Order of frequency
Maxillary third molar impactions
Indications,Contraindications for removal
Degree of difficulty
steps for removing impacted teeth
Maxillary canine impaction
Impaction is the cessation of the eruption of a tooth
caused by a clinically or radiographycally
detectable physical barrier in the eruption path or
by an ectopic position of the tooth. Andreasen et al
Archer (1975) defines impacted tooth as one which
is completely or partially unerupted and is
positioned against another tooth or bone or soft
tissue so that its further eruption is unlikely
ORDER OF FREQUENCY
1. Mandibular 3rd molars
2. Maxillary 3rd molars.
3. Maxillary cuspids.
4. Mandibular bicuspids.
5. Mandibular cuspids.
6. Maxillary bicuspids.
7. Maxillary central incisors.
8. Maxillary lateral incisors.
1. Based on state of eruption
Within the bone
Immediatey beneath the soft tisses
2. Based on Angulation
Vertical – 63 %
Mesioangular - 25 %
Laterally displaced with the crown facing the
cheek,horizontal,inverted,and transverse positions -
Aberrant position associated with pathologial
condition such as cyst.
3. Based on the depth: (Pell and
Position A - highest point of 2nd
molar and highest point of
impacted 3rd molar is in line.
Position B - highest point of 3rd
molar is in between plane of
occlusion and cervical line.
Position C - highest point of 3rd
molar is below cervical line.
4.Based on relationship of the impacted max
3rd molar to the maxillary sinus
Sinus Approximation (S.A) no bone or a thin
partition of bone between the impacted tooth
and the maxillary sinus.
No Sinus Approximation (N.S.A) 2 mm or more
5. Based on nature of roots
Indications for removal
Malplaced tooth which causes the patient to adopt a
convenience bite to avoid cheek biting.
Tooth involved in pathogical process like cyst,
Buccaly erupting tooth which causes impinging on the
Interference with placement of prosthesis.
Local Contraindications for removal
Symptomless tooth completely embedded in bone
Tooth positioned high in alveolus-Risk of displacing
tooth into max antrum
Deeply impacted tooth – removal may cause
damage to adjacent structures.
Degree of difficulty
Angulation - opposite to mandibular 3rdmolar.DA < V
< MA. In MA impactions,bone in distal region is more
and dense with less accessability.
Buccoangular position:more buccal more easy,less
bone removal needed.
Type of overlying tissue - Easier if soft tissue
Sinus poximity – Chance of oro antral communiation.
Poximity to tuberosity – chance of fracture.
Tooth with thin,curved,hypercementosed roots
Tooth with wider periodontal space,follicular space –
Presence of large restoration on second molar.
STEPS FOR REMOVING IMPACTED TEETH
1. Adequate exposure of the area-flap
2. Bone removal.
3. Sectioning of tooth.
4. Tooth delivery.
5. Cleaning ,debridement and closure of wound.
releasing incision from
the mesial aspect of 2nd
Envelope flap - starts
from the mesial aspect
of 1st molar
Palatal diagonal flap - Dr. Lee Darichuk (2005)
• Gives excellent unrestricted access to the maxillary
tuberosity region.The Laster (Surgical Science, Toronto, Ont.)
and the Minnesota (Hu-Friedy, Chicago),cheek retractors
both provide good access to the tuberosity region and
prevents displacement of tooth
Removal of overlying bone
The aim of bone removal is to visualize most of the
crown of the tooth and establish access for extraction
Restricted to occlusal and buccal aspect of tooth down
to cervical line with bur or chisel.
Purchase point is made on the mesial aspect of the
tooth above the height of countour.This can be
accomplished using chiesel with hand pressure as
maxillary bone is thin.
Tooth sectioning and delivery
Sectioning should be avoided and considered only
as a last resort as small fragments can be
displaced into the sinus or infratemporal fossa.
Delivery of the tooth is achieved by using small strt
elevator like 301 elevator with a distobuccal force.
Further elevation and delivery by angled
elevators, such as the Potts or Miller elevators.
The practitioner should be careful with the forces
directed superiorly or posteriorly because of the
presence of the maxillary sinus and tuberosity
The tooth is delivered with straight elevators applied on
the mesiobuccal with rotational and lever types of
motions.The tooth is always delivered in a distobuccal
and occlusal direction
Farish and Bouloux (2007) advice the use of
Minnesota retractor or periosteal elevator to be
placed distal to 3rd molar so that it wil not be
displaced under the flap and into the infratemporal
Should not apply excessive pressure anteriorly to
avoid damage to the root of the 2nd molar.
As force is applied to displace the tooth posteriorly,
the surgeon should have a finger on the tuberosity
(especially in MA impcn) to detect tuberosity
Debridement and closure
Upon completion, thorough examination of the
socket followed by irrigation of the area beneath the
flap is advised so as to flush any and all debris.
Suturing is not essential for max 3rd molars as
gravity and surrounding soft tissues favour wound
Displacement into maxillary sinus
• If entire tooth is displaced it should be removed as
early as possible to prevent infection.
• According to Pogrel (1990) initial attempt should be
with a suction at the opening, if It fails irrigate with
saline again use suction.if again fails place the
patient on antibiotics and nasal decongestants and
plan caldwell Luc approach.
Dislodged into soft tissues
Usually to buccal soft tissues and infratemporal
The tooth should be removed as early as possible
to avoid infection.
Put an incision and try to retrieve with a hemostat
or allis forceps.if it is not possible wait till fibrosis
occurs and tooth become stable.and place the
patient under antibiotic coverage.
Damage to adjacent 2nd molar-during bone
removal and elevation.
Fracture of maxillary tuberosity – If the operator
anticipates such a fracture, avoiding reflection of
the periosteum will preserve the blood supply
and will provide the best chance of survival
If the overlying tissue has been reflected and a
fracture is noted, removal of the fractured
segment is advocated to prevent infection.
Oro antral fistula – Rare complication once
detected should be repaired as soon as possible.
Prolapse of buccal fat pad –because of wrong
incision. Management by pushing the prolapsed fat
back into the cheek and giving a suture.
MAXILLARY CANINE IMPACTION
Permanent max canine is considered impacted
when its eruption is retarded in relation to the
normal eruption sequence
Incidence 1-3 % of general population,Twice in
women than men,5 times more in caucasians than
asian.85% palatally and 15% labially.
Deleyed resorption of deciduous teeth,trauma to its
bud,disturbances in eruption sequence,arch length
descrepancy ,rotation of tooth bud,premature root
closure,endocrine disturbances ,vit D
deficiency,cleft lip and cleft palate.
Guidance theory: Distal aspect of lateral incisor root
act as a guide to allow the canine to erupt into
Genetic theory : impacted canines are usually seen
associated with other anomalies of tooth and these
are genetically related.
CLASSIFICATION OF IMPACTED MAXILLARY CANINES
By Archer (1975)
Class I : palatally placed maxillary canine
Class II : Labially placed maxillary canine
Class III : Involving both buccal and palatal bone
Class IV : Impacted in the alveolar process
between the incisors and the first premolar
Class V : Impacted in the edentulous maxilla
Based on the location:-
1. Labially or palatally placed.
2. Intermediate position
i. Crown between lateral incisor and premolar.
ii. Crown above root tip with labial or palatal
orientation of lateral incisor or premolar.
3. Aberrant position: Impacted maxillary canine lie in
maxillary sinus or nasal cavity.
SEQUELAE OF CANINE IMPACTION
Resorption of adjacent teeth-incisors-most common
Poclination of lat incisor - due to pressure from
Cyst – dentigerous cyst or adenoameloblastoma
Loss of vitality of incisors
LOCALIZATION OF IMPACTED CANINE
over retained primary canine, Lack of canine
prominence in the buccal sulcus, inclined lat incisor,
swelling in either labial or palatal side of arch.non
vital or mobile lat incisors.
palpable protuberance of the area designates the
position of the tooth quite accurately.
Accurate methods – CAT,CBCT ,3D imaging
Plane radiographs – OPG, Occlusal radiography,
Anteroposterior and lateral radiographic views
For localisation using conventional radiographs 2
pinciples are used
Parallax technique or cone shift
Degree of magnification - objects away from film wil be
more magnified for a given focal spot film distance.buccal
Parallax technique or cone shift (Clark)
Parallax in horizontal plane - taking 2 peri apical
radiographs at 2 diff horizontal angle and with
same vertical angle.Due to parallax lingual object
moves in the same direction of tube shift and
buccal opposite.(SLOB rule )
Parallax in vertical plane –different vertical
angulation bt same horizontal
Occlusal view - shows buccal or palatal
OPG – shows vertical and mesiodistal relationship
Lateral skull view – vertical height and antero
posterior position of the canine
Depends on age of the patient, stage of root
formation, presence of pathology, condition of
adjacent teeth, position of tooth, patient’s
willingness to undergo orthodontic treatment,
physical health etc.
Extraction of deciduos canine – for palatally
impacted canines of age group 10 -13. it may erupt
if local space conditions are favorable.
Surgical exposure of the tooth –if sufficient
space for eruption available and root formation is
Surgical exposure and orthodontically assisted
eruption -for favorably impacted canine and pt who
is willing for ortho treatment.
Surgical removal of the impacted tooth - tooth in
unfavorable position and which are likely to create
Surgical removal with orthodontic space
Surgical removal with prosthetic replacement
No treatment – completely formed canine without
any pathology and well above the apices of
adjacent teeth esp in an elderly individual can be
left alone.regular check up needed.
Surgical repositioning or auto transplantation
impacted canine with a favorable root pattern can
be tried to be transplanted into the socket of
deciduous canine or 1st premolar.
SURGICAL REMOVAL OF PLATALLY IMPACTED
Flap design – bilateral palatal flap-
The incision for creation of the flap begins at the
first or second ipsilateral premolar and, after
continuing along the cervical lines of the teeth,
ends at the first premolar on the contralateral side
Bone removal and delivery
Bone is removed around the tooth with a chisel or a
round bur or both taking care not to damage the
roots of adjacent teeth.
once sufficient bone is removed a groove is made
on the mesial side.
Introduce elevater into the groove and luxate tooth.
Upper anterior or premolar forceps is used to
remove the tooth.
If the tooth is resistant to elevation do tooth
A groove is created on the cervical line of the tooth
using a fissure bur and, after placing the elevator
blade in the groove created, the instrument is
rotated until the crown is separated from the root .
The crown is then removed, and, after using the
round bur to create a purchase point on the root it
The bone edges are smoothed, and the area is
thoroughly irrigated,The flap is repositioned and
sutured with interrupted sutures
Sectioning of an impacted tooth at the cervical line and
separation of the crown from the root
Placement of the straight elevator in the groove created to
separate the crown from the root and removal of
Damage to adjacent teeth
Hematoma under palatal flap may cause infection
Necrosis of palatal flap
Perforation of the floor of the maxillary sinus or
SURGICAL REMOVAL OF LABIALY IMPACTED
Flap design – trapezoidal or semilunar incision is
created and the mucoperiosteum is then reflected.
The bone covering the tooth is removed using a
round bur, with a steady stream of saline solution,
until the entire crown of the tooth and part of the
root are exposed
A groove is then created at the cervical line using a
fissure bur, in order to separate the crown from the
A round bur is used to
remove the bone covering
the crown of the tooth
Complete exposure of the
crown of the tooth
and part of the root
Sectioning of the crown–
root at the cervical line
of the tooth, using a fissure
Tooth after sectioning
Separation is achieved using a straight elevator,
which is placed in the groove. Upon rotation, the
instrument separates the tooth into two segments.
The crown is removed first and the root is then
luxated, after creating a purchase point on the
surface of the root.
After smoothing the bone, the area is thoroughly
irrigated with saline solution, and the wound is
Removal of the crown of the
using a straight elevator
Root of the tooth after
removal of the crown
Purchase point created on
the root for placement
of the elevator blade
Luxation of the root using a
Final step of root extraction
Removal of follicle using a
hemostat and periapical
Smoothing of the bone
edges of the wound using
a bone file
Surgical field after suturing
An impacted tooth that fails to attain a functional
position can cause infection, cysts, tumours,
unrestorable caries, periodontal disease,
In such situation surgical removal is indicted.the
surgeon should consider patient’s overall health
status and potential risk of complications prior to
The atraumatic removal of the impacted teeth is the
most commonly performed surgical procedure in
oral & maxillofacial surgery.
A Practical Guide to the Management of Impacted
Teeth – by Dr K George Varghese
A synopsis of minor oral surgery –G Dimitroulis
Oral Surgery -Fragiskos D. Fragiskos (Ed.)
Contemporary Oral and Maxillofacial Surgery,4th Ed by
Illustrated Manual of Oral and Maxillofacial Surgery -
Geeti Vajdi Mitra
Text Book Of Oral And Maxillofacial Surgery -Neelima