Prepared by : Group B

Supervised by: Dr.nehad hashla

Assocait.Prof. Dr. Said Gaira Ph.D.

Impacted 3rd molar

DefinitionImpacted wisdom teeth are third molars at the back of the mouth that don't have enough room to emerge or grow normally. Wisdom teeth usually emerge between the ages of 17 and 25. An impacted wisdom tooth may partially emerge so that some of the crown is visible (partially impacted), or it may never break through the gums (fully impacted).

CausesWisdom teeth (third molars) become impacted because they are the last adult teeth to come into the mouth and then they don't have enough room to come in (erupt) or grow normally.

Orientation (direction of impaction): • Whether partially or fully impacted, the tooth may: • Grow at an angle toward the next tooth (second

molar)• Grow at an angle toward the back of the mouth• Grow at a right angle to the other teeth, as if the

wisdom tooth is "lying down" within the jawbone• Grow straight up or down like other teeth but stay

trapped within the jawbone

Tests and diagnosis : :

about dental symptoms and

Indications for extraction :• Symptoms of third molar• Clinical or radiological signs of disease• Other dental or general disease• Life situation, work or hobby

Contraindicationfor extraction :• Unerupted and symptomless third molar totally covered with bone• When an extraction would pose an unreasonable local or general

risk to health• Previous radiation therapy on the jaw area

Risks of Non-Intervention1) lack of space for normal M3 eruption: Most studies agree that it is impossible to predict if there will be a lack of space for normal M3 eruption, Recent attempts to predict the positioning of an M3 have been contradictory, and prophylactic extraction on those grounds is not warranted.

2) damage the root of adjacent teeth: Horizontally and mesio-angular impacted M3 may damage the root of adjacent teeth in a small number of cases. Most studies agree that M2 root resorption occurs in less than 2% of such cases. In some studies involving young adults, less than 1% had M3 periodontitis, while another study found more frequent periodontitis in all late erupting M3s.

3) Pericoronitis: is most often seen in a vertically positioned mandibular M3 partially covered with soft tissue or bone ,It is one of the most common reasons for M3 extraction.

4) The development of cysts and tumors as a result of an impacted M3 (rare). Tumors are found in less than 1% of cases.

Risks of InterventionMinor complications : 1-Alveolitis, or dry socket: is the most common complication, and is more commonly seen in patients older than 25 years and in women. It is also seen more often in patients who had their teeth removed therapeutically as opposed to prophylactically. Alveolitis will occur in 1-5% of patients regardless of the skill of the operator or surgical protocol.

2-labial paresthesia.

3-infection, trismus, hemorrhage, fractures, periodontal injury and adjacent tooth injury.

Major complications: 1-dysesthesia: Although most nerve injuries heal after a period of temporary dysfunction, permanent injuries to the cranial nerves do occur; deficiency beyond six months is likely to be permanent. These injuries are often, although not exclusively associated with deep impaction.

2-bacteremia: Although the bacteremia often seen after M3 removal is usually minor, infection can occasionally lead to endocarditis, and brain, liver or heart abscesses.

Benefits of Non-Intervention• Non-intervention allows the patient the full potential

for growth and development of the teeth and jaws, while full eruption and functional position allows the maximum occlusal table.

• An M3 can also be used for transplant in the case of premature tooth loss elsewhere in the arch.

• -Non-intervention also avoids exposing the patient to the risks of surgery.

Benefits of Intervention• germectomy: A preventive approach to extraction

involves germectomy in late childhood.• lateral trephination and removal during

adolescence.• curative approach :involves exposure of the crown

if the tooth has good positioning. • ablation: when there is a lack of space for eruption.

NOTES• The younger a patient is at the time of extraction, the

less morbidity is observed. • there are a number of useful therapeutic measures

that can be taken to ease the complications associated with extraction. These include antibiotics for infection, tetracycline and lavage for dry socket, dexamethasone during extraction for swelling and trismus, and NSAIDs post-operatively for pain and swelling.

classifications of lower impacted tooth :

classification of the upper impacted tooth : • angulation and depth classification is same as mandibular

third molar .• classification of maxillary third molar in relation to the floor

of maxillary sinuss . a-sinus approximation ( SA )• no bone or a thin bony partition present between impacted

third molar and the floor of maxillary sinus. b- sinus approximation ( NSA ) 2mm or more bone is present between the sinus floor and impacted maxillary third molar.

Complecations of surgical intervention ( upper & lower ) : • The prevalence of postoperative complications after the

surgical extraction of a third molar in Finnish 20- to 30-year-olds is 9.1%. The most common complications are alveolitis, postoperative infection, bleeding, and numbness of the tongue or lower lip. Postoperative complications are even more prevalent in elderly patients.

Case report :A 30 year old female reported with a chief complaint of pain in the upper part of face of left side since one weak. Family and personal histories were unremarkable. There were no abnormalities in general growth

Discussion: On detailed literature search only six case reports of inverted teeth were found. Among these only two had impacted maxillary third molars (Gold & Demby, 1973, Held, 1979). In all case reports the management of impacted molars was done conservatively. Tooth impactions can occur because of various reasons, such as:

• mechanical obstruction in the path of eruption• malpositioning of the tooth germ • primary failure of eruption of wellformed

tooth may have strong genetic component or it could be an acquired condition,

• circumference of the tooth (crown) is towards the sinus and the infratemporal fossa

• Kapur et al, 2008). Access to inverted maxillary molars can be a problem, since the largest

Case report:Patient 31 years old ,male Chief complain : dull pain in the area of lower left molar ,although it could not be observe intraorally , the crown could be touch with the probe through the gingival pocket distal to mandibular second molar.

In panoramic x-ray : a horizontally impacted mandibular left molar was identified . configuration and number of roots : single root with no abnormality . Slight radiolucency noticed under the crown.prediction to extraction : flap reflection is necessary , bone removal will be in considerableTooth sectioning : section the crown at the cervical region

Operation : anaesthesia (mandibular block) • Incision made distal to 7 . a transverse incision

made forward and downward into the mesiobuccal region of 7 usin scalpel . the distal incision made on a line between the external and internal oblique lines or slightely buccal and the bone palpated.

• Periosteal elevator was pushed against the surface of the bone and the mucoperiosteum was reflected. Then the buccal and distal bone covering the crown was removed. The cervical region of the third molar was sectioned buccolingually using turbine .

• The separated crown could be extracted easily by inserting the elevator under it . the root can be luxated by inserting the elevator into the formed space. After extraction granulation tissue curette and irrigate with normal saline.

• Reposition of mucoperiosteal flap ,sutures were placed first in transverse then in distal incision.

Case report :

• Partially-erupted mesio-angular • lower third molar : • PMcD, a 17-year-old student, had an episode of pericoronitis

related to his lower left third molar, which was treated successfully with penicillin and with warm saline mouthwashes.

• The treatment plan involved extraction of this tooth, and prophylactic removal of the other third molars. He agreed to have the teeth removed, one side at a time, under local anaesthesia.

• The symptomatic side, the left, was treated first, but the operation on the right side is illustrated.

Radiographic assessment :

Operation site : • The partially-erupted third molar is

surrounded by a gingival cuff of variable thickness, free of inflammation. The mesial part of the crown is directly in contact with the distal surface of the second molar crown.

Incision:

Reflection: Bone removal ::

Elevation and delivery :

Socket:The socket is free of debris, and the flap lies in position.

Closure:

Two sutures are used. The first advances the mesial corner across the socket, and the second closes the distal incision.

Follow-up: A week later the wound has closed, though the tissue margins are still oedematous. Frequent warm saline mouthbaths are advised and, if necessary, a disposable syringe may be given to the patient to be used for irrigation

Case reportRemoval of unerupted upper third molar : AH, a 19-year-old dental surgery assistant, had suffered an episode of pericoronitis related to the lower right third molar, and had in the past undergone orthodontic treatment to align the upper canines following surgical exposure. The third molars were all completely unerupted and their removal was indicated. Despite having one congenitally-absent kidney, she was in good health and agreed to have the teeth removed, one side at a time, under local anaesthesia

  Radiographic assessment:

Operation:

Operation site: The second molar has an intact distal surface and there is no sign of eruption of the third molar.•

Incision : Reflection :

Bone removal :

Elevation and delivery :

Closure :

Follow-up: The wound healed perfectly .

Thank you