Ppt on Impaction
Transcript of Ppt on Impaction
-
8/11/2019 Ppt on Impaction
1/44
Impaction
resented by
Binod adhikary
Bds 2004
Rolll no 214
-
8/11/2019 Ppt on Impaction
2/44
Contents:
1. Introduction2. Etiology
3. Classifications
4. Indications for removal5. clinical and radiographic assessment
6. Management
7. Complications
-
8/11/2019 Ppt on Impaction
3/44
Defini t ion :-
The word impaction comes from the Latin wordimpactus
Impacted tooth is the tooth that fails to erupt to its
normal position due to obstruction by a physical barrier
(adjacent tooth, bone or soft tissue overlying it) ORectopic positioning of the tooth itself .
A tooth should be termed as impacted only if the root
formation is complete & yet it has not erupted fully up
to the final position.
Also known as the embedded tooth
Its the one that is erupted, partially erupted or unerupted & will not eventually assume a normal archrelationship with the other teeth & the tissues.
-
8/11/2019 Ppt on Impaction
4/44
Order of frequency:
1. Mandibular 3rd
molars2. Maxillary 3rdmolars
3. Maxillary canine
4. Mandibular premolars5. Maxillary premolars
6. Mandibular canine
7. Maxillary central incisors
8. Mandibular lateral incisors
-
8/11/2019 Ppt on Impaction
5/44
Etiology: Multifactorial etiology (local & systemic)
Two theories impaction are:1. Phylogenetic theory
2. Mendalian theory
o Local causes:
1. Obstruction for eruption2. irregularity in position & presence of adjacent tooth
3. density of the overlying bone
4. Lack of space in the archcrowding, supernumeraryteeth
5. Ankylosis of primary or the permanent tooth6. Non resorbing or over retained deciduous tooth.
7. Non absorbing alveolar bone
8. Ectopic position of the tooth bud
9. Dilacerated roots10. Ton ue thrustin or thumb suckin habits
-
8/11/2019 Ppt on Impaction
6/44
o Systemic causes:
1. Prenatalhereditary
2. Postnatalrickets, anemia, TB, malaria,
congenital syphilis
3. Endocrine disorders: hypothyroidism,
achondroplasia4. Hereditary disorders : downs syndrome,
hurlers syndrome, cleidocranial
dysostosis, cleft lip and palate etc.
-
8/11/2019 Ppt on Impaction
7/44
Classification :
1. Classification of impacted mandibular third
molars
a)Based on angulationa) mesioangular
b) distoangular
c) vertical
d) horizontal
e) buccoangular
f) linguoangular
g) Inverted.
-
8/11/2019 Ppt on Impaction
8/44
B) Based on depth :
as per relation to the occlusal surface of the adjacent
2ndmolar
1. Position A: highest position of the tooth is on a level or
below the occlusal plane
2. Position B: highest position is below the occlusal plane ,but
above the cervical level of the 2ndmolar.
3. Position C: highest position of the tooth is below the
cervical level of the 2ndmolar.
-
8/11/2019 Ppt on Impaction
9/44
C) Pell & Gregorys classification:
based on the space available distal to the 2ndmolar
1. Class1: sufficient space is available between the anteriorborder of the ascending ramus & distal side of the 2ndmolar
for the eruption of 3rdmolar.
2. Class2: the space available between the anterior border of
ramus & the distal side of the 2ndmolar is less than the MDwidth of the crown of the 3rdmolar
3. Class 3: the third molar is totally embedded in the bone on
the ascending ramus, because of absolute lack of space .
-
8/11/2019 Ppt on Impaction
10/44
Classification of impacted maxillary 3rd
molar
1. Angulation and depth classification:
mesioangular, distoangular, vertical, horizontal,
buccoversion ,linguoversion inverted
..position A,B, C
-
8/11/2019 Ppt on Impaction
11/44
2) Classification in relation to the floor of
maxillary sinus :
a) Sinus approximation (SA):
no bone or a thin bony portion is present
between the impacted maxillary 3rdmolar and
floor of the maxillary sinusb) No sinus approximation (NSA):
2mm or more bone is present between the sinus floor
& the impacted maxillary 3rdmolar.
-
8/11/2019 Ppt on Impaction
12/44
Classification of impacted maxillary canine
Class1:
palatally placed horizontal, vertical,semivertical
Class2:
labially/bucally placed horizontal, vertical,semivertical
Class3:
involving both buccal and palatal bone eg
crown is placed in the palatal aspect & theroot is towards the buccal alveolar process.
-
8/11/2019 Ppt on Impaction
13/44
Class4:
vertically impacted canine between the roots of
lateral incisor and the 1st
premolar.Class5:
canine impacted in the edentulous maxilla
Class6:
maxillary canine in unusual position eg. nasoantral
wall or infraorbital margin
-
8/11/2019 Ppt on Impaction
14/44
When to remove impacted too th?
1. All impacted teeth should be removed as soon as the
diagnosis is made.2. Early removal reduces the postoperative morbidity &
allows for best healing
3. Younger patients tolerate the procedure better &
recover more quickly because of the more completeregeneration of the periodontal tissues.
4. Ideal time for the removal of impacted 3rdmolar is
when the roots of the teeth are 1/3rdformed and before
they are 2/3rd
formed, usually between the age of 17-20 years.
-
8/11/2019 Ppt on Impaction
15/44
Ind icat ions for the removal of impacted
teeth:
1. Prevention of periodontal disease
2. Prevention of dental caries
3. Prevention of pericoronitis
4. Prevention of root resorption
5. Impacted tooth under a denture or prosthesis
6. Prevention of odontogenic cyst and tumors
7. Treatment of pain of unknown origin
8. Facilitation of orthodontic treatment9. Optimal periodontal healing
10. If involved To prevent crowding of dentition
11. in a fracture
12. Preparation for orthognathic surgery.
-
8/11/2019 Ppt on Impaction
16/44
Clinical and radiograph ic assessment o f
impacted teeth
Purpose:
I. possible difficulties and
complications.
II. facilities availableIII. necessary surgical skills
IV. to decide whether to remove or not .
-
8/11/2019 Ppt on Impaction
17/44
CLINICAL EXAMINATION :
A conscious assessment of the general condition of the pt
including his attitude. Age of the patient
Size of the oral cavity , size of the tongue, the degree ofmouth opening & the extensibility of the lips and cheeks allcontribute to the surgical access.
Large crowns , inlays or amalgam restorations in the secondmolar can dislodge during elevation of the third molar
The amount of crown visible clinically.
If no part of 3rdmolar is visible clinically ,the gingival
crevice distal to the 2nd
molar should be probed for pockets . Note the condition of the soft tissue above the impacted
molar
Palpate the related lymph nodes to determine the extent ofany infection.
-
8/11/2019 Ppt on Impaction
18/44
RADIOGRAPHIC ASSESSMENT :
A) Intraoral radiographs possible if the tooth is in the
alveolus and not in the ramus
if the oral opening is adequate
if no gagging
useful to study the relation to the adjoining structure
like the IAN canal.
useful to study the status of the crown &
configuration of the roots
-
8/11/2019 Ppt on Impaction
19/44
The position and depth of the tooth canbe assessed using three imaginary
lines (winters lines), they are: White line:
corresponds to the occlusal plane
a line touching the occlusal plane of the 1st& 2ndmolar &
extended posteriorly over the third molar. indicates the difference in the occlusal level of the 2nd& 3rd
molars
Amber line:
represents the bone level a line is drawn from the crest of the interdental septum between the
molars & extend posteriorly distal to the 3rdmolar
it denotes the amount of alveolar bone covering the impacted tooth .
-
8/11/2019 Ppt on Impaction
20/44
Red line:
is drawn perpendicular to the amber line
indicates the amount of bone to be removed before
elevation.
if length>5mm .extraction is difficult
every additional mm renders the extraction 3 times
more difficult .
if >9the 3rd molar is below the apices of 2ndmolar
extraction under GA indicated.
-
8/11/2019 Ppt on Impaction
21/44
Very difficult: 7-10
Moderately difficult: 5-7
Minimal difficult: 3-4.
-
8/11/2019 Ppt on Impaction
22/44
Extraoral radiographs :1. OPG
2. lateral oblique for mandible
3. Waters (PA)view for maxilla.
-
8/11/2019 Ppt on Impaction
23/44
Radiographic prediction for the proximityof inferior alveolar nerve canal.
o Darkening of rooto Deflection of root
o Narrowing of root
o Interruption of the white line of the canalo Narrowing of canal
o Divergence of canal
-
8/11/2019 Ppt on Impaction
24/44
Management :1. Asepsis and isolation
2. Anesthesia3. Incision-flap design
4. Reflection of mucoperiosteal flap
5. Bone removal
6. Sectioning of tooth
7. Elevation, extraction
8. Debridement & smoothening the bone .
9. Control of bleeding10. Closuresuturing
11. Medications-antibiotics, analgesics etc..
12. Follow up
-
8/11/2019 Ppt on Impaction
25/44
-
8/11/2019 Ppt on Impaction
26/44
Isolation of surgical site:
Scrubbing +painting the skin & oral mucosa
with cetrimide+ povidone +iodine/absolutealcohol. OR cetrimide + abs alcohol
+CHX(providone iodine 5% for skin & 1% for
oral mucosa , CHX 0.2% for oral mucosa &7.5%
for skin.
Drape the patient with sterile drape to cover
upper part of face to isolate the oral cavity .
-
8/11/2019 Ppt on Impaction
27/44
Local anesthetic: IAN + lingual+long buccal nerve block for
mandibular molars PSA nerve block + greater palatine nerve block
for maxillary molars
Infraorbital +nasopalatine nerve block for
maxary canines. Local infiltration for homeostasis.
-
8/11/2019 Ppt on Impaction
28/44
Incision (mucoperiosteal flap design):
For adequate access
Incision for flap has an anterior limb , a posterior limb, connected with/out a intermediate limb .
Incision for mandibular 3rdmolar extends anteriorly to
midway of CEJ of 2ndmolar at an angle & posteriorly
to distal most point of the 3rd
molar.-incision shouldnt extend too far upward distally.
-
8/11/2019 Ppt on Impaction
29/44
Bone removal
Aimto expose the crown & to create a path for the
removal of the tooth .
Adequate amount of bone should be removed ,but can be
minimized by sectioning the tooth
2 ways of bone removal;
-high speed hand piece & bur technique-chisel and mallet technique.
-
8/11/2019 Ppt on Impaction
30/44
Lingual split bone technique:
Described by Sir William Kelsey fry
Quick and clean technique
Causes saucerization of the socket thereby reduces the
size of the residual blood clot.
Used for lingually impacted mandibular 3
rd
molars Incidence of transient lingual anesthesia post
operatively .
-
8/11/2019 Ppt on Impaction
31/44
Tooth sectioning : Reduces the amount of bone removal
Reduces the risk of damage to the adjacent teeth Planned sectioning permits the parts to be removed
separately in an atraumatic way.
The direction in which the impacted tooth should besectioned depends upon the angulation of impaction ,based
on line of withdraw of the segment. Can be done with bur/chisel ,bur is preferred.
-
8/11/2019 Ppt on Impaction
32/44
Elevation & extraction:
1. Coupland elevator :
placed at the base of the crown2. Winter cryer :
may be used for wedging action /buccal elevation.
buccal elevation can be done in molars & canineby creating a purchase point in the roots just
below the CEJ.
support inferior border +lingual alveolar bone
during elevation.
-
8/11/2019 Ppt on Impaction
33/44
Debridement & smoothening of bone :1. Irrigate the socket
2. Curette the socket to remove any remaining dentalfollicle and epithelium.
3. Check for pieces of coronal portion ,remnants ofbone ,granulation tissue &bleeding points .
4. Check for caries (crown/root) ,erosion damage ofthe adjacent tooth.
5. Round off the margins of the socket with largevulcanite round bur or bone file .
6. Irrigate the socket again and control bleeding beforesuturing .
-
8/11/2019 Ppt on Impaction
34/44
Closure:
3-0 black silk suture used
Interrupted sutures placed & maintained for 7days
In case of 3rdmolars sutures distal to 2ndmolar
should be placed first & should be water tight toprevent pocket formation.
-
8/11/2019 Ppt on Impaction
35/44
-
8/11/2019 Ppt on Impaction
36/44
-
8/11/2019 Ppt on Impaction
37/44
-
8/11/2019 Ppt on Impaction
38/44
-
8/11/2019 Ppt on Impaction
39/44
o Factors making impaction surgery more
difficult:
1. Distoangular
2. Class3 ramus
3. Class C depth
4. Long thin roots5. Divergent curved roots
6. Narrow pdl
7. Thin follicle
8. Dense inelastic bone
9. Contact with 2ndmolar
10. Close to IAN canal
11. Complete bony impaction.
-
8/11/2019 Ppt on Impaction
40/44
o Factors making impaction surgery lessdifficult
1. Mesioangular position2. Class1 ramus
3. Class A depth
4. Roots 1/3-2/3rdformed
5. Fused conical roots
6. Wide periodontal ligament
7. Large follicle
8. Elastic bone9. Separated from 2ndmolar, IAN canal
10. Soft tissue impaction
-
8/11/2019 Ppt on Impaction
41/44
COMPLICATIONS :
Hemorrhage
Injury to the inferior alveolar nerve . During bone removal:
damage to 2ndmolar
damage to the root of the overlying tooth
slipping of the bur into the soft tissue
fracture of mandible when chisel & mallet are used.
During elevation:
luxation of the neighboring/overlying tooth
fracture of adjoining bone
displacement of the bone into the nearby space.
injury to the IAN ,lingual nerve etc.
-
8/11/2019 Ppt on Impaction
42/44
Post operative complications:
pain,
swelling, trismus,
hypoesthesia,
sensitivity,
loss of vitality of the nearby tooth,
pocket formation etc.
-
8/11/2019 Ppt on Impaction
43/44
References
1. Textbook of oral and maxillofacial surgery-
Neelima Anil Malik
2. Contemporary oral &maxillofacial surgery-
Peterson.3. Oral & maxillofacial surgeryLaskin
4. www.google.com
http://www.google.com/http://www.google.com/ -
8/11/2019 Ppt on Impaction
44/44