BY: KARISHMA ASHOK [IV/I ] ROLL NO: 33 IMPACTED MAXILLARY THIRD MOLARS & CANINE
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BY: KARISHMA ASHOK [IV/I ] ROLL NO: 33IMPACTED MAXILLARY THIRD MOLARS &CANINE
INTRODUCTION
2nd largest bone of face
2 maxillae forms whole of upper jaw
Each maxilla contributes in formation of FaceNoseMouth OrbitInfratemporal fossaPterygopalatine fossa
BODY OF MAXILLA
Shape pyramidal
Each maxilla has A body4 processes frontal zygomatic alveolar palatine
It has Base directed medially at nasal surfaceApex - directed laterally at zygomatic process4 surfaces anterior / facial posterior / infratemporal medial / nasal superior / orbitalEncloses a cavity maxillary sinus
TERMINOLOGIESUnerupted teeth: tooth in the process of eruption & is likely to erupt.
Impacted teeth: that has failed to erupt completely or partially to its correct position in the dental arch &its eruption potential is lost.
More common in females than males, in maxilla than in mandible and on right side than left.
Frequency of impactionmandibular 3rd molarsmaxillary 3rd molarsmaxillary cuspidmandibular bicuspidsMaxillary bicuspidsMandibular caninemaxillary central and lateral incisors
EtiologyLocal causes:Density of overlying boneLack of space due to undedeveloped jawsObstruction-Over-retained deciduous toothThick fibrous alveolar mucosaCyst/tumorsDialcerationEctopic tooth eruption
Systemic causes:Pre-natal: heredityPost-natal: factors that interfer with development-RicketsMalnutritionanaemiaRare conditions:Cleft liposteoporosis
Indications for removalInfectionCariesPeriodontal diseasesDentigerous cystExternal resorptionProphylactic removal
PERICORONITISPericoronitis was found to be common in vertical (23.0%) followed by mesioangular (15.0%), distoangular(8.0%) and horizontal angulatio(3.0%).Common in females than malesStreptococcus Viridans is the most common facultative isolate.
Clinical featuresMarkedly red, swollen suppurating lesion
Marked tenderness
toxic systemic complications - fever, leukocytosis and malaise.
Contraindications Teeth which can be used as abutments of FPDAge (Longer recovery periodsDifficult - more densely calcified boneBone removal more due to reduced PDL spaceLonger healing time )Medical history Deeply impacted teeth; in relation with vital structures (vessels, sinus)
Classifications Based on nature of overlying tissueSoft tissueHard tissueSIGNIFICANCE - Each type of impaction has some definitepath of withdrawalof theteeth.
Winters classification:
Pell & Gregorys classification
Relationship with occlusal plane
Sinus approximation
Clinical Assesment GeneralSystemic disordersRadiation therapyAge
Extra oral:
Signs of swelling & redness of the cheek. Lymph node - enlargment & tenderness.Anesthesia or paraesthesia of lower lip.
Intra oral:State of eruption of tooth, signs of pericoronitisCondition of 1st & 2nd molarsElasticity of oral tissues
RadiographicINTRA ORAL RADIOGRAPHSIOPAOcclusal
EXTRAORAL RADIOGRAPHSOPGLateral cephalometric
DIGITAL IMAGINGCTCBCT
LOCALIZATION TECHNIQUES: -Buccal object rule (SLOB) -CBCT(3D)
ARMAMENTARIUMAnasthetic syringe and catridgesMouth mirror Tissue forceps ; retractorsCurved scalpel Periosteal elevatorsBurs ; bone filesChisels ; rongeursIrrigation syringe Forceps Elevators Suture material ; needle holder Hemostats
SURGICAL REMOVALAnasthesiaIncision and flapBone removalSectioningElevationTooth removalWound toilet and closure
Flap
Bone removal
To remove the bone obstructing the pathway for removal of the impacted tooth.Bone should be removed till we reach below the height of contour, where we can apply the elevator.
Tooth sectioningRationale of tooth sectioning is to create a space into which impacted tooth can be displaced & then removed.Impacted maxillary teeth are rarely sectioned, because the overlying bone is relatively thin & elastic.Also, in no case should a chisel be used, for it may cause displacement of tooth in the sinus.Sectioning when done, is done at the cervical line.
Wound debridement and closurePeriapical curettage.Smoothening of sharp bony margins by Bone file / burs.Thorough irrigation of the socket with Betadine solution + Saline .Suturing
Management of maxillary canine impaction
Assesment
Amount of space available in dental arch for impacted canine is assessed in model.Study model analysisGives clue of position of impacted tooth.Morphology of adjacent toothCanine bulge present buccally or palatally.Contours of adjacent alveolar boneRoot resorption. Mobility of adjacent tooth
FACTORS INFLUENCING THE TREATMENT DECISION OF AN IMPACTED CANINE
Age of patient
Suitability of 1st premolar to replace a permanent caninePatient motivation for orthodontic applaincesGeneral dental health and oral hygieneRadiographic position of canineAvailability of space
Treatment options
monitoringInterceptive removalSurgical exposure with orthodontic tractionautotransplantationSurgical removal
FLAP DESIGN:canine is located buccally-Angulated flap
canine is high & buccally Semilunar flap
Labial impactionInitial orthodontic treatment was aimed at creating space in the maxillary arch with fixed appliance therapy.Surgical exposure and orthodontic traction.
Flap is elevatedAttachment placed on impacted toothLigature or chain placed over the attachment to activate after a weekRaised flap is repositioned in its original locationPermit eruption of impacted canine in normal direction
Complications 1. During incision a. Injury to facial arteryb. Injury to lingual nerve
2. During bone removal a. Damage to second molar b. Slipping of bur- soft tissue injury c. Extra oral/ mucosal burns d. Fracture of the mandible when using chisel & mallet e. Subcutaneous emphysema
3. During elevation or tooth removal
a. Luxation of neighbouring tooth/ fractured restorationb. Soft tissue injury due to slipping of elevatorc. Forcing tooth root INTO MAXILAARY SINUS or BUCCAL SPACE d. Breakage of instruments
Post-operative ComplicationsImmediate- Hemorrhage- Pain- Edema- Drug reactionDelayed - Alveolitis- Infection
Displacement of tooth into maxillary sinus
patient complains of mild pain and heaviness in the left maxillary sinus area and the left maxillary sinus was tender on palpation. maxillary sinus was exposed through a Caldwell-Luc approach. The sinus was irrigated with sterile saline solution under pressure and the tooth was removed only by negative pressure of the suction pump
DISPLACEMENT INTO BUCCAL SPACE
CT image of the case depicting the displaced tooth between the buccinator and masseter muscle in the buccal space..3D CT image of the displaced maxillary third molar seen as localized obliquely in front of the anterior border of the ramus of the mandible in the buccopalatine direction.