Treatment and Complications of Impactions
By Suparn V Kelkar4th 1st
Roll no 27
Contents Treatment of Mandibular 3rd molar
impaction with complications Treatment of Maxillary 3rd molar
impaction with complications Treatment of Maxillary and Mandibular
Canine impactions ini. Class 1 position ii. Class 2 position iii. Class 3 position iv. Class 4 positionv. Class 5 position
Treatment of Mandibular 3rd Molars
HISTORY› Patients might be asymptomatic› when symptomatic- pain, swelling of the face, trismus› Symptoms of acute pulpitis or abscess› In denture wearers if denture no longer fits & at the same time
show the symptoms of pericoronitis.› General medical history & assessment of physical condition
EXAMINATION Clinical
Extra oral Intra oral
Radiographs
DECISION Diagnosis Treatment planning – type of anesthesia
- surgical procedure
Local Examination
EXTRA ORAL: • Signs of swelling & redness of the cheek• LN’s - enlargment & tenderness,• TMJ• Anesthesia or paraesthesia of lower lip,
INTRA ORAL:• Mouth opening & any evidence of trismus• State of eruption of tooth, signs of pericoronitis• Condition of 1st & 2nd molars• Space present b/w 2nd M & ascending ramus• Elasticity of oral tissues• Size of tongue
Investigations
Radiological Assesment by:a. IOPA
Bitewing
Occlusal Radiograph
Lateral Oblique Radiograph
Orthopantomograph (OPG)
CBCT( Cone Beam Computed Tomography)
Interpretation1. Assessing Access2. Assesing Position and Depth:o WAR LINESo White line, Amber Line, Red Line1. Asses Rootso Lengtho Fusion of rootso Curvature of rootso Width of rootso Roots of 2nd molar1. Asses Bone Texture2. Asses Relationship with Inferior
Alveolar Nerve
7 Radiological Signs (Howe and Poyton 1960)
1. Darkening of roots2. Deflected root3. Narrowing of the Roots4. Dark and Bifid roots5. Interruption of the white lines6. Diversion of Inferior Alveolar Canal7. Narrowing of the inferior alveolar
canal
Darkening of roots
Deflected root
Narrowing of the Roots
Dark and Bifid roots
Interruption of the white lines
Narrowing of the Inferior Alveolar Canal
WAR LINES (WINTERS LINES) White Line
Amber Line
Red Line
Assessment of Difficulty of removal
Wharf’s assessment
Pederson Scale
Surgical Removal
Factors affecting Type and Degree of impaction Amount of Soft tissue exposure Amount and technique of bone removal Odentectomy
SURGICAL INTRUMENTS
Step 1
Anesthesia LA : nerve block of the Inferior alveolar,
lingual, and long buccal nerve GA: indicated if tooth is situated deep
inside the jaw, when more than 2 impacted molars are to be removed
Step 2 Mucoperiosteal Flap Ideal Requirements: Adequate Exposure Base of flap Wide Expose entire site of operation No overextension of flap Incision should not damage vital
anatomic structures
MUCOPERIOSTEAL FLAP
Incision – 3 parts: Anterior, posterior & intermediate limb
Not to be extended too distally- Bleeding from buccal vessels & other arteries Postoperative trismus – temporalis muscle damage Herniation of buccal fat pad Damage to lingual nerve (lingual extention)
Step 3
Planned Ward’s IncisionAnterior release incision made including
the interdental papilla distal to 37. the incision extends downwards at 35 degree angle to the long axis of 36 extending 5 mm beyond the Mucogingival Junction taking care that the anterior limit of the incision does not cross the mesial line angle of 37 to avoid encountering facial artery
Crevicular incision or interdental bevel incision is done in relation to 38
Distal release incision is made from the distobuccal line angle of 38 buccolaterally to avoid encountering lingual nerve
Types of Flaps
L – shaped flap
(2nd molar para marginal Flap with vestibular extension)
Envelope flap(2nd molar
sulcus incision)
Bayonet – shaped flap (2nd molar sulcus incision
With vestibular extension)
Ward’s incision
ModifiedWard’s incision
Buccal extension flap
Triangular flap
Step 3
Buccal mucoperiosteal flap is raised staring the elevator frm the base of the falp at vestibular ( labial) mucosafor easy identification of the subperiosteal plane
Buccal mucoperiosteal flap is raisedincluding the interdental papilla
Complete elevation of the buccal mucopriosteal flap exposing the impacted 38
Step 4
Raising of the lingual mucoperiosteal flap
Complete exposure of the impacted 38 and surrounding bone
Step 5
Guttering of the mesial, buccal, and distal bone of 38 closest to the tooth ( Moore-Gillbe collar Technique)
Step 6
Initiation of dontectomy along long axis of the tooth midway at the bifurcation
Odontectomy performed uptill 2/3rd of the buccolingual width of the tooth using rotary instruments
Step 7
Completion of odontectomy using straight elevator
The working end of the elevator is engaged into created groove and rotated clockwise to complete odontectomy
Step 8
Removal of Distal segment of 38 Removal of mesial segment of 38
Step 9
Extraoral reorientation of the extracted tooth fragment and confirmtion of complete tooth removal
Step 10- Debridement of Wound & Closure
Thorough debridement of the socket by Periapical
curettage.
Smoothening of sharp bony margins by Bone file / burs.
Thorough irrigation of the socket Betadine solution +
Saline .
Initial wound closure is achieved by placing 1stsuture just
distal to 2ndmolar, sufficient number of sutures to get a
proper closure.
Bone Removal
Aim
1. To expose the crown by removing the bone overlying it.2. To remove the bone obstructing the pathway for
removal of the impacted tooth.
Types1. By consecutive sweeping action of bur (in layers).2. By chisel or osteotomy cut (in sections).
How much bone has to be removed?
1. Bone should be removed till we reach below the height of contour, where we can apply the elevator.
2. Extensive bone removal can be minimized by tooth sectioning
Moore & Gillbe’s Collar Technique
- Conventional tech of using bur.
- Rosehead round bur no.3 is used to create a gutter along the
buccal side & distal aspect of tooth.
A point of elevation is created with bur.
Amount of bone sacrificed is less.
Can be used in old patient.
Convenient for patient.
Split Bone / Lingual Split Technique Sir William Kelsey Fry(1933)
- Quick & clean tech - Reduces the size of blood clot by means of saucerization of socket. - Decreased risk of damage to the periodontium of the
second molar.
- Less risk of inferior alveolar nerve damage.
- Decreased risk of socket healing problems - Can use regional anaesthesia but endotracheal anaesthesia
is preferred one.
- Only suitable for young adults whose bone is elastic
- Inconvenience to patients due to chisel useage.
Incision Vertical stop cut
Split of Distolingual bone
Horizontal cut
Removal of distal & buccal bone
Removal of disto lingual bone
Elevation
Closure
Post Operative Instructions
Pressure pack – 1hr
Ice application
Soft diet –1st two days
1st dose of analgesic should be taken before the anesthetic
effect of LA wears off.
Avoid strenuous exercises for 1st 24 hrs.
Avoid gargling / spitting / smoking / drinking with straw.
Warm water saline gargling after 24 hrs + mouth wash
regularly thereafter.
Suture removal on 5th POD.
Complications
Intra Operative 1. During incision
a. Injury to facial arteryb. Injury to lingual nervec. Hemorrhage – careful history
2. During bone removal a. Damage to second molar b. Slipping of bur into soft tissue & causing injury c. Extra oral/ mucosal burns d. Fracture of the mandible when using chisel & mallet e. Subcutaneous emphysema
3. During elevation or tooth removala. Luxation of neighbouring tooth/
fractured restorationb. Soft tissue injury due to slipping of
elevatorc. Injury to inferior alveolar neurovascular
bundled. Fracture of mandiblee. Forcing tooth root into submandibular
space or inferior alveolar nerve canal
f. Breakage of instrumentsg. TMJ Dislocation – careful history
Nerve Injuries 0.6-5% of all the third molar surgeries are involved with nerve
damages of which 0.2% are irreversible
IAN: immediate disturbance - 4-5% (1.3-7.8%) permanent disturbances - <1% (0-2.2%)
Lingual N: immediate - 0.2-22% permanent - 0-2%
96% IAN injuries show spontaneous recovery within 9 months, better than lingual nerve which is about 87%
Beyond 2yrs recovery is unlikely
Post-operative Complications Immediate
- Hemorrhage
- Pain
- Edema
- Drug reaction
Delayed
- Alveolitis
- Infection
- Trismus
Dry Socket 20% of extraction of mandibular 3rd molar 2% of routine extraction Moderate-severe pain develops generally on 3rd/4th day.(with no signs
of infection) Dull aching pain usually radiates to ear Empty socket Bad odor & taste Management
Gentle irrigation with warm saline followed by superficial suctioning.
Pack iodoform gauze socked with medications change every day for 3-6
days.
Intra-alveolar medicaments(controversial)
-with eugenol
-topical LA
-antifibrinolytic agents.
Analgesics.
Treatment of Maxillary 3rd Molar Impaction
Indications1. Pain2. Overeruption of the upper 3rd molar3. 3rd molar errupting towards cheek4. Exacerbation of pericoronitis of lower
3rd molar5. Complete Maxillary denture
Assessment
Clinical1. State of erruption2. Buccolingual displcement3. Impaction against 2nd molar4. Mouth opening5. Space around 3rd molar
Radiographical assessment1. Iopa 2. Lateral oblique3. Opg Interpretation: Position and
Morphology1. Vertical2. Distovertical3. Mesioangular4. Partially errupted
Complicating factors
1. Maxillary Sinus approximation2. 3rd molar within or above roots of 2nd
molar3. Fusion of roots with 2nd molar4. Abnormal root curvature5. Hypercementosis6. Extreme bone density: elderly patients7. Follicular space filled with bone8. Inability t open mouth widely
Armamentarium
Same as that of mandibular molars bt difference in choice of elevators and forceps
1. Upper molar forcep2. Miller and Potts elevator3. BP- no 12
Surgical Procedure
Step 1: Incision and Flap1. Incision beyond the tuberosity in the
hamular notch2. Mucous Membrane incised from the distal
most portion anteriorly3. Incision is continued buccally around the
neck of 2nd molar to the interproximal space os 1st molar and the towards mucobuca fold at 45 degree angle
4. Last incision using no 15 BP blade
Step 2:Elevation and Bone removal1. Overlying bone is not dense and can
be readily removed with a chisel2. Elevator is inserted at the height of
contour using buccal plate as fulcrum3. Extreme care must be taken not to
inadvertently drive tooth into maxillary sinus or Pterygomaxillary space
Step 3: Wound Toilet and Closure1. Debridement of socket and
smothening of bone margins before wound is closed
2. Sutures are placed
Complications
Intraoperative1. Fracture of tuberosity2. Dislodgement into maxillary sinus3. Dislodgement of tooth into maxillary
sinus4. Damage to adjacent 2nd molar
Postoperative1. Infection2. Dry Socket3. Oraantral fistula
Treatment of Impacted Maxillary and Mandibular Canines
Clinical Assessment1. Distinct bulge in palate or buccal
aspect of maxilla2. Deflection of lateral incisors in AP
plane
Radiographical Assessment1. IOPA2. Vertex
Occlusal film3. CBCT
Factors determining treatment
A. AgeB. Stage of tooth developmentC. Position of toothD. Evidence of root resorption of adjacent
permanent teeth
Treatment options
1. No treatment2. Surgical removal of unerupted canine3. Surgical exposure of crown with or
without orthodontic treatment4. Surgical repositioning5. Surgical transplantation
Indications for Surgeryi. No other methord possible to retain toothii. Tooth is located very far from occlusal
planeiii. Pt unwilling to undergo ortho treatmentiv. Resorption of adjacent toothv. Cystslike infection, cyst formationvi. Required space does not existvii. When repositioning is unfavorable
Contraindications for Surgery:i. When tooth can be repositioned
orthodontically ii. Medically compromised pts
Factors complicating surgery
1. Proximity to adjacent teeth2. Proximity to the antral and nasal
cavity3. Formation of oroantral fistulas leading
to acute sinusitis
Surgical Technique
Removal of Canine in Class 1 position (Maxillary)
1. Soft tissue flapNo 12 BP blade usedIncise tissuse around neck of teeth from
lingual side of central incisor
Mucoperiosteal flap raised from hard palte
Bone RemovalRemoved circumferentially 3mm around
the crown with burs
Elevation of toothPalatal bone is used as a fulcrum
Removal of tooth
Impacted Mandibular Canine removal
Wound Irrigation and Closure
Examination of extracted tooth
Flap is compressed onto the palatal bone with a gauze palatal packing placed for 4 hrs
Alternatively a compound stent may be used to prevent hematoma collection
Removal of Canine in Class 2 position
Labially placed impacted canine can be exposed by
1. Trapezoidal flap- 2 vertical limbs2. Semilunar flap- no vertical limb3. Triangular flap- one vertical limb
1. Mucoperiosteal flap2. Bone removed by chisel3. Labial cortical plate as fulcrum luxate
tooth4. Wound debridement and closure
Removal of impacted cuspid in class 3 position
A. Crown in palatal bone root on buccal side
1. Semilunar flap2. Circumferential bone removal3. Root is sectioned4. Palatal flap outlined and
mucoperiosteal flap reflected5. Blunt instrumentation used to elevate6. Wound closure
B. Maxillary cuspid lying in line of arch along alveolar crest
1. Trapezoidal flap2. Bone removal with chisel and mallet3. Buccal mucoperiosteal flap4. Removal of tooth in sections or toto5. Primary wound closure
ThankYou!!!!!
Top Related