1) The document discusses impacted teeth, which are teeth that fail to fully erupt. It describes common causes and locations of impactions as well as classification systems.
2) Surgical removal of impacted teeth involves asepsis, anesthesia, incisions, bone removal, tooth sectioning, elevation and extraction while protecting surrounding structures.
3) Radiographs aid in determining the depth, orientation and relationship to nearby anatomy to assess difficulty prior to surgery. Careful treatment planning is important for safe and effective removal of impacted teeth.
3. IMPACTED TOOTH
It is the tooth that has
failed to erupt
completely or
partially to its correct
position in the dental
arch and its eruption
potential has been
lost.
4. UNERUPTED TOOTH
It is a tooth that is in
the process of
eruption and is likely
to erupt based on
clinical and
radiographic findings.
5. MALPOSED TEETH
A tooth unerupted or
erupted which is in
an abnormal position
in the maxilla or in
the mandible.
8. CAUSES OF IMPACTION
LOCAL CAUSE
Obstruction for eruption
Lack of space
Ankylosis of primary or permanent tooth
Nonabsorbing, over retained tooth
Nonabsorbing alveolar bone
Ectopic position of tooth bud
Dilaceration of roots
Soft tissue or bony lesions- fibrosis
Habits.
12. Deep periodontal
pocket
- associated with
partially erupted
tooth.
Prior to
orthodontic
treatment
- to control the tooth
crowding in the
mandible.
13. Prevention of root
resorption and
caries
Prevention of
pathological
fractures.
14. Management of
cysts and tumors.
Abscess of
odontogenic
origin
Management of
preprosthetic
concerns
Prophylactic
removal
15. CONTRAINDICATION
Extremes of age
Compromised medical status
Excessive risk of damage to adjacent structure
When there is question about the future status of the
second molar
Uncontrolled active pericoronal infection
Socioeconomic status
Fracture of atrophic mandible may occur
Abutment selection
16. SIGN AND SYMPTOMS
Pain
Difficulty in mastication
Paraesthesia of lip
Swelling of retro-molar tissue
Soreness
Erythemia of overlaying soft tissue or operculum
Trismus
Facial swelling of the affected side
Raised temperature
Regional lymphodenopathy.
17. RISK OF NONINTERVENTION
Crowding of dentition
Resorption of adjacent tooth and
periodontal status
Development of pathological conditions
such as infection, cysts, tumors.
18. RISK OF INTERVENTION
Minor transient- sensory nerve alteration,
alveolitis, trismus and infection. Haemorrhage,
dentoalveolar fracture and displacement of
tooth.
Minor permanent- periodontal injury, adjacent
tooth injury, temporomandibular joint injury.
Major – altered sensation, vital organ infection,
fracture of mandible, maxillary tuberosity.
21. Acc to depth
1. Position A : highest position of the tooth
is on a level with or above the occlusal line.
2. Position B : highest position is below the
occlusal plane, but above the cervical level of
the second molar.
3. Position C : highest position is below the
cervical level of the second molar.
23. Pell and Gregory’s classification
relationship of the impacted lower third molar to ramus
of the mandible and the second molar.
1. Class I : sufficient space available between the anterior
border of the ascending ramus and the distal side of
the second molar for the eruption of the third molar.
2. Class II : the space available between the anterior
border of the ramus and the distal side of the second
molar is less than the mesiodistal width of the crown of
the third molar.
3. Class III : the third molar is totally embedded in the
bone from the ascending ramus because of absolute
lack of space.
25. Maxillary third molar classification
acc to relation to the floor of maxillary sinus.
1. Sinus approximation (SA)- no bone or thin
bony partition present between impacted
maxillary third molar and the floor of the
maxillary sinus.
2. No sinus approximation (NSA)- 2mm or more
bone is present between the sinus floor and the
impacted maxillary third molar.
27. Classification of impacted maxillary
canines
1. class I : palatally placed maxillary canine
a. Horizontal
b. Vertical
c. semivertical
2. class II : labially or buccally placed maxillary
canine
a. Horizontal
b. Vertical
c. semivertical
28. 3. class III : involving both buccal and palatal
bone
4. class IV : impacted in the alveolar process
between the incisors and first premolar.
5. class V : impacted in edentulous maxilla.
30. DIFFICULTY INDEX
Pederson difficulty index
angulationangulation
- mesioangular : 1
- horizontal-transverse : 2
- vertical : 3
- distoangular : 4
depthdepth
- level A : 1
- level B : 2
- level C : 3
31. ramus relationship/ space available
- class I : 1
- class II : 2
- class III : 3
Difficulty index
Very difficult : 7 to 10
Moderately difficult : 5 to 7
Minimally difficult : 3 to 4
32. Wharfe assessment
six factor chosen for scoring are
Winter’s classification
- horizontal : 3
- distoangular : 2
- mesioangular : 1
- vertical : 0
Height of mandible
- 1 to 30 mm : 0
- 31 to 34 mm : 1
- 35 to 39 mm : 2
33. Angulation of third molar
- 1 to 59 degrees : 0
- 60 to 69 : 1
- 70 to 79 : 2
- 80 to 89 : 3
- 90 + : 4
Root shape
- favorable curvature : 1
- unfavorable curvature : 2
- complex : 3
34. Follicle
- normal : 1
- possibly enlarged : 2
- enlarged : 3
Path of exit
- space available : 0
- distal cusp covered : 1
- mesial cusp covered : 2
- both covered : 3
36. Radiological assessment aids in
determining
Classification of impacted tooth
Orientation of impacted tooth
Depth of the tooth
Root shape
Relation to inferior alveolar canal
Localization of impacted tooth
37. 1. Darkening of root
2. Deflection of root
3. Narrowing of root
4. Dark and bifid
apex
1
2
3
4
40. Winter’s lines
White line – corresponds to occlusal plane.
- indicates the difference in occlusal level of second and third molar.
Amber line – represents the bone level.
- denotes the alveolar bone covering the impacted tooth and the
portion of tooth not covered by the bone.
Red line – represents depth of the tooth in bone and the difficulty
encountered in removing the tooth.
- indicates the amount of bone that has to be remover before
elevation.
- if the length of red line is more than 5 mm then extraction is
difficult.
- every additional mm renders the removal of the impacted tooth
three times more difficult.
41.
42. Assessment of third molar
Case history
Intraoral and Extraoral examination
Examination of site of impacted tooth
Analysis- IOPA and OPG
Structure
-inferior alveolar nerve
-Lingual nerve
-Pterygomandibular space
-Facial artery
-External oblique ridge
-Retromolar pad
-Retromolar triangle
43. SURGICAL REMOVAL OF IMPACTED
TEETH
1. Asepsis and isolation
2. Local anaesthesia/ sedation+ LA/ general anaesthesia.
3. Incision – flap design.
4. Reflection of mucoperiosteal flap.
5. Bone removal.
6. Sectioning (division) of tooth.
7. Elevation.
8. Extraction.
9. Debridement and smoothening of bone.
10. Control of bleeding.
11. Closure – suturing.
12. Medication – antibiotics, analgesics, etc.
13. Follow-up.
44. Instruments
Mouth mirror
Probe
No 15 blade on a Bard Parker handle.
Mosquito artery forceps
Retractors
Chisel
Bur: rose head, straight fissure
Elevators
forceps
Bone file
Needle holder
Tissue forceps
Scissors
Drape
Syringe
46. Asepsis and Isolation
Scrubbing + painting of skin and oral mucosa
- Cetrimide + absolute alcohol or cetrimide + povidine+ iodine
- Cetrimide + absolute alcohol + chlorhexidine.
Cleaning solution- used on skin to remove residual soap solution.
- Normal saline
-Alcohol – spirit
Painting solution – act topically to inhibit further growth of microbes
- Povidine – iodine 5% for skin, 1% for oral mucosa
- Chlorhexidine gluconate - 7.5% for skin, 0.2% for rinsing oral
cavity.
Drape the patient
47.
48. Local anaesthesia
For mandibular molar and canines – pterygomandibular
nerve block.
For maxillary molars – posterior superior alveolar nerve
block and palatine nerve block or infiltration.
For maxillary canines – infraorbital nerve block + palatal
infiltration of incisive canal and bilateral palatine nerve
blocks.
50. Incision
(flap design)
Incision should be away from surgical site.
Not on vital structure.
Should be perpendicular to tissue
Triangular flap recommended for
adequate blood supply.
55. 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 a tooth.
Two ways of bone removal
1. High speed, high torque handpiece and technique
2. Chisel and mallet technique.
Adequate amount of bone should be
removed to enable for elevation
56. Bur technique
No. 7/8 round bur or a straight no. 703 fissure bur is
used.
Sealed bearing handpieces or surgical handpieces with
extra ball bearing must be used.
Medium speed drills(12000- 20000r.p.m) are preferred
for dento -alveolar surgery.
The bur is used in sweeping motion around the occlusal ,
buccal and distal aspect of the crown to exposed it.
Once the crown has been located, the buccal surface of
the tooth is exposed with the bur to the cervical level of
the crown and a buccal trough or gutter is created.
Continuous irrigation with 1% povidine -iodine or with
normal saline to reduce the thermal necrosis of bone.
58. Lingual split bone technique
It is described by Sir William Kelsey Fry.
Later popularized by T. Ward.
Quick and clean technique.
Creates saucerization of the socket, thereby
reduces the size of residual blood clot.
Used for mandibular third molar especially those
are placed lingually.
59. Steps
1. 3mm wide or 5mm wide chisel is used
2. Vertical stop cut is made by placing the chisel with the
bevel facing posteriorly, distal to second molar.
3. With the chisel bevel downward, a horizontal cut is
made backward from the lower end of vertical limiting
stop cut.
4. The buccal bone plate is removed above the horizontal
cut.
5. The distolingual bone is then fractured inward by
placing the cutting edge of the chisel. Bevel side of
chisel facing upward and cutting edge is parallel to the
external oblique ridge.
6. Finally small wedge of bone , which then remaining
distal to the tooth and between the buccal and lingual
cut, is excised and removed.
60. 6. A sharp straight elevator is then applied and minimum
force is used to elevate the tooth, as the tooth moves
upward and backward, the lingual plate gets fractured
and facilitates the delivery of the tooth.
7. After the tooth is removed , the lingual plate is grasped
with the hemostat and freed from the soft tissue and
removed
8. Smoothening of the edges is done with bone file.
9. Wound irrigated and sutured
62. Tooth sectioning, elevation and
extraction
Reduces amount of bone removal required prior to
elevation of the tooth.
Reduces the risk of damage to the neighboring teeth.
The direction in which impacted tooth should be
sectioned is dependent on the angulation of the
impacted tooth, based on line of draw of the segments.
Can be performed either with bur or chisel.
The bur is used in controlled fashion to avoid damage to
the vital structures and surrounding teeth and soft issue.
The tooth is sectioned one-half to three-fourths with bur
and then it is completely sectioned with the elevator.
63. Tooth sectioning, elevation and
extraction
Sectioning of the
1. Horizontally placed
lower third molar
2. Mesiobuccally placed
molar
3. Vertically placed molar
4. Distobuccally placed
molar
64. Elevation
1. Coupland elevator- placed at the base of
the crown.
2. Winter cryer’s – may be used in wedging
action/ buccal elevation.
Wedging action is useful, when molar crown is
split vertically down to bifurcation of roots
66. Debridement and smoothening of
bone margins
Irrigation of the socket.
Curetting to remove any remaining dental follicle and
epithelium.
Look for piece of coronal portion, check for remnants of
bone /granulation tissue, bleeding points.
Check for caries/ erosion/damage to the adjacent teeth.
Round off the margins of the socket with large vulcanite
round bur or bone file.
Irrigate the socket again.
Control bleeding before suturing.
67. closure
3-0 black silk and 21or 22mm half circle or 1 25 mm, 5/8
circle cutting needle is commonly used.
Interrupted sutures given and maintained for 7 days.
In case of molars, suture distal to second molar should
be placed first and should water tight to prevent pocket
formation.
In case of palatally placed canines, incisive papilla
should be sutured carefully to reduce postoperative
bleeding.
68. Principle of suturing
Use few suture as possible
Should not be excessively tight.
Suture should penetrate the lingual flap
close to and behind the third molar and
the buccal flap further distally
70. Post Operative instruction
Pressure pack for 1hr.
Ice application
Soft diet for 1st
two days
1st
dose of analgesic should be taken before the
anesthetic effect of LA wears off
Avoid gargling / spitting / smoking / drinking with straw
warm water saline gargling after 24 hrs + mouth wash
regularly thereafter
Suture removal after 7 days.
71. COMPLICATION
Intraoperative complications
During Incision
- for molars- facial vessel or buccal vessel may be cut.
- for lower canines- mental vessel may e damaged.
- for upper canines- incisive canal or greater palatine
vessel may be damaged.
During Bone Removal
- damage to the second molar, damage to the roots of
overlying teeth, slipping of the bur into soft tissues,
fracture of the mandible when using chisel and mallet
72. During Elevation
- Luxation o neighboring/ overlying tooth
- Fracture of the adjoining bone
- Fracture of the tuberosity
- Slipping of the tooth into pterygomandibular/ temporal
spaces, sublingual pouch and/ maxillary sinus
- Damage to nasal wall/ overlying teeth/ lingual, inferior
alveolar or mental nerve.
During Debridement
- damage to inferior alveolar nerve /lingual nerve
- damage to maxillary sinus.