Impaction 27.8.6
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Transcript of Impaction 27.8.6
IMPACTION
Dr.V.RAMKUMAR
CONSULTANT DENTALFACIOMAXILLARYSURGEON
REG NO: 4118 TAMILNADU- INDIA(ASIA)
DEFINITIONImpacted tooth is one that fails to erupt and will not eventually assume its anatomical arch relationship, beyond the chronological eruption date
ETIOLOGY
* NATURE - LACK OF SPACE IN JAWS
* NURTURE - CHANGE IN DIET
LACK OF SPACE
ETIOLOGY
Theories..
Phylogenetic
Mendelian
DILACERATION
ETIOLOGY
ETIOLOGY
retained deciduous teeth
OBSTRUCTIONS
Odontome
ETIOLOGY
Cyst / Odontogenic tumour
ETIOLOGY
Thick scar band
Dense bone
Systemic causes – Hormonal imbalance
ETIOLOGY
INDICATIONS
Recurrent pericoronitis
Presence of a pathological lesion
INDICATIONS
Caries Periodontal disease Obscure facial pain Previous attempted extraction Prosthetic considerations Social and economic factors
INDICATIONS
CONTRA INDICATIONS
Health considerations Prosthetic considerations Availability of adequate
space socio economic reasons
Mandibular 3rd Molar Impaction
CLASSIFICATION
Based on the long axis of the impacted tooth in relation to the long axis of the second molar
WINTER’S CLASSIFICATION
Angulation Depth
Mesioangular
WINTER’S CLASSIFICATIONAngulation
Distoangular
WINTER’S CLASSIFICATIONAngulation
Horizontal
WINTER’S CLASSIFICATIONAngulation
Vertical
WINTER’S CLASSIFICATIONAngulation
Buccoversion
WINTER’S CLASSIFICATIONAngulation
Linguoversion
Angulation WINTER’S CLASSIFICATION
Inverted
Angulation WINTER’S CLASSIFICATION
Angulation
Unusual / Ectopic
WINTER’S CLASSIFICATION
ASSESSMENTCLINICAL
RADIOLOGICAL
CLINICAL ASSESSMENT
AGE
EXTERNAL OBLIQUE RIDGE
BUCCAL PAD OF FAT
POSITION OF TONGUE
STATUS OF ADJACENT TOOTH
LENGTH OF BOTH ANGLES OF MOUTH
PRESENCE OF ANY ACUTE INFECTION
PRESENCE OF ANY PATHOLOGY
PRESENCE OF ASSOCIATED JAW #
FACIAL FORM
RADIOLOGICAL ASSESSMENT
W A R Lines
W A R Lines
W A R Lines
W A R LinesW A R Lines
W A R Lines
WHITE Line
Amber Line
RED Line
Sl. NO Category Score
1. Winter’s Classification Horizontal Distoangular Mesioangular Vertical
2210
2. Height of the mandible 1-30 mm31-41 mm35-39 mm
012
3. Angulation of III molar 1° - 50°60°-69°70-79°80°-89°90°+
01234
4. Root shape Complex Favourable curvature Unfavourble curvature
123
5. Follicles Normal Possibly enlarged Enlarged
012
6. Path of Exit Space available Distal cusps covered Mesial cusps also covered Both covered
012 3
Total 33
SCORING DETAILS FOR WHARFE ASSESSMENT
Maxillary 3rd Molar Impaction
Classification
Archer’s.. Class A
Class B
Class C
Canine Impaction
Classification
Ackerman (1935):
Maxillary canines
Palatal position Labial position
Class I Class II
Class III
involve both buccal and palatal bone
Class IV
in the alveolar process between the incisors & 1st premolar
Class V
in the edentulous maxilla
SURGICAL TECHNIQUE IN IMPACTED TOOTH REMOVAL
FLAPS : L - SHAPE, ENYELOPE, BAYONET
BONE : BUR VS CHISELREMOVAL
TOOTH : TOOTH VS BONE (KELSY FRY RETRIEVAL SPLIT & DAVIS)
WOUND : CONVENTIONAL VS TISSUE ADHESIVES
Incision
Flap Design
BONE SPLIT TECHNIQUE
SIR WILLIAM KELSY FRY ?
VS
W.H.DAVIS ?
ADVANTAGES OF DAVIS
- DECREASED INCIDENCE OF INFECTION IN II MOLAR AREA - OBVIATES LINGUAL BONE REMOVAL
- ↓ LINGUAL NERVE COMPLICATION
DISADVANTAGES OF KELSY FRY
-↑ LINGUAL NERVE COMPLICATION - BLEEDING - ELEVATION OF LINGUAL
SOFT TISSUE
POSTOPERATIVE CARE
i) Rest is necessary for the prompt healing of wounds.
ii) Cold applications to the face prevent disfiguring swelling and postoperative edema.
iii) They should be instructed to drink plenty of fluids in the form of milk, juices, Tea, Water etc.,
iv) Proper oral care must not be neglected
v) Should rinse 4 to 6 times daily. Best mouth rinse is a warm saline water.
vi) In take of alcohol and use of smoking should be discontinued for five days.
vii) Antibiotics and analgesic drug should be started.
During bone removal
jaw #
During elevationjaw #
Swelling
Post operative
Subcutaneous emphysema
Post operative
Complications of surgical removal of impacted tooth
During LA Intra operative Post operative
During LA Pain Snycope LA toxicity Role of adrenalin in systemically
compromised pts
Management: Slow injection Aspiration before injecting Proper case history to rule out systemic
illness Proper DOCTOR-PATIENT rapport..
Intra operative complicationsIncision Flap elevation Bone
removal
Tooth sectioning Elevation of tooth
During incision Local inflammation immediately prior to
surgery hemorrhage
Subside the inflammation prior to surgery by anti inflammatory drugs
Placement of incision:Buccal:
downward & forward placement of incision towards the vestibule
damage to the facial artery or anterior facial vein
Management:Temporary Permanent
extra oral finger pressure ligation
Direct the cut upwards towards the tooth
Distal:incision directly in line with the
anterior border of ramus Damage the retromolar vessels
Lingual extension Damage lingual nerve
Direct the incision more bucally
During bone removal
Damage to the distal aspect of 2nd molar
sensitivity
Improper cooling of the bur
Local bone death
Sequestration
slip & embed into the soft tissue
Damage mucosa & lingual nerve
Bur
Mandibular canal openingemorrhage
Hemorrhage Anestheisa
Careful drillingAdequate retractionLingual nerve protection
Advantage:1. Safe 2. Rapid3. Efficient method
Disadvantage:1. Damage adjacent
structures2. Fracture of the jaw3. Splitting of the
lingual plate
Chisel
Firm controlAnterior vertical limit cutOptimum force of malleting
During tooth sectioning
Incorrect line of sectioning
Difficult removal of the tooth
Damage to mandibular canal
HemorrhagePost op numbness of
the lower lip on the side of surgery
Bur
Section across the cervical portion at right angle to the long axis of the tooth
Difficult to achieve correct line of cleavge
More accurate sectioning
Chisel Osteotome
Inadequate control
•Damage to soft tissues•Lingual nerve•2nd molar
Excessive malleting force
•Dislodgement of tooth into the lingual pouch•Fracture of the tooth in unwanted angulation
Retrieval of the dislodged tooth
Tooth
Lingual pouch
Finger pressure
Manipulation upwards
Retrieval with forceps
During elevation of the tooth Fracture of the tooth Displacement of the tooth into lingual pouch
or lateral pharyngeal space or tonsillar area (retrieval – finger manipulation or surgical exploration)
Sublux]ation to 2nd molar or complete dislodgement out of its socket
Damage to the disto-occlusion restoration Fracture of the jaw (due to excessive force)
Root apices penetrating mandibular canal – hemorrhage & numbness
Prevention of dislodgement into the lingual pouch or lateral pharyngeal space
Relieve the tooth from the overlying gingival pad
Finger over the 3rd molar during elevation
Post operative complicationsImmediate 1. pain2. Hemorrhage 3. Swelling4. Anesthesia5. Trismus6. Pain on swallowing & sore throat pyrexia
Late 1. Infection 2. Hemorrhage 3. Pain in TMJ4. Trismus
Immediate post op complications
1. Pain: cause:
dry sockethematomatrauma to the adjacent tooth
Pain thershold – varies for each individualJudicious manipulation of the tissues
2. Hemorrhage:
Injection
Incision
Infection
Hemorrhage
Reactionary Hemorrhage Occuring during the first 24 hours following surgery
Cause:1. failure to achieve complete
hemostasis during surgery2. wearing of adrenalin action
Management:
source of bleeding is identified
Ligation Pressure pack
3. Swelling:
Cause: Bleeding under a tight suture
lack of escape of hemorrhage through the sutural line
Seepage into the soft tissues
1. Tongue base 2. Pharyngeal tissue planes
Impairment of airway
Swelling
Edema
Not painful
Hematoma
Tense & Tender