lateral incisor distal to the midline of the lateral incisor

Not successful when canine is mesial to the Not successful when canine is mesial to the midline of the lateral incisormidline of the lateral incisor

The more horizontally, the less likely to erupt The more horizontally, the less likely to erupt spontaneouslyspontaneously

* INDICATIONS *

* * INDICTIONS FOR REMOVAL OF IMPACTED TOOTH ARE INDICTIONS FOR REMOVAL OF IMPACTED TOOTH ARE AS FOLLOWSAS FOLLOWS : :(1) (1) CHANGED POSITION OF ADJACENT TEETH :CHANGED POSITION OF ADJACENT TEETH :

- - Because of pressure exerted due to the attempt for Because of pressure exerted due to the attempt for eruption of the canine. eruption of the canine.

(2) (2) RESORPTION OF ROOTS OF ADJACENT TEETHRESORPTION OF ROOTS OF ADJACENT TEETH : :

- Because of pressure exerted by the impacted - Because of pressure exerted by the impacted canine.canine.

(3) (3) CYST FORMATIONCYST FORMATION ::- - From the follicle around the canine. Attempt should be From the follicle around the canine. Attempt should be

made to remove the cyst & facilitate the eruption of made to remove the cyst & facilitate the eruption of impacted canine impacted canine

(4) CLEFT PALATE :

- Repair of cleft palate may cause scarring & narrowing of the arch leaving no space for canine to erupt

(5) PRESENCE IN EDENTULOUS PATIENT :

- In edentulous jaw, an impacted canine can be left unnoticed. It starts erupting with denture irritation & needs to be removed .

(6) NEUROLOGIC SYMPTOMS :

- Pain in eye , ear , side of the head , entire face & back of the neck can be attributed to impacted canine & calls for its removal .

* CONTRAINDICATIONS *

CONTRAINDICATIONS FOR REMOVAL OF

IMPACTED TOOTH ARE AS FOLLOWS : * EXTREME OF AGE * COMPROMISED MEDICAL STATUS * PROBABLE EXCESSIVE DAMAGE TO

ADJACENT STRUCTURE

* DIAGNOSIS *

* CLINICAL CLINICAL ::

- - crown inclination of lateral incisorcrown inclination of lateral incisor - bulging in the palate, lingually or - bulging in the palate, lingually or buccallybuccally

RADIOGRAPHIC RADIOGRAPHIC : :

- - shift-shot periapical (“Clark’s rule”, shift-shot periapical (“Clark’s rule”, “SLOB” rule,“SLOB” rule, parallex method, tube or parallex method, tube or buccal shift)buccal shift)

- occlusal (use shift-shot technique) - occlusal (use shift-shot technique) - panoramic x-ray / split panoramic- panoramic x-ray / split panoramic- lateral ceph- lateral ceph- trans-nasal- trans-nasal- size of the impacted size of the impacted caninecanine

F - d VARIOUS I.O.P.A. showing impacted canines

F – e OCCLUSAL view showing palatally impacted

maxil lary canine

F- f OCCLUSAL RADIOGRAPH showing impacted mandibular canine

F - g O.P.G. showing impacted mandibular left canine

F - h O.P.G.- Bilateral palatally impacted maxillary canine

F- i LATERAL CEPHALOMETRIC projection shows impacted maxillary canine

F - k AXIAL CT IMAGE showing superio – lateral displacement of cuspid into nasal fossa

F – l CORONAL CT IMAGE showing superio – lateral displacement of cuspid into nasal fossa

* RADIOGRAPHIC INTERPRETATION:RADIOGRAPHIC INTERPRETATION CAN BE

DONE BY 1) INTRA ORAL X-RAY - IOPA(INTRA ORAL

PERIAPICAL RADIOGRAPH - OCCLUSAL RADIOGRAPH

2) EXTRA ORAL X-RAY - OPG - LATERAL OBLIQUE VIEW

(MANDIBULAR) - PA VIEW WATER’S POSITION

(MAXILLARY)(2) NATURE OF COVERING TISSUES :-

* SOFT TISSUE IMPACTION* PARTIAL BONY IMPACTION* FULLY BONY IMPACTION

3) CROWN SIZE :

4) ROOT CONFIGURATION:- 1) NUMBER OF ROOTS 2) LENGTH OF ROOTS 3) SIZE OF ROOTS

4) CURVATURE OF ROOT 5) DEVELOPMENT OF ROOT 6) RESORPTION - INTERNAL &

EXTERNAL5) BONE TEXTURE & DENSITY:-6) SIZE OF FOLLICULAR SAC: 7) RELATIONSHIP TO VITAL ORGANS:-

- MENTAL NERVE - MAXILLARY SINUS

*SURGICAL CONSIDERATIONS :

- AVOID EXCESSIVE BONE REMOVAL .

- AVOID DAMAGE TO ADJACENT TEETH & SURROUNDING STRUCTURE .

- AVOID MOVEMENT , OR EXCESSIVE MOVEMENT .

* IMPACTED MAXILLARY CANINE *

• SINCE IT IS A COMMON OCCURANCE, IT HAS BEEN STUDIED EXTENSIVELY.

• JACOBY IN 1983, SEPARATED LABIALLY FROM PALATALLY IMPACTED CANINES

• ETIOLOGY; EXTRA SPACE, PEG- LATERAL OR MISSING MAXILLARY LATERAL CAUSE PALATAL IMPACTION

• PALATALLY INCLINED CANINES HAVE ADEQUATE SPACE,SELDOM ERUPT WITHOUT SURGICAL INTERVENTION

• LABIAL IMPACTION HAVE ARCH LENGTH DISCREPANCY, ERUPT ECTOPICALLY

• BISHARA IN 1992, PRESENCE OF LATERAL INCISIOR ROOT WITH NORMAL LENGTH IS IMPORTANT IN GUIDING THE CANINE IN PROPER POSITION.

* SURGICAL REMOVAL OF

IMPACTED CANINE * * PRE OPERATIVE PROCEDURE :

- ISOLATION- ANAESTHESIA

*OPERATIVE PROCEDURE :

- INCISION – FLAP DESIGN- OPERATIVE STEPS a) ELEVATION OF MUCOPERIOSTEAL FLAP

b) BONE REMOVAL / ODONTECTOMY

c) LUXATION OF THE TOOTH &/ or SECTIONENING OF THE TOOTH

d) DEBRIDEMENT & SMOOTHENING OF BONE MARGINS

e) CONTROL OF BLEEDING / HEMOSTATE

f) SUTURING

g) FOLLOW- UP

* ARMAMENTARIUM :

* PREOPERATIVE PROCEDURE :

* ISOLATION :* ANAESTHESIA :

IMPACTED CANINES MAY BE REMOVED WITH THE PATIENT UNDER

- GENERAL or - LOCAL ANAESTHESIA

LOCAL ANAESTHESIA :FOR MAXILLARY CANINE :

- INFRA ORBITAL NERVE- GREATER PALATINE NERVE- NASOPALATINE NERVE should be blocked.

FOR MANDIBULAR CANINE :- INFERIOR ALVEOLAR NERVE- LINGUAL NERVE should be blocked

MAXILLARY IMPACTED CANINE

LABIAL APPOROACH

* IMACTED MAXILLARY CANINE

* LABIAL APPROACH :-

- Apically repositioned for attached gingiva preservation ( vanarsdall & corn 1977 )

- Laterally positioned flap for high impactions

- Repositioned flap / incision in vestibule for very high impactions

- “tunnelling” method ( crenscini

- 1994 )

LABIAL APPROACH- IMPACTED MAXI CANINE

F-1 (A) POSITION OF THE IMPACTED CANINE

* FLAP DESIGN – INCISION *

MAXILLARY CANINE :- LABIAL APPROACH

* IF CANINE IS BUCCALLY PLACED: - FLAP WITH ANTERIOR RELEASING INCISION. - SEMILUNAR FLAP. - TRAPEZOIDAL / ANGULATED FLAP

* IF UNILATERAL: - AN ICISION IS RESTRICTED TO CANINE REGION OF OPPOSITE SIDE.

* IF BILATERAL: - AN INCISION IS EXTENDED TO FIRST MOLAR OF THE OPPOSITE SIDE.

F – 1 ( B ) FLAP DESIGN

SEMILUNAR FLAP

1 ) SEMILUNAR FLAP:- [ F -1(b) & F-m ]

- IS DESIGNED ON THE ALVEOLAR MUCOSA.

- STARTS FROM THE FRENUM KEEPING THE BULDGE OF THE TOOTH IN THE CENTRE AND EXTENDS IN THE PREMOLAR REGION. - THE LOWER MARGIN OF THE INCISION SHOULD BE 5 mm AWAY

FROM GINGIVAL MARGIN.

F- m SEMILUNAR INCISION

( 2 ) ANGULATED FLAP DESIGN: ( F-n )

- IS GIVEN IN THE GINGIVAL CREVICE OF INCISORS AND PREMOLARS WITH VERTICAL ARM GOING INTO THE MUCO BUCCAL FOLD.

- EVEN TWO VERTICAL INCISIONS CAN BE MADE ONE ON EACH SIDE OF THE IMPACTED CANINE.

F - n ANGULATED FLAP INCISION :

* OPERATIVE STEPS :

(A) ELEVATION OF MUCO PERIOSTEAL FLAP : [ F-1 ( c ) ]

- ELEVATE THE MUCO PERIOSTEAL FLAP AND EXPOSE THE CROWN WITH PERIOSTEAL ELEVATOR.

(B) BONE REMOVAL / ODONTECTOMY :

- AIM- BURS USED- STEPS / TECHNIQUE

* AIM:- 1) TO EXPOSE THE CROWN BY REMOVING THE

OVERLYING BONE. 2) TO REMOVE THE BONE

OBSTRUCTING THE PATHWAY FOR REMOVAL OF A TOOTH.

# BONE REMOVAL TECHNIQUE :

* BUR TECHNIQUE:- * BUR USED:- NO.7/8 ROUND BUR OR NO.703 STRAIGHT FISSURE BUR.

* BUR SHOULD BE ALWAYS USED ALONG WITH COPIOUS SALINE IRRIGATION TO AVOID THERMAL TRAUMA TO THE BONE.

* STEPS :-

(1) SWEEPING MOTION AROUND OCCLUSAL , BUCCAL AND DISTAL ASPECT OF CROWN.

(2) TOOTH IS EXPOSED TO THE CERVICAL LEVEL OF CROWN

CONTOUR AND BUCCAL THOUGH IS CREATED.

F-1 (c) REFLECTION OF THE FLAP

( C ) LUXATION OF TOOTH : [ f – 1 ( d ) ]

- MAKE A DEEP CUT ON THE MESIAL SIDE OF THE CROWN AND ELEVATE THE TOOTH

WITH THE CRIER OR STRAIGHT ELEVATOR.

( d ) SECTIONENING OF THE TOOTH :

- IF TOOTH CAN NOT BE LUXETED & THERE ARE CHANCES OF DAMAGE TO THE ADJACENT TOOTH, THE CROWN CAN BE SECTIONED & ROOT REMOVED SEPARPTELY.

F-1 (d) LUXATION OF THE TOOTH

(e) DEBRIDEMENT & SMOOTHENING OF BENE MARGINS :

- IRRIGATION.

- CURETTING TO REMOVE ANY REMAINING DENTAL FOLLICLE & EPITHELIUM

- ROUND OFF THE MARGINS OF SOCKET

- IRRIGATION

(f) CONTROL OF BLEEDING - - BEFORE SUTURING

F-1 (e) APPEARNCE OF SOCKET AFTER

TOOTH REMOVAL

(g) SUTURING –INCISION CLOSURE

[ F-1 ( f ) ]- 3-0 BLACK SILK IS USED - INTERRUPTED SUTURES GIVEN- MAINTAINED FOR 7 DAYS

(h) FOLLOW-UP :-- FOLLOW UP THE PATIENT

AFTER 7 DAYS FOR REMOVAL OF SUTURES.

F-1 (f) SUTURING – INCISION CLOSURE

MAXILLARY IMPACTED CANINE

PALATAL APPROACH

* IMPACTED MAXILLARY CANINE

* PALATAL APPROACH :

- Plenty of keratinized gingiva.

- Full thickness palatal flap.

* FLAP DESIGN - INCISION :-

‘ * IF CANINE IS PLACED PALATALLY : - THE INCISION IS TAKEN IN THE GINGIVAL SULCUS ON THE PALATAL SIDE FROM THE MESIAL ASPECT OF FIRST MOLAR OF THE SAME SIDE. - RELEASING INCISION IS GIVEN OBLIQUELY ACROSS THE PALATE AND SHOULD BE DEFLACTED AWAY FROM THE PALATINE FORAMEN.

* IF UNILATERAL: - AN ICISION IS RESTRICTED TO CANINE

REGION OF OPPOSITE SIDE. * IF BILATERAL:

- AN INCISION IS EXTENDED TO FIRST MOLAR OF THE OPPOSITE SIDE.

1 ) PALATAL INCISION :

[ F – 2 ( a ) , F - o ]

- INCISION , FOR REMOVAL OF UNILATERAL PALATALLY IMPACTED MAXILLARY CANINE ,

SHOULD START IN THE SECOND PREMOLAR REGION AND EXTEND

FORWARD EITHER IN GINGIVAL SULCUS or NEAR THE GINGIVAL MARGIN TO APPROXIMATELY THE LATERAL INCISIOR REGION ON THE OPPOSITE SIDE

PALATAL APPROACH- IMPACTED MAXI. CANINE

F - 2 ( A ) FLAP DESIGN - INCISION

F – O PALATAL INCISION

2 ) COMPLETE PALATAL INCISION : [ F – p ]

- IF BILATERALLY PALATALLY IMPACTED MAXILLARY CANINES ARE PLANNED TO BE REMOVED IN A SINGAL SITTING, COMPLETE PALATAL INCISION SHOULD BE GIVEN.

- INCISION SHOULD BE EXTENDED ACROSS

- THE MIDLINE UPTO THE FIRST MOLAR REGION OF THE OPPOSIDE SIDE

COMPLETE PALATAL INCISION :

[ F – p ]

* REFLECTION OF THE FLAP : [ F – 2 ( B ) ]

- THE MUCO PERIOSTEAL FLAP IS REFLACTED WITH A SHARP PERIOSTEAL ELEVATOR . - IT CAN BE KEPT RETRACTED BY A SUTURE, PLACED AROUND AN

ADJACENT TOOTH .

* BONE REMOVAL/ODONECTOMY :

- BUR TECHNIQUE .

F-2 ( B ) REFLECTION OF FLAP

* SECTIONENING & REMOVAL OF THE CROWN : [ F – 2 (C) ]

* REMOVAL OF THE ROOT :[ F – 2 ( D ) ; F – 2 ( E ) ]

* DEBRIDEMENT & SMOOTHENING OF THE BONY MARGINS :

* CONTROL OF BLEEDING : - BEFORE SUTURING .

F-2 (C) SECTIONING & REMOVAL OF

THE CROWN

F-2 ( D , E ) REMOVAL OF THE ROOT

* SUTURING – INCISION CLOSURE

[ F-2 ( f ) ]- 3-0 BLACK SILK IS USED - INTERRUPTED SUTURES GIVEN- MAINTAINED FOR 7 DAYS

* FOLLOW-UP :-- FOLLOW UP THE PATIENT

AFTER 7 DAYS FOR REMOVAL OF SUTURES.

F-2( F ) SUTURING – INCISION CLOSURE

MAXILLARYIMPACTED CANINE

INTERMEDIATE POSITION

* MAXILLARY IMPACTED CANINE INTERMEDIATE POSITION :

- CANINES IN AN INTERMEDIATE POSITION USUALLY EASIER TO REMOVE THAN THOSE IN A PURELY LABIAL or PALATAL LOCATION

* OPERATIVE PROCEDURE *

* FLAP DESIGN – INCISION : - FLAP SHOULD BE DESIGNED ACCORDING

TO THE LOCATION OF THE TOOTH .

( i ) CANINE IS NOT WEDGED B/W LATERAL INCISIOR & FIRST PREMOLAR

( ii ) CANINE IS WEDGED B/W LATERAL

INCISIOR & FIRST PREMOLAR .

( 1 ) CANINE IS NOT WEDGED B/W LATERAL INCISIOR & FIRST

PREMOLAR :

- INCISION SHOULD INCLUDE THE MARGINAL GINGIVA SO THAT THE TISSUE WILL NOT BE

TRAUMATIZED BY THE APPLICATION OF THE INSTRUMENT.

- THE TOOTH CAN BE REMOVED BY A FORCEPS OR ELEVATOR TECHNIQUE.

( 2 ) CANINE IS WEDGED BETWEEN LATERAL INCISIOR & FIRST

PREMOLAR :

- INCISION SHOULD INCLUDE THE MARGINAL GINGIVA SO THAT THE TISSUE WILL NOT BE TRAUMATIZED BY THE APPLICATION OF THE INSTRUMENT.

* REFLACTION OF THE FLAP :

* BONE REMOVAL / ODONECTOMY:

- WHEN THE BONE IS COVERING THE CROWN, IT IS FIRST REMOVED ON THE SIDE TOWARD WHICH THE

TOOTH IS POINTING .

- IT SOMETIMES ALSO IS NECESSARY TO REMOVE A SMALL AMOUNT ON THE OPPOSITE SIDE TO PERMIT

EITHER APPLICATION OF FORCEPS OR INSERTION OF AN ELEVATOR .

- IF THE DECIDUOUS CANINE HAS BEEN RETAINED, ITS EXTRACTION

WILL PERMIT LOCALIZATION OF THE CROWN OF THE PERMANENT TOOTH THROUGH THE SOCKET AND FACILITATE ITS SUBSEQUENT REMOVAL

* SECTIONING OF THE TOOTH : - IF CANINE IS WEDGED BETWEEN THE ADJACENT TEETH, IT WILL BE NECESSARY TO SECTION THE CROWN FROM THE ROOT AND REMOVE IT.

* LUXATION OF THE TOOTH :

* DEBRIDMENT & SMOOTHENING OF THE BONY MARGINS :

* CONTROL OF BLEEDING* SUTURING : - AFTER REMOVAL OF THE TOOTH, THE

INCISION IS CLOSED WITH INTERRUPTED SUTURES.

MAXILLARY IMPACTED CANINE

UNUSUAL POSITION

MAXILLARY IMPACTED CANINE UNUSUAL POSITION

* CANINES MAY ERUPT IN AN UNUSUAL SITES like; - NEAR/ BENEATH THE INFRAORBITAL MARGINS, - IN THE NASO-ANTRAL WALL, etc.

* MAY OCCUR DUE TO : - MIGRATION OF THE TOOTH GERM - CYST FORMATION, etc.

* OPERATIVE PROCEDURE *

* CANINE LYING AT THE INFRAORBITAL MARGIN :

- IS REMOVED INTRAORALLY BY EXPOSING THE INFRAORBITAL MARGIN THROUGH AN INCISION GIVEN IN THE VESTIBULE .

* CANINE IN THE NASO-ANTRAL WALL :

- IF ERUPTING IN THE MAXILLARY ANTRUM :

- IF ERUPTING IN THE NASAL CAVITY

- IF ERUPTING IN THE MAXILLARY ANTRUM :

HAS TO BE REMOVED BY GOING INTO THE ANTRUM THROUGH

‘ CALDWELL-LUC APPROACH ’

- IF ERUPTING IN THE NASAL CAVITY :

HAS TO BE REMOVED BY GOING INTO THE ANTRUM THROUGH

‘ INTRA-NASAL APPROACH ’

* OPERATIVE PROCEDURE:

* INCISION :

- IS MADE ACROSS THE CANINE FOSSA EXTENDING TO THE PIRIFORM APERTURE OF THE NOSE.

* ODONECTOMY :

- TOOTH GENERALLY CAN BE EXPOSED BY CUTTING AWAY THE OVERLYING

BONE.

- THE NASAL MEMBRANE SHOULD BE DETATCHED AND RETRACTED TO AVOID PERFORATION INTO THE NOSE .

* SECTIONENING AND REMOVAL OF TOOTH :

* CONTROL OF BLEEDING :

* SUTURING :

- AFTER REMOVAL OF THE TOOTH, THE INCISION IS CLOSED WITH INTERRUPTED SUTURES.

MANDIBULAR IMPACTED CANINE

LABIAL APPROACH

* IMPACTED MANDIBULAR CANINE *

* LABIAL APPROACH :

- Utilize apically repositioned flap or vestibular incision. - Watch for mental nerve.- Labial impactions often associated

with retained primary dentition.

SURGICAL REMOVAL OF LABIALLY IMPACTED MANDIBULAR CANINE :

* SURGICAL REMOVAL OF LABIALLY IMPACTED MANDIBULAR CANINE :

- MANDIBULAR CANINES GENERALLY EMBADED IN THE BASE OF THE MANDIBLE ON THE BUCCAL ASPECT IN AN OBLIQUE OR HORIZONTAL POSITION .

* FLAP DESIGN – INCISION : [ F -4 (A) ] - THE INCISION CAN BE MADE HORIZONTALLY OR WITH OBLIQUE SIDE CUTS , INTRAORALLY , ON THE BUCCAL ASPECT OF THE MANDIBULE.

LABIAL APPROACH-IMPACTED MANDIBULAR CANINE

F-3 (A) FLAP DESIGN - INCISION

* REFLECTION OF THE FLAP : [ F – 3 ( B ) ]

- REFLECT THE MUCOPERIOSTEAL FLAP WITH THE HELP OF A SHARP

PERIOOSTEAL ELEVATOR .* ODONECTOMY : [ F – 3 ( C ) ]

- REMOVAL OF THE LABIAL CORTEX IS DONE BY USING BUR TECHNIQUE:

-DRILL THE HOLES IN THE BONE THROUGH THE LABIAL CORTEX AROUND THE CROWN.

- JOIN THESE HOLES TO REMOVE THE OVERLYING BONE AND EXPOSE TE CROWN.

F – 3 ( B )

REFLACTION OF THE MUCOPERIOSTEAL FLAP

* LUXATION OF THE TOOTH : [ F– 3 (C) ]- LUXATE THE TOOTH; IF IT IS DIFFICULT TO LUXUTE THEN

SECTIONENING OF THE TOOTH SHOULD BE DONE .

* DEBRIDEMENT & SMOOTHENING OF BONY MARGINS :

- IRRIGATION. - CURETTING TO REMOVE ANY REMAINING DENTAL FOLLICLE & EPITHELIUM. - ROUND OFF THE MARGINS OF SOCKET . - IRRIGATION.

F – 3 ( C )

REMOVAL OF THE LABIAL CORTEX &

LUXATION OF THE TOOTH

* CONTROL OF BLEEDING - - BEFORE SUTURING

* SUTURING –INCISION CLOSURE : [ F – 3 ( D ) ]

- 3-0 BLACK SILK IS USED

- INTERRUPTED SUTURES GIVEN

- MAINTAINED FOR 7 DAYS

* FOLLOW-UP :-- FOLLOW UP THE PATIENT AFTER

7 DAYS FOR REMOVAL OF SUTURES.

F – 3 ( D )

SUTURING – INCISION CLOSURE

MANDIBULAR IMPACTED CANINE

LINGUAL APPROACH

* LINGUAL APPROACH :

- Full thickness flap.

- No releasing incisions.

- Very difficult access

- Fortunately, rare.

- Watch for significant anatomy.

- Lingual impaction associated with shortage of arch length.

MANDIBULAR IMPACTED CANINE

UNUSUAL POSITION

MANDIBULAR IMPACTED CANINE UNUSUAL POSITION

- SOME TIMES , MANDIBULAR CANINES MAY BE FOUND IN THE UNUSUAL POSITIONS like ;

- AT THE INFERIOR BORDER OF THE MANDIBLE ;

- IN THE MENTAL PROTRUBERANCE;

- MIGRATED TO THE OPPOSITE SIDE CROSSING THE MIDLINE.

( IN CERTAIN CASES )

* SURGICAL REMOVAL :

- IMPACTED MANDIBULAR CANINES IN UNUSUAL POSITION, SURGICALLY CAN BE REMOVED INTRAORALLY OR EXTRAORALLY , DEPENDING ON THE LOCATION OF THE TOOTH.

* FLAP DESIGN - INCISION :- WHEN THE CANINE IS IMPACTED IN THE

MENTAL PROTRUBERANCE , IT CAN BE REMOVED BY - INTRAORAL APPROACH.

- WHEN THE CANINE IS IMPACTED AT THE INFERIOR BORDER BORDER OF MANDIBLE IS THE BEST REMOVED BY – EXTRAORAL APPROACH .

T

* IMPACTED MANDIBULAR CANINE AT THE INFERIOR BORDER THE CANINE :

- EXTRA ORAL APPROACH IS THE BEST :

( SKIN INCISION )

1) MORE EASY TO REACH.

2) TO PREVENT INJURY TO THE MENTAL NERVE.

- TECHNIQUE :

- UNDER GENERAL ANAESTHESIA .

- POSITION : THE HEAD OF THE PATIENT IS INCLIENED BACK AS MUCH AS POSSIBLE.

INCISION : IS MADE IN THE CREASE OF THE SKIN ALONG THE LOWER BORDER OF THE

MANDIBLE AT A DISTANCE OF 2 cm BELOW THE LOWER BORDER TO SAVE THE MANDIBULAR BRANCH OF THE FACIAL NERVE .

- AFTER THE SKIN , SUBCUTANEOUS TISSUE , PLATYSMA AND DEEP FASCIA ARE CUT ,

AND PERIOSTEUM IS INCISED .

* REFLECTION OF THE FLAP :

- AFTER INCISING THE PERIOSTEUM , REFLECT THE FLAP WITH A HEAVY PERIOSTEAL ELEVATOR .

* ODONTECTOMY : - LIGATE THE BLEEDING VESSELS,RETRACT

THE WOUND MARGINS AND EXPOSE THE JAW.

- LOCATE THE BULGE OF THE CROWN ON THE OUTER SURFACE OF THE JAW .

- EXPOSE THE BULGE OF THE CROWN BY DRILLING HOLES IN THE CORTEX AND JOIN THESE HOLES.

- REMOVE SUFFICIENT OVERLYING BONE TO EXPOSE ENTIRE CROWN AND PART OF

THE ROOT.

F * LUXATION OF THE TOOTH :

- LUXATE THE TOOTH; IF IT IS DIFFICULT TO LUXUTE THEN SECTIONENING OF THE TOOTH

SHOULD BE DONE .* DEBRIDEMENT & SMOOTHENING

OF BENE MARGINS :

- IRRIGATION. - CURETTING TO REMOVE ANY REMAINING DENTAL FOLLICLE & EPITHELIUM. - ROUND OFF THE MARGINS OF SOCKET . - IRRIGATION.

* CONTROL OF BLEEDING - - BEFORE SUTURING

* SUTURING –INCISION CLOSURE :- WOUND IS SUTURED IN LAYERS

- 3-0 CATGUT- FOR DEEPER LAYER.

- 4-0 NAYLON – FOR SKIN.

- INTERRUPTED SUTURES GIVEN

- MAINTAINED FOR 7 DAYS

* FOLLOW-UP :-- FOLLOW UP THE PATIENT AFTER

7 DAYS FOR REMOVAL OF SUTURES

* * POSTOPERATIVE TREATMENT , POSTOPERATIVE TREATMENT , INSTRUCTIONS AND CAREINSTRUCTIONS AND CARE : :

# MEDICATION : * ANTIBIOTICS : - GENERALLY NOT NECESSARY UNLESS THERE ISPREEXESTING INFECTION OR THE ANTRUM OR NASAL CAVITY HAS BEEN OPENED . - IF NECESSARY , THEN PRESCRIBE FOR 1 WEEK.

Amoxycillin 500mg tds/5 days or Cefadroxil 500mg bd/5 days or Metrogyle 400mg tds/5 days

* ANALGESICS : - - PRESCRIBE THEPRESCRIBE THE ANALGESIC DRUGS FOR RELIEVING ANALGESIC DRUGS FOR RELIEVING

FROM THE PAINFROM THE PAIN Brufen 400mg tds/5days orBrufen 400mg tds/5days or Diclophenac sodium 50mg tds/5 daysDiclophenac sodium 50mg tds/5 days

# INSTRUCTIONS AND CAREINSTRUCTIONS AND CARE : :

1 ) PATIENT IS ADVISED 1 ) PATIENT IS ADVISED NOT TO EATNOT TO EAT NORMAL NORMAL DIET FOR 1 0R 2 DAYS DIET FOR 1 0R 2 DAYS

- SHOULD BE INSTRUCTED - SHOULD BE INSTRUCTED TO DRINKTO DRINK PLENTY OF FLUIDS IN THE FORM OF MILK, PLENTY OF FLUIDS IN THE FORM OF MILK,

JUICES ,TEA, etc.JUICES ,TEA, etc. 2 ) AVOID TO CONSUME HOT & HARD FOOD / 2 ) AVOID TO CONSUME HOT & HARD FOOD /

DRINK . ADVISE TO CONSUME COLD & DRINK . ADVISE TO CONSUME COLD & SOFT DIET .SOFT DIET .

3 ) 3 ) COLD APPLICATIONCOLD APPLICATION : : - ADVISE COLD APPLICATION TO THE FACE- ADVISE COLD APPLICATION TO THE FACE

INTERMITTENTLY ( 30 min. ON , 30 min. OFF) INTERMITTENTLY ( 30 min. ON , 30 min. OFF) FOR FIRST 24 TO 48 hrs ; PREVENTS FOR FIRST 24 TO 48 hrs ; PREVENTS

DISFIGURING SWELLING AND DISFIGURING SWELLING AND POSTOPERATIVE EDEMA.POSTOPERATIVE EDEMA.

- - IF SURGERY WAS PERFORMED ON THE IF SURGERY WAS PERFORMED ON THE PALATE, THE MAY DISSOLVE SMALL PIECE PALATE, THE MAY DISSOLVE SMALL PIECE OF ICE IN THE MOUTH.OF ICE IN THE MOUTH. THIS DECREASES ANY INFLAMMATORY THIS DECREASES ANY INFLAMMATORY REACTION THAT MAY OCCUR .REACTION THAT MAY OCCUR .

4 ) 4 ) HOT MOIST APPLICATIONHOT MOIST APPLICATION : :

-- AFTER COLD APPLICATION , IF SWELLING IS AFTER COLD APPLICATION , IF SWELLING IS STILL PRESENT ,AFTER THAT HOT MOIST STILL PRESENT ,AFTER THAT HOT MOIST

COMPRESSES SHOULD BE USED IN THE COMPRESSES SHOULD BE USED IN THE SAME SAME MANNER UNTILIT RESOLVES.MANNER UNTILIT RESOLVES.

THIS WILL ALSO HELP TO REDUCE ANY DISCOLORATIONOF THE SKIN RESULTING FROMBLEEDING INTO THE TISSUE .

5 ) AVOID VIGOROUS RINSING OF THE MOUTH FOR 8 TO 12 hrs. POST OPERATIVELY .

- AFTER THAT , THEY SHOULD RINSE AT LEAST 4 TO 6 TIMES DAILY,

PARTICULARLY AFTER MEALS, AND BRUSHTHEIR TEETH USUAL.

6 ) ADVISE MOUTH WASH :

THE BEST MOUTH RINSE IS A WARM SALINE SOLUTION ( ½ teaspoon of salt to a glass of water ) .

- CAN BE FOLLOWED BY A FLAVORED MOUTH WASH – DILUTED AT LEAST 50% WITH WATER BECAUSE MOST CONTAINS AGENTS THAT CAN BE IRRITATING THE HEALING WOUND.

- AVOID HYDROGEN PEROXIDE CONTAINING MOUTH WASH DURING FIRST 5 to 7 DAYS BECAUSE IT CAN DISSOLVE BLOOD CLOT

7 ) DISCOURAGE THE PATIENT FOR SMOKING AT LEAST FOR 5 DAYS AFTER SURGERY BECAUSE SMOKING INCREASES THE INCIDENCE OF ALVEOLAR OSTEITIS [ DRY SOCKET ] . 8 ) ADVICE TO LIMIT THE ACTIVITY FOR AT LEAST HE REMAINDER OF THE DAY .

IF THE PATIENT WISH TO LIE DOWN, THE HEAD SHOULD BE ELEVATED ON SEVERAL PILLOWS – BECAUSE A SUPINE POSITION INCRESES HYDROSTATIC PRESURE AND CAN CAUSE BLEEDING.

9 ) IF OOZING OF BLOOD OCCURS , CAN BE CONTROLLED BY HAVING THE PATIENT BITE FIRMLY FOR 30 min. ON A PAD OF STERILE GAUZE . - IF STILL CONTINUE /EXCESSIVELY OCCURS,

CONSULT THE DOCTOR IMMEDIATELY .

* COMPLICATIONS *

(1) INTRAOPERATIVE COMPLICATIONS:-

# DURING INCISION:-

* FOR UPPER CANINES - INCISIVE OR GREATER PALATINE VESSELS MAY BE DAMAGED

* FOR LOWER CANINES – MENTAL VESSELS MAY BE DAMAGED.

# DURING BONE REMOVAL:- * DAMAGE TO THE ROOTS OF OVERLYING TEETH * SLIPPING OF THE BUR INTO THE SOFT TISSUES.

* POSTOPERATIVE COMPLICATIONS *

* PAIN* SWELLING* SECONDARY HEMORRHAGE* INFECTION* DRY SOCKET* POST EXTRACTION PYOGENIC GRANULOMA* TRISMUS* LOSS OF VITALITY OF NEIGHBOURING TOOTH

• IMMEDIATE :- DAMAGE TO ADJACENT STRUCTURES

- DIFFICULT TO ACCESS

• DELAYED :- INFECTION

- WOUND DEHISCENCE

• LATE :- PULP NECROSIS

- PERIODONTAL PROBLEMS

- PARESTHESIA

*CAUSES FOR POOR PROGNOSIS *

- HORIZONTAL

- HIGH PALATE

- HIGH LABIAL (if above adjacent)

- TRANSEALVEOLAR (apex on one side , crown on the other side of alveolus)

- SCLEROTIC BONE

- CLOSED APICES

- ABNORMAL ROOT CONFIGURATION

- OLD AGE

THANK YOU .. !!