3. Definition
An impacted tooth is one that has failed to fully
erupt into the oral cavity within its expected
developmental time period and can no longer
be expected to do so.
5. Commonest affected teeth
• mandibular third molars
• maxillary canines
• mandibular
premolars/canines
• maxillary incisors
• maxillary third molars
• 95% of all teeth that will
erupt are erupted by age
24.
• 75% of mandibular third
molars are impacted
6. Classification Systems
Angulations
Vertical
Distoangular
Mesioangular
Horizontal
Buccal/Lingual
Relationship to anterior border of ramus
Depth of impaction
Nature of overlying tissue
10. Relationship to Anterior Border of
Ramus
(Pell and Gregory)
Class I - adequate room to erupt
Class II - one half covered
Class III- completely embedded
13. Radiographic Assessment
• Minimum of an OPG
• Visualize all the teeth and
adjacent structures
including bone,
morphology and number of
roots, hypercementosis
• Depth of bone around
tooth
• Follicular pathology
14. Other Important Factors
Size of Follicular Sac
Density of Surrounding Bone
Contact with Mandibular Second Molar
Relationship to Inferior Alveolar Nerve
17. Darkening of the root.Darkening of the root.
Deflection of the root.Deflection of the root.
Narrowing of the root.Narrowing of the root.
Dark and bifid root apex.Dark and bifid root apex.
Interruption of the whiteInterruption of the white
line of the canal.line of the canal.
Diversion of the canal.Diversion of the canal.
Narrowing of the canal.Narrowing of the canal.
19. Problem #1 – Soft Tissue
Even with adequate arch length and full eruption,
3rd
molars are often surrounded by thin,
unkeratinized, highly distensible lining mucosa of
the buccal vestibule.
Encourages pathogenic bacteria retention
Poorly withstands hygiene measures
20. Problem #2 – Periodontal
Compromise
Bone loss distal to the 2rd
molar after
removal of the 3rd
molar is controversial, at
best. Even with some loss of bone, the
result is stable and cleansable – the goal of
periodontal therapy.
37. Problem #5 - Infection
Can turn an elective procedure into an
urgent or emergent situation
Unscheduled loss of work
Increased pain and healing time
Compromise of adjacent teeth
Compromise of patient’s systemic health
38. Types of Infection
1. Simple dental caries
and periodontal disease
2. Pericoronitis
3. Abscess
4. Cellulitis
5. Abscess extension into
adjacent fascial spaces
5. Abscess spread to
distant sites
6. Recurrent infections
7. Infections resistant to
initial local and systemic
treatment measures
42. Pericoronitis
A failure of preventive measures
A failure of early recognition, or a failure to
seek proper treatment
A step along the pathway of infection
Pericoronitis should be a warning sign that
initiates immediate and aggressive
treatment with careful observation.
43. Pericoronitis
Features of pericoronitis
Trismus, pain, dysphagia, malaise, bad taste
Signs of inflammation of the pericoronal tissues, with
frank pus from under the operculum
Cheek biting and cuspal indentations on the operculum
Halitosis, food packing
Can progress with systemic symptoms and spread to
adjacent tissue spaces
44. Pericoronitis
• Treatment for pericoronitis
• Local measures
Irrigation, oral hygiene measures
Remove trauma, i.e. Extract upper 8, consider lower 8
later
• General measures
Soft diet, analgesics, antibiotics, admission in
some cases
55. Cysts – A Few Facts
May be prevented by early removal – when
normal dental follicle is still evident.
The pericoronal pocket, or residual follicle,
is responsible for most cystic pathology.
All cystic tissues should be removed and
biopsied.
56. Cysts
Cysts themselves are not catastrophic – the
problem is that we don’t know exactly what
they are until they are histopathologically
examined – which necessitates removal.
All cysts result in bone loss.
Some cysts recur more than others.
57. Problem #9 - Tumors
Benign vs. malignant
Odontogenic vs. non-odontogenic
Each of these factors has important
treatment implications.
69. Problem #12 - Orthodontics
Prevent loss of post-
retention stability
Allow distalization of
2nd
molars
These are
controversial
indications
70.
71. Possible Contraindications to Removal
of Impacted Teeth
• Extremes of age
• Compromised medical
status
• Probable excessive
damage to adjacent
structures
• Asymptomatic teeth
72.
73.
74. Factors that Contribute to Risk
Assessment for Patients
Age
Location of IAN
Body mass index
Drug history
Systemic conditions
Surgical access space
Tongue size
Anesthesia history
Maxillary sinus location
Root contour
Third molar position
Interincisal opening
Health of second molar
Bone mass and density
75. Factors that makes surgery
Less difficult
Mesio-angular position
Class I ramus
Position A depth
Roots ½ to 2/3 formed
Fused conical roots
Wide periodontal ligament
Large follicle
Elastic bone
Separated from 2nd
molar
Separated from inferior
alveolar nerve
More difficult
Disto-angular position
Class III ramus
Position C depth
Long, thin roots
Divergent curved roots
Narrow periodontal ligament
Thin follicle
Dense, inelastic bone
Contact with 2nd
molar
Close to inferior alveolar nerve
Complete bone impaction
76. Presurgical Patient Counseling
• Decision on method of anaesthesia [LA,+/- IV sedation, GA]
• Preoperative warnings of pain, swelling, bruising, possible
hypoesthesia of lip/ tongue ,trismus, diet advice,
• Verbal and written warnings (information sheet), enter into notes,
nursing staff as witness
• Warn patient of post operative complications with a greater than 5%
incidence and permanent complications even if less than 1%
• If patient declines treatment need to be informed of likely long term
problems
77.
78. conclusion
• Emerge between 18-24 yrs in 95% of the
population.
• Fail to develop in 1:4 adults
• 72% mandibular molars impacted
• Decision to remove based on balance of
risks/benefits of retention observation against
risks/benefits of removal.
79. conclusion
• Adequate patient assessment ensuring good case
selection
• More conservative approach
• Essential to give explanation of procedure with its
associated potential complications and
alternatives reinforced with information leaflet
• Details noted for medicolegal reasons
80. conclusion
The third molar controversy is still going-on.
As with all surgical procedures, the surgeon
wants to do surgery, it is his or her
profession!
From a patient point of view, non-surgical
treatment should be the first option in an
asymptomatic environment.
81. Management of impacted
third molars
RemovalRemoval
Risks
•Crowding of
dentition.
• Resorption of
adjacent tooth
and periodontal
status.
• Development
of infection, cyst
and tumor
RetentionRetention
Benefits
•Preservation of
functional teeth.
•Preservation of
residual ridge
Risks
Minor Complications:
•Alveolitis
•Paresthesia
•Trismus
•Fractures
•Hemorrhage
Major
Complications:
Dysesthesia
Bacteremia
Benefits
•Decreased
morbidity in
younger patients
•Therapeutic
control
89. Results
Buccal cortex mean
thickness = 2.3mm at the
first molar
Buccal cortex mean
thickness = 1.7mm at the
third molar
90. At the 3rd
molar site
Linear distance from the IA
canal to the lingual surface of
the buccal cortex = 1.7mm
91. Assessment of the lingual nerve in the third molar
region using MRI
Miloro, JOMS 55:134-37, 1997
Purpose: Determine the precise insitu
location of the lingual nerve in the third
molar region using high-resolution magnetic
resonance imaging
92. Methods
Ten healthy volunteers (20 sites) with mandibular third molars
underwent axial and coronal high-resolution MRI of the
posterior mandible and floor of mouth
Three individuals measure the horizontal and vertical position
of the LN
107. Complications
Factors that may influence the occurrence of complications
Age
Gender “F”
Medical condition
Presence of pericoronitis
Poor oral hygiene
Type of impaction
Relationship to inferior alveolar nerve
Surgical time and technique
Surgeon experience
Use of perioperative antibiotics
Use of topical antiseptics
Anesthetic technique
108. Complications
•Alveolar Osteitis (dray Socket)
•Infection
•Bleeding
•Damage TO adjacent teeth
•Mandibular fracture
•Maxillary tuberosity fracture
•Displacement of third Molars
•Aspiration
•Oro-antral communication/fistula
•IAN/lingual nerve damage
110. Definition of Sensory Disturbances
Paresthesia:
an abnormal sensation, such as burning,
pricking, tickling or tingling
Dysesthesia:
condition in which a disagreeable sensation
is produced by ordinary stimuli
Anesthesia;
state characterized by loss of sensation, the
result of pharmacologic depression of nerve
function or of neurological disease
111. Partial Odentectomy
Indicated if intimate
relationship with IAN
Root should be 3mm
below bone level
Contraindicated if there
is root pathology or
loose tooth
119. AAOMS Workshop on the Management of
Patients With Third Molar Teeth 1993
Little evidence that antibiotics decreases
pain, edema, alveolar osteitis or infection
Lavage of the surgical site reduces risk of
complications
120. AAOMS Workshop on the Management of
Patients With Third Molar Teeth 1993
Tight primary closure increases frequency
and severity of postoperative pain and
swelling
Pericoronitis is a risk factor for alveolar
osteitis and postoperative infection
122. Five Possible Reasons
An infection is present and must be treated
The patient is medically compromised and requires antibiotic
prophylaxis against metastatic infection
Patient or patient’s family demands antibiotics
The standard of care in the oral surgery community is to use
antibiotics
The risk of postoperative infection is high
123. Risk/Benefit Assessment
Incidence of serious infections is low (estimated
risk of 1-5%)
Cost of antibiotic therapy is low
Risk of development of resistant strains of
bacteria is undetectable for individual practitioner
Risk of allergic reaction is higher than risk of
infection
124. JOMS 53:53-60 1995
Piecuch JF et al- A Supportive Opinion
January 1994 survey of Connecticut Society of Oral and
Maxillofacial Surgeons
N=104 (of 122)
58% routinely used antibiotics for surgical removal of fully
submerged (impacted) mandibular third molars in patients
who are not medically compromised
Dose regimens and method of application varied widely
126. JOMS 53:53-60 1995
Zeitler D, A Dissenting Opinion
The low complication rate associated with the procedure
does not support the routine use of antibiotic prophylaxis
The use of antibiotics to decrease the incidence of other
adverse outcomes (alveolar osteitis, or dry socket) has not
been determined to be successful
127. “Antibiotic Therapy in Impacted Third Molar Surgery” Monaco
G, et al, Eur J Oral Sci 107 (6): 437-41, Dec 1999
N = 141 patients
66 patients with 2 gm amoxicillin daily for 5 days
75 patient without antibiotic therapy
No significant difference between groups
Association between smoking, habitual drinking and
increase post op pain and fever
146. Dionne RA. 1999. JOMS. 57:
673-678.
Sample size: 118 subjects
Surgical removal of 2 or 4 impacted third molars with
sedation and local anesthetic
Subjects were questioned 15, 30, and 45 min. after loss
of anesthesia about their pain
152. Analgesic Strategies
Use of long acting local anesthetic does
display a synergistic effect with NSAIDs
Pre-emptive analgesia/anesthesia still
being researched-recent data does not
support presurgical administration for pain
control
154. Esen E, et al, “Determination of the anti-inflammatory effects
of methylprednisolone on the sequelae of third molar
surgery”, J Oral Maxillofac Surg 57(10):1201-6, Oct 1999
N =20
Double blind crossover study
125 mg methylprednisolone vs. placebo
Pain and trismus evaluated
155. Esen E, et al, “Determination of the anti-inflammatory effects
of methylprednisolone on the sequelae of third molar
surgery”, J Oral Maxillofac Surg 57(10):1201-6, Oct 1999
Significant decrease in edema, trismus
and pain in the methylprednisolone group
Normal HPA axis before and after
Plasma cortisol nonsignificant decrease
in both groups
156. Esen E, et al, “Determination of the anti-inflammatory effects
of methylprednisolone on the sequelae of third molar
surgery”, J Oral Maxillofac Surg 57(10):1201-6, Oct 1999
No clinically apparent infection or
disturbance of wound healing
90 % preferred the post operative course
associated with steroid administration
157. What We Don’t Know
What are the
risks/complications/morbidities
when impacted third molars
are not removed?
158. What we do know
Cost in both time and risk exists with third
molar removal in the older adult
159. Increased Costs Associated with Third Molar
Removal in the Older Adult
Increased number of symptomatic post
operative days requiring convalesence
Increased overhead costs due to increase in
surgical complexity
160. Increased Costs Associated with Third Molar
Removal in the Older Adult
Increase in complication management requiring
an increase in the number of office visits
Increase in litigation costs
163. Obligations to observe
Frequency of imaging evaluation
every two years?
every five years?
Frequency of clinical evaluation
regular basis?
only when symptomatic?
164. Conclusions
Elective removal of symptomatic third
molars in older adults is more costly and
engenders greater risk than with
prophylactic removal of third molars
Risks can be reduced with proper surgical
technique
165. Conclusions
Modeling with computer enhanced “virtual
reality” may allow study of predictability
More study is needed as the debate
continues
166. IMPACTED MAXILLARY CANINE
The surgical removal of a deeply seated maxillary canine in relation to
the maxillary sinus and the nasal cavity is one of the most difficult
oral surgical procedures
Frequency :
Maxillary canine is 20 times more than mandibular canine
More frequent in females than males
Palatal impaction is 3 times more than buccal impaction
167. Classification of impacted maxillary canine:
ARCHER,S CLASSIFICATION
Class I
Palatally Impacted canine
a) Horizontal
b) Vertical
c) semivertical
Class II
Buccally impacted canine
a) Horizontal
b) Vertical
c) Semivertical
Class III
Impacted canine located in both the palatal and labial surfaces.
Class IV
Impacted canine located in the alveolar process.
Class V
Impacted canine located in an edentulous maxilla.
168. Contra-indications for the removal of an impacted maxillary
canine:
When it can be brought into normal position either by surgical
repositioning or a combination of surgery and orthodontic
treatment..
Factors complicating the removal of the impacted canine:
Close relationship to the roots of the neighboring teeth.
Intimate relation to the maxillary sinus.
Curvature or hypercementosis of the root.
Difficulty in localization most important factor.
169. SURGICAL REMOVAL OF IMPACTED
MAXILLARY CANINE
Planning the operative procedure
X-ray examination
Classify the impaction
Extent of the flap
Sectioning of the tooth is needed or not
170.
171.
172.
173.
174. Localization of impacted maxillary canine:
clinical examination
Radiographic examination
Clinical examination:
By palpation:
Presence of distinct bulge
Deflection of crowns: mostly of lateral incisors pr
premolars.
Radiological examination:
a) Intra-oral periapical films
b) Occlusal radiographs ( topographical & cross
sectional ): Canine will appear as a round radioapaque
structure.
175. c) Shift sketch technique:
In This technique, the films are in the same
position while the cone is shifted, if the
canine moves with same direction of the
cone , it indicates that it is located far
(palatally), while if the canine moves
opposite to the direction of the cone , it
indicates that it is near (buccally).
176. e) Tomograms:
Sections are taken, if the canine is impacted
buccally , it's tip will appear first , while if
impacted palatally, the apex will appear
first.
179. Object Localization
A periapical film will identify the location of an object vertically
and in a horizontal (mesiodistal) direction. However, we cannot
tell where the object is located buccolingually, since the
periapical film is two-dimensional. Therefore we need another
method for locating objects in a buccolingual direction. The two
primary methods of determining the buccolingual location of
objects are:
Right-Angle Technique (Occlusal projection)
Primarily identifies buccolingual location, but may
also confirm mesiodistal location seen on periapical
Tube-shift Technique (SLOB rule, Clark’s rule)
Utilizes two films with different horizontal or vertical
angulations
180. Right Angle (Occlusal) technique
Right Angle Technique
Once you have identified an object on the periapical
film, you can take an occlusal film with the beam at a
right angle (perpendicular) to the direction of the beam
for the periapical. The beam may also be perpendicular
to the film, especially in the mandible. The occlusal film
below shows that the impacted canine is lingually
positioned.
181. The SLOB rule is used to identify the buccal or
lingual location of objects (impacted teeth, root
canals, etc.) in relation to a reference object
(usually a tooth). If the image of an object moves
mesially when the tubehead is moved mesially
(same direction), the object is located on the
lingual. If the image of the object moves distally
when the tubehead moves mesially (opposite
direction), the object is located on the buccal.
Tube-Shift Localization (Clark)
SLOB Rule
Same Lingual Opposite Buccal
182. For the SLOB rule to work, there must be a
change in the horizontal or vertical
angulation of the x-ray beam as the tubehead
is moved. This change in angulation will alter
the relationship between the object of
interest and the reference object, allowing
you to determine the buccal or lingual
location.
The closer the object to be localized is to the
reference object, the less the amount of
movement of the image of the object in
relation to the reference object.
183. In the diagram at right, the
tubehead is moved, but there is no
change in direction of the x-ray
beam, which results in no change
in location of the object of interest
in relation to reference object (see
below). Moving the tubehead
without changing the beam
direction would often result in a
cone cut , depending on how far
the tubehead is moved (see below
right).
184. premolar molar
For the films above, we know that the tubehead was moved distally from
the premolar to the molar film. The zygomatic process (red arrows) is
located at the distal aspect of the 2nd molar on the premolar film and it is
located over the distal aspect of the 1st molar on the molar film. This
indicates that it moved mesially as the tubehead moved distally. We know
that the zygomatic process is buccal to the teeth and, using the SLOB
rule, it follows that the x-ray beam was directed more mesially on the
molar film (Buccal object moved opposite to tubehead movement).
185. premolar molar
Another way of determining the change in the direction of the beam is to
look at the angulation of the teeth. In the premolar film, the roots of the
teeth are angled distally, indicating that the beam was directed distally
(from the mesial). In the molar film, the roots are more upright or angled
slightly mesially, indicating the beam was directed more mesially (from
the distal). Therefore, the tubehead shifted distally and the beam was
angled in the opposite direction, allowing the use of the SLOB rule (These
films were taken from Slide 3 in the review films to follow).
186. Is the composite restoration on tooth # 8 (arrows)
located on the buccal or lingual?
canine film incisor film
1The restoration is located on the buccal. The tubehead moves mesially
from the canine film to the incisor film (x-ray beam projected more
distally) and the composite moves distally, which is the opposite
direction.
187. canine film
premolar film
The arrow in the canine film is pointing to the gutta
percha in which canal of the maxillary first premolar?
2
The arrow identifies the lingual canal. The tubehead moves
mesially from the premolar film to the canine film (beam
directed more distally) and the gutta percha indicated by
the arrow also moves mesially. (See following slide).
188. PID
PID
lingual
buccal
When the tubehead is moved mesially, with the beam
directed distally, the two canals, which are initially
superimposed (premolar periapical above) will separate. The
lingual canal (red arrow) will follow the tubehead movement
and the buccal canal (blue arrow) will move in the opposite
direction, as seen on the canine film.
189. Is the maxillary second
premolar (arrows) displaced
to the buccal or the lingual?
premolar film molar film
premolar bitewing
3
The tubehead moves distally from the
premolar film to the molar film. The
second premolar also moves distally,
overlapping the first molar more in the
molar film. In moving from the premolar
periapical to the bitewing, the tubehead
moves down and the premolar also
moves down. The displacement is to the
lingual.