Impacted teeth | by Dr.Basma Elbeshlawy

77
Mansoura University Faculty of Dentistry Oral Surgery department Impacted Teeth Presented By : Dr/ Basma Elbeshlawy

Transcript of Impacted teeth | by Dr.Basma Elbeshlawy

Page 1: Impacted teeth | by Dr.Basma Elbeshlawy

Mansoura UniversityFaculty of Dentistry

Oral Surgery department

Impacted Teeth Presented By

Dr Basma Elbeshlawy

Items- Definition of Impacted Tooth- Causes- Classification- Frequency- Indications for removal of Impacted Tooth

ldquo Complication that may result from impacted tooth ldquo Prophylactic removal of impacted tooth

- Contraindications for removal of Impacted Tooth- Diagnosis - Surgical Technique for removal of impacted tooth - Operative complications- Post operative complications

- References

Definition - To ldquoImpactrdquo mean ldquoto contact and Pressurerdquo Impacted tooth is that tooth that fails to erupt into its normal functioning position

in the dental arch within the expected time

The term Unerupted includes both impacted teeth and teeth that are in the process of eruption

Causes of impaction

bull Systemic causes bull Local causes

Systemic Causes 1- Prenatal causes ndash hereditarya hereditary syndrome of cleidocranial dysistosis termed primary

Retention 2- Postnatal causes Rickets

Anemia Tuberculosis Congenital syphilis Malnutrition

Endocrinal deficiency (hypothyrodism hypopituitarism)Febrile disease Down syndrome Gorlin syndrome

Local Factors 1- Lack of space in dental arch due to

Small size dental arch with disproportion between teeth and jaw size Macrodontia2- Over retained deciduous teeth 3- Premature loss of deciduous teeth4- High density of overlying and surrounding bone5- Long standing chronic inflammation soft tissue fibrosis6- Incorrect alignment and abnormality of teeth 7- Direct or indirect effect of cysts or neoplasm8- Cleft palate or lip9- Ectopic position of tooth bud

Classification system of impacted teeth

This is done to help dentist in evaluation of the extent of the surgical procedure and in the planning of this procedure

A - Relation of the tooth to the ascending ramus of the mandible and to the distal surface of the 2nd molar (Pell ampGregory)ndash This show the anterioposterior relationship of the

tooth to the arch and the amount of resistance offered by the bone of the ascending ramus that may influence the tooth removal

1-Classification of impacted mandibular third molar

Class1bull The space between

the anterior part of the ascending ramus and the distal surface of the 2nd molar is sufficient to accommodate the mesiodistal diameter of the crown of the third molar

Class2bull The space between

the anterior part of the ascending ramus and distal surface of the 2nd molar is less than the mesiodistal diameter of the crown of the third molar (part of the tooth located within the ramus)

Class3bull All the third molar is

located within the ascending ramus of the mandible

- This show the superior inferior relationship of the tooth in relation to the occlusal plan (Pell amp Gregory)

bull Position A The highest portion of the tooth is on level

with or above the occlusal planebull Position B The highest portion is below the occlusal plane but above the cervical margin of the

2nd molarbull Position C The highest point of the tooth is below the cervical margins of the 2nd molar (deep impaction)

B - Relative depth of the third molar in bone

1-Vertical the long axis of the third molar is parallel to that of the 2nd molar

2-Horizontal the long axis of the third molar is at right angle to that of the 2nd molar

3-Mesioangular impaction4-Destoangular impaction all the previous four classes can come in a - lingual deflection b - buccal deflection

5-Inverted impaction

C - The position of the long axis of the impacted tooth in relation to the long axis of the 2nd molar (winters classification)

Classification of impactionof mandibular third molars according to Archer (1975) and Kruger (1984)1 Mesioangular 2 Distoangular3 Vertical 4 Horizontal 5 Buccoangular6 Linguoangular 7 inverted

Classification of impactedmandibular third molars according toPell and Gregory (1933) according to a The depth of impaction b their positionaccording to the distance between the 2nd and the anterior border of raums of the mandible

Soft tissue impaction in which crown of tooth is covered by soft tissue only and can be removed without bone removal

Partial bony impactionin which part of tooth usually posterior aspect is covered with bone and requires either bone removal or tooth sectioning for extraction

Complete bony impaction in which tooth is completely covered with bone and requires extensive removal of bone for extraction

Another classification of impaction

2 -Classification of impacted maxillary third

molaraccording toArcher (maxillary 1975) depending on the depth of impaction compared to the adjacent second molarClass AThe occlusal surface of the impacted tooth is at approximately the same level as the occlusal surface of the 2nd molar (Figa)Class B The occlusal surface of the impacted tooth is at the middle of the crown of the adjacent 2nd molar (Figb)Class C The occlusal surface of the crown of the impacted tooth is below the cervical line of the adjacent molar or even deeper or even above its roots (Figscndashe)

According to Archer (1975) 1Mesioangular2 distoangular 3 vertical 4 horizontal5 buccoangular6 linguoangular7 inverted

According to the relationship of tooth to maxillary sinus a-Sinus approximation (sa) where no bone or very thin bone exist between the impacted teeth and floor of sinus b-No sinus approximation (nsa) where 2 mm or more of bone exist between the floor of sinus and impacted teeth

bull Class1 Palatally impacted cuspids these could be in vertical horizontal

semivertical positionbull Class2 Labialy impacted cuspide which could be in vertical horizontal

semiverticalbull Class3 Impacted cuspid located both in the palatal and labial surfacesbull Class4 Impacted cuspid in the alveolar process bull Class5 Impacted cuspid that are present in an edentulous maxilla

3-Classification of impacted maxillary cuspids

frequency of impaction1 mandibular 3rd molar2 maxillary 3rd molar3 maxillary cuspid4 mandibular cuspid5 Mandibular premolar6 maxillary premolars7 maxillary central and lateral incisors( wisdom teeth are very common to be impacted as they

are the last molar to emerge They are normally emerge between 17 -21 years of age )

COMPLICATIONS Complications of impacted tooth

Operative complications

Postoperative complications

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 2: Impacted teeth | by Dr.Basma Elbeshlawy

Items- Definition of Impacted Tooth- Causes- Classification- Frequency- Indications for removal of Impacted Tooth

ldquo Complication that may result from impacted tooth ldquo Prophylactic removal of impacted tooth

- Contraindications for removal of Impacted Tooth- Diagnosis - Surgical Technique for removal of impacted tooth - Operative complications- Post operative complications

- References

Definition - To ldquoImpactrdquo mean ldquoto contact and Pressurerdquo Impacted tooth is that tooth that fails to erupt into its normal functioning position

in the dental arch within the expected time

The term Unerupted includes both impacted teeth and teeth that are in the process of eruption

Causes of impaction

bull Systemic causes bull Local causes

Systemic Causes 1- Prenatal causes ndash hereditarya hereditary syndrome of cleidocranial dysistosis termed primary

Retention 2- Postnatal causes Rickets

Anemia Tuberculosis Congenital syphilis Malnutrition

Endocrinal deficiency (hypothyrodism hypopituitarism)Febrile disease Down syndrome Gorlin syndrome

Local Factors 1- Lack of space in dental arch due to

Small size dental arch with disproportion between teeth and jaw size Macrodontia2- Over retained deciduous teeth 3- Premature loss of deciduous teeth4- High density of overlying and surrounding bone5- Long standing chronic inflammation soft tissue fibrosis6- Incorrect alignment and abnormality of teeth 7- Direct or indirect effect of cysts or neoplasm8- Cleft palate or lip9- Ectopic position of tooth bud

Classification system of impacted teeth

This is done to help dentist in evaluation of the extent of the surgical procedure and in the planning of this procedure

A - Relation of the tooth to the ascending ramus of the mandible and to the distal surface of the 2nd molar (Pell ampGregory)ndash This show the anterioposterior relationship of the

tooth to the arch and the amount of resistance offered by the bone of the ascending ramus that may influence the tooth removal

1-Classification of impacted mandibular third molar

Class1bull The space between

the anterior part of the ascending ramus and the distal surface of the 2nd molar is sufficient to accommodate the mesiodistal diameter of the crown of the third molar

Class2bull The space between

the anterior part of the ascending ramus and distal surface of the 2nd molar is less than the mesiodistal diameter of the crown of the third molar (part of the tooth located within the ramus)

Class3bull All the third molar is

located within the ascending ramus of the mandible

- This show the superior inferior relationship of the tooth in relation to the occlusal plan (Pell amp Gregory)

bull Position A The highest portion of the tooth is on level

with or above the occlusal planebull Position B The highest portion is below the occlusal plane but above the cervical margin of the

2nd molarbull Position C The highest point of the tooth is below the cervical margins of the 2nd molar (deep impaction)

B - Relative depth of the third molar in bone

1-Vertical the long axis of the third molar is parallel to that of the 2nd molar

2-Horizontal the long axis of the third molar is at right angle to that of the 2nd molar

3-Mesioangular impaction4-Destoangular impaction all the previous four classes can come in a - lingual deflection b - buccal deflection

5-Inverted impaction

C - The position of the long axis of the impacted tooth in relation to the long axis of the 2nd molar (winters classification)

Classification of impactionof mandibular third molars according to Archer (1975) and Kruger (1984)1 Mesioangular 2 Distoangular3 Vertical 4 Horizontal 5 Buccoangular6 Linguoangular 7 inverted

Classification of impactedmandibular third molars according toPell and Gregory (1933) according to a The depth of impaction b their positionaccording to the distance between the 2nd and the anterior border of raums of the mandible

Soft tissue impaction in which crown of tooth is covered by soft tissue only and can be removed without bone removal

Partial bony impactionin which part of tooth usually posterior aspect is covered with bone and requires either bone removal or tooth sectioning for extraction

Complete bony impaction in which tooth is completely covered with bone and requires extensive removal of bone for extraction

Another classification of impaction

2 -Classification of impacted maxillary third

molaraccording toArcher (maxillary 1975) depending on the depth of impaction compared to the adjacent second molarClass AThe occlusal surface of the impacted tooth is at approximately the same level as the occlusal surface of the 2nd molar (Figa)Class B The occlusal surface of the impacted tooth is at the middle of the crown of the adjacent 2nd molar (Figb)Class C The occlusal surface of the crown of the impacted tooth is below the cervical line of the adjacent molar or even deeper or even above its roots (Figscndashe)

According to Archer (1975) 1Mesioangular2 distoangular 3 vertical 4 horizontal5 buccoangular6 linguoangular7 inverted

According to the relationship of tooth to maxillary sinus a-Sinus approximation (sa) where no bone or very thin bone exist between the impacted teeth and floor of sinus b-No sinus approximation (nsa) where 2 mm or more of bone exist between the floor of sinus and impacted teeth

bull Class1 Palatally impacted cuspids these could be in vertical horizontal

semivertical positionbull Class2 Labialy impacted cuspide which could be in vertical horizontal

semiverticalbull Class3 Impacted cuspid located both in the palatal and labial surfacesbull Class4 Impacted cuspid in the alveolar process bull Class5 Impacted cuspid that are present in an edentulous maxilla

3-Classification of impacted maxillary cuspids

frequency of impaction1 mandibular 3rd molar2 maxillary 3rd molar3 maxillary cuspid4 mandibular cuspid5 Mandibular premolar6 maxillary premolars7 maxillary central and lateral incisors( wisdom teeth are very common to be impacted as they

are the last molar to emerge They are normally emerge between 17 -21 years of age )

COMPLICATIONS Complications of impacted tooth

Operative complications

Postoperative complications

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 3: Impacted teeth | by Dr.Basma Elbeshlawy

Definition - To ldquoImpactrdquo mean ldquoto contact and Pressurerdquo Impacted tooth is that tooth that fails to erupt into its normal functioning position

in the dental arch within the expected time

The term Unerupted includes both impacted teeth and teeth that are in the process of eruption

Causes of impaction

bull Systemic causes bull Local causes

Systemic Causes 1- Prenatal causes ndash hereditarya hereditary syndrome of cleidocranial dysistosis termed primary

Retention 2- Postnatal causes Rickets

Anemia Tuberculosis Congenital syphilis Malnutrition

Endocrinal deficiency (hypothyrodism hypopituitarism)Febrile disease Down syndrome Gorlin syndrome

Local Factors 1- Lack of space in dental arch due to

Small size dental arch with disproportion between teeth and jaw size Macrodontia2- Over retained deciduous teeth 3- Premature loss of deciduous teeth4- High density of overlying and surrounding bone5- Long standing chronic inflammation soft tissue fibrosis6- Incorrect alignment and abnormality of teeth 7- Direct or indirect effect of cysts or neoplasm8- Cleft palate or lip9- Ectopic position of tooth bud

Classification system of impacted teeth

This is done to help dentist in evaluation of the extent of the surgical procedure and in the planning of this procedure

A - Relation of the tooth to the ascending ramus of the mandible and to the distal surface of the 2nd molar (Pell ampGregory)ndash This show the anterioposterior relationship of the

tooth to the arch and the amount of resistance offered by the bone of the ascending ramus that may influence the tooth removal

1-Classification of impacted mandibular third molar

Class1bull The space between

the anterior part of the ascending ramus and the distal surface of the 2nd molar is sufficient to accommodate the mesiodistal diameter of the crown of the third molar

Class2bull The space between

the anterior part of the ascending ramus and distal surface of the 2nd molar is less than the mesiodistal diameter of the crown of the third molar (part of the tooth located within the ramus)

Class3bull All the third molar is

located within the ascending ramus of the mandible

- This show the superior inferior relationship of the tooth in relation to the occlusal plan (Pell amp Gregory)

bull Position A The highest portion of the tooth is on level

with or above the occlusal planebull Position B The highest portion is below the occlusal plane but above the cervical margin of the

2nd molarbull Position C The highest point of the tooth is below the cervical margins of the 2nd molar (deep impaction)

B - Relative depth of the third molar in bone

1-Vertical the long axis of the third molar is parallel to that of the 2nd molar

2-Horizontal the long axis of the third molar is at right angle to that of the 2nd molar

3-Mesioangular impaction4-Destoangular impaction all the previous four classes can come in a - lingual deflection b - buccal deflection

5-Inverted impaction

C - The position of the long axis of the impacted tooth in relation to the long axis of the 2nd molar (winters classification)

Classification of impactionof mandibular third molars according to Archer (1975) and Kruger (1984)1 Mesioangular 2 Distoangular3 Vertical 4 Horizontal 5 Buccoangular6 Linguoangular 7 inverted

Classification of impactedmandibular third molars according toPell and Gregory (1933) according to a The depth of impaction b their positionaccording to the distance between the 2nd and the anterior border of raums of the mandible

Soft tissue impaction in which crown of tooth is covered by soft tissue only and can be removed without bone removal

Partial bony impactionin which part of tooth usually posterior aspect is covered with bone and requires either bone removal or tooth sectioning for extraction

Complete bony impaction in which tooth is completely covered with bone and requires extensive removal of bone for extraction

Another classification of impaction

2 -Classification of impacted maxillary third

molaraccording toArcher (maxillary 1975) depending on the depth of impaction compared to the adjacent second molarClass AThe occlusal surface of the impacted tooth is at approximately the same level as the occlusal surface of the 2nd molar (Figa)Class B The occlusal surface of the impacted tooth is at the middle of the crown of the adjacent 2nd molar (Figb)Class C The occlusal surface of the crown of the impacted tooth is below the cervical line of the adjacent molar or even deeper or even above its roots (Figscndashe)

According to Archer (1975) 1Mesioangular2 distoangular 3 vertical 4 horizontal5 buccoangular6 linguoangular7 inverted

According to the relationship of tooth to maxillary sinus a-Sinus approximation (sa) where no bone or very thin bone exist between the impacted teeth and floor of sinus b-No sinus approximation (nsa) where 2 mm or more of bone exist between the floor of sinus and impacted teeth

bull Class1 Palatally impacted cuspids these could be in vertical horizontal

semivertical positionbull Class2 Labialy impacted cuspide which could be in vertical horizontal

semiverticalbull Class3 Impacted cuspid located both in the palatal and labial surfacesbull Class4 Impacted cuspid in the alveolar process bull Class5 Impacted cuspid that are present in an edentulous maxilla

3-Classification of impacted maxillary cuspids

frequency of impaction1 mandibular 3rd molar2 maxillary 3rd molar3 maxillary cuspid4 mandibular cuspid5 Mandibular premolar6 maxillary premolars7 maxillary central and lateral incisors( wisdom teeth are very common to be impacted as they

are the last molar to emerge They are normally emerge between 17 -21 years of age )

COMPLICATIONS Complications of impacted tooth

Operative complications

Postoperative complications

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 4: Impacted teeth | by Dr.Basma Elbeshlawy

Causes of impaction

bull Systemic causes bull Local causes

Systemic Causes 1- Prenatal causes ndash hereditarya hereditary syndrome of cleidocranial dysistosis termed primary

Retention 2- Postnatal causes Rickets

Anemia Tuberculosis Congenital syphilis Malnutrition

Endocrinal deficiency (hypothyrodism hypopituitarism)Febrile disease Down syndrome Gorlin syndrome

Local Factors 1- Lack of space in dental arch due to

Small size dental arch with disproportion between teeth and jaw size Macrodontia2- Over retained deciduous teeth 3- Premature loss of deciduous teeth4- High density of overlying and surrounding bone5- Long standing chronic inflammation soft tissue fibrosis6- Incorrect alignment and abnormality of teeth 7- Direct or indirect effect of cysts or neoplasm8- Cleft palate or lip9- Ectopic position of tooth bud

Classification system of impacted teeth

This is done to help dentist in evaluation of the extent of the surgical procedure and in the planning of this procedure

A - Relation of the tooth to the ascending ramus of the mandible and to the distal surface of the 2nd molar (Pell ampGregory)ndash This show the anterioposterior relationship of the

tooth to the arch and the amount of resistance offered by the bone of the ascending ramus that may influence the tooth removal

1-Classification of impacted mandibular third molar

Class1bull The space between

the anterior part of the ascending ramus and the distal surface of the 2nd molar is sufficient to accommodate the mesiodistal diameter of the crown of the third molar

Class2bull The space between

the anterior part of the ascending ramus and distal surface of the 2nd molar is less than the mesiodistal diameter of the crown of the third molar (part of the tooth located within the ramus)

Class3bull All the third molar is

located within the ascending ramus of the mandible

- This show the superior inferior relationship of the tooth in relation to the occlusal plan (Pell amp Gregory)

bull Position A The highest portion of the tooth is on level

with or above the occlusal planebull Position B The highest portion is below the occlusal plane but above the cervical margin of the

2nd molarbull Position C The highest point of the tooth is below the cervical margins of the 2nd molar (deep impaction)

B - Relative depth of the third molar in bone

1-Vertical the long axis of the third molar is parallel to that of the 2nd molar

2-Horizontal the long axis of the third molar is at right angle to that of the 2nd molar

3-Mesioangular impaction4-Destoangular impaction all the previous four classes can come in a - lingual deflection b - buccal deflection

5-Inverted impaction

C - The position of the long axis of the impacted tooth in relation to the long axis of the 2nd molar (winters classification)

Classification of impactionof mandibular third molars according to Archer (1975) and Kruger (1984)1 Mesioangular 2 Distoangular3 Vertical 4 Horizontal 5 Buccoangular6 Linguoangular 7 inverted

Classification of impactedmandibular third molars according toPell and Gregory (1933) according to a The depth of impaction b their positionaccording to the distance between the 2nd and the anterior border of raums of the mandible

Soft tissue impaction in which crown of tooth is covered by soft tissue only and can be removed without bone removal

Partial bony impactionin which part of tooth usually posterior aspect is covered with bone and requires either bone removal or tooth sectioning for extraction

Complete bony impaction in which tooth is completely covered with bone and requires extensive removal of bone for extraction

Another classification of impaction

2 -Classification of impacted maxillary third

molaraccording toArcher (maxillary 1975) depending on the depth of impaction compared to the adjacent second molarClass AThe occlusal surface of the impacted tooth is at approximately the same level as the occlusal surface of the 2nd molar (Figa)Class B The occlusal surface of the impacted tooth is at the middle of the crown of the adjacent 2nd molar (Figb)Class C The occlusal surface of the crown of the impacted tooth is below the cervical line of the adjacent molar or even deeper or even above its roots (Figscndashe)

According to Archer (1975) 1Mesioangular2 distoangular 3 vertical 4 horizontal5 buccoangular6 linguoangular7 inverted

According to the relationship of tooth to maxillary sinus a-Sinus approximation (sa) where no bone or very thin bone exist between the impacted teeth and floor of sinus b-No sinus approximation (nsa) where 2 mm or more of bone exist between the floor of sinus and impacted teeth

bull Class1 Palatally impacted cuspids these could be in vertical horizontal

semivertical positionbull Class2 Labialy impacted cuspide which could be in vertical horizontal

semiverticalbull Class3 Impacted cuspid located both in the palatal and labial surfacesbull Class4 Impacted cuspid in the alveolar process bull Class5 Impacted cuspid that are present in an edentulous maxilla

3-Classification of impacted maxillary cuspids

frequency of impaction1 mandibular 3rd molar2 maxillary 3rd molar3 maxillary cuspid4 mandibular cuspid5 Mandibular premolar6 maxillary premolars7 maxillary central and lateral incisors( wisdom teeth are very common to be impacted as they

are the last molar to emerge They are normally emerge between 17 -21 years of age )

COMPLICATIONS Complications of impacted tooth

Operative complications

Postoperative complications

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 5: Impacted teeth | by Dr.Basma Elbeshlawy

Systemic Causes 1- Prenatal causes ndash hereditarya hereditary syndrome of cleidocranial dysistosis termed primary

Retention 2- Postnatal causes Rickets

Anemia Tuberculosis Congenital syphilis Malnutrition

Endocrinal deficiency (hypothyrodism hypopituitarism)Febrile disease Down syndrome Gorlin syndrome

Local Factors 1- Lack of space in dental arch due to

Small size dental arch with disproportion between teeth and jaw size Macrodontia2- Over retained deciduous teeth 3- Premature loss of deciduous teeth4- High density of overlying and surrounding bone5- Long standing chronic inflammation soft tissue fibrosis6- Incorrect alignment and abnormality of teeth 7- Direct or indirect effect of cysts or neoplasm8- Cleft palate or lip9- Ectopic position of tooth bud

Classification system of impacted teeth

This is done to help dentist in evaluation of the extent of the surgical procedure and in the planning of this procedure

A - Relation of the tooth to the ascending ramus of the mandible and to the distal surface of the 2nd molar (Pell ampGregory)ndash This show the anterioposterior relationship of the

tooth to the arch and the amount of resistance offered by the bone of the ascending ramus that may influence the tooth removal

1-Classification of impacted mandibular third molar

Class1bull The space between

the anterior part of the ascending ramus and the distal surface of the 2nd molar is sufficient to accommodate the mesiodistal diameter of the crown of the third molar

Class2bull The space between

the anterior part of the ascending ramus and distal surface of the 2nd molar is less than the mesiodistal diameter of the crown of the third molar (part of the tooth located within the ramus)

Class3bull All the third molar is

located within the ascending ramus of the mandible

- This show the superior inferior relationship of the tooth in relation to the occlusal plan (Pell amp Gregory)

bull Position A The highest portion of the tooth is on level

with or above the occlusal planebull Position B The highest portion is below the occlusal plane but above the cervical margin of the

2nd molarbull Position C The highest point of the tooth is below the cervical margins of the 2nd molar (deep impaction)

B - Relative depth of the third molar in bone

1-Vertical the long axis of the third molar is parallel to that of the 2nd molar

2-Horizontal the long axis of the third molar is at right angle to that of the 2nd molar

3-Mesioangular impaction4-Destoangular impaction all the previous four classes can come in a - lingual deflection b - buccal deflection

5-Inverted impaction

C - The position of the long axis of the impacted tooth in relation to the long axis of the 2nd molar (winters classification)

Classification of impactionof mandibular third molars according to Archer (1975) and Kruger (1984)1 Mesioangular 2 Distoangular3 Vertical 4 Horizontal 5 Buccoangular6 Linguoangular 7 inverted

Classification of impactedmandibular third molars according toPell and Gregory (1933) according to a The depth of impaction b their positionaccording to the distance between the 2nd and the anterior border of raums of the mandible

Soft tissue impaction in which crown of tooth is covered by soft tissue only and can be removed without bone removal

Partial bony impactionin which part of tooth usually posterior aspect is covered with bone and requires either bone removal or tooth sectioning for extraction

Complete bony impaction in which tooth is completely covered with bone and requires extensive removal of bone for extraction

Another classification of impaction

2 -Classification of impacted maxillary third

molaraccording toArcher (maxillary 1975) depending on the depth of impaction compared to the adjacent second molarClass AThe occlusal surface of the impacted tooth is at approximately the same level as the occlusal surface of the 2nd molar (Figa)Class B The occlusal surface of the impacted tooth is at the middle of the crown of the adjacent 2nd molar (Figb)Class C The occlusal surface of the crown of the impacted tooth is below the cervical line of the adjacent molar or even deeper or even above its roots (Figscndashe)

According to Archer (1975) 1Mesioangular2 distoangular 3 vertical 4 horizontal5 buccoangular6 linguoangular7 inverted

According to the relationship of tooth to maxillary sinus a-Sinus approximation (sa) where no bone or very thin bone exist between the impacted teeth and floor of sinus b-No sinus approximation (nsa) where 2 mm or more of bone exist between the floor of sinus and impacted teeth

bull Class1 Palatally impacted cuspids these could be in vertical horizontal

semivertical positionbull Class2 Labialy impacted cuspide which could be in vertical horizontal

semiverticalbull Class3 Impacted cuspid located both in the palatal and labial surfacesbull Class4 Impacted cuspid in the alveolar process bull Class5 Impacted cuspid that are present in an edentulous maxilla

3-Classification of impacted maxillary cuspids

frequency of impaction1 mandibular 3rd molar2 maxillary 3rd molar3 maxillary cuspid4 mandibular cuspid5 Mandibular premolar6 maxillary premolars7 maxillary central and lateral incisors( wisdom teeth are very common to be impacted as they

are the last molar to emerge They are normally emerge between 17 -21 years of age )

COMPLICATIONS Complications of impacted tooth

Operative complications

Postoperative complications

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 6: Impacted teeth | by Dr.Basma Elbeshlawy

Local Factors 1- Lack of space in dental arch due to

Small size dental arch with disproportion between teeth and jaw size Macrodontia2- Over retained deciduous teeth 3- Premature loss of deciduous teeth4- High density of overlying and surrounding bone5- Long standing chronic inflammation soft tissue fibrosis6- Incorrect alignment and abnormality of teeth 7- Direct or indirect effect of cysts or neoplasm8- Cleft palate or lip9- Ectopic position of tooth bud

Classification system of impacted teeth

This is done to help dentist in evaluation of the extent of the surgical procedure and in the planning of this procedure

A - Relation of the tooth to the ascending ramus of the mandible and to the distal surface of the 2nd molar (Pell ampGregory)ndash This show the anterioposterior relationship of the

tooth to the arch and the amount of resistance offered by the bone of the ascending ramus that may influence the tooth removal

1-Classification of impacted mandibular third molar

Class1bull The space between

the anterior part of the ascending ramus and the distal surface of the 2nd molar is sufficient to accommodate the mesiodistal diameter of the crown of the third molar

Class2bull The space between

the anterior part of the ascending ramus and distal surface of the 2nd molar is less than the mesiodistal diameter of the crown of the third molar (part of the tooth located within the ramus)

Class3bull All the third molar is

located within the ascending ramus of the mandible

- This show the superior inferior relationship of the tooth in relation to the occlusal plan (Pell amp Gregory)

bull Position A The highest portion of the tooth is on level

with or above the occlusal planebull Position B The highest portion is below the occlusal plane but above the cervical margin of the

2nd molarbull Position C The highest point of the tooth is below the cervical margins of the 2nd molar (deep impaction)

B - Relative depth of the third molar in bone

1-Vertical the long axis of the third molar is parallel to that of the 2nd molar

2-Horizontal the long axis of the third molar is at right angle to that of the 2nd molar

3-Mesioangular impaction4-Destoangular impaction all the previous four classes can come in a - lingual deflection b - buccal deflection

5-Inverted impaction

C - The position of the long axis of the impacted tooth in relation to the long axis of the 2nd molar (winters classification)

Classification of impactionof mandibular third molars according to Archer (1975) and Kruger (1984)1 Mesioangular 2 Distoangular3 Vertical 4 Horizontal 5 Buccoangular6 Linguoangular 7 inverted

Classification of impactedmandibular third molars according toPell and Gregory (1933) according to a The depth of impaction b their positionaccording to the distance between the 2nd and the anterior border of raums of the mandible

Soft tissue impaction in which crown of tooth is covered by soft tissue only and can be removed without bone removal

Partial bony impactionin which part of tooth usually posterior aspect is covered with bone and requires either bone removal or tooth sectioning for extraction

Complete bony impaction in which tooth is completely covered with bone and requires extensive removal of bone for extraction

Another classification of impaction

2 -Classification of impacted maxillary third

molaraccording toArcher (maxillary 1975) depending on the depth of impaction compared to the adjacent second molarClass AThe occlusal surface of the impacted tooth is at approximately the same level as the occlusal surface of the 2nd molar (Figa)Class B The occlusal surface of the impacted tooth is at the middle of the crown of the adjacent 2nd molar (Figb)Class C The occlusal surface of the crown of the impacted tooth is below the cervical line of the adjacent molar or even deeper or even above its roots (Figscndashe)

According to Archer (1975) 1Mesioangular2 distoangular 3 vertical 4 horizontal5 buccoangular6 linguoangular7 inverted

According to the relationship of tooth to maxillary sinus a-Sinus approximation (sa) where no bone or very thin bone exist between the impacted teeth and floor of sinus b-No sinus approximation (nsa) where 2 mm or more of bone exist between the floor of sinus and impacted teeth

bull Class1 Palatally impacted cuspids these could be in vertical horizontal

semivertical positionbull Class2 Labialy impacted cuspide which could be in vertical horizontal

semiverticalbull Class3 Impacted cuspid located both in the palatal and labial surfacesbull Class4 Impacted cuspid in the alveolar process bull Class5 Impacted cuspid that are present in an edentulous maxilla

3-Classification of impacted maxillary cuspids

frequency of impaction1 mandibular 3rd molar2 maxillary 3rd molar3 maxillary cuspid4 mandibular cuspid5 Mandibular premolar6 maxillary premolars7 maxillary central and lateral incisors( wisdom teeth are very common to be impacted as they

are the last molar to emerge They are normally emerge between 17 -21 years of age )

COMPLICATIONS Complications of impacted tooth

Operative complications

Postoperative complications

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 7: Impacted teeth | by Dr.Basma Elbeshlawy

Classification system of impacted teeth

This is done to help dentist in evaluation of the extent of the surgical procedure and in the planning of this procedure

A - Relation of the tooth to the ascending ramus of the mandible and to the distal surface of the 2nd molar (Pell ampGregory)ndash This show the anterioposterior relationship of the

tooth to the arch and the amount of resistance offered by the bone of the ascending ramus that may influence the tooth removal

1-Classification of impacted mandibular third molar

Class1bull The space between

the anterior part of the ascending ramus and the distal surface of the 2nd molar is sufficient to accommodate the mesiodistal diameter of the crown of the third molar

Class2bull The space between

the anterior part of the ascending ramus and distal surface of the 2nd molar is less than the mesiodistal diameter of the crown of the third molar (part of the tooth located within the ramus)

Class3bull All the third molar is

located within the ascending ramus of the mandible

- This show the superior inferior relationship of the tooth in relation to the occlusal plan (Pell amp Gregory)

bull Position A The highest portion of the tooth is on level

with or above the occlusal planebull Position B The highest portion is below the occlusal plane but above the cervical margin of the

2nd molarbull Position C The highest point of the tooth is below the cervical margins of the 2nd molar (deep impaction)

B - Relative depth of the third molar in bone

1-Vertical the long axis of the third molar is parallel to that of the 2nd molar

2-Horizontal the long axis of the third molar is at right angle to that of the 2nd molar

3-Mesioangular impaction4-Destoangular impaction all the previous four classes can come in a - lingual deflection b - buccal deflection

5-Inverted impaction

C - The position of the long axis of the impacted tooth in relation to the long axis of the 2nd molar (winters classification)

Classification of impactionof mandibular third molars according to Archer (1975) and Kruger (1984)1 Mesioangular 2 Distoangular3 Vertical 4 Horizontal 5 Buccoangular6 Linguoangular 7 inverted

Classification of impactedmandibular third molars according toPell and Gregory (1933) according to a The depth of impaction b their positionaccording to the distance between the 2nd and the anterior border of raums of the mandible

Soft tissue impaction in which crown of tooth is covered by soft tissue only and can be removed without bone removal

Partial bony impactionin which part of tooth usually posterior aspect is covered with bone and requires either bone removal or tooth sectioning for extraction

Complete bony impaction in which tooth is completely covered with bone and requires extensive removal of bone for extraction

Another classification of impaction

2 -Classification of impacted maxillary third

molaraccording toArcher (maxillary 1975) depending on the depth of impaction compared to the adjacent second molarClass AThe occlusal surface of the impacted tooth is at approximately the same level as the occlusal surface of the 2nd molar (Figa)Class B The occlusal surface of the impacted tooth is at the middle of the crown of the adjacent 2nd molar (Figb)Class C The occlusal surface of the crown of the impacted tooth is below the cervical line of the adjacent molar or even deeper or even above its roots (Figscndashe)

According to Archer (1975) 1Mesioangular2 distoangular 3 vertical 4 horizontal5 buccoangular6 linguoangular7 inverted

According to the relationship of tooth to maxillary sinus a-Sinus approximation (sa) where no bone or very thin bone exist between the impacted teeth and floor of sinus b-No sinus approximation (nsa) where 2 mm or more of bone exist between the floor of sinus and impacted teeth

bull Class1 Palatally impacted cuspids these could be in vertical horizontal

semivertical positionbull Class2 Labialy impacted cuspide which could be in vertical horizontal

semiverticalbull Class3 Impacted cuspid located both in the palatal and labial surfacesbull Class4 Impacted cuspid in the alveolar process bull Class5 Impacted cuspid that are present in an edentulous maxilla

3-Classification of impacted maxillary cuspids

frequency of impaction1 mandibular 3rd molar2 maxillary 3rd molar3 maxillary cuspid4 mandibular cuspid5 Mandibular premolar6 maxillary premolars7 maxillary central and lateral incisors( wisdom teeth are very common to be impacted as they

are the last molar to emerge They are normally emerge between 17 -21 years of age )

COMPLICATIONS Complications of impacted tooth

Operative complications

Postoperative complications

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 8: Impacted teeth | by Dr.Basma Elbeshlawy

A - Relation of the tooth to the ascending ramus of the mandible and to the distal surface of the 2nd molar (Pell ampGregory)ndash This show the anterioposterior relationship of the

tooth to the arch and the amount of resistance offered by the bone of the ascending ramus that may influence the tooth removal

1-Classification of impacted mandibular third molar

Class1bull The space between

the anterior part of the ascending ramus and the distal surface of the 2nd molar is sufficient to accommodate the mesiodistal diameter of the crown of the third molar

Class2bull The space between

the anterior part of the ascending ramus and distal surface of the 2nd molar is less than the mesiodistal diameter of the crown of the third molar (part of the tooth located within the ramus)

Class3bull All the third molar is

located within the ascending ramus of the mandible

- This show the superior inferior relationship of the tooth in relation to the occlusal plan (Pell amp Gregory)

bull Position A The highest portion of the tooth is on level

with or above the occlusal planebull Position B The highest portion is below the occlusal plane but above the cervical margin of the

2nd molarbull Position C The highest point of the tooth is below the cervical margins of the 2nd molar (deep impaction)

B - Relative depth of the third molar in bone

1-Vertical the long axis of the third molar is parallel to that of the 2nd molar

2-Horizontal the long axis of the third molar is at right angle to that of the 2nd molar

3-Mesioangular impaction4-Destoangular impaction all the previous four classes can come in a - lingual deflection b - buccal deflection

5-Inverted impaction

C - The position of the long axis of the impacted tooth in relation to the long axis of the 2nd molar (winters classification)

Classification of impactionof mandibular third molars according to Archer (1975) and Kruger (1984)1 Mesioangular 2 Distoangular3 Vertical 4 Horizontal 5 Buccoangular6 Linguoangular 7 inverted

Classification of impactedmandibular third molars according toPell and Gregory (1933) according to a The depth of impaction b their positionaccording to the distance between the 2nd and the anterior border of raums of the mandible

Soft tissue impaction in which crown of tooth is covered by soft tissue only and can be removed without bone removal

Partial bony impactionin which part of tooth usually posterior aspect is covered with bone and requires either bone removal or tooth sectioning for extraction

Complete bony impaction in which tooth is completely covered with bone and requires extensive removal of bone for extraction

Another classification of impaction

2 -Classification of impacted maxillary third

molaraccording toArcher (maxillary 1975) depending on the depth of impaction compared to the adjacent second molarClass AThe occlusal surface of the impacted tooth is at approximately the same level as the occlusal surface of the 2nd molar (Figa)Class B The occlusal surface of the impacted tooth is at the middle of the crown of the adjacent 2nd molar (Figb)Class C The occlusal surface of the crown of the impacted tooth is below the cervical line of the adjacent molar or even deeper or even above its roots (Figscndashe)

According to Archer (1975) 1Mesioangular2 distoangular 3 vertical 4 horizontal5 buccoangular6 linguoangular7 inverted

According to the relationship of tooth to maxillary sinus a-Sinus approximation (sa) where no bone or very thin bone exist between the impacted teeth and floor of sinus b-No sinus approximation (nsa) where 2 mm or more of bone exist between the floor of sinus and impacted teeth

bull Class1 Palatally impacted cuspids these could be in vertical horizontal

semivertical positionbull Class2 Labialy impacted cuspide which could be in vertical horizontal

semiverticalbull Class3 Impacted cuspid located both in the palatal and labial surfacesbull Class4 Impacted cuspid in the alveolar process bull Class5 Impacted cuspid that are present in an edentulous maxilla

3-Classification of impacted maxillary cuspids

frequency of impaction1 mandibular 3rd molar2 maxillary 3rd molar3 maxillary cuspid4 mandibular cuspid5 Mandibular premolar6 maxillary premolars7 maxillary central and lateral incisors( wisdom teeth are very common to be impacted as they

are the last molar to emerge They are normally emerge between 17 -21 years of age )

COMPLICATIONS Complications of impacted tooth

Operative complications

Postoperative complications

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 9: Impacted teeth | by Dr.Basma Elbeshlawy

Class1bull The space between

the anterior part of the ascending ramus and the distal surface of the 2nd molar is sufficient to accommodate the mesiodistal diameter of the crown of the third molar

Class2bull The space between

the anterior part of the ascending ramus and distal surface of the 2nd molar is less than the mesiodistal diameter of the crown of the third molar (part of the tooth located within the ramus)

Class3bull All the third molar is

located within the ascending ramus of the mandible

- This show the superior inferior relationship of the tooth in relation to the occlusal plan (Pell amp Gregory)

bull Position A The highest portion of the tooth is on level

with or above the occlusal planebull Position B The highest portion is below the occlusal plane but above the cervical margin of the

2nd molarbull Position C The highest point of the tooth is below the cervical margins of the 2nd molar (deep impaction)

B - Relative depth of the third molar in bone

1-Vertical the long axis of the third molar is parallel to that of the 2nd molar

2-Horizontal the long axis of the third molar is at right angle to that of the 2nd molar

3-Mesioangular impaction4-Destoangular impaction all the previous four classes can come in a - lingual deflection b - buccal deflection

5-Inverted impaction

C - The position of the long axis of the impacted tooth in relation to the long axis of the 2nd molar (winters classification)

Classification of impactionof mandibular third molars according to Archer (1975) and Kruger (1984)1 Mesioangular 2 Distoangular3 Vertical 4 Horizontal 5 Buccoangular6 Linguoangular 7 inverted

Classification of impactedmandibular third molars according toPell and Gregory (1933) according to a The depth of impaction b their positionaccording to the distance between the 2nd and the anterior border of raums of the mandible

Soft tissue impaction in which crown of tooth is covered by soft tissue only and can be removed without bone removal

Partial bony impactionin which part of tooth usually posterior aspect is covered with bone and requires either bone removal or tooth sectioning for extraction

Complete bony impaction in which tooth is completely covered with bone and requires extensive removal of bone for extraction

Another classification of impaction

2 -Classification of impacted maxillary third

molaraccording toArcher (maxillary 1975) depending on the depth of impaction compared to the adjacent second molarClass AThe occlusal surface of the impacted tooth is at approximately the same level as the occlusal surface of the 2nd molar (Figa)Class B The occlusal surface of the impacted tooth is at the middle of the crown of the adjacent 2nd molar (Figb)Class C The occlusal surface of the crown of the impacted tooth is below the cervical line of the adjacent molar or even deeper or even above its roots (Figscndashe)

According to Archer (1975) 1Mesioangular2 distoangular 3 vertical 4 horizontal5 buccoangular6 linguoangular7 inverted

According to the relationship of tooth to maxillary sinus a-Sinus approximation (sa) where no bone or very thin bone exist between the impacted teeth and floor of sinus b-No sinus approximation (nsa) where 2 mm or more of bone exist between the floor of sinus and impacted teeth

bull Class1 Palatally impacted cuspids these could be in vertical horizontal

semivertical positionbull Class2 Labialy impacted cuspide which could be in vertical horizontal

semiverticalbull Class3 Impacted cuspid located both in the palatal and labial surfacesbull Class4 Impacted cuspid in the alveolar process bull Class5 Impacted cuspid that are present in an edentulous maxilla

3-Classification of impacted maxillary cuspids

frequency of impaction1 mandibular 3rd molar2 maxillary 3rd molar3 maxillary cuspid4 mandibular cuspid5 Mandibular premolar6 maxillary premolars7 maxillary central and lateral incisors( wisdom teeth are very common to be impacted as they

are the last molar to emerge They are normally emerge between 17 -21 years of age )

COMPLICATIONS Complications of impacted tooth

Operative complications

Postoperative complications

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 10: Impacted teeth | by Dr.Basma Elbeshlawy

Class2bull The space between

the anterior part of the ascending ramus and distal surface of the 2nd molar is less than the mesiodistal diameter of the crown of the third molar (part of the tooth located within the ramus)

Class3bull All the third molar is

located within the ascending ramus of the mandible

- This show the superior inferior relationship of the tooth in relation to the occlusal plan (Pell amp Gregory)

bull Position A The highest portion of the tooth is on level

with or above the occlusal planebull Position B The highest portion is below the occlusal plane but above the cervical margin of the

2nd molarbull Position C The highest point of the tooth is below the cervical margins of the 2nd molar (deep impaction)

B - Relative depth of the third molar in bone

1-Vertical the long axis of the third molar is parallel to that of the 2nd molar

2-Horizontal the long axis of the third molar is at right angle to that of the 2nd molar

3-Mesioangular impaction4-Destoangular impaction all the previous four classes can come in a - lingual deflection b - buccal deflection

5-Inverted impaction

C - The position of the long axis of the impacted tooth in relation to the long axis of the 2nd molar (winters classification)

Classification of impactionof mandibular third molars according to Archer (1975) and Kruger (1984)1 Mesioangular 2 Distoangular3 Vertical 4 Horizontal 5 Buccoangular6 Linguoangular 7 inverted

Classification of impactedmandibular third molars according toPell and Gregory (1933) according to a The depth of impaction b their positionaccording to the distance between the 2nd and the anterior border of raums of the mandible

Soft tissue impaction in which crown of tooth is covered by soft tissue only and can be removed without bone removal

Partial bony impactionin which part of tooth usually posterior aspect is covered with bone and requires either bone removal or tooth sectioning for extraction

Complete bony impaction in which tooth is completely covered with bone and requires extensive removal of bone for extraction

Another classification of impaction

2 -Classification of impacted maxillary third

molaraccording toArcher (maxillary 1975) depending on the depth of impaction compared to the adjacent second molarClass AThe occlusal surface of the impacted tooth is at approximately the same level as the occlusal surface of the 2nd molar (Figa)Class B The occlusal surface of the impacted tooth is at the middle of the crown of the adjacent 2nd molar (Figb)Class C The occlusal surface of the crown of the impacted tooth is below the cervical line of the adjacent molar or even deeper or even above its roots (Figscndashe)

According to Archer (1975) 1Mesioangular2 distoangular 3 vertical 4 horizontal5 buccoangular6 linguoangular7 inverted

According to the relationship of tooth to maxillary sinus a-Sinus approximation (sa) where no bone or very thin bone exist between the impacted teeth and floor of sinus b-No sinus approximation (nsa) where 2 mm or more of bone exist between the floor of sinus and impacted teeth

bull Class1 Palatally impacted cuspids these could be in vertical horizontal

semivertical positionbull Class2 Labialy impacted cuspide which could be in vertical horizontal

semiverticalbull Class3 Impacted cuspid located both in the palatal and labial surfacesbull Class4 Impacted cuspid in the alveolar process bull Class5 Impacted cuspid that are present in an edentulous maxilla

3-Classification of impacted maxillary cuspids

frequency of impaction1 mandibular 3rd molar2 maxillary 3rd molar3 maxillary cuspid4 mandibular cuspid5 Mandibular premolar6 maxillary premolars7 maxillary central and lateral incisors( wisdom teeth are very common to be impacted as they

are the last molar to emerge They are normally emerge between 17 -21 years of age )

COMPLICATIONS Complications of impacted tooth

Operative complications

Postoperative complications

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 11: Impacted teeth | by Dr.Basma Elbeshlawy

Class3bull All the third molar is

located within the ascending ramus of the mandible

- This show the superior inferior relationship of the tooth in relation to the occlusal plan (Pell amp Gregory)

bull Position A The highest portion of the tooth is on level

with or above the occlusal planebull Position B The highest portion is below the occlusal plane but above the cervical margin of the

2nd molarbull Position C The highest point of the tooth is below the cervical margins of the 2nd molar (deep impaction)

B - Relative depth of the third molar in bone

1-Vertical the long axis of the third molar is parallel to that of the 2nd molar

2-Horizontal the long axis of the third molar is at right angle to that of the 2nd molar

3-Mesioangular impaction4-Destoangular impaction all the previous four classes can come in a - lingual deflection b - buccal deflection

5-Inverted impaction

C - The position of the long axis of the impacted tooth in relation to the long axis of the 2nd molar (winters classification)

Classification of impactionof mandibular third molars according to Archer (1975) and Kruger (1984)1 Mesioangular 2 Distoangular3 Vertical 4 Horizontal 5 Buccoangular6 Linguoangular 7 inverted

Classification of impactedmandibular third molars according toPell and Gregory (1933) according to a The depth of impaction b their positionaccording to the distance between the 2nd and the anterior border of raums of the mandible

Soft tissue impaction in which crown of tooth is covered by soft tissue only and can be removed without bone removal

Partial bony impactionin which part of tooth usually posterior aspect is covered with bone and requires either bone removal or tooth sectioning for extraction

Complete bony impaction in which tooth is completely covered with bone and requires extensive removal of bone for extraction

Another classification of impaction

2 -Classification of impacted maxillary third

molaraccording toArcher (maxillary 1975) depending on the depth of impaction compared to the adjacent second molarClass AThe occlusal surface of the impacted tooth is at approximately the same level as the occlusal surface of the 2nd molar (Figa)Class B The occlusal surface of the impacted tooth is at the middle of the crown of the adjacent 2nd molar (Figb)Class C The occlusal surface of the crown of the impacted tooth is below the cervical line of the adjacent molar or even deeper or even above its roots (Figscndashe)

According to Archer (1975) 1Mesioangular2 distoangular 3 vertical 4 horizontal5 buccoangular6 linguoangular7 inverted

According to the relationship of tooth to maxillary sinus a-Sinus approximation (sa) where no bone or very thin bone exist between the impacted teeth and floor of sinus b-No sinus approximation (nsa) where 2 mm or more of bone exist between the floor of sinus and impacted teeth

bull Class1 Palatally impacted cuspids these could be in vertical horizontal

semivertical positionbull Class2 Labialy impacted cuspide which could be in vertical horizontal

semiverticalbull Class3 Impacted cuspid located both in the palatal and labial surfacesbull Class4 Impacted cuspid in the alveolar process bull Class5 Impacted cuspid that are present in an edentulous maxilla

3-Classification of impacted maxillary cuspids

frequency of impaction1 mandibular 3rd molar2 maxillary 3rd molar3 maxillary cuspid4 mandibular cuspid5 Mandibular premolar6 maxillary premolars7 maxillary central and lateral incisors( wisdom teeth are very common to be impacted as they

are the last molar to emerge They are normally emerge between 17 -21 years of age )

COMPLICATIONS Complications of impacted tooth

Operative complications

Postoperative complications

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 12: Impacted teeth | by Dr.Basma Elbeshlawy

- This show the superior inferior relationship of the tooth in relation to the occlusal plan (Pell amp Gregory)

bull Position A The highest portion of the tooth is on level

with or above the occlusal planebull Position B The highest portion is below the occlusal plane but above the cervical margin of the

2nd molarbull Position C The highest point of the tooth is below the cervical margins of the 2nd molar (deep impaction)

B - Relative depth of the third molar in bone

1-Vertical the long axis of the third molar is parallel to that of the 2nd molar

2-Horizontal the long axis of the third molar is at right angle to that of the 2nd molar

3-Mesioangular impaction4-Destoangular impaction all the previous four classes can come in a - lingual deflection b - buccal deflection

5-Inverted impaction

C - The position of the long axis of the impacted tooth in relation to the long axis of the 2nd molar (winters classification)

Classification of impactionof mandibular third molars according to Archer (1975) and Kruger (1984)1 Mesioangular 2 Distoangular3 Vertical 4 Horizontal 5 Buccoangular6 Linguoangular 7 inverted

Classification of impactedmandibular third molars according toPell and Gregory (1933) according to a The depth of impaction b their positionaccording to the distance between the 2nd and the anterior border of raums of the mandible

Soft tissue impaction in which crown of tooth is covered by soft tissue only and can be removed without bone removal

Partial bony impactionin which part of tooth usually posterior aspect is covered with bone and requires either bone removal or tooth sectioning for extraction

Complete bony impaction in which tooth is completely covered with bone and requires extensive removal of bone for extraction

Another classification of impaction

2 -Classification of impacted maxillary third

molaraccording toArcher (maxillary 1975) depending on the depth of impaction compared to the adjacent second molarClass AThe occlusal surface of the impacted tooth is at approximately the same level as the occlusal surface of the 2nd molar (Figa)Class B The occlusal surface of the impacted tooth is at the middle of the crown of the adjacent 2nd molar (Figb)Class C The occlusal surface of the crown of the impacted tooth is below the cervical line of the adjacent molar or even deeper or even above its roots (Figscndashe)

According to Archer (1975) 1Mesioangular2 distoangular 3 vertical 4 horizontal5 buccoangular6 linguoangular7 inverted

According to the relationship of tooth to maxillary sinus a-Sinus approximation (sa) where no bone or very thin bone exist between the impacted teeth and floor of sinus b-No sinus approximation (nsa) where 2 mm or more of bone exist between the floor of sinus and impacted teeth

bull Class1 Palatally impacted cuspids these could be in vertical horizontal

semivertical positionbull Class2 Labialy impacted cuspide which could be in vertical horizontal

semiverticalbull Class3 Impacted cuspid located both in the palatal and labial surfacesbull Class4 Impacted cuspid in the alveolar process bull Class5 Impacted cuspid that are present in an edentulous maxilla

3-Classification of impacted maxillary cuspids

frequency of impaction1 mandibular 3rd molar2 maxillary 3rd molar3 maxillary cuspid4 mandibular cuspid5 Mandibular premolar6 maxillary premolars7 maxillary central and lateral incisors( wisdom teeth are very common to be impacted as they

are the last molar to emerge They are normally emerge between 17 -21 years of age )

COMPLICATIONS Complications of impacted tooth

Operative complications

Postoperative complications

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 13: Impacted teeth | by Dr.Basma Elbeshlawy

1-Vertical the long axis of the third molar is parallel to that of the 2nd molar

2-Horizontal the long axis of the third molar is at right angle to that of the 2nd molar

3-Mesioangular impaction4-Destoangular impaction all the previous four classes can come in a - lingual deflection b - buccal deflection

5-Inverted impaction

C - The position of the long axis of the impacted tooth in relation to the long axis of the 2nd molar (winters classification)

Classification of impactionof mandibular third molars according to Archer (1975) and Kruger (1984)1 Mesioangular 2 Distoangular3 Vertical 4 Horizontal 5 Buccoangular6 Linguoangular 7 inverted

Classification of impactedmandibular third molars according toPell and Gregory (1933) according to a The depth of impaction b their positionaccording to the distance between the 2nd and the anterior border of raums of the mandible

Soft tissue impaction in which crown of tooth is covered by soft tissue only and can be removed without bone removal

Partial bony impactionin which part of tooth usually posterior aspect is covered with bone and requires either bone removal or tooth sectioning for extraction

Complete bony impaction in which tooth is completely covered with bone and requires extensive removal of bone for extraction

Another classification of impaction

2 -Classification of impacted maxillary third

molaraccording toArcher (maxillary 1975) depending on the depth of impaction compared to the adjacent second molarClass AThe occlusal surface of the impacted tooth is at approximately the same level as the occlusal surface of the 2nd molar (Figa)Class B The occlusal surface of the impacted tooth is at the middle of the crown of the adjacent 2nd molar (Figb)Class C The occlusal surface of the crown of the impacted tooth is below the cervical line of the adjacent molar or even deeper or even above its roots (Figscndashe)

According to Archer (1975) 1Mesioangular2 distoangular 3 vertical 4 horizontal5 buccoangular6 linguoangular7 inverted

According to the relationship of tooth to maxillary sinus a-Sinus approximation (sa) where no bone or very thin bone exist between the impacted teeth and floor of sinus b-No sinus approximation (nsa) where 2 mm or more of bone exist between the floor of sinus and impacted teeth

bull Class1 Palatally impacted cuspids these could be in vertical horizontal

semivertical positionbull Class2 Labialy impacted cuspide which could be in vertical horizontal

semiverticalbull Class3 Impacted cuspid located both in the palatal and labial surfacesbull Class4 Impacted cuspid in the alveolar process bull Class5 Impacted cuspid that are present in an edentulous maxilla

3-Classification of impacted maxillary cuspids

frequency of impaction1 mandibular 3rd molar2 maxillary 3rd molar3 maxillary cuspid4 mandibular cuspid5 Mandibular premolar6 maxillary premolars7 maxillary central and lateral incisors( wisdom teeth are very common to be impacted as they

are the last molar to emerge They are normally emerge between 17 -21 years of age )

COMPLICATIONS Complications of impacted tooth

Operative complications

Postoperative complications

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 14: Impacted teeth | by Dr.Basma Elbeshlawy

Classification of impactionof mandibular third molars according to Archer (1975) and Kruger (1984)1 Mesioangular 2 Distoangular3 Vertical 4 Horizontal 5 Buccoangular6 Linguoangular 7 inverted

Classification of impactedmandibular third molars according toPell and Gregory (1933) according to a The depth of impaction b their positionaccording to the distance between the 2nd and the anterior border of raums of the mandible

Soft tissue impaction in which crown of tooth is covered by soft tissue only and can be removed without bone removal

Partial bony impactionin which part of tooth usually posterior aspect is covered with bone and requires either bone removal or tooth sectioning for extraction

Complete bony impaction in which tooth is completely covered with bone and requires extensive removal of bone for extraction

Another classification of impaction

2 -Classification of impacted maxillary third

molaraccording toArcher (maxillary 1975) depending on the depth of impaction compared to the adjacent second molarClass AThe occlusal surface of the impacted tooth is at approximately the same level as the occlusal surface of the 2nd molar (Figa)Class B The occlusal surface of the impacted tooth is at the middle of the crown of the adjacent 2nd molar (Figb)Class C The occlusal surface of the crown of the impacted tooth is below the cervical line of the adjacent molar or even deeper or even above its roots (Figscndashe)

According to Archer (1975) 1Mesioangular2 distoangular 3 vertical 4 horizontal5 buccoangular6 linguoangular7 inverted

According to the relationship of tooth to maxillary sinus a-Sinus approximation (sa) where no bone or very thin bone exist between the impacted teeth and floor of sinus b-No sinus approximation (nsa) where 2 mm or more of bone exist between the floor of sinus and impacted teeth

bull Class1 Palatally impacted cuspids these could be in vertical horizontal

semivertical positionbull Class2 Labialy impacted cuspide which could be in vertical horizontal

semiverticalbull Class3 Impacted cuspid located both in the palatal and labial surfacesbull Class4 Impacted cuspid in the alveolar process bull Class5 Impacted cuspid that are present in an edentulous maxilla

3-Classification of impacted maxillary cuspids

frequency of impaction1 mandibular 3rd molar2 maxillary 3rd molar3 maxillary cuspid4 mandibular cuspid5 Mandibular premolar6 maxillary premolars7 maxillary central and lateral incisors( wisdom teeth are very common to be impacted as they

are the last molar to emerge They are normally emerge between 17 -21 years of age )

COMPLICATIONS Complications of impacted tooth

Operative complications

Postoperative complications

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 15: Impacted teeth | by Dr.Basma Elbeshlawy

Soft tissue impaction in which crown of tooth is covered by soft tissue only and can be removed without bone removal

Partial bony impactionin which part of tooth usually posterior aspect is covered with bone and requires either bone removal or tooth sectioning for extraction

Complete bony impaction in which tooth is completely covered with bone and requires extensive removal of bone for extraction

Another classification of impaction

2 -Classification of impacted maxillary third

molaraccording toArcher (maxillary 1975) depending on the depth of impaction compared to the adjacent second molarClass AThe occlusal surface of the impacted tooth is at approximately the same level as the occlusal surface of the 2nd molar (Figa)Class B The occlusal surface of the impacted tooth is at the middle of the crown of the adjacent 2nd molar (Figb)Class C The occlusal surface of the crown of the impacted tooth is below the cervical line of the adjacent molar or even deeper or even above its roots (Figscndashe)

According to Archer (1975) 1Mesioangular2 distoangular 3 vertical 4 horizontal5 buccoangular6 linguoangular7 inverted

According to the relationship of tooth to maxillary sinus a-Sinus approximation (sa) where no bone or very thin bone exist between the impacted teeth and floor of sinus b-No sinus approximation (nsa) where 2 mm or more of bone exist between the floor of sinus and impacted teeth

bull Class1 Palatally impacted cuspids these could be in vertical horizontal

semivertical positionbull Class2 Labialy impacted cuspide which could be in vertical horizontal

semiverticalbull Class3 Impacted cuspid located both in the palatal and labial surfacesbull Class4 Impacted cuspid in the alveolar process bull Class5 Impacted cuspid that are present in an edentulous maxilla

3-Classification of impacted maxillary cuspids

frequency of impaction1 mandibular 3rd molar2 maxillary 3rd molar3 maxillary cuspid4 mandibular cuspid5 Mandibular premolar6 maxillary premolars7 maxillary central and lateral incisors( wisdom teeth are very common to be impacted as they

are the last molar to emerge They are normally emerge between 17 -21 years of age )

COMPLICATIONS Complications of impacted tooth

Operative complications

Postoperative complications

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 16: Impacted teeth | by Dr.Basma Elbeshlawy

2 -Classification of impacted maxillary third

molaraccording toArcher (maxillary 1975) depending on the depth of impaction compared to the adjacent second molarClass AThe occlusal surface of the impacted tooth is at approximately the same level as the occlusal surface of the 2nd molar (Figa)Class B The occlusal surface of the impacted tooth is at the middle of the crown of the adjacent 2nd molar (Figb)Class C The occlusal surface of the crown of the impacted tooth is below the cervical line of the adjacent molar or even deeper or even above its roots (Figscndashe)

According to Archer (1975) 1Mesioangular2 distoangular 3 vertical 4 horizontal5 buccoangular6 linguoangular7 inverted

According to the relationship of tooth to maxillary sinus a-Sinus approximation (sa) where no bone or very thin bone exist between the impacted teeth and floor of sinus b-No sinus approximation (nsa) where 2 mm or more of bone exist between the floor of sinus and impacted teeth

bull Class1 Palatally impacted cuspids these could be in vertical horizontal

semivertical positionbull Class2 Labialy impacted cuspide which could be in vertical horizontal

semiverticalbull Class3 Impacted cuspid located both in the palatal and labial surfacesbull Class4 Impacted cuspid in the alveolar process bull Class5 Impacted cuspid that are present in an edentulous maxilla

3-Classification of impacted maxillary cuspids

frequency of impaction1 mandibular 3rd molar2 maxillary 3rd molar3 maxillary cuspid4 mandibular cuspid5 Mandibular premolar6 maxillary premolars7 maxillary central and lateral incisors( wisdom teeth are very common to be impacted as they

are the last molar to emerge They are normally emerge between 17 -21 years of age )

COMPLICATIONS Complications of impacted tooth

Operative complications

Postoperative complications

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 17: Impacted teeth | by Dr.Basma Elbeshlawy

According to Archer (1975) 1Mesioangular2 distoangular 3 vertical 4 horizontal5 buccoangular6 linguoangular7 inverted

According to the relationship of tooth to maxillary sinus a-Sinus approximation (sa) where no bone or very thin bone exist between the impacted teeth and floor of sinus b-No sinus approximation (nsa) where 2 mm or more of bone exist between the floor of sinus and impacted teeth

bull Class1 Palatally impacted cuspids these could be in vertical horizontal

semivertical positionbull Class2 Labialy impacted cuspide which could be in vertical horizontal

semiverticalbull Class3 Impacted cuspid located both in the palatal and labial surfacesbull Class4 Impacted cuspid in the alveolar process bull Class5 Impacted cuspid that are present in an edentulous maxilla

3-Classification of impacted maxillary cuspids

frequency of impaction1 mandibular 3rd molar2 maxillary 3rd molar3 maxillary cuspid4 mandibular cuspid5 Mandibular premolar6 maxillary premolars7 maxillary central and lateral incisors( wisdom teeth are very common to be impacted as they

are the last molar to emerge They are normally emerge between 17 -21 years of age )

COMPLICATIONS Complications of impacted tooth

Operative complications

Postoperative complications

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 18: Impacted teeth | by Dr.Basma Elbeshlawy

bull Class1 Palatally impacted cuspids these could be in vertical horizontal

semivertical positionbull Class2 Labialy impacted cuspide which could be in vertical horizontal

semiverticalbull Class3 Impacted cuspid located both in the palatal and labial surfacesbull Class4 Impacted cuspid in the alveolar process bull Class5 Impacted cuspid that are present in an edentulous maxilla

3-Classification of impacted maxillary cuspids

frequency of impaction1 mandibular 3rd molar2 maxillary 3rd molar3 maxillary cuspid4 mandibular cuspid5 Mandibular premolar6 maxillary premolars7 maxillary central and lateral incisors( wisdom teeth are very common to be impacted as they

are the last molar to emerge They are normally emerge between 17 -21 years of age )

COMPLICATIONS Complications of impacted tooth

Operative complications

Postoperative complications

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 19: Impacted teeth | by Dr.Basma Elbeshlawy

frequency of impaction1 mandibular 3rd molar2 maxillary 3rd molar3 maxillary cuspid4 mandibular cuspid5 Mandibular premolar6 maxillary premolars7 maxillary central and lateral incisors( wisdom teeth are very common to be impacted as they

are the last molar to emerge They are normally emerge between 17 -21 years of age )

COMPLICATIONS Complications of impacted tooth

Operative complications

Postoperative complications

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 20: Impacted teeth | by Dr.Basma Elbeshlawy

COMPLICATIONS Complications of impacted tooth

Operative complications

Postoperative complications

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 21: Impacted teeth | by Dr.Basma Elbeshlawy

Complication of impacted teeth

(indication for removal) the presence of impacted teeth in the jaw can create a variety of problems so it should be removed as soon as diagnosis is made

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 22: Impacted teeth | by Dr.Basma Elbeshlawy

Pain Pain may originate frombull caries bull Periodontal diseasebull Pericoronitisbull Root resorptionbull Pressure on nerve

(neuroalagic pain)

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 23: Impacted teeth | by Dr.Basma Elbeshlawy

bull When third molar is impacted or partially impacted the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar as well as to third molar

Dental Caries

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 24: Impacted teeth | by Dr.Basma Elbeshlawy

bull Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease

bull As it decrease amount of bone on the distal aspect of adjacent 2nd molar with deep periodontal pocket on the distal aspect of the 2nd molar

Periodontal Disease

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 25: Impacted teeth | by Dr.Basma Elbeshlawy

Pericoronitisbull when a tooth is partially

impacted with a large amount of soft tissue over the axial and occlusal surfaces the patient frequently has one or more episodes of pericoronitis

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 26: Impacted teeth | by Dr.Basma Elbeshlawy

Definition

bull Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 27: Impacted teeth | by Dr.Basma Elbeshlawy

Causes

Decrease in host defenseMinor trauma from maxillary 3rd molar ldquoThe soft tissue that covers the occlusal surface of the

partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molarrdquo

Entrapment of food under operculum this pocket can not be cleaned bacteria invade it and pericoronitis begins

Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 28: Impacted teeth | by Dr.Basma Elbeshlawy

bull pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient A In its mildest form- - Percronitis is present as a localized swelling and

soreness - Mild irrigation and curettage by dentist and home

irrigation by pt is sufficientB In sever infection with local tissue swelling that is traumatized by maxillary 3rd molar the dentist should consider the maxillary 3rd molar

and local irrigation

Treatment and Management

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 29: Impacted teeth | by Dr.Basma Elbeshlawy

bull For the patient who have in addition to local swelling and pain mild facial swelling mild trismus secondary to inflammation extending into muscle of mastication and a low grade fever the dentist should consider administration of antibiotics along with irrigation and extraction (penicillin is the antibiotic of choice)

bull The mandibular third molar shouldnt be removed until sign and symptoms of pericronitis have been completely resolved

bull The incidence of post operative complication as dry socket and post operative infection increases if tooth is removed during time of active infection

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 30: Impacted teeth | by Dr.Basma Elbeshlawy

bull Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption

Root Resorption

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 31: Impacted teeth | by Dr.Basma Elbeshlawy

Orthodontic problems

crowding of mandibular anterior teethMalocclusion (maxillary canine)

Prosthetic problemsDentulous patient under bridgeEdentulous patient under dentureMucosal ulceration so itrsquos very important to have preprosthetic radiograph

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 32: Impacted teeth | by Dr.Basma Elbeshlawy

Odontogenic cyst and Tumors

bull The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst

bull Ameloblastoma may developed from epithelium within the dental follicle

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 33: Impacted teeth | by Dr.Basma Elbeshlawy

Fracture of the jaw

Impacted third molar occupies space that is usually filled with bone this weaken the mandible and render the mandible to fracture

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 34: Impacted teeth | by Dr.Basma Elbeshlawy

Prophylactic removal of impacted tooth

bull If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation

bull Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence

They have no useful role in the mouth They may increase risk of pathological changes and symptoms If they are removed only when pathological changes occur patient may be

older and the risk of serious complications after surgery may be greater

bull But prophylactic removal should only be carried out if there is good evidence of patient benefit

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 35: Impacted teeth | by Dr.Basma Elbeshlawy

Contraindication for removal of impacted

teeth

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 36: Impacted teeth | by Dr.Basma Elbeshlawy

1 Extreme of age- As the bone become highly calcified less flexible

less likely to bend under force of tooth extraction the result bone more surgically removed to displace tooth from its socket and less post operative sequels

2 Compromised medical statuseg cardiovascular patient

3 Probable excessive damage to adjacent structure

eg teeth nerves or previously constructed bridges

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 37: Impacted teeth | by Dr.Basma Elbeshlawy

Diagnosis

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 38: Impacted teeth | by Dr.Basma Elbeshlawy

History Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva)2- Unpleasant taste when biting down on or near the area3- A visible gap where a tooth did not emerge4- Bad breath5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally)8- Difficulty opening the mouth (occasionally)9- Headache or jaw ache Physical exam Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially 2-The impacted tooth may be pressing on adjacent teeth 3-The gums around the area may show signs of infection (such as redness drainage and tenderness) 4-As gums swell over impacted wisdom teeth and then drain and tighten it may seem to the individual that the tooth came in and then went back out again

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 39: Impacted teeth | by Dr.Basma Elbeshlawy

Radiological assessment of impacted teeth should cover

ndash Type orientation of impaction amp the access to the toothndash Crown size amp conditionndash Root number amp morphologyndash Alveolar bone level including depth amp densityndash Follicular widthndash Periodontal status adjacent toothndash Relationship or proximity of upper tooth to the nasal cavity or

maxillary antrumndash Relationship or proximity of lower tooth to the inter dental

canal mental foramen amp lower border of the mandible

RadiographyDental x-rays confirm the presence of a tooth (or teeth) that has not emerged

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 40: Impacted teeth | by Dr.Basma Elbeshlawy

Standard radiographic techs used to localize the unerupted teeth these include

Periapical films The tube shift method Occlusal films Panoramic view CT

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 41: Impacted teeth | by Dr.Basma Elbeshlawy

The tube shift method

bull Uses two periapical radiographs shifting the tube horizontally between exposures

bull If the unerupted teeth moves in the same direction in which the tube is shifted its located on the lingual or palatal side

bull A facial or buccally located tooth moves in the opposite direction to the tube shift

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 42: Impacted teeth | by Dr.Basma Elbeshlawy

The periapical ampocclusal method

bull Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth

bull Panoramic film can be used to assess maxillary canine position

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 43: Impacted teeth | by Dr.Basma Elbeshlawy

45

More accurate 3-D views of impacted teeth Provides more accurate 3-D views of

impacted molars impacted cuspids and other supernumerary anomalies

Visualize impaction within the alveolar bone location relative to adjacent teeth and proximity to vital structures

More accurate information can result in less invasive surgerydecreased surgical time

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 44: Impacted teeth | by Dr.Basma Elbeshlawy

Surgical removal of impacted teeth

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 45: Impacted teeth | by Dr.Basma Elbeshlawy

Factors that Make Impaction Surgery Less Difficultbull Mesioangular positionbull Class 1 ramusbull Class A depthbull Roots one third to two third formedbull Fused conic rootsbull Wide periodontal ligamentsbull Large folliclebull Elastic bone bull Separated from 2nd molarbull Separated from inferior alveolar nervebull Soft tissue impaction

Factors that Make Impaction Surgery More Difficultbull Destoangular positionbull Class 3 ramusbull Class C depthbull Long thin rootsbull Divergent curved rootsbull Narrow periodontal ligamentsbull Thin folliclebull Dense inelastic bonebull Contact with 2nd molarbull Close to inferior alveolar nervebull Complete bony impaction

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 46: Impacted teeth | by Dr.Basma Elbeshlawy

1- Proper radiographic and clinical evaluation of the condition

2- Classification of impaction to help in planning the surgical procedure

3- Selection of the time for surgical procedure

If the impacted tooth is to be removed the most suitabletime to do so is when the patient is young that for these reasons-Avoid the aforementioned complications and undesirable situations that could get worse with time Younger patients generally deal with the overall surgical procedure and stress well Present fewer complications Faster postsurgical wound healing compared to older patient Easier bone removal

Preparation for the surgery

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 47: Impacted teeth | by Dr.Basma Elbeshlawy

4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position

5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on

a- general condition of the patient and his ability psychologically and physically take the procedure in very apprehensive patient general anesthesia is preferred

b- position of impaction and extent of surgical procedurec- patient co-operationd- number of impaction that will be removed

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 48: Impacted teeth | by Dr.Basma Elbeshlawy

The surgical procedure is divided into following stages

1 Incision and reflection of the mucoperiosteal flap2 Removal of bone to expose the impacted tooth3 Tooth delivary4 Care of the postsurgical socket and suturing of the woundThe main factors for a successful outcome to the surgical procedure are as follows1048655 Correct flap design which must be based on theclinical and radiographic examination (position oftooth relationship of roots to anatomic structuresroot morphology)1048655 Ensuring the pathway for removal of the impactedtooth with as little bone removal as possible This isachieved when the tooth is sectioned and removedin segments which causes the least trauma possible

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 49: Impacted teeth | by Dr.Basma Elbeshlawy

A- Elevation of an adequate mucoperosteal flap to expose the field of surgery Pyramidal flap used in all third molar

impaction the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold

In deep impaction a bigger flap is advisable the anterior incision could start from the mesial aspect of 2nd molar

1- gaining access to impacted tooth

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 50: Impacted teeth | by Dr.Basma Elbeshlawy

Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap

Incision for the creation of a triangular flap which is indicated in certain cases of extraction of impacted mandibular 3rd molar

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 51: Impacted teeth | by Dr.Basma Elbeshlawy

When impaction is deep (vertical releasing incision is distal to the first molar)

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 52: Impacted teeth | by Dr.Basma Elbeshlawy

B-Horizontal flap These types of flaps used in case of impaction is relatively superficial

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 53: Impacted teeth | by Dr.Basma Elbeshlawy

Incision and reflection of the flap for impacted maxillary 3rd molar

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 54: Impacted teeth | by Dr.Basma Elbeshlawy

Incision and reflection of the flap for impacted maxillary canine

Palatal approachLabial approach

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 55: Impacted teeth | by Dr.Basma Elbeshlawy

2-Bone removal

This is done for - A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 56: Impacted teeth | by Dr.Basma Elbeshlawy

3- Tooth delivery1- Total delivery by application of force using elevators

a- Mesial application of force straight elevators and pots elevators b- Buccal application of force winter elevator

2- Delivery of the tooth after tooth division Division is indicated to reduce resistance create a space or remove interlocked cusps of the tooth

a- Decapitation- Division of the crown of the tooth at cervical margin level - indicated in horizontal mandibular and maxillary third molar impaction and

pallataly impacted maxillary cuspid b- Longitudinal tooth division - indicated when the impacted tooth has a widely divergent straight roots

or when one root is straight and the other is curvedc- Division of the interlocking cusp - this is done with mesioangular impaction removal of the inter locking

segment of the tooth usually located under the distal surface of 2nd molar

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 57: Impacted teeth | by Dr.Basma Elbeshlawy

Extraction of Impacted 3rd Molar in Horizontal Position

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 58: Impacted teeth | by Dr.Basma Elbeshlawy

Extraction of Impacted 3rd Molar in mesioangular position

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 59: Impacted teeth | by Dr.Basma Elbeshlawy

Extraction of Impacted 3rd Molar in distoangular position

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 60: Impacted teeth | by Dr.Basma Elbeshlawy

Extraction of Impacted maxillary 3rd Molar

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 61: Impacted teeth | by Dr.Basma Elbeshlawy

Extraction of Impacted maxillary canine

Labial approach

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 62: Impacted teeth | by Dr.Basma Elbeshlawy

Extraction of Impacted maxillary canine

Palatal approach

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 63: Impacted teeth | by Dr.Basma Elbeshlawy

4-Preparation for wound closure

- After removal of the tooth from its socket the wound is gently irrigated with sterile normal saline solution and inspected fora- any remnant of the residual tooth sac is removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is

trimmed and smoothed - Then final irrigation and wound now is ready for

closure

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 64: Impacted teeth | by Dr.Basma Elbeshlawy

5-closure of the woundbull Well designed and properly reflected flap fall back easily

into place using half circle a traumatic needle and 000 black silk suture to hold flap into place

post operative care1 A pressure pack is held in place for 1hour2 Proper antibiotic therapy3 Patient return back for check up after two days 4 Suture removal after 5 days

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 65: Impacted teeth | by Dr.Basma Elbeshlawy

POST OPERATIVE INSTRUCTIONS

ON THE DAY OF TREATMENTDo not rinse your mouth for at least 24 hoursAvoid hot fluids alcohol hard or chewy foods Choose cool drinks and soft foodsAvoid vigorous exerciseSmokers should avoid smoking If the wound start to bleed apply a small compressThis can be made by placing cotton wool on the bleeding point and bite firmly on it bull If you cannot stop the bleeding yourself please seek professional adviceAny pain or soreness can be relieved by taking the prescribed medication such as paracetamol (Panadol) 2 tablets every 4 hours as required Do not take more than the recommended number per daySTARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days This should be carried out three times a day after each meal

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 66: Impacted teeth | by Dr.Basma Elbeshlawy

Complications associated with surgical removal of impacted

tooth

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 67: Impacted teeth | by Dr.Basma Elbeshlawy

1- laceration of the soft tissue flapa-improper incisionb-improper elevation of the flap and improper retraction this

leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw

- in angle of mandible improper use of elevator with uncontrolled force

4- Fracture of tuberosity - due to improper use of force

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 68: Impacted teeth | by Dr.Basma Elbeshlawy

5-Comlications related to injury of adjacent structurea-Injury to inferior alveolar canal

- occurs in deeply seated vertical impaction the nerve pass between roots of impacted tooth permanent numbness and heamorraghe

b-Damage to nasal floor - during surgical removal of impacted maxillary cuspid profuse bleeding from

nasal mucosa c- Involvement of maxillary sinus - during removal of impacted maxillary third molar oro anntral fistula

resultsd- Pushing of impacted tooth into maxillary sinuse- Pushing of impacted maxillary molar into ptrygopalatine

fossa- uncontrolled mesial application of force in deep impaction

f- Pushing impacted mandibular third molar into sub -mandibular space

- uncontrolled buccal application of force and fracture of the lingual plateg-Aspiration or swallowing of impacted tooth

- with general anesthesia

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 69: Impacted teeth | by Dr.Basma Elbeshlawy

post operative complications1 pain2 infection3 hemorrhage4 Nerve injury (lingual or inferior alveolar nerve)5 Trismus limitation of jaw movement6 osteomylitis7 pain at TMJ8 pain on swallowing due to edema of pharynx and

hematoma formation

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 70: Impacted teeth | by Dr.Basma Elbeshlawy

references Peterson΄s principles of oral and Maxillofacial surgery Master Dentistry Pub Med central Journal Fragiskos D fragiskos (ed) Net pages wwwDentalcarecom wwwadaorg wwwdentistrycom

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77
Page 71: Impacted teeth | by Dr.Basma Elbeshlawy

Thank you

  • Mansoura University Faculty of Dentistry Oral Surger
  • Slide 2
  • Items
  • Definition -
  • Causes of impaction
  • Systemic Causes
  • Local Factors
  • Classification system of impacted teeth
  • Slide 9
  • Class1
  • Class2
  • Class3
  • Slide 13
  • Slide 14
  • Slide 15
  • Slide 16
  • Slide 17
  • Slide 18
  • Slide 19
  • frequency of impaction
  • COMPLICATIONS
  • Complication of impacted teeth (indication for removal)
  • Pain
  • Slide 24
  • Periodontal Disease
  • Pericoronitis
  • Definition
  • Causes
  • Slide 29
  • Slide 30
  • Root Resorption
  • Orthodontic problems
  • Odontogenic cyst and Tumors
  • Fracture of the jaw
  • Prophylactic removal of impacted tooth
  • Contraindication for removal of impacted teeth
  • Slide 37
  • Diagnosis
  • History Symptomatic individuals with an impacted tooth may re
  • Slide 40
  • Slide 41
  • The tube shift method
  • The periapical ampocclusal method
  • Slide 44
  • Slide 45
  • Slide 46
  • Surgical removal of impacted teeth
  • Slide 48
  • Slide 49
  • Slide 50
  • Slide 51
  • 1- gaining access to impacted tooth
  • Slide 53
  • Slide 54
  • Slide 55
  • Slide 56
  • Slide 57
  • 2-Bone removal
  • 3- Tooth delivery
  • Slide 60
  • Slide 61
  • Slide 62
  • Slide 63
  • Slide 64
  • Slide 65
  • Slide 66
  • Slide 67
  • Slide 68
  • 4-Preparation for wound closure
  • 5-closure of the wound
  • Slide 71
  • Complications associated with surgical removal of impacted toot
  • Slide 73
  • Slide 74
  • post operative complications
  • references
  • Slide 77