Impacted teeth

IMPACTED TEETH

Dr Samreen YounasPGR FCPS OMFSKing Edward Medical University Lahore

OUTLINE

Definition Theories of impaction Classifaction Indicatiions and contraindications Steps of extracton Canine impaction Complications

DEFINITION :-

is a tooth that fails to erupt into its normal

functioning position in the dental arch within

the expected time. The term Unerupted includes bothimpacted teeth and teeth that are in

theprocess of erupting.

THEORIES OF IMPACTIONTHEORIES OF IMPACTION

ORTHODONTIC

Jaw growth and

movement of teeth

PHYLOGENICDisuse

causes slow atrophy of

organ

MANDELIAN

Heredity

PATHOLOGICAL

Chronic infections

ENDOCRINEGrowth

Hormone

LOCAL CAUSES1. Inadequate space 2. Inclination 3. Obstruction of tooth eruption – Irregularity in position &

presence of an adjacent tooth , Density of the overlying & surrounding bone , Cysts & tumours, Odontomes, Supernumerary teeth

4. Retained deciduous teeth5. Ankylosis of primary or permanent teeth6. Dilaceration of roots(trauma)7. Ectopic position of tooth bud8. Non absorbing alveolar bone

SYSTEMIC CAUSES

Prenatal causes -Hereditary

Postnatal causes – Rickets, anaemia, tuberculosis, congenital syphilis, malnutrition

Endocrinal disorders – Hypothyroidism, hypopituitarism, achondroplasia (Due to lack of osteoclastic activity)

Hereditary linked disorders – Osteopetrosis, Cleidocranial dysostosis, Cleft palate.Down syndrome, Hurlers syndrome,  Gardner’s syndrome, Aarskog syndrome, Zimmerman-Laband syndrome and Noonan’s syndrome,

FREQUENCY OF IMPACTIONMandibular 3rd molar

Maxillary 3rd molar

Maxillary cuspid

Mandibular cuspid

Mandibular premolarMaxillary premolarsMaxillary central and

lateral incisors

CLASSIFICATION

MAANDIBLE

Mesioangular

43%Horizontal

3%Vertical

38%Distoangul

ar6%

Disangular25%

Vertical63%

Mesioangular12%

MAXILLA

PELL AND GREGORY

Class 1

Class 2 Class 3

Relation to anterior Ramal border

PELL AND GREGORY

Relation to occlusal plane Class A

Class B Class C

ADA-AAOMS CLASSIFICATION 07220- Soft tissue impaction.

07230- Partially bony impaction.

07240- Completely bony impaction.

07241- Completely bony impaction with

unusual surgical complications.

DIFFICULTY INDEX

WINTER’S LINES

White line: It indicates the difference in occlusal level of second and third molars.

Amber line; This line denotes the alveolar bone covering the impacted tooth and the portion of the tooth not covered.

Red Line: It indicates the amount that will have to be removed before elevation. Red line <5mm: extraction - easy, there after every 1mm increase in depth increases the difficulty three folds & if it is >9mm then plan the surgery under GA.

WHARFE’S ASSESMENT

W… Winter’s classification H….Hight of mandible A…Angulation of 2nd molar R… Root shape and morphology F….Follicle development Path of Exit of tooth during

extraction

PEDERSON DIFFICULTY INDEX

DIFFICULTY INDEXMinimal difficult 3-4Mod. Difficult 5-7Very difficult 7-10

Factors that Make Surgery More Difficult Disto-angular impaction Class 3 ramus Class C depth Long thin roots (present in the older patient) Divergent curved roots Narrow periodontal ligament (present in the older patient) Dense, inelastic bone (present in the older patient) Contact with 2nd molar Close to IDN Complete bony impaction

INDICATONS FOR REMOVAL

Pericoronitis

Prevention or

Treatment

Prevention of

Dental Disease

Orthodontic

Consideration

Orthognathic surgery

Prevention of

Odontogenic Cysts

and Tumors

Teeth under Dental

Prostheses

Prevention of Jaw Fracture

Management of

Unexplained Pain

Root Resorptio

n of adjacnet

teeth

NICE(NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE) GUIDELINES ON EXTRACTION OF WISDOM TEETH. The practice of prophylactic removal of pathology-

free impacted third molars should be discontinued .

Surgical removal of impacted third molars should be limited to patients with evidence of pathology, or teeth impending surgery or within field of tumor.

The evidence suggests that a first episode of pericoronitis, unless particularly severe, should not be considered an indication for surgery. Second or subsequent episodes should be considered the appropriate indication for surgery. https://www.nice.org.uk/guidance/GID-TAG525/.../final-protocol

CONTRAINDICATIONS

1. Extremes of age2. Compromised medical status3. Excessive risk of damage to

adjacent structures4. When there is question about future

status of 2nd molar5. Fracture risk of atrophic mandible6. Abutment selection

Pre-Operative Assessment History Clinical examination Radiographic examination INTRAORAL Periapical Occlusal EXTRAORAL For Mandible, OPG, Lateral oblique For Maxilla, OPG, Water’s view CBCT

TUBE SHIFT LOCALIZATIION(Clark) SLOB Rule Same Lingual Opposite

Buccal

Identify buccal or lingual location of impacted teeth.

SEQUENCE OF PROCEDURE1) Isolation.2) Anaesthesia3) Incision- Flap design.4) Removal of overlying bone.5) Sectioning of tooth.6) Delivery of sectioned tooth.7) Smoothening & debridement of socket.8) Arrest of haemorrhage9) Closure of wound.10) Follow up

ENVELOPE FLAP

INCISIONS AND FLAPS L – shaped flap (2nd molar para marginal Flap with vestibular extension

Bayonet – shaped flap (2nd molar sulcus incision With vestibular extension)

Buccal extension Triangular

Ward’s Modified Ward’s

Coma shaped incision

‘S’ shaped incision

VESTIBULAR TONGUE SHAPED FLAP (Berwick,1966)

Extend onto the buccal shelf of the mandible

Incision line doesnt lie over the bony defect created by the removal of the impacted teeth

Its base is distolingual aspect of the second molar

BONE REMOVALThe bone on the occlusal aspect of the tooth is removed first .Then bone on the buccal aspect of the tooth is.

1. Bone should be removed till we reach below the height of contour, where we can apply the elevator.

2. Extensive bone removal can be minimized by tooth sectioning.

SECTIONING OF TOOTH

DELIVERY OF SECTIONED TOOTH

Debridement of Wound & Closure Thorough debridement of the socket . Smoothening of sharp bony margins by Bone

file / burs. Thorough irrigation of the socket . Initial wound closure is achieved by placing

1stsuture just distal to 2ndmolar, sufficient number of sutures to get a proper closure.

IMPACTED CANINE

INCIDENCE

Maxillary canine impaction occurs in approximately 2% of the population.

More common In females than in males Maxillry than mandibular Palatally placed than labially in maxilla Labially placed than lingual in mandible

CLASSIFICATION OF IMPACTED MANDIBULAR CANINE

Labial AberrantVertical At inferior borderOblique On the opposit sideHorizontal

DEPTH OF IMPACTED CANINE

Grade 1: Grade 2: Grade 3: Grade 4:

MANAGEMENT OF IMPACTED CANINE(1) No treatment except monitoring

(2) Interceptive removal of primary canine

(3) Surgical removal of the impacted canine

(4) Surgical exposure with orthodontic alignment

(5) Autotransplantation of the canine

Surgical removal of the impacted canine If it is ankylosed . Root resorption.

Dilacerated root.

If the impaction is severe ,e.g., the canine is lodged between the roots of the central and lateral incisors.

If the occlusion is acceptable, with the first premolar in the position of the canine.

Pathologic changes (e.g., cystic formation, infection)

.FLAP DESIGN:canine is located buccally- Angulated flap

canine is high & buccally – Semilunar flap

Palatally impacted

COMPLICATIONS

INTRA OPERATIVE

1. During incision a. Injury to facial artryb. Injury to lingual nervec. Hemorrhage 2. During bone removal

a. Damage to second molar b. Slipping of bur into soft tissue & causing 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.  Injury to inferior alveolar neurovascular bundled. Fracture of mandiblee. Tooth displacementf. Breakage of instrumentsg. TMJ Dislocation – careful history

POST OPERATIVE COMPLICATIONS Pain Trismus Periodontal defect Echymosis/hematoma Wound dehiscence Infection Dry socket Oroantral fistula Oronasal fistula Loss of vitality of neighboring teeth

NERVE INJURY

IAN: immediate disturbance 1-5%

Lingual N: immediate - 0.4-1.5%

96% IAN injuries show spontaneous recovery within 9 months, better than lingual nerve which is about 87%

Beyond 2yrs recovery is unlikely

DRY SOCKET(2-20%)

DEFINITION“postoperative pain in and around the

extraction site, which increases in severity at any time between 3 and 4days after theextraction accompanied by a partially ortotally disintegrated blood clot within thealveolar socket with or without halitosis.”

.First described by CRAWFORD

SYNONYMS Alveolar osteitis(ao) Alveolitis Localized osteitis Alveolitis sicca dolorosa Localized alveolar osteitis Fibrinolytic alveolitis Septic socket Necrotic socket Alveolalgia

ETIOLOGYSuggested factors include

-Oral micro organisms(Trepanoma denticola) -Traumatic surgery -Roots or bone fragments remaining in the wound -Excessive curettage of the alveolous after

extraction-Physical dislodgement of the clot-Oral contraceptives-estrogens, like pyrogens, will

activate the fibrinolytic system indirectly

-Smoking

SIGNS AND SYMPTOMS

Moderate to severe pain without signs of infection.

Frequently radiates to ear. Exposed bone is necrotic. Socket has a bad odor. Unpleasant taste. Regional lymphadenopathy(occasionally) Trismus

PREVENTION Use of good quality current preoperative radiographs Careful planning of the surgery Use of good surgical principles

Extractions should be performed with minimum amount of trauma and maximum amount of care

Confirm presence of blood clot subsequent to extraction (if absent,scrape alveolar walls gently)

Pre and post op antimicrobial mouth rinses. Topical antibiotics(Tetracyclines)

. Encourage the patient to stop (or)limit smoking in the immediate postoperative period

Advise patient to avoid vigorous mouthrinsing for  the first 24 hr post extraction & to use gentle tooth

brushing.

For patients taking oral contraceptives extractions should ideally be performed during days 23 through 28 of the menstrual cycle

Comprehensive pre- and postoperative verbal instructions.

MANAGEMENT Gentle irrigation with warm saline. Pack iodoform gauze socked with medications

change every other day for 3-6 days. Intra-alveolar medicaments(controversial)

-eugenol

-topical LA

-Balsam of Peru

-antifibrinolytic agents.

Analgesics.

IANI-RISK REDUCING PROCEDURES

RODE’S CRITERIA

Darkening Deflection Narrowing Dark and bifid

Radiological changes in roots

Calcification of inferior alveolar canal is completed before the roots of 3rd molar are formed. Thus growing roots may impinge upon the canal or get deflected.

RODE’S CRITERIARadiological changes in canal

Loss of lines Diversion of canal Narrowing

Coronectomy – oral surgery’s answer to modern day conservative dentistry

A method of removing the crown of a tooth but leaving the roots untouched, which may be intimately related with the inferior alveolar nerve, so that the possibility of nerve injury is reduced.

first proposed in 1984 by Ecuyer and Debien. Also known as intentional partial odontoectomy, partial root

removal and deliberate vital root retention

BASIS FOR CORONECTOMYIt is common practice for broken fragments of the root of vital

teeth to be left in place and most heal uneventfully.

CORONECTOMY

Coronectomy:A, cutting crown below cement-enamel junction (arrow); B, trimming cutted surface to less than 3 to 4 mm below alveolar crest.

FATE AFTER CORONECTOMY

Bone formation over the retained root fragment.

In all cases the root fragments move into a safer position with regard to the nerve and it can be envisaged that should removal become necessary the nerve would not then be at high risk.

Root migration is more in distoangular impaction.

Dry socket can be treated in the conventional manner with irrigation and dressing, if it occurs.

There does not appear to be any need to treat the exposed pulp of the tooth.

CASES TO AVOIDTeeth 1) infected 2) mobile 3) horizontally impacted along the course of the inferior alveolar nerve

DRAWBACKS OF CORONECTOMYRoot walk out during surgery(FAILED CORONECTOMY)Deep periodontal pockets on the distal of the second molar,Delayed postoperative root migration with the possible need of a second procedurePostoperative painDry socketInfection

Postoperative radiograph after the right mandibular third molar was surgically sectioned. The space distal to the second molar would allow mesial migration of the impacted tooth.

Three months after odontectomy. The third molar moved mesially. However, the mesial root was still in contact with the alveolar canal. A second sectioning was required.

Postoperative radiograph after second sectioning of the right mandibular third molar. A pulpotomy has been performed.More space was created distal to the right mandibular second Molar to allow further migration

Periapical radiograph obtained 2 months after second sectioning. At that time, the roots were away from the alveolar canal, and a riskless extraction could be scheduled.

ORTHODONTIC EXTRUSION

1. Risk of direct trauma to IAN is eliminated2. A potential problem with this technique is soft

tissue damage.3. Difficult in working in this area 4. no applicable for ankylosed teeth.5. It is time consuming and not always successful

PERICORONAL OSTECTOMY The removal of the overlying bone to allow for the tooth

to erupt away from the IAN,in cases of incomplete root formation in younger patients 14 to 18 years old

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