1. IMPACTION
Dr.V.RAMKUMAR
CONSULTANT
DENTALFACIOMAXILLARYSURGEON
REG NO: 4118 TAMILNADU- INDIA(ASIA)

2. DEFINITION
Impacted tooth is one that fails to erupt and
will not eventually assume its anatomical
arch relationship, beyond the chronological
eruption date

3. ETIOLOGY
* NATURE - LACK OF SPACE IN JAWS
* NURTURE - CHANGE IN DIET

4. LACK OF SPACE
ETIOLOGY

5. Theories..
 Phylogenetic
 Mendelian

6. DILACERATION
ETIOLOGY

7. ETIOLOG
Y
OBSTRUCTIONS
retained deciduous teeth

8. Odontome
ETIOLOGY

9. Cyst / Odontogenic tumour
ETIOLOGY

10.  Thick scar band
 Dense bone
ETIOLOGY
 Systemic causes – Hormonal imbalance

11. INDICATIONS
Recurrent pericoronitis

12. Presence of a pathological lesion
INDICATIONS

13.  Caries
 Periodontal disease
 Obscure facial pain
 Previous attempted extraction
 Prosthetic considerations
 Social and economic factors
INDICATIONS

14. CONTRA INDICATIONS
 Health considerations
 Prosthetic considerations
 Availability of adequate
space
 socio economic reasons

15. Mandibular 3rd Molar Impaction

16. CLASSIFICATION
WINTER’S CLASSIFICATION
Angulation Depth
Based on the long axis of the
impacted tooth in relation to the long
axis of the second molar

17. WINTER’S Angulation CLASSIFICATION
Mesioangula
r

18. WINTER’S Angulation CLASSIFICATION
Distoangul
ar

19. WINTER’S Angulation CLASSIFICATION
Horizont
al

20. WINTER’S Angulation CLASSIFICATION
Vertical

21. WINTER’S Angulation CLASSIFICATION
Buccoversi
on

22. Angulation WINTER’S CLASSIFICATION
Linguoversio
n

23. Angulation WINTER’S CLASSIFICATION
Inverted

24. Angulation
Unusual / Ectopic
WINTER’S CLASSIFICATION

27. ASSESSMENT
CLINICAL
RADIOLOGICAL

28. CLINICAL ASSESSMENT
AGE

29. FACIAL FORM
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 #

30. RADIOLOGICAL ASSESSMENT

31. W A R Lines W A R Lines
W A R Lines
W A R Lines
W A R Lines
W A R Lines

32. WHITE Line

33. Amber Line

34. RED Line

35. SCORING DETAILS FOR WHARFE ASSESSMENT
Sl. NO Category Score
1. Winter’s Classification Horizontal
Distoangular
Mesioangular
Vertical
2210
2. Height of the mandible 1-30 mm
31-41 mm
35-39 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

36. Maxillary 3rd Molar Impaction

37. Classification
Archer’s..
Class A

38. Class B

39. Class C

40. Canine Impaction

41. Classification
Ackerman (1935):
Maxillary canines
Class I Class II
Palatal position Labial position

42. 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

43. SURGICAL TECHNIQUE IN IMPACTED
TOOTH REMOVAL
FLAPS : L - SHAPE, ENYELOPE, BAYONET
BONE : BUR VS CHISEL
REMOVAL
TOOTH : TOOTH VS BONE (KELSY FRY
RETRIEVAL SPLIT & DAVIS)
WOUND : CONVENTIONAL VS TISSUE ADHESIVES

44. Incision
Flap Design

45. BONE SPLIT TECHNIQUE
SIR WILLIAM KELSY FRY ?
VS
W.H.DAVIS
?

46. ADVANTAGES OF DAVIS
- DECREASED INCIDENCE OF
INFECTION IN II MOLAR AREA
- OBVIATES LINGUAL BONE
REMOVAL
- ¯ LINGUAL NERVE COMPLICATION

47. DISADVANTAGES OF KELSY FRY
-­ LINGUAL NERVE COMPLICATION
- BLEEDING - ELEVATION OF LINGUAL
SOFT TISSUE

48. 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.

49.  During bone removal
jaw #

50.  During elevation
jaw #

51. Post operative
 Swelling

52. Post operative
 Subcutaneous emphysema

53. Complications of surgical removal
of impacted tooth
 During LA
 Intra operative
 Post operative

54. During LA
 Pain
 Snycope
 LA toxicity
 Role of adrenalin in systemically
compromised pts

55. Management:
 Slow injection
 Aspiration before injecting
 Proper case history to rule out systemic
illness
 Proper DOCTOR-PATIENT rapport..

56. Intra operative complications
Incision Flap elevation Bone
removal
Tooth sectioning Elevation of tooth

57. During incision
 Local inflammation immediately prior to
surgery hemorrhage
Subside the inflammation prior to surgery
by anti inflammatory drugs

58.  Placement of incision:
Buccal:
downward & forward placement of
incision towards the vestibule
damage to the facial artery or
anterior facial vein
Management:
Direct the cut upwards towards the tooth
Temporary Permanent
extra oral finger pressure ligation

59. 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

60. 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 drilling
Adequate retraction
Lingual nerve protection

61. Advantage:
1. Safe
2. Rapid
3. Efficient method
Disadvantage:
1. Damage adjacent
structures
2. Fracture of the jaw
3. Splitting of the
lingual plate
Chisel
Firm control
Anterior vertical limit cut
Optimum force of malleting

62. During tooth sectioning
Incorrect line of
sectioning
Difficult removal of the
tooth
Damage to mandibular
canal
Hemorrhage
Post 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

63. Chisel Osteotome
 Difficult to achieve
correct line of
cleavge
More accurate
sectioning
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

64. Retrieval of the dislodged
tooth
Tooth
Lingual pouch
Finger pressure
Manipulation upwards
Retrieval with forceps

65. 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

66. 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

67. Post operative complications
Immediate
1. pain
2. Hemorrhage
3. Swelling
4. Anesthesia
5. Trismus
6. Pain on swallowing
& sore throat
pyrexia
Late
1. Infection
2. Hemorrhage
3. Pain in TMJ
4. Trismus

68. Immediate post op complications
1. Pain:
cause:
dry socket
hematoma
trauma to the adjacent tooth
Pain thershold – varies for each individual
Judicious manipulation of the tissues

69. 2. Hemorrhage:
Injection
Incision
Infection
Hemorrhage

70. Reactionary Hemorrhage
Occuring during the first 24 hours following surgery
Cause:
1. failure to achieve complete
hemostasis during surgery
2. wearing of adrenalin action
Management:
source of bleeding is identified
Ligation Pressure pack

71. 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

72. Swelling
Edema
 Not painful
Hematoma
 Tense & Tender