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Items
- Definition of Impacted Tooth
- Causes
- Classification
- Frequency
- Indications for removal of Impacted Tooth
“ C...
Definition :-
To “Impact” mean “to contact and Pressure”
Impacted tooth is that tooth that fails
to erupt into its normal ...
Causes of impaction
• Systemic causes
• Local causes
Systemic Causes
1- Prenatal causes – hereditary
a hereditary syndrome of cleidocranial dysistosis termed primary
Retention...
Local Factors
1- Lack of space in dental arch due to
Small size dental arch with disproportion between teeth and jaw size
...
Classification system
of impacted teeth
This is done to help dentist in evaluation of the extent
of the surgical procedure...
A - Relation of the tooth to the ascending
ramus of the mandible and to the distal
surface of the 2nd molar (Pell
&Gregory...
Class1
• The space between
the anterior part of the
ascending ramus and
the distal surface of
the 2nd molar is
sufficient ...
Class2
• The space between
the anterior part of the
ascending ramus and
distal surface of the
2nd molar is less than
the m...
Class3
• All the third molar is
located within the
ascending ramus of
the mandible.
- This show the superior
inferior relationship of the tooth
in relation to the occlusal plan.
(Pell & Gregory)
• Position ...
1-Vertical: the long axis of the third molar
is parallel to that of the 2nd molar.
2-Horizontal: the long axis of the thir...
Classification of impaction
of mandibular third molars,
according to
Archer (1975) and Kruger (1984).
1 Mesioangular, 2 Di...
Soft tissue impaction
in which crown of tooth is
covered by soft tissue only and
can be removed without bone
removal
Parti...
2 -Classification of
impacted maxillary
third molar:according to
Archer (maxillary 1975), depending on the depth of impact...
According to Archer (1975).
1Mesioangular,
2 distoangular,
3 vertical,
4 horizontal,
5 buccoangular,
6 linguoangular,
7 in...
• Class1:
Palatally impacted cuspids ,these could be in vertical, horizontal,
semivertical position.
• Class2:
Labialy imp...
frequency of impaction
1. mandibular 3rd molar
2. maxillary 3rd molar
3. maxillary cuspid
4. mandibular cuspid
5. Mandibul...
 Complications of impacted tooth.
 Operative complications.
 Postoperative complications.
Complication of impacted
teeth
(indication for removal):
the presence of impacted teeth in the jaw can create
a variety of...
Pain
Pain may originate from
• caries
• Periodontal disease
• Pericoronitis
• Root resorption
• Pressure on nerve
(neuroal...
• When third molar is
impacted or partially
impacted ,the bacteria
that cause dental
caries can be
exposed to the distal
a...
• Erupted teeth adjacent to
impacted teeth are
predisposed to periodontal
disease.
• As it decrease amount of
bone on the ...
Pericoronitis
• when a tooth is partially
impacted with a large
amount of soft tissue over
the axial and occlusal
surfaces...
Definition
• Is an infection of the soft
tissue around the crown of
partially impacted tooth and
is caused by the normal
o...
Causes
Decrease in host defense.
Minor trauma from maxillary 3rd molar.
“The soft tissue that covers the occlusal surface ...
• pericronitis can present as a very mild infection or as
a sever infection that requires hospitalization of the
patient ....
• For the patient who have in addition to local swelling and
pain, mild facial swelling ,mild trismus secondary to
inflamm...
• Impacted teeth cause
sufficient pressure on
the root of an adjacent
tooth to cause root
resorption.
Root Resorption
Orthodontic problems
crowding of mandibular anterior teeth.
Malocclusion (maxillary canine)
Prosthetic problems
Dentulous ...
Odontogenic cyst and Tumors
• The dental follicle
may undergo cystic
degeneration and
become a dentigerios
cyst or keratoc...
Fracture of the jaw
Impacted third molar
occupies space that is
usually filled with bone, this
weaken the mandible and
ren...
Prophylactic removal of
impacted tooth
• If the impacted tooth is asymptomatic there are two
opinions either remove it as ...
Contraindication for
removal of impacted
teeth:
1. Extreme of age:
- As the bone become highly calcified, less flexible,
less likely to bend under force of tooth extracti...
History:
Symptomatic individuals with an impacted tooth may report
1- Pain and tenderness of the gums (gingiva)
2- Unpleas...
 Radiological assessment of impacted teeth should
cover:
– Type, orientation of impaction & the access to the tooth
– Cro...
Standard radiographic techs used to localize the
unerupted teeth, these include:
 Periapical films The tube shift method
...
The tube shift method
• Uses two periapical radiographs, shifting
the tube horizontally between exposures.
• If the unerup...
The periapical &occlusal
method
• Uses the periapical radiograph taken with
standard technique and an occlusal
radiograph ...
45
More accurate 3-D views of impacted teeth
 Provides more accurate 3-D views of
impacted molars, impacted cuspids, and ...
Surgical removal of
impacted teeth:
Factors that Make Impaction Surgery Less Difficult
• Mesioangular position.
• Class 1 ramus.
• Class A depth.
• Roots one ...
1- Proper radiographic and clinical evaluation of the
condition.
2- Classification of impaction to help in planning the
su...
4- The condition should be explained to patient in a simple
easy way directing his attention to possible complication
that...
The surgical procedure is divided
into following stages:
1. Incision and reflection of the mucoperiosteal flap
2. Removal ...
A- Elevation of an adequate
mucoperosteal flap to expose the
field of surgery:
Pyramidal flap used in all third molar
imp...
Incision and types of flap for impacted
mandibular 3rd molar
Types of flaps A- Triangular flap
Incision for the creation o...
When impaction is deep (vertical releasing incision is distal to the first
molar).
B-Horizontal flap
These types of flaps used in case of impaction is relatively superficial
Incision and reflection of the flap for
impacted maxillary 3rd molar
Incision and reflection of the flap for
impacted maxillary canine
Palatal approachLabial approach
2-Bone removal:
This is done for :-
A- Exposure of impaction
B- Reduction of resistance
C- Making a point for application ...
3- Tooth delivery
1- Total delivery by application of force using elevators:
a- Mesial application of force :straight elev...
Extraction of Impacted 3rd Molar in Horizontal
Position
Extraction of Impacted 3rd Molar in
mesioangular position
Extraction of Impacted 3rd Molar in
distoangular position
Extraction of Impacted maxillary 3rd
Molar
Extraction of Impacted
maxillary canine
Labial approach
Extraction of Impacted
maxillary canine
Palatal approach
4-Preparation for wound closure:
- After removal of the tooth from it's socket the
wound is gently irrigated with sterile ...
5-closure of the wound:
• Well designed and properly reflected flap fall back easily
into place. using half circle a traum...
POST OPERATIVE INSTRUCTIONS
ON THE DAY OF TREATMENT
Do not rinse your mouth for at least 24 hours.
Avoid hot fluids, alcoh...
Complications associated with
surgical removal of impacted
tooth:
1- laceration of the soft tissue flap:
a-improper incision
b-improper elevation of the flap and improper retraction this
l...
5-Comlications related to injury of adjacent structure:
a-Injury to inferior alveolar canal:
- occurs in deeply seated ver...
post operative complications:
1. pain.
2. infection
3. hemorrhage
4. Nerve injury (lingual or inferior alveolar nerve)
5. ...
references
 Peterson΄s principles of oral and Maxillofacial surgery
 Master Dentistry
 Pub Med central Journal.
 Fragi...
Impacted teeth | by Dr.Basma Elbeshlawy
Impacted teeth | by Dr.Basma Elbeshlawy
Impacted teeth | by Dr.Basma Elbeshlawy
Impacted teeth | by Dr.Basma Elbeshlawy
Impacted teeth | by Dr.Basma Elbeshlawy
Impacted teeth | by Dr.Basma Elbeshlawy
Impacted teeth | by Dr.Basma Elbeshlawy
Impacted teeth | by Dr.Basma Elbeshlawy
Impacted teeth | by Dr.Basma Elbeshlawy
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Impacted teeth - learn everything about it (classification - complications - indications of removal - contraindications for removal - operative and post operative complications - and more about it)
موضوع باوربوينت عن الاسنان المنحصرة : تتعلم فيها كل ما يتعلق عنها:
(الاعراض والاختلاطات - دواعي الازالة - موانع الازالة - اختلاطات المعالجة واختلاطات بعد المعالجة - والمزيد..)
Prepared by:
Dr.Basma Elbeshlawy

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Impacted teeth | by Dr.Basma Elbeshlawy

  1. 1. Items - Definition of Impacted Tooth - Causes - Classification - Frequency - Indications for removal of Impacted Tooth “ Complication that may result from impacted tooth “ * Prophylactic removal of impacted tooth . - Contraindications for removal of Impacted Tooth - Diagnosis - Surgical Technique for removal of impacted tooth . - Operative complications. - Post operative complications - References.
  2. 2. Definition :- To “Impact” mean “to contact and Pressure” Impacted tooth is that tooth that fails to erupt into its normal functioning position in the dental arch within the expected time. The term Unerupted includes both impacted teeth and teeth that are in the process of eruption.
  3. 3. Causes of impaction • Systemic causes • Local causes
  4. 4. Systemic Causes 1- Prenatal causes – hereditary a hereditary syndrome of cleidocranial dysistosis termed primary Retention. 2- Postnatal causes Rickets Anemia Tuberculosis Congenital syphilis Malnutrition Endocrinal deficiency (hypothyrodism, hypopituitarism). Febrile disease, Down syndrome , Gorlin syndrome.
  5. 5. Local Factors 1- Lack of space in dental arch due to Small size dental arch with disproportion between teeth and jaw size Macrodontia 2- Over retained deciduous teeth 3- Premature loss of deciduous teeth 4- High density of overlying and surrounding bone 5- Long standing chronic inflammation soft tissue fibrosis 6- Incorrect alignment and abnormality of teeth 7- Direct or indirect effect of cysts or neoplasm. 8- Cleft palate or lip 9- Ectopic position of tooth bud
  6. 6. Classification system of impacted teeth This is done to help dentist in evaluation of the extent of the surgical procedure and in the planning of this procedure.
  7. 7. A - Relation of the tooth to the ascending ramus of the mandible and to the distal surface of the 2nd molar (Pell &Gregory): – This show the anterioposterior relationship of the tooth to the arch and the amount of resistance offered by the bone of the ascending ramus that may influence the tooth removal 1-Classification of impacted mandibular third molar:
  8. 8. Class1 • The space between the anterior part of the ascending ramus and the distal surface of the 2nd molar is sufficient to accommodate the mesiodistal diameter of the crown of the third molar.
  9. 9. Class2 • The space between the anterior part of the ascending ramus and distal surface of the 2nd molar is less than the mesiodistal diameter of the crown of the third molar (part of the tooth located within the ramus)
  10. 10. Class3 • All the third molar is located within the ascending ramus of the mandible.
  11. 11. - This show the superior inferior relationship of the tooth in relation to the occlusal plan. (Pell & Gregory) • Position A: The highest portion of the tooth is on level with or above the occlusal plane. • Position B: The highest portion is below the occlusal plane but above the cervical margin of the 2nd molar. • Position C: The highest point of the tooth is below the cervical margins of the 2nd molar. (deep impaction) B - Relative depth of the third molar in bone:
  12. 12. 1-Vertical: the long axis of the third molar is parallel to that of the 2nd molar. 2-Horizontal: the long axis of the third molar is at right angle to that of the 2nd molar . 3-Mesioangular impaction. 4-Destoangular impaction: all the previous four classes can come in: a - lingual deflection. b - buccal deflection. 5-Inverted impaction . C - The position of the long axis of the impacted tooth in relation to the long axis of the 2nd molar (winter's classification):
  13. 13. Classification of impaction of mandibular third molars, according to Archer (1975) and Kruger (1984). 1 Mesioangular, 2 Distoangular, 3 Vertical, 4 Horizontal, 5 Buccoangular,6 Linguoangular, 7 inverted. Classification of impacted mandibular third molars according to Pell and Gregory (1933): according to a The depth of impaction b their position according to the distance between the 2nd and the anterior border of raums of the mandible
  14. 14. Soft tissue impaction in which crown of tooth is covered by soft tissue only and can be removed without bone removal Partial bony impaction in which part of tooth, usually posterior aspect, is covered with bone and requires either bone removal or tooth sectioning for extraction . Complete bony impaction in which tooth is completely covered with bone and requires extensive removal of bone for extraction. Another classification of impaction
  15. 15. 2 -Classification of impacted maxillary third molar:according to Archer (maxillary 1975), depending on the depth of impaction compared to the adjacent second molar Class A: The occlusal surface of the impacted tooth is at approximately the same level as the occlusal surface of the 2nd molar (Fig.a). Class B: The occlusal surface of the impacted tooth is at the middle of the crown of the adjacent 2nd molar (Fig.b). Class C: The occlusal surface of the crown of the impacted tooth is below the cervical line of the adjacent molar or even deeper, or even above its roots (Figs.c–e).
  16. 16. According to Archer (1975). 1Mesioangular, 2 distoangular, 3 vertical, 4 horizontal, 5 buccoangular, 6 linguoangular, 7 inverted According to the relationship of tooth to maxillary sinus a-Sinus approximation : (s.a) where no bone or very thin bone exist between the impacted teeth and floor of sinus. b-No sinus approximation : (n.s.a) where 2 mm or more of bone exist between the floor of sinus and impacted teeth
  17. 17. • Class1: Palatally impacted cuspids ,these could be in vertical, horizontal, semivertical position. • Class2: Labialy impacted cuspide which could be in vertical, horizontal, semivertical. • Class3: Impacted cuspid located both in the palatal and labial surfaces. • Class4: Impacted cuspid in the alveolar process • Class5: Impacted cuspid that are present in an edentulous maxilla. 3-Classification of impacted maxillary cuspids:
  18. 18. frequency of impaction 1. mandibular 3rd molar 2. maxillary 3rd molar 3. maxillary cuspid 4. mandibular cuspid 5. Mandibular premolar 6. maxillary premolars 7. maxillary central and lateral incisors ( wisdom teeth are very common to be impacted as they are the last molar to emerge. They are normally emerge between 17 -21 years of age )
  19. 19.  Complications of impacted tooth.  Operative complications.  Postoperative complications.
  20. 20. Complication of impacted teeth (indication for removal): the presence of impacted teeth in the jaw can create a variety of problems, so it should be removed as soon as diagnosis is made:
  21. 21. Pain Pain may originate from • caries • Periodontal disease • Pericoronitis • Root resorption • Pressure on nerve (neuroalagic pain)
  22. 22. • When third molar is impacted or partially impacted ,the bacteria that cause dental caries can be exposed to the distal aspect of the 2nd molar, as well as to third molar Dental Caries
  23. 23. • Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease. • As it decrease amount of bone on the distal aspect of adjacent 2nd molar, with deep periodontal pocket on the distal aspect of the 2nd molar. Periodontal Disease
  24. 24. Pericoronitis • when a tooth is partially impacted with a large amount of soft tissue over the axial and occlusal surfaces, the patient frequently has one or more episodes of pericoronitis.
  25. 25. Definition • Is an infection of the soft tissue around the crown of partially impacted tooth and is caused by the normal oral flora.
  26. 26. Causes Decrease in host defense. Minor trauma from maxillary 3rd molar. “The soft tissue that covers the occlusal surface of the partially erupted mandibular 3rd known as the operculum can be traumatized and become swollen this can be treated by removal of maxillary 3rd molar.” Entrapment of food under operculum ,this pocket can not be cleaned ,bacteria invade it and pericoronitis begins. Streptococci and anaerobic bacteria (the usual bacteria inhabit the gingival sulcus) cause pericronitis.
  27. 27. • pericronitis can present as a very mild infection or as a sever infection that requires hospitalization of the patient . A. In its mildest form:- - Percronitis is present as a localized swelling and soreness. - Mild irrigation and curettage by dentist and home irrigation by pt is sufficient. B. In sever infection with local tissue swelling: that is traumatized by maxillary 3rd molar, the dentist should consider the maxillary 3rd molar and local irrigation . Treatment and Management
  28. 28. • For the patient who have in addition to local swelling and pain, mild facial swelling ,mild trismus secondary to inflammation extending into muscle of mastication ,and a low grade fever, the dentist should consider administration of antibiotics along with irrigation and extraction, (penicillin is the antibiotic of choice). • The mandibular third molar shouldn't be removed until sign and symptoms of pericronitis have been completely resolved • The incidence of post operative complication as dry socket and post operative infection ,increases if tooth is removed during time of active infection.
  29. 29. • Impacted teeth cause sufficient pressure on the root of an adjacent tooth to cause root resorption. Root Resorption
  30. 30. Orthodontic problems crowding of mandibular anterior teeth. Malocclusion (maxillary canine) Prosthetic problems Dentulous patient under bridge Edentulous patient under denture Mucosal ulceration so it’s very important to have preprosthetic radiograph
  31. 31. Odontogenic cyst and Tumors • The dental follicle may undergo cystic degeneration and become a dentigerios cyst or keratocyst. • Ameloblastoma may developed from epithelium within the dental follicle
  32. 32. Fracture of the jaw Impacted third molar occupies space that is usually filled with bone, this weaken the mandible and render the mandible to fracture.
  33. 33. Prophylactic removal of impacted tooth • If the impacted tooth is asymptomatic there are two opinions either remove it as a prophylactic line of treatment or do not remove it and follow up the case periodically by x-ray for any cystic formation • Several reasons are given for the early removal of asymptomatic or pathology free impacted teeth especially wisdom teeth almost all of which are not based on reliable evidence.  They have no useful role in the mouth  They may increase risk of pathological changes and symptoms.  If they are removed only when pathological changes occur patient may be older and the risk of serious complications after surgery may be greater. • But prophylactic removal should only be carried out if there is good evidence of patient benefit
  34. 34. Contraindication for removal of impacted teeth:
  35. 35. 1. Extreme of age: - As the bone become highly calcified, less flexible, less likely to bend under force of tooth extraction the result ,bone more surgically removed to displace tooth from its socket and less post operative sequels 2. Compromised medical status: e.g. cardiovascular patient 3. Probable excessive damage to adjacent structure: e.g. teeth, nerves or previously constructed bridges
  36. 36. History: Symptomatic individuals with an impacted tooth may report 1- Pain and tenderness of the gums (gingiva) 2- Unpleasant taste when biting down on or near the area 3- A visible gap where a tooth did not emerge 4- Bad breath 5- Redness 6- Swelling of the gums around the impacted tooth 7- Swollen lymph nodes (occasionally) 8- Difficulty opening the mouth (occasionally) 9- Headache or jaw ache. Physical exam: Examination of the teeth by the dentist may show 1-Enlargement of the tissue where a tooth has not emerged or has emerged only partially. 2-The impacted tooth may be pressing on adjacent teeth. 3-The gums around the area may show signs of infection (such as redness, drainage, and tenderness). 4-As gums swell over impacted wisdom teeth and then drain and tighten, it may seem to the individual that the tooth came in and then went back out again.
  37. 37.  Radiological assessment of impacted teeth should cover: – Type, orientation of impaction & the access to the tooth – Crown size & condition – Root number & morphology – Alveolar bone level including depth & density – Follicular width – Periodontal status, adjacent tooth – Relationship or proximity of upper tooth to the nasal cavity or maxillary antrum – Relationship or proximity of lower tooth to the inter dental canal, mental foramen & lower border of the mandible Radiography: Dental x-rays confirm the presence of a tooth (or teeth) that has not emerged.
  38. 38. Standard radiographic techs used to localize the unerupted teeth, these include:  Periapical films The tube shift method  Occlusal films  Panoramic view  CT
  39. 39. The tube shift method • Uses two periapical radiographs, shifting the tube horizontally between exposures. • If the unerupted teeth moves in the same direction in which the tube is shifted, its located on the lingual or palatal side • A facial or buccally located tooth moves in the opposite direction to the tube shift.
  40. 40. The periapical &occlusal method • Uses the periapical radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth. • Panoramic film can be used to assess maxillary canine position
  41. 41. 45 More accurate 3-D views of impacted teeth  Provides more accurate 3-D views of impacted molars, impacted cuspids, and other supernumerary anomalies  Visualize impaction within the alveolar bone, location relative to adjacent teeth, and proximity to vital structures  More accurate information can result in less invasive surgery/decreased surgical time
  42. 42. Surgical removal of impacted teeth:
  43. 43. Factors that Make Impaction Surgery Less Difficult • Mesioangular position. • Class 1 ramus. • Class A depth. • Roots one third to two third formed. • Fused conic roots. • Wide periodontal ligaments. • Large follicle. • Elastic bone. • Separated from 2nd molar. • Separated from inferior alveolar nerve. • Soft tissue impaction. Factors that Make Impaction Surgery More Difficult • Destoangular position. • Class 3 ramus. • Class C depth. • Long thin roots. • Divergent curved roots. • Narrow periodontal ligaments. • Thin follicle. • Dense inelastic bone. • Contact with 2nd molar. • Close to inferior alveolar nerve. • Complete bony impaction.
  44. 44. 1- Proper radiographic and clinical evaluation of the condition. 2- Classification of impaction to help in planning the surgical procedure 3- Selection of the time for surgical procedure: If the impacted tooth is to be removed, the most suitable time to do so is when the patient is young, that for these reasons:- *Avoid the aforementioned complications and undesirable situations that could get worse with time. * Younger patients generally deal with the overall surgical procedure and stress well, * Present fewer complications * Faster postsurgical wound healing compared to older patient * Easier bone removal Preparation for the surgery
  45. 45. 4- The condition should be explained to patient in a simple easy way directing his attention to possible complication that may arise from leaving tooth in position 5- Surgical removal can be made under local anesthesia as well as general anesthesia the choice of the anesthetic technique depends on: a- general condition of the patient and his ability psychologically and physically take the procedure. in very apprehensive patient, general anesthesia is preferred. b- position of impaction and extent of surgical procedure c- patient co-operation d- number of impaction that will be removed
  46. 46. The surgical procedure is divided into following stages: 1. Incision and reflection of the mucoperiosteal flap 2. Removal of bone to expose the impacted tooth 3. Tooth delivary 4. Care of the postsurgical socket and suturing of the wound The main factors for a successful outcome to the surgical procedure are as follows: 􀁏 Correct flap design, which must be based on the clinical and radiographic examination (position of tooth, relationship of roots to anatomic structures, root morphology). 􀁏 Ensuring the pathway for removal of the impacted tooth, with as little bone removal as possible. This is achieved when the tooth is sectioned and removed in segments, which causes the least trauma possible
  47. 47. A- Elevation of an adequate mucoperosteal flap to expose the field of surgery: Pyramidal flap used in all third molar impaction, the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold. In deep impaction ,a bigger flap is advisable. the anterior incision could start from the mesial aspect of 2nd molar 1- gaining access to impacted tooth:
  48. 48. Incision and types of flap for impacted mandibular 3rd molar Types of flaps A- Triangular flap Incision for the creation of a triangular flap, which is indicated in certain cases of extraction of impacted mandibular 3rd molar
  49. 49. When impaction is deep (vertical releasing incision is distal to the first molar).
  50. 50. B-Horizontal flap These types of flaps used in case of impaction is relatively superficial
  51. 51. Incision and reflection of the flap for impacted maxillary 3rd molar
  52. 52. Incision and reflection of the flap for impacted maxillary canine Palatal approachLabial approach
  53. 53. 2-Bone removal: This is done for :- A- Exposure of impaction B- Reduction of resistance C- Making a point for application of the elevator
  54. 54. 3- Tooth delivery 1- Total delivery by application of force using elevators: a- Mesial application of force :straight elevators and pot's elevators. b- Buccal application of force :winter elevator 2- Delivery of the tooth after tooth division : Division is indicated to reduce resistance ,create a space or remove interlocked cusps of the tooth a- Decapitation:- Division of the crown of the tooth at cervical margin level . - indicated in horizontal mandibular and maxillary third molar impaction and pallataly impacted maxillary cuspid b- Longitudinal tooth division: - indicated when the impacted tooth has a widely divergent straight roots, or when one root is straight and the other is curved c- Division of the interlocking cusp: - this is done with mesioangular impaction ,removal of the inter locking segment of the tooth usually located under the distal surface of 2nd molar
  55. 55. Extraction of Impacted 3rd Molar in Horizontal Position
  56. 56. Extraction of Impacted 3rd Molar in mesioangular position
  57. 57. Extraction of Impacted 3rd Molar in distoangular position
  58. 58. Extraction of Impacted maxillary 3rd Molar
  59. 59. Extraction of Impacted maxillary canine Labial approach
  60. 60. Extraction of Impacted maxillary canine Palatal approach
  61. 61. 4-Preparation for wound closure: - After removal of the tooth from it's socket the wound is gently irrigated with sterile normal saline solution and inspected for: a- any remnant of the residual tooth sac is removed b- remnant of tooth structure or fragments of bone debris is gently removed c- small fragments of the detached bone d- sharp edges of interseptal or alveolar bone is trimmed and smoothed - Then final irrigation and wound now is ready for closure.
  62. 62. 5-closure of the wound: • Well designed and properly reflected flap fall back easily into place. using half circle a traumatic needle and 000 black silk suture to hold flap into place post operative care: 1. A pressure pack is held in place for 1hour 2. Proper antibiotic therapy 3. Patient return back for check up after two days 4. Suture removal after 5 days
  63. 63. POST OPERATIVE INSTRUCTIONS ON THE DAY OF TREATMENT Do not rinse your mouth for at least 24 hours. Avoid hot fluids, alcohol, hard or chewy foods. Choose cool drinks and soft foods. Avoid vigorous exercise. Smokers should avoid smoking. If the wound start to bleed, apply a small compress. This can be made by placing cotton wool on the bleeding point and bite firmly on it . • If you cannot stop the bleeding yourself please seek professional advice. Any pain or soreness can be relieved by taking the prescribed medication. such as paracetamol (Panadol) 2 tablets every 4 hours as required. Do not take more than the recommended number per day. STARTING 24 HOURS LATER Gently rinse the wound with hot saltwater mouth rinses for a few days. This should be carried out three times a day after each meal.
  64. 64. Complications associated with surgical removal of impacted tooth:
  65. 65. 1- laceration of the soft tissue flap: a-improper incision b-improper elevation of the flap and improper retraction this leads to delayed healing and sever discomfort 2- Affection of the alveolar bone 3- Fracture of the jaw: - in angle of mandible ,improper use of elevator with uncontrolled force 4- Fracture of tuberosity: - due to improper use of force
  66. 66. 5-Comlications related to injury of adjacent structure: a-Injury to inferior alveolar canal: - occurs in deeply seated vertical impaction, the nerve pass between roots of impacted tooth .permanent numbness and heamorraghe b-Damage to nasal floor: - during surgical removal of impacted maxillary cuspid, profuse bleeding from nasal mucosa c- Involvement of maxillary sinus: - during removal of impacted maxillary third molar. oro anntral fistula results d- Pushing of impacted tooth into maxillary sinus e- Pushing of impacted maxillary molar into ptrygopalatine fossa: - uncontrolled mesial application of force in deep impaction f- Pushing impacted mandibular third molar into sub - mandibular space: - uncontrolled buccal application of force and fracture of the lingual plate g-Aspiration or swallowing of impacted tooth: - with general anesthesia
  67. 67. post operative complications: 1. pain. 2. infection 3. hemorrhage 4. Nerve injury (lingual or inferior alveolar nerve) 5. Trismus , limitation of jaw movement 6. osteomylitis 7. pain at TMJ 8. pain on swallowing due to edema of pharynx and hematoma formation.
  68. 68. references  Peterson΄s principles of oral and Maxillofacial surgery  Master Dentistry  Pub Med central Journal.  Fragiskos D. fragiskos (ed.)  Net pages : www.Dentalcare.com www.ada.org www.dentistry.com

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