Detailed review of treatment of impacted teeth without including the classification of all impactions

2. Treatment of Mandibular 3rd molar impaction
with complications
Treatment of Maxillary 3rd molar impaction
with complications
Treatment of Maxillary and Mandibular
Canine impactions in
i. Class 1 position
ii. Class 2 position
iii. Class 3 position
iv. Class 4 position
v. Class 5 position

3. 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

4. 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

5. Radiological Assesment by:
a. IOPA

6. Bitewing

7. Occlusal Radiograph

8. Lateral Oblique Radiograph

9. Orthopantomograph (OPG)

10. CBCT( Cone Beam Computed Tomography)

11. Interpretation
1. Assessing Access
2. Assesing Position and Depth:
o WAR LINES
o White line, Amber Line, Red Line
1. Asses Roots
o Length
o Fusion of roots
o Curvature of roots
o Width of roots
o Roots of 2nd molar
1. Asses Bone Texture
2. Asses Relationship with Inferior Alveolar
Nerve

12. 7 Radiological Signs (Howe and Poyton
1960)
1. Darkening of roots
2. Deflected root
3. Narrowing of the Roots
4. Dark and Bifid roots
5. Interruption of the white lines
6. Diversion of Inferior Alveolar Canal
7. Narrowing of the inferior alveolar canal

13. Darkening of roots

14. Deflected root

15. Narrowing of the Roots

16. Dark and Bifid roots

17. Interruption of the white lines

18. Narrowing of the Inferior Alveolar Canal

19. White Line

20. Amber Line

21. Red Line

22. Assessment of Difficulty of removal
 Wharf’s assessment

23. Pederson Scale

26. Factors affecting
 Type and Degree of impaction
 Amount of Soft tissue exposure
 Amount and technique of bone removal
 Odentectomy

28. 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

29. 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

31. 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)

32. Planned Ward’s Incision
Anterior 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

33. 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

34. 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)

35. Ward’s incision
ModifiedWard’s incision

36. Buccal extension flap
Triangular flap

37. 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

38. Raising of the lingual mucoperiosteal flap
Complete exposure of the impacted 38 and
surrounding bone

40. Guttering of the mesial, buccal, and distal
bone of 38 closest to the tooth ( Moore-
Gillbe collar Technique)

42. 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

44. Completion of odontectomy using straight
elevator
The working end of the elevator is engaged
into created groove and rotated clockwise to
complete odontectomy

45. Removal of Distal segment of 38
Removal of mesial segment of 38

46. Extraoral reorientation of the extracted tooth
fragment and confirmtion of complete tooth
removal

47. 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.

50. 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.
Types
1. 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

51. - 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.

52. - 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.

53. Incision Vertical stop cut
Split of Disto
lingual bone
Horizontal cut
Removal of distal
& buccal bone
Removal of disto
lingual bone
Elevation
Closure

54. 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.

55. Intra Operative
1. During incision
a. Injury to facial artery
b. Injury to lingual nerve
c. Hemorrhage – careful history

56. 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

57. 3. During elevation or tooth removal
a. Luxation of neighbouring tooth/ fractured
restoration
b. Soft tissue injury due to slipping of elevator
c. Injury to inferior alveolar neurovascular bundle
d. Fracture of mandible
e. Forcing tooth root into submandibular space or
inferior
alveolar nerve canal
f. Breakage of instruments
g. TMJ Dislocation – careful history

58. 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

59. Post-operative Complications
Immediate
- Hemorrhage
- Pain
- Edema
- Drug reaction
Delayed
- Alveolitis
- Infection
- Trismus

60. 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.

61. Indications
1. Pain
2. Overeruption of the upper 3rd molar
3. 3rd molar errupting towards cheek
4. Exacerbation of pericoronitis of lower 3rd
molar
5. Complete Maxillary denture

62. Clinical
1. State of erruption
2. Buccolingual displcement
3. Impaction against 2nd molar
4. Mouth opening
5. Space around 3rd molar

63. Radiographical assessment
1. Iopa
2. Lateral oblique
3. Opg
Interpretation: Position and Morphology
1. Vertical
2. Distovertical
3. Mesioangular
4. Partially errupted

65. 1. Maxillary Sinus approximation
2. 3rd molar within or above roots of 2nd molar
3. Fusion of roots with 2nd molar
4. Abnormal root curvature
5. Hypercementosis
6. Extreme bone density: elderly patients
7. Follicular space filled with bone
8. Inability t open mouth widely

66. Same as that of mandibular molars bt
difference in choice of elevators and forceps
1. Upper molar forcep
2. Miller and Potts elevator
3. BP- no 12

67. Step 1: Incision and Flap
1. Incision beyond the tuberosity in the hamular
notch
2. Mucous Membrane incised from the distal most
portion anteriorly
3. 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

69. Step 2:Elevation and Bone removal
1. Overlying bone is not dense and can be
readily removed with a chisel
2. Elevator is inserted at the height of contour
using buccal plate as fulcrum
3. Extreme care must be taken not to
inadvertently drive tooth into maxillary sinus
or Pterygomaxillary space

71. Step 3: Wound Toilet and Closure
1. Debridement of socket and smothening of
bone margins before wound is closed
2. Sutures are placed

72. Intraoperative
1. Fracture of tuberosity
2. Dislodgement into maxillary sinus
3. Dislodgement of tooth into maxillary sinus
4. Damage to adjacent 2nd molar

73. Postoperative
1. Infection
2. Dry Socket
3. Oraantral fistula

74. Clinical Assessment
1. Distinct bulge in palate or buccal aspect of
maxilla
2. Deflection of lateral incisors in AP plane

75. Radiographical Assessment
1. IOPA
2. Vertex Occlusal
film
3. CBCT

76. A. Age
B. Stage of tooth development
C. Position of tooth
D. Evidence of root resorption of adjacent
permanent teeth

77. 1. No treatment
2. Surgical removal of unerupted canine
3. Surgical exposure of crown with or without
orthodontic treatment
4. Surgical repositioning
5. Surgical transplantation

78. Indications for Surgery
i. No other methord possible to retain tooth
ii. Tooth is located very far from occlusal plane
iii. Pt unwilling to undergo ortho treatment
iv. Resorption of adjacent tooth
v. Cystslike infection, cyst formation
vi. Required space does not exist
vii. When repositioning is unfavorable

79. Contraindications for Surgery:
i. When tooth can be repositioned
orthodontically
ii. Medically compromised pts

80. 1. Proximity to adjacent teeth
2. Proximity to the antral and nasal cavity
3. Formation of oroantral fistulas leading to
acute sinusitis

81. Removal of Canine in Class 1 position
(Maxillary)
1. Soft tissue flap
No 12 BP blade used
Incise tissuse around neck of teeth from lingual
side of central incisor

83. Mucoperiosteal flap raised from hard palte

84. Bone Removal
Removed circumferentially 3mm around the
crown with burs

85. Elevation of tooth
Palatal bone is used as a fulcrum

86. Removal of tooth

87. Impacted Mandibular Canine removal

88. Wound Irrigation and Closure

89. Examination of extracted tooth

90. 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

91. Labially placed impacted canine can be
exposed by
1. Trapezoidal flap- 2 vertical limbs
2. Semilunar flap- no vertical limb
3. Triangular flap- one vertical limb

92. 1. Mucoperiosteal flap
2. Bone removed by chisel
3. Labial cortical plate as fulcrum luxate tooth
4. Wound debridement and closure

94. A. Crown in palatal bone root on buccal side
1. Semilunar flap
2. Circumferential bone removal
3. Root is sectioned
4. Palatal flap outlined and mucoperiosteal flap
reflected
5. Blunt instrumentation used to elevate
6. Wound closure

95. B. Maxillary cuspid lying in line of arch along
alveolar crest
1. Trapezoidal flap
2. Bone removal with chisel and mallet
3. Buccal mucoperiosteal flap
4. Removal of tooth in sections or toto
5. Primary wound closure