Dentist in pune. (BDS), Oral SurgeoMDS) - Dr. Amit T. Suryawanshi. Seminar-Canine Impaction. Contact - Ph no.-9405622455 Email ID- amitsuryawanshi999@gmail.com

1. Canine Impaction
Dr. Amit T. Suryawanshi
Oral and Maxillofacial Surgeon
Pune, India
Contact details :
Email ID -
amitsuryawanshi999@gmail.com
Mobile No - 9405622455

2. Canine Impaction
 IINNTTRROODDUUCCTTIIOONN
 FFRREEQQUUEENNCCYY OOFF IIMMPPAACCTTIIOONN
 IINNCCIIDDEENNCCEE
 CCLLAASSSSIIFFIICCAATTIIOONN
 RRIISSKKSS AASSSSOOCCIIAATTEEDD WWIITTHH IIMMPPAACCTTEEDD TTEEEETTHH
 CCAAUUSSEESS OOFF DDEELLAAYYEEDD EERRUUPPTTIIOONN OOFF CCUUSSPPIIDDSS
 PPRREEVVEENNTTIIOONN OOFF CCAANNIINNEE IIMMPPAACCTTIIOONN
 IINNDDIICCAATTIIOONNSS
 CCOONNTTRRAA IINNDDIICCAATTIIOONNSS
 DDIIAAGGNNOOSSIISS
 RRAADDIIOOGGRRAAPPHHIICC IINNTTEERRPPRREETTAATTIIOONN
 SSUURRGGIICCAALL RREEMMOOVVAALL
 PPOOSSTTOOPPEERRAATTIIVVEE TTRREEAATTMMEENNTT ,, IINNSSTTRRUUCCTTIIOONNSS AANNDD
CCAARREE
 CCOOMMPPLLIICCAATTIIOONNSS
 CCAAUUSSEESS FFOORR PPOOOORR PPRROOGGNNOOSSIISS

3. * IINNTTRROODDUUCCTTIIOONN **
IMPORTANACE OF CUSPID
* FUNCTION
* OCCLUSION (Cuspid rise)
* ESTHETICS
* ARCH HARMONY AND INTEGRITY

4. ** NNOORRMMAALL CCUUSSPPIIDD DDEEVVEELLOOPPMMEENNTT **
** DDeevveellooppss eeaarrllyy -- eerruuppttss late (~ age 11)
* OOccccuuppiieess sseevveerraall aarreeaass dduurriinngg DDeevveellooppmmeenntt
* DDeennttaall llaammiinnaa ddeevveellooppss lliinngguuaall ttoo
ddeecciidduuoouuss tteeeetthh,, tteerrmmiinnaatteess aappiiccaall ttoo 11sstt
ddeecciidduuoouuss mmoollaarr aanndd bbiiccuussppiidd
*MMiiggrraatteess aanntteerriioorrllyy aanndd iinnffeerriioorrllyy
**AAllmmoosstt nneevveerr ccoonnggeenniittaallllyy mmiissssiinngg

5. * DDEEFFIINNIITTIIOONN *
 IMPACTED TOOTH :-
• IIMMPPAACCTTEEDD TTOOOOTTHH TTHHAATT HHAASS FFAAIILLEEDD TTOO EERRUUPPTT
CCOOMMPPLLEETTEELLYY OORR PPAARRTTIIAALLLLYY TTOO IITTSS CCOORRRREECCTT
PPOOSSIITTIIOONN IINN TTHHEE DDEENNTTAALL AARRCCHH AANNDD IITTSS EERRUUPPTTIIOONN
PPOOTTEENNTTIIAALL HHAASS BBEEEENN LLOOSSTT..
** TTHHEE WWOORRDD IIMMPPAACCTTIIOONN IISS FFRROOMM LLAATTIINN WWOORRDD -
“IMPACTUS”.
 IMPACTION :-
** IIMMPPAACCTTIIOONN IISS CCEESSSSAATTIIOONN OOFF EERRUUPPTTIIOONN OOFF AA
TTOOOOTTHH CCAAUUSSEEDD BBYY AA PPHHYYSSIICCAALLBBAARRRRIIEERR OORR
EECCTTOOPPIICC PPOOSSIITTIIOONNIINNGG OOFF AA TTOOOOTTHH.
Continue..

6. *CAUSES OF IMPACTED TOOTH
- THERE ARE MAINLY TWO TYPES
OF CAUSES OF IMPACTION OF
TOOTH.
1) LOCAL CAUSES
2) SYSTEMIC CAUSES
Continue……

7. ( 1 ) LOCAL CAUSES :-
* OBSTRUCTION FOR ERUPTION :
- IRREGULARITY IN POSITION &
PRESENCE OF AN ADJACENT
TOOTH.
- DENSITYOF OVERLYING &
SURROUNDING BONE.
* LACK OF SPACE IN THE DENTAL
ARCH :
- CROWDING, SUPERNUMERARY
TEETH
* ANKYLOSIS OF PRIMARY &
PERMANENT TEETH

8. * NON ABSORBING , OVER-RETAINED
DECIDUOUS TEETH
* NON ABSORBING ALVEOLAR BONE
* ECTOPIC POSITION OF TOOTH BUD
* ASSOCIATED SOFT TISSUE OR BONY
LESIONS
( 2 ) SYSTEMIC CAUSES :-
* PRENATAL CAUSES – HEREDITY
* POST NATAL CAUSES – RICKETS,
ANAEMIA,TUBERCULOSIS , CONGINITAL
SYPHILIS, MALNUTRITION

9. * ENDOCRINAL DISORDERS – OF
- THYROID,
- PARATHYROID,
- PITUTARY GLANDS; like primary
retention of teeth is seen due to lack of
osteoclastic activity
* HEREDITARY- LINKED DISORDERS :
- Down syndrome
- Hurler’s syndrome
- Osteopetrosis
- Cleidocranial dysostosis
- Cleft palate etc.

10. *FFRREEQQUUEENNCCYY OOFF IIMMPPAACCTTIIOONN *
FFRREEQQUUEENNCCYY OORRDDEERR OOFF IIMMPPAACCTTEEDD
TTEEEETTHH NNOORRMMAALLLLYY OOBBSSEERRVVEEDD
AASS FFOOLLLLOOWWSS :
1) MAXILLARY THIRD MOLAR
2) MANDIBULAR THIRD MOLAR
3) MAXILLARY CANINE
4) MANDIBULAR PREMOLAR
5) MANDIBULAR CANINE
6) MAXILLARY PREMOLAR
7) SUPERNUMERARY TEETH
8) MAXILLARY CENTRAL INCISOR
9) MAXILLARY LATERAL INCISOR

11. * INCIDENCE *
 Grover and Lorton in 1985 - 5,000 Army
recruits, maxillary canine most likely to be
impacted after 3rd molars
DDaacchhii aanndd HHoowweellll iinn11996611 -- 33,,887744 ffuullll--mmoouutthh
rraaddiiooggrraapphhss,, 00..9922%% iinncciiddeennccee ooff mmaaxxiillllaarryy
ccaanniinnee iimmppaaccttiioonnss
 tthhiirrdd mmoollaarrss,, mmaaxxiillllaarryy ccaanniinneess,, mmaannddiibbuullaarr
pprreemmoollaarrss,, mmaaxxiillllaarryy pprreemmoollaarrss,, sseeccoonndd mmoollaarrss
 33::11 ffeemmaallee ttoo mmaallee,,
 33:: 11 ppaallaattaall ttoo llaabbiiaall mmaaxxiillllaarryy ccuussppiidd iimmppaaccttiioonnss
CCoonnttiinnuuee……

12. * INCIDENCE ,Continue..*
 Lingual mandibular impactions much more
common than labial
 Maxillary impactions 20X more common than
mandibular
 Maxillary impactions 1% in general population,
2% in orthodontic population, 8% are impactions
 Cuspid impactions occur in normal arch length
and anodontia

13. * CLASSIFICATION *
* FIELD AND ACKERMAN(1935)
* Classification is based on the findings of FIELD AND
ACKERMAN (1935).
 Class-1
1.Maxillary Canines :
a.Labial Position
(1).Crown in intimate relationship with incisors
(2).Crown well above apices of incisors
Continue..

14. b. Palatal Position
(1).Crown near surface in close
relationship to roots of incisors.
(2).Crown deeply embedded in close
relationship to apices of incisors

15. C. Intermediate Position
(1).Crown between lateral incisor and
first premolar roots.
(2).Crown above this teeth with crown
labially placed and roots palatally place or
vice versa .
D. Unusual Positions
(1) In nasal or antral wall
(2) In infraorbital region
( f – 3 )

16. F- a O.P.G. SHOWING UNUSUAL POSITION
OF MAXILLARY IMPACTED CANINE

17. 2.Mandibular canines :
a. Labial position ( f – 3 )
(1) Vertical
(2) Oblique
(3) Horizontal
( f – 4 )

18. b. Unusual Position
(1) At inferior Border.
(2) In mental protuberance.
(3) Migrated to the opposite side.

19. F - b O.P.G. showing impacted
mandibular canine

20. F - c O.P.G. showing impacted
mandibular canine ( vertical )

21. *CALSSIFICATION OF IMPACTED
MAXILLARY CANINE * ( V. KAPOOR )
CLASS I:- MAXILLARY CANINE IN PALATALPOSITION.
- HORIZONTAL,
- VERTICAL &
- ANGULATED.
CLASS II:- LABIALLY IMPACTED CANINE.
- HORIZANTAL,
- VERTICAL &
- ANGULATED.
(IN THIS POSITION THE CORWN OF IMPACTED CANINE CAN BE
IN INTIMATE RELATIONSHIP WITH THE INCISOR OR WELL
ABOVE THE APICES OF INCISORS.)
CLASS III:- IMPACTED CANINE WITH CROWN ON THE
PALATAL SIDE AND ROOT ON THE BUCCAL
SIDE OR VICE VERSA.

22. CLASS IV : VERTICALLY IMPACTED
CANINE BETWEEN LATERAL
INCISOR & FIRST PREMOLAR
CLASS V : CANINE IMPACTED IN
EDENTULOUS MAXILLA.
CLASS VI : MAXILLARY CANINE IN
UNUSUAL POSITIONS.
e.g.
- in NASO- ANTRAL WALL or
- INFRAORBITAL MARGIN

23. * RISKS ASSOCIATED WITH
IMPACTED TEETH *
 Malocclusion and loss of arch lleennggtthhIInnffeeccttiioonn
 DDeennttiiggeerroouuss ccyyssttss oorr ooddoonnttooggeenniicc ttuummoorrss
 RRoooott rreessoorrppttiioonn ooff aaddjjaacceenntt tteeeetthh
 MMaalleerruuppttiioonn ooff aaddjjaacceenntt tteeeetthh
 MMiiggrraattiioonn oorr lloossss ooff nneeiigghhbboorriinngg tteeeetthh
 RReessoorrppttiioonn ((iinntteerrnnaall,, eexxtteerrnnaall)) ooff tthhee iimmppaacctteedd
ttooootthh
 HHeeaaddaacchhee
 NNeeuurraallggiiaa

24. * CCAAUUSSEESS OOFF DDEELLAAYYEEDD EERRUUPPTTIIOONN
OOFF CCUUSSPPIIDDSS *
 AArrcchh lleennggtthh ddeeffiicciieennccyy
 EEccttooppiicc ppoossiittiioonn ooff ttooootthh
MMaallffoorrmmeedd ttooootthh,, ttrraauummaa,, iinnffeeccttiioonn
 PPrroolloonnggeedd rreetteennttiioonn ooff ddeecciidduuoouuss tteeeetthh
MMeecchhaanniiccaall oobbssttrruuccttiioonn ffrroomm ssuuppeerrnnuummeerraarryy oorr
eeccttooppiicc ttooootthh,, ccyysstt,, nneeooppllaassmm
 OOddoonnttooggeenniicc ttuummoorrss
 NNuuttrriittiioonnaall ddeeffiicciieenncciieess,, ggeenneettiicc aanndd eennddooccrriinnee
aabbnnoorrmmaalliittiieess
 HHeeaadd aanndd nneecckk ssyynnddrroommeess
 CClleefftt lliipp aanndd ppaallaattee

25. ** PPRREEVVEENNTTIIOONN OOFF CCAANNIINNEE
IIMMPPAACCTTIIOONN **
PPrreevveennttiioonn -- cclloossee oobbsseerrvvaattiioonn ffoorr eerruuppttiioonn
ppaatttteerrnnss aanndd eeaarrllyy ddeennttaall ccrroowwddiinngg
SSoommee aaddvvooccaattee eexxttrraaccttiioonn ooff ddeecciidduuoouuss ccaanniinneess
wwhheenn iimmppaaccttiioonn iiss ssuussppeecctteedd,, aass eeaarrllyy aass 88 yy//oo,,
bbyy aaggee 1111
SSppoonnttaanneeoouuss eerruuppttiioonn ssuucccceessssffuull wwhheenn ccaanniinnee iiss
ddiissttaall ttoo tthhee mmiiddlliinnee ooff tthhee llaatteerraall iinncciissoorr
NNoott ssuucccceessssffuull wwhheenn ccaanniinnee iiss mmeessiiaall ttoo tthhee
mmiiddlliinnee ooff tthhee llaatteerraall iinncciissoorr
TThhee mmoorree hhoorriizzoonnttaallllyy,, tthhee lleessss lliikkeellyy ttoo eerruupptt
ssppoonnttaanneeoouussllyy

26. * INDICATIONS *
** IINNDDIICCTTIIOONNSS FFOORR RREEMMOOVVAALL OOFF IIMMPPAACCTTEEDD TTOOOOTTHH AARREE
AASS FFOOLLLLOOWWSS ::
((11)) CCHHAANNGGEEDD PPOOSSIITTIIOONN OOFF AADDJJAACCEENNTT TTEEEETTHH ::
-- BBeeccaauussee ooff pprreessssuurree eexxeerrtteedd dduuee ttoo tthhee aatttteemmpptt ffoorr
eerruuppttiioonn ooff tthhee ccaanniinnee..
((22)) RREESSOORRPPTTIIOONN OOFF RROOOOTTSS OOFF AADDJJAACCEENNTT TTEEEETTHH ::
-- BBeeccaauussee ooff pprreessssuurree eexxeerrtteedd bbyy tthhee iimmppaacctteedd
ccaanniinnee..
((33)) CCYYSSTT FFOORRMMAATTIIOONN ::
-- FFrroomm tthhee ffoolllliiccllee aarroouunndd tthhee ccaanniinnee.. AAtttteemmpptt sshhoouulldd bbee
mmaaddee ttoo rreemmoovvee tthhee ccyysstt && ffaacciilliittaattee tthhee eerruuppttiioonn ooff
iimmppaacctteedd ccaanniinnee

27. (4) CLEFT PALATE :
- Repair of cleft palate may cause scarring &
narrowing of the arch leaving no space for canine
to erupt
(5) PRESENCE IN EDENTULOUS PATIENT :
- In edentulous jaw, an impacted canine can be left
unnoticed. It starts erupting with denture
irritation & needs to be removed .
(6) NEUROLOGIC SYMPTOMS :
- Pain in eye , ear , side of the head , entire face &
back of the neck can be attributed to impacted
canine & calls for its removal .

28. * CONTRAINDICATIONS *
CONTRAINDICATIONS FOR REMOVAL OF
IMPACTED TOOTH ARE AS FOLLOWS :
* EXTREME OF AGE
* COMPROMISED MEDICAL STATUS
* PROBABLE EXCESSIVE DAMAGE TO
ADJACENT STRUCTURE

29. * DIAGNOSIS *
* CCLLIINNIICCAALL ::
-- ccrroowwnn iinncclliinnaattiioonn ooff llaatteerraall iinncciissoorr
-- bbuullggiinngg iinn tthhee ppaallaattee,, lliinngguuaallllyy oorr
bbuuccccaallllyy

30.  RRAADDIIOOGGRRAAPPHHIICC ::
-- sshhiifftt--sshhoott ppeerriiaappiiccaall ((““CCllaarrkk’’ss rruullee””,,
““SSLLOOBB”” rruullee,, ppaarraalllleexx mmeetthhoodd,, ttuubbee oorr
bbuuccccaall sshhiifftt))
-- oocccclluussaall ((uussee sshhiifftt--sshhoott tteecchhnniiqquuee))
-- ppaannoorraammiicc xx--rraayy // sspplliitt ppaannoorraammiicc
-- llaatteerraall cceepphh
-- ttrraannss--nnaassaall
- ssiizzee ooff tthhee iimmppaacctteedd
ccaanniinnee

31. F - d VARIOUS I.O.P.A. showing
impacted canines

32. F – e OCCLUSAL view showing
palatally impacted
maxillary canine

33. F- f OCCLUSAL RADIOGRAPH
showing impacted mandibular canine

34. F - g O.P.G. showing impacted mandibular
left canine

35. F - h O.P.G.- Bilateral palatally impacted
maxillary canine

36. F- i LATERAL CEPHALOMETRIC
projection shows impacted maxillary canine

37. F - k AXIAL CT IMAGE showing superio –
lateral displacement of cuspid into nasal fossa

38. F – l CORONAL CT IMAGE showing
superio – lateral displacement of cuspid
into nasal fossa

39. * RADIOGRAPHIC INTERPRETATION:
RADIOGRAPHIC INTERPRETATION CAN BE
DONE BY
1) INTRA ORAL X-RAY - IOPA(INTRA ORAL
PERIAPICAL RADIOGRAPH
- OCCLUSAL RADIOGRAPH
2) EXTRA ORAL X-RAY - OPG
- LATERAL OBLIQUE VIEW
(MANDIBULAR)
- PA VIEW WATER’S POSITION
(MAXILLARY)
(2) NATURE OF COVERING TISSUES :-
* SOFT TISSUE IMPACTION
* PARTIAL BONY IMPACTION
* FULLY BONY IMPACTION

40. 3) CROWN SIZE :
4) ROOT CONFIGURATION:-
1) NUMBER OF ROOTS
2) LENGTH OF ROOTS
3) SIZE OF ROOTS
4) CURVATURE OF ROOT
5) DEVELOPMENT OF ROOT
6) RESORPTION - INTERNAL &
EXTERNAL
5) BONE TEXTURE & DENSITY:-
6) SIZE OF FOLLICULAR SAC:
7) RELATIONSHIP TO VITAL ORGANS:-
- MENTAL NERVE
- MAXILLARY SINUS

41. *SURGICAL CONSIDERATIONS :
- AVOID EXCESSIVE BONE
REMOVAL .
- AVOID DAMAGE TO ADJACENT
TEETH & SURROUNDING
STRUCTURE .
- AVOID MOVEMENT , OR
EXCESSIVE MOVEMENT .

42. * IMPACTED MAXILLARY CANINE *
• SINCE IT IS A COMMON OCCURANCE, IT HAS BEEN
STUDIED EXTENSIVELY.
• JACOBY IN 1983, SEPARATED LABIALLY FROM
PALATALLY IMPACTED CANINES
• ETIOLOGY; EXTRA SPACE, PEG- LATERAL OR MISSING
MAXILLARY LATERAL CAUSE PALATAL IMPACTION
• PALATALLY INCLINED CANINES HAVE ADEQUATE
SPACE,SELDOM ERUPT WITHOUT SURGICAL
INTERVENTION
• LABIAL IMPACTION HAVE ARCH LENGTH
DISCREPANCY, ERUPT ECTOPICALLY
• BISHARA IN 1992, PRESENCE OF LATERAL INCISIOR
ROOT WITH NORMAL LENGTH IS IMPORTANT IN
GUIDING THE CANINE IN PROPER POSITION.

43. * SURGICAL REMOVAL OF
IMPACTED CANINE *
* PRE OPERATIVE PROCEDURE :
- ISOLATION
- ANAESTHESIA
*OPERATIVE PROCEDURE :
- INCISION – FLAP DESIGN
- OPERATIVE STEPS
a) ELEVATION OF MUCOPERIOSTEAL
FLAP
b) BONE REMOVAL / ODONTECTOMY

44. c) LUXATION OF THE TOOTH &/ or
SECTIONENING OF THE TOOTH
d) DEBRIDEMENT & SMOOTHENING
OF BONE MARGINS
e) CONTROL OF BLEEDING / HEMOSTATE
f) SUTURING
g) FOLLOW- UP

45. * ARMAMENTARIUM :

46. * PREOPERATIVE PROCEDURE :
* ISOLATION :
* ANAESTHESIA :
IMPACTED CANINES MAY BE REMOVED
WITH THE PATIENT UNDER
- GENERAL or
- LOCAL ANAESTHESIA
LOCAL ANAESTHESIA :
FOR MAXILLARY CANINE :
- INFRA ORBITAL NERVE
- GREATER PALATINE NERVE
- NASOPALATINE NERVE should be blocked.
FOR MANDIBULAR CANINE :
- INFERIOR ALVEOLAR NERVE
- LINGUAL NERVE should be blocked

47. MAXILLARY
IMPACTED CANINE
LABIAL APPOROACH

48. * IMACTED MAXILLARY CANINE
* LABIAL APPROACH :-
- Apically repositioned for attached
gingiva preservation ( vanarsdall &
corn 1977 )
- Laterally positioned flap for high
impactions
- Repositioned flap / incision in
vestibule for very high impactions
- “tunnelling” method ( crenscini
- 1994 )

49. LABIAL APPROACH-IMPACTED
MAXI CANINE
F-1 (A) POSITION OF THE IMPACTED CANINE

50. * FLAP DESIGN – INCISION *
MAXILLARY CANINE :- LABIAL APPROACH
* IF CANINE IS BUCCALLY PLACED:
- FLAP WITH ANTERIOR RELEASING
INCISION.
- SEMILUNAR FLAP.
- TRAPEZOIDAL / ANGULATED FLAP
* IF UNILATERAL:
- AN ICISION IS RESTRICTED TO
CANINE REGION OF OPPOSITE
SIDE.
* IF BILATERAL:
- AN INCISION IS EXTENDED TO
FIRST MOLAR OF THE OPPOSITE
SIDE.

51. F – 1 ( B ) FLAP DESIGN
SEMILUNAR FLAP

52. 1 ) SEMILUNAR FLAP:- [ F -1(b) & F-m ]
- IS DESIGNED ON THE ALVEOLAR
MUCOSA.
- STARTS FROM THE FRENUM
KEEPING THE BULDGE OF THE
TOOTH IN THE CENTRE AND
EXTENDS IN THE PREMOLAR
REGION.
- THE LOWER MARGIN OF THE
INCISION SHOULD BE 5 mm AWAY
FROM GINGIVAL MARGIN.

53. F - m S E M I L U N AR INCISION

54. ( 2 ) ANGULATED FLAP DESIGN: ( F-n )
- IS GIVEN IN THE GINGIVAL
CREVICE OF INCISORS AND
PREMOLARS WITH VERTICAL ARM
GOING INTO THE MUCO BUCCAL
FOLD.
- EVEN TWO VERTICAL INCISIONS
CAN BE MADE ONE ON EACH SIDE
OF THE IMPACTED CANINE.

55. F - n ANGULATED FLAP INCISION :

56. * OPERATIVE STEPS :
(A) ELEVATION OF MUCO PERIOSTEAL FLAP :
[ F-1 ( c ) ]
- ELEVATE THE MUCO PERIOSTEAL FLAP
AND EXPOSE THE CROWN WITH
PERIOSTEAL ELEVATOR.
(B) BONE REMOVAL / ODONTECTOMY :
- AIM
- BURS USED
- STEPS / TECHNIQUE

57. * AIM:- 1) TO EXPOSE THE CROWN BY
REMOVING THE
OVERLYING BONE.
2) TO REMOVE THE BONE
OBSTRUCTING THE
PATHWAY FOR REMOVAL
OF A TOOTH.
# BONE REMOVAL TECHNIQUE :
* BUR TECHNIQUE:-
* BUR USED:- NO.7/8 ROUND BUR OR
NO.703 STRAIGHT FISSURE BUR.

58. * BUR SHOULD BE ALWAYS USED ALONG
WITH COPIOUS SALINE IRRIGATION TO
AVOID THERMAL TRAUMA TO THE
BONE.
* STEPS :-
(1) SWEEPING MOTION AROUND
OCCLUSAL , BUCCAL AND DISTAL
ASPECT OF CROWN.
(2) TOOTH IS EXPOSED TO THE
CERVICAL LEVEL OF CROWN
CONTOUR AND BUCCAL
THOUGH IS CREATED.

59. F-1 (c) REFLECTION OF THE FLAP

60. ( C ) LUXATION OF TOOTH : [ f – 1 ( d ) ]
- MAKE A DEEP CUT ON THE
MESIAL SIDE OF THE CROWN
AND ELEVATE THE TOOTH
WITH THE CRIER OR STRAIGHT
ELEVATOR.
( d ) SECTIONENING OF THE TOOTH :
- IF TOOTH CAN NOT BE LUXETED
& THERE ARE CHANCES OF
DAMAGE TO THE ADJACENT
TOOTH, THE CROWN CAN BE
SECTIONED & ROOT REMOVED
SEPARPTELY.

61. F-1 (d) LUXATION OF THE TOOTH

62. (e) DEBRIDEMENT & SMOOTHENING
OF BENE MARGINS :
- IRRIGATION.
- CURETTING TO REMOVE ANY
REMAINING DENTAL FOLLICLE &
EPITHELIUM
- ROUND OFF THE MARGINS OF
SOCKET
- IRRIGATION
(f) CONTROL OF BLEEDING -
- BEFORE SUTURING

63. F-1 (e) APPEARNCE OF SOCKET AFTER
TOOTH REMOVAL

64. (g) SUTURING –INCISION
CLOSURE
[ F-1 ( f ) ]
- 3-0 BLACK SILK IS USED
- INTERRUPTED SUTURES GIVEN
- MAINTAINED FOR 7 DAYS
(h) FOLLOW-UP :-
- FOLLOW UP THE PATIENT
AFTER 7 DAYS FOR REMOVAL
OF SUTURES.

65. F-1 (f) SUTURING – INCISION CLOSURE

66. MAXILLARY
IMPACTED CANINE
PALATAL APPROACH

67. * IMPACTED MAXILLARY CANINE
* PALATAL APPROACH :
- Plenty of keratinized gingiva.
- Full thickness palatal flap.

68. * FLAP DESIGN - INCISION :-
‘ * IF CANINE IS PLACED PALATALLY :
- THE INCISION IS TAKEN IN THE GINGIVAL
SULCUS ON THE PALATAL SIDE FROM
THE MESIAL ASPECT OF FIRST MOLAR
OF THE SAME SIDE.
- RELEASING INCISION IS GIVEN
OBLIQUELY ACROSS THE PALATE AND
SHOULD BE DEFLACTED AWAY FROM
THE PALATINE FORAMEN.
* IF UNILATERAL:
- AN ICISION IS RESTRICTED TO CANINE
REGION OF OPPOSITE SIDE.
* IF BILATERAL:
- AN INCISION IS EXTENDED TO FIRST
MOLAR OF THE OPPOSITE SIDE.

69. 1 ) PALATAL INCISION :
[ F – 2 ( a ) , F - o ]
- INCISION , FOR REMOVAL OF
UNILATERAL PALATALLY
IMPACTED MAXILLARY CANINE ,
SHOULD START IN THE SECOND
PREMOLAR REGION AND EXTEND
FORWARD EITHER IN GINGIVAL
SULCUS or NEAR THE GINGIVAL
MARGIN TO APPROXIMATELY THE
LATERAL INCISIOR REGION ON
THE OPPOSITE SIDE

70. PALATAL APPROACH-IMPACTED
MAXI. CANINE
F - 2 ( A ) FLAP DESIGN - INCISION

71. F – O PALATAL INCISION

72. 2 ) COMPLETE PALATAL
INCISION :
[ F – p ]
- IF BILATERALLY PALATALLY
IMPACTED MAXILLARY CANINES ARE
PLANNED TO BE REMOVED IN A
SINGAL SITTING, COMPLETE
PALATAL INCISION SHOULD BE
GIVEN.
- INCISION SHOULD BE EXTENDED
ACROSS
- THE MIDLINE UPTO THE FIRST MOLAR
REGION OF THE OPPOSIDE SIDE

73. COMPLETE PALATAL INCISION :
[ F – p ]

74. * REFLECTION OF THE FLAP :
[ F – 2 ( B ) ]
- THE MUCO PERIOSTEAL FLAP IS
REFLACTED WITH A SHARP
PERIOSTEAL ELEVATOR .
- IT CAN BE KEPT RETRACTED BY
A SUTURE, PLACED AROUND AN
ADJACENT TOOTH .
* BONE REMOVAL/ODONECTOMY :
- BUR TECHNIQUE .

75. F-2 ( B ) REFLECTION OF FLAP

76. * SECTIONENING & REMOVAL
OF THE CROWN : [ F – 2 (C) ]
* REMOVAL OF THE ROOT :
[ F – 2 ( D ) ; F – 2 ( E ) ]
* DEBRIDEMENT & SMOOTHENING
OF THE BONY MARGINS :
* CONTROL OF BLEEDING :
- BEFORE SUTURING .

77. F-2 (C) SECTIONING & REMOVAL OF
THE CROWN

78. F-2 ( D , E ) REMOVAL OF THE ROOT

79. * SUTURING –
INCISION CLOSURE
[ F-2 ( f ) ]
- 3-0 BLACK SILK IS USED
- INTERRUPTED SUTURES GIVEN
- MAINTAINED FOR 7 DAYS
* FOLLOW-UP :-
- FOLLOW UP THE PATIENT
AFTER 7 DAYS FOR REMOVAL
OF SUTURES.

80. F-2( F ) SUTURING – INCISION CLOSURE

81. MAXILLARY
IMPACTED CANINE
INTERMEDIATE POSITION

82. * MAXILLARY IMPACTED CANINE
INTERMEDIATE POSITION :
- CANINES IN AN INTERMEDIATE
POSITION USUALLY EASIER TO REMOVE
THAN THOSE IN A PURELY LABIAL or
PALATAL LOCATION
* OPERATIVE PROCEDURE *
* FLAP DESIGN – INCISION :
- FLAP SHOULD BE DESIGNED ACCORDING
TO THE LOCATION OF THE TOOTH .

83. ( i ) CANINE IS NOT WEDGED B/W
LATERAL INCISIOR & FIRST PREMOLAR
( ii ) CANINE IS WEDGED B/W LATERAL
INCISIOR & FIRST PREMOLAR .
( 1 ) CANINE IS NOT WEDGED B/W
LATERAL INCISIOR & FIRST
PREMOLAR :
- INCISION SHOULD INCLUDE THE MARGINAL
GINGIVA SO THAT THE TISSUE WILL NOT BE
TRAUMATIZED BY THE APPLICATION OF THE
INSTRUMENT.

84. - THE TOOTH CAN BE REMOVED BY A
FORCEPS OR ELEVATOR TECHNIQUE.
( 2 ) CANINE IS WEDGED BETWEEN
LATERAL INCISIOR & FIRST
PREMOLAR :
- INCISION SHOULD INCLUDE THE
MARGINAL GINGIVA SO THAT THE
TISSUE WILL NOT BE TRAUMATIZED
BY THE APPLICATION OF THE
INSTRUMENT.

85. * REFLACTION OF THE FLAP :
* BONE REMOVAL / ODONECTOMY:
- WHEN THE BONE IS COVERING THE
CROWN, IT IS FIRST REMOVED ON
THE SIDE TOWARD WHICH THE
TOOTH IS POINTING .
- IT SOMETIMES ALSO IS NECESSARY
TO REMOVE A SMALL AMOUNT ON
THE OPPOSITE SIDE TO PERMIT
EITHER APPLICATION OF FORCEPS OR
INSERTION OF AN ELEVATOR .
- IF THE DECIDUOUS CANINE HAS
BEEN RETAINED, ITS EXTRACTION

86. WILL PERMIT LOCALIZATION OF THE CROWN
OF THE PERMANENT TOOTH THROUGH THE
SOCKET AND FACILITATE ITS SUBSEQUENT
REMOVAL
* SECTIONING OF THE TOOTH :
- IF CANINE IS WEDGED BETWEEN THE
ADJACENT TEETH, IT WILL BE
NECESSARY TO SECTION THE CROWN
FROM THE ROOT AND REMOVE IT.
* LUXATION OF THE TOOTH :
* DEBRIDMENT & SMOOTHENING OF
THE BONY MARGINS :
* CONTROL OF BLEEDING
* SUTURING :
- AFTER REMOVAL OF THE TOOTH, THE
INCISION IS CLOSED WITH INTERRUPTED
SUTURES.

87. MAXILLARY
IMPACTED CANINE
UNUSUAL POSITION

88. MAXILLARY IMPACTED CANINE
UNUSUAL POSITION
* CANINES MAY ERUPT IN AN UNUSUAL
SITES like;
- NEAR/ BENEATH THE INFRAORBITAL
MARGINS,
- IN THE NASO-ANTRAL WALL, etc.
* MAY OCCUR DUE TO :
- MIGRATION OF THE TOOTH GERM
- CYST FORMATION, etc.

89. * OPERATIVE PROCEDURE *
* CANINE LYING AT THE INFRAORBITAL
MARGIN :
- IS REMOVED INTRAORALLY BY
EXPOSING THE INFRAORBITAL
MARGIN THROUGH AN INCISION
GIVEN IN THE VESTIBULE .
* CANINE IN THE NASO-ANTRAL WALL :
- IF ERUPTING IN THE MAXILLARY
ANTRUM :
- IF ERUPTING IN THE NASAL CAVITY

90. - IF ERUPTING IN THE MAXILLARY
ANTRUM :
HAS TO BE REMOVED BY GOING
INTO THE ANTRUM THROUGH
‘ CALDWELL-LUC APPROACH ’
- IF ERUPTING IN THE NASAL CAVITY :
HAS TO BE REMOVED BY GOING
INTO THE ANTRUM THROUGH
‘ INTRA-NASAL APPROACH ’

91. * OPERATIVE PROCEDURE:
* INCISION :
- IS MADE ACROSS THE CANINE FOSSA
EXTENDING TO THE PIRIFORM
APERTURE OF THE NOSE.
* ODONECTOMY :
- TOOTH GENERALLY CAN BE EXPOSED
BY CUTTING AWAY THE OVERLYING
BONE.
- THE NASAL MEMBRANE SHOULD BE
DETATCHED AND RETRACTED TO AVOID
PERFORATION INTO THE NOSE .

92. * SECTIONENING AND REMOVAL OF
TOOTH :
* CONTROL OF BLEEDING :
* SUTURING :
- AFTER REMOVAL OF THE TOOTH,
THE INCISION IS CLOSED
WITH INTERRUPTED SUTURES.

93. MANDIBULAR
IMPACTED CANINE
LABIAL APPROACH

94. * IMPACTED
MANDIBULAR CANINE *
* LABIAL APPROACH :
- Utilize apically repositioned flap or
vestibular incision.
- Watch for mental nerve.
- Labial impactions often associated
with
retained primary dentition.

95. SURGICAL REMOVAL OF LABIALLY
IMPACTED MANDIBULAR CANINE :

96. * SURGICAL REMOVAL OF LABIALLY
IMPACTED MANDIBULAR CANINE :
- MANDIBULAR CANINES GENERALLY
EMBADED IN THE BASE OF THE
MANDIBLE ON THE BUCCAL ASPECT IN
AN OBLIQUE OR HORIZONTAL
POSITION .
* FLAP DESIGN – INCISION : [ F -4 (A) ]
- THE INCISION CAN BE MADE
HORIZONTALLY OR WITH OBLIQUE SIDE
CUTS , INTRAORALLY , ON THE
BUCCAL ASPECT OF THE MANDIBULE.

97. LABIAL APPROACH-IMPACTED
MANDIBULAR CANINE
F-3 (A) FLAP DESIGN - INCISION

98. * REFLECTION OF THE FLAP :
[ F – 3 ( B ) ]
- REFLECT THE MUCOPERIOSTEAL
FLAP WITH THE HELP OF A SHARP
PERIOOSTEAL ELEVATOR .
* ODONECTOMY : [ F – 3 ( C ) ]
- REMOVAL OF THE LABIAL CORTEX
IS DONE BY USING BUR TECHNIQUE:
-DRILL THE HOLES IN THE BONE
THROUGH THE LABIAL CORTEX
AROUND THE CROWN.
- JOIN THESE HOLES TO REMOVE
THE OVERLYING BONE AND
EXPOSE TE CROWN.

99. F – 3 ( B )
REFLACTION OF THE MUCOPERIOSTEAL FLAP

100. * LUXATION OF THE TOOTH : [ F– 3 (C) ]
- LUXATE THE TOOTH; IF IT IS
DIFFICULT TO LUXUTE THEN
SECTIONENING OF THE TOOTH
SHOULD BE DONE .
* DEBRIDEMENT & SMOOTHENING
OF BONY MARGINS :
- IRRIGATION.
- CURETTING TO REMOVE ANY
REMAINING DENTAL FOLLICLE &
EPITHELIUM.
- ROUND OFF THE MARGINS OF
SOCKET .
- IRRIGATION.

101. F – 3 ( C )
REMOVAL OF THE LABIAL CORTEX &
LUXATION OF THE TOOTH

102. * CONTROL OF BLEEDING -
- BEFORE SUTURING
* SUTURING –INCISION CLOSURE :
[ F – 3 ( D ) ]
- 3-0 BLACK SILK IS USED
- INTERRUPTED SUTURES GIVEN
- MAINTAINED FOR 7 DAYS
* FOLLOW-UP :-
- FOLLOW UP THE PATIENT AFTER
7 DAYS FOR REMOVAL OF SUTURES.

103. F – 3 ( D )
SUTURING – INCISION CLOSURE

104. MANDIBULAR
IMPACTED CANINE
LINGUAL APPROACH

105. * LINGUAL APPROACH :
- Full thickness flap.
- No releasing incisions.
- Very difficult access
- Fortunately, rare.
- Watch for significant anatomy.
- Lingual impaction associated with
shortage of arch length.

106. MANDIBULAR
IMPACTED CANINE
UNUSUAL POSITION

107. MANDIBULAR IMPACTED CANINE
UNUSUAL POSITION
- SOME TIMES , MANDIBULAR CANINES
MAY BE FOUND IN THE UNUSUAL
POSITIONS like ;
- AT THE INFERIOR BORDER OF THE
MANDIBLE ;
- IN THE MENTAL PROTRUBERANCE;
- MIGRATED TO THE OPPOSITE SIDE
CROSSING THE MIDLINE.
( IN CERTAIN CASES )

108. * SURGICAL REMOVAL :
- IMPACTED MANDIBULAR CANINES IN
UNUSUAL POSITION, SURGICALLY CAN BE
REMOVED INTRAORALLY OR EXTRAORALLY ,
DEPENDING ON THE LOCATION OF THE TOOTH.
* FLAP DESIGN - INCISION :
- WHEN THE CANINE IS IMPACTED IN THE
MENTAL PROTRUBERANCE , IT CAN BE
REMOVED BY - INTRAORAL APPROACH.
- WHEN THE CANINE IS IMPACTED AT THE
INFERIOR BORDER BORDER OF MANDIBLE IS
THE BEST REMOVED BY – EXTRAORAL
APPROACH .

109. T
* IMPACTED MANDIBULAR CANINE AT
THE INFERIOR BORDER THE CANINE :
- EXTRA ORAL APPROACH IS THE BEST :
( SKIN INCISION )
1) MORE EASY TO REACH.
2) TO PREVENT INJURY TO THE MENTAL
NERVE.
- TECHNIQUE :
- UNDER GENERAL ANAESTHESIA .
- POSITION : THE HEAD OF THE PATIENT
IS INCLIENED BACK AS MUCH AS
POSSIBLE.

110. INCISION : IS MADE IN THE CREASE OF THE
SKIN ALONG THE LOWER BORDER OF THE
MANDIBLE AT A DISTANCE OF 2 cm BELOW
THE LOWER BORDER TO SAVE THE
MANDIBULAR BRANCH OF THE FACIAL
NERVE .
- AFTER THE SKIN , SUBCUTANEOUS TISSUE ,
PLATYSMA AND DEEP FASCIA ARE CUT ,
AND PERIOSTEUM IS INCISED .
* REFLECTION OF THE FLAP :
- AFTER INCISING THE PERIOSTEUM ,
REFLECT THE FLAP WITH A HEAVY
PERIOSTEAL ELEVATOR .

111. * ODONTECTOMY :
- LIGATE THE BLEEDING VESSELS,RETRACT
THE WOUND MARGINS AND EXPOSE THE
JAW.
- LOCATE THE BULGE OF THE CROWN ON
THE OUTER SURFACE OF THE JAW .
- EXPOSE THE BULGE OF THE CROWN BY
DRILLING HOLES IN THE CORTEX AND
JOIN THESE HOLES.
- REMOVE SUFFICIENT OVERLYING BONE
TO EXPOSE ENTIRE CROWN AND PART OF
THE ROOT.

112. F * LUXATION OF THE TOOTH :
- LUXATE THE TOOTH; IF IT IS
DIFFICULT TO LUXUTE THEN
SECTIONENING OF THE TOOTH
SHOULD BE DONE .
* DEBRIDEMENT & SMOOTHENING
OF BENE MARGINS :
- IRRIGATION.
- CURETTING TO REMOVE ANY
REMAINING DENTAL FOLLICLE
& EPITHELIUM.
- ROUND OFF THE MARGINS OF
SOCKET .
- IRRIGATION.

113. * CONTROL OF BLEEDING -
- BEFORE SUTURING
* SUTURING –INCISION CLOSURE :
- WOUND IS SUTURED IN LAYERS
- 3-0 CATGUT- FOR DEEPER LAYER.
- 4-0 NAYLON – FOR SKIN.
- INTERRUPTED SUTURES GIVEN
- MAINTAINED FOR 7 DAYS
* FOLLOW-UP :-
- FOLLOW UP THE PATIENT AFTER
7 DAYS FOR REMOVAL OF SUTURES

114. ** PPOOSSTTOOPPEERRAATTIIVVEE TTRREEAATTMMEENNTT ,,
IINNSSTTRRUUCCTTIIOONNSS AANNDD CCAARREE ::
# MEDICATION :
* ANTIBIOTICS :
- GENERALLY NOT NECESSARY UNLESS THERE IS
PREEXESTING INFECTION OR THE ANTRUM OR
NASAL CAVITY HAS BEEN OPENED .
- IF NECESSARY , THEN PRESCRIBE FOR 1 WEEK.
Amoxycillin 500mg tds/5 days or
Cefadroxil 500mg bd/5 days or
Metrogyle 400mg tds/5 days
* ANALGESICS :
-- PPRREESSCCRRIIBBEE TTHHEE AANNAALLGGEESSIICC DDRRUUGGSS FFOORR RREELLIIEEVVIINNGG
FFRROOMM TTHHEE PPAAIINN
BBrruuffeenn 440000mmgg ttddss//55ddaayyss oorr
DDiicclloopphheennaacc ssooddiiuumm 5500mmgg ttddss//55 ddaayyss

115. # IINNSSTTRRUUCCTTIIOONNSS AANNDD CCAARREE ::
11 )) PPAATTIIEENNTT IISS AADDVVIISSEEDD NNOOTT TTOO EEAATT NNOORRMMAALL
DDIIEETT FFOORR 11 00RR 22 DDAAYYSS
-- SSHHOOUULLDD BBEE IINNSSTTRRUUCCTTEEDD TTOO DDRRIINNKK
PPLLEENNTTYY OOFF FFLLUUIIDDSS IINN TTHHEE FFOORRMM OOFF MMIILLKK,,
JJUUIICCEESS ,,TTEEAA,, eettcc..
22 )) AAVVOOIIDD TTOO CCOONNSSUUMMEE HHOOTT && HHAARRDD FFOOOODD //
DDRRIINNKK .. AADDVVIISSEE TTOO CCOONNSSUUMMEE CCOOLLDD &&
SSOOFFTT DDIIEETT ..
33 )) CCOOLLDD AAPPPPLLIICCAATTIIOONN ::
-- AADDVVIISSEE CCOOLLDD AAPPPPLLIICCAATTIIOONN TTOO TTHHEE FFAACCEE
IINNTTEERRMMIITTTTEENNTTLLYY (( 3300 mmiinn.. OONN ,, 3300 mmiinn.. OOFFFF))
FFOORR FFIIRRSSTT 2244 TTOO 4488 hhrrss ;; PPRREEVVEENNTTSS
DDIISSFFIIGGUURRIINNGG SSWWEELLLLIINNGG AANNDD
PPOOSSTTOOPPEERRAATTIIVVEE EEDDEEMMAA..

116. -- IIFF SSUURRGGEERRYY WWAASS PPEERRFFOORRMMEEDD OONN TTHHEE
PPAALLAATTEE,, TTHHEE MMAAYY DDIISSSSOOLLVVEE SSMMAALLLL PPIIEECCEE
OOFF IICCEE IINN TTHHEE MMOOUUTTHH..
TTHHIISS DDEECCRREEAASSEESS AANNYY IINNFFLLAAMMMMAATTOORRYY
RREEAACCTTIIOONN TTHHAATT MMAAYY OOCCCCUURR ..
44 )) HHOOTT MMOOIISSTT AAPPPPLLIICCAATTIIOONN ::
-- AAFFTTEERR CCOOLLDD AAPPPPLLIICCAATTIIOONN ,, IIFF SSWWEELLLLIINNGG IISS
SSTTIILLLL PPRREESSEENNTT ,,AAFFTTEERR TTHHAATT HHOOTT MMOOIISSTT
CCOOMMPPRREESSSSEESS SSHHOOUULLDD BBEE UUSSEEDD IINN TTHHEE SSAAMMEE
MMAANNNNEERR UUNNTTIILLIITT RREESSOOLLVVEESS..
THIS WILL ALSO HELP TO REDUCE
ANY DISCOLORATIONOF THE SKIN
RESULTING FROMBLEEDING INTO THE
TISSUE .
5 ) AVOID VIGOROUS RINSING OF THE MOUTH
FOR 8 TO 12 hrs. POST OPERATIVELY .

117. - AFTER THAT , THEY SHOULD RINSE AT
LEAST 4 TO 6 TIMES DAILY,
PARTICULARLY AFTER MEALS, AND
BRUSHTHEIR TEETH USUAL.
6 ) ADVISE MOUTH WASH :
THE BEST MOUTH RINSE IS A WARM
SALINE SOLUTION ( ½ teaspoon of salt to a glass
of water ) .
- CAN BE FOLLOWED BY A FLAVORED
MOUTH WASH – DILUTED AT LEAST 50% WITH
WATER BECAUSE MOST CONTAINS AGENTS
THAT CAN BE IRRITATING THE HEALING
WOUND.
- AVOID HYDROGEN PEROXIDE CONTAINING
MOUTH WASH DURING FIRST 5 to 7 DAYS
BECAUSE IT CAN DISSOLVE BLOOD CLOT

118. 7 ) DISCOURAGE THE PATIENT FOR SMOKING
AT LEAST FOR 5 DAYS AFTER SURGERY
BECAUSE SMOKING INCREASES THE
INCIDENCE OF ALVEOLAR OSTEITIS [ DRY
SOCKET ] .
8 ) ADVICE TO LIMIT THE ACTIVITY FOR AT
LEAST HE REMAINDER OF THE DAY .
IF THE PATIENT WISH TO LIE DOWN,
THE HEAD SHOULD BE ELEVATED ON
SEVERAL PILLOWS – BECAUSE A SUPINE
POSITION INCRESES HYDROSTATIC
PRESURE AND CAN CAUSE BLEEDING.
9 ) IF OOZING OF BLOOD OCCURS , CAN BE
CONTROLLED BY HAVING THE PATIENT BITE
FIRMLY FOR 30 min. ON A PAD OF STERILE
GAUZE .
- IF STILL CONTINUE /EXCESSIVELY OCCURS,
CONSULT THE DOCTOR IMMEDIATELY .

119. * COMPLICATIONS *
(1) INTRAOPERATIVE COMPLICATIONS:-
# DURING INCISION:-
* FOR UPPER CANINES - INCISIVE OR GREATER
PALATINE VESSELS
MAY BE DAMAGED
* FOR LOWER CANINES – MENTAL VESSELS MAY
BE DAMAGED.
# DURING BONE REMOVAL:-
* DAMAGE TO THE ROOTS OF OVERLYING TEETH
* SLIPPING OF THE BUR INTO THE SOFT TISSUES.

120. * POSTOPERATIVE
COMPLICATIONS *
* PAIN
* SWELLING
* SECONDARY HEMORRHAGE
* INFECTION
* DRY SOCKET
* POST EXTRACTION PYOGENIC
GRANULOMA
* TRISMUS
* LOSS OF VITALITY OF
NEIGHBOURING TOOTH

121. • IMMEDIATE :
- DAMAGE TO ADJACENT
STRUCTURES
- DIFFICULT TO ACCESS
• DELAYED :
- INFECTION
- WOUND DEHISCENCE
• LATE :
- PULP NECROSIS
- PERIODONTAL PROBLEMS
- PARESTHESIA

122. *CAUSES FOR POOR PROGNOSIS *
- HORIZONTAL
- HIGH PALATE
- HIGH LABIAL (if above adjacent)
- TRANSEALVEOLAR (apex on one
side , crown on the other side of alveolus)
- SCLEROTIC BONE
- CLOSED APICES
- ABNORMAL ROOT CONFIGURATION
- OLD AGE

123. THANK YOU .. !!