Principles, indications and contraindications of removal of

PRINCIPLES, INDICATIONS AND CONTRAINDICATIONS OF REMOVAL OF IMPACTED TEETHDr Ijaz Khan KCD Peshawar

WHAT IS AN IMPACTED TOOTH?

an impacted tooth is one that fails to erupt into the dental arch within the expected time.

they are retained for the patient's lifetime unless surgically removed..

Possible causes

» Irregularity in the position and pressure of an adjacent tooth. 

» Density of the overlying or surrounding bone. » Chronic inflammation with resultant fibrosis of the

overlying mucosa. » Lack of space due to under developed jaws.

Unduly over retention of the deciduous teeth.  » Inflammatory changes in the bone due to diseases

in children, like, Chicken pox, Parotitis.» Heredity» Malnutrition» Endocrine dysfunctions» Diseases of jaw and surrounding tissue

Which teeth are most commonly impacted?

Impaction In The Following Order Of Frequency» Mandibular third molars.» Maxillary thirds molars.» Maxillary cuspids.» Mandibular bicuspids.» Maxillary bicuspids.» Upper central incisors.» Upper lateral incisors

Classification systems

With careful classification of the impacted teeth using a variety of systems, the surgeon can approach the proposed surgery in an orderly fashion.

The majority of the classifying results from analysis of the radiograph.

1.Angulation

Pro p o s e d by Arche r (1 9 7 5 ) a nd Krug e r (1 9 8 4). This classification system employs a

description of the angulation of the long axis of the impacted third molar with respect to the long axis of the second molar. This can be

1 . Me s io a ng ula r, 2 . d is to a ng ula r, 3 . v e rtic a l, 4. ho riz o nta l, 5 . buc c o a ng ula r, 6 . ling uo a ng ula r, 7 . inve rte d

2.Relationship of tooth to anterior border of ramus

This type of classification is based on the amount of impacted tooth that is covered with the mandibular ramus. It is known as the Pell and Gregory classification, classes 1,2 and 3

3.Relationship of tooth to occlusal plane The depth of the impacted tooth compared with

the adjacent second molar gives the basis for this type of classification. This was also given by Pell and Gregory and is called as Pell and Gregory A,B and C classification.

What are indications for removal of impacted teeth?

If impacted teeth are left in the alveolar process, it is highly probable that one or more of several following problems will result. To prevent this, impacted teeth should be removed

Prevention of Periodontal Disease

Because the most difficult tooth surface to keep clean is the distal aspect of the last tooth in the arch, the patient may have gingivitis with apical migration of the gingival attachment leading to peridontitis and Presence of deep periodontal pockets as shown in figure

Prevention of Dental Caries

 When a third molar is impacted or partially impacted, the bacteria that cause dental caries can be exposed to the distal aspect of the second molar, as well as to the third molar

Prevention of Pericoronitis  

 Pericoronitis is an infection of the soft tissue around the crown of a partially impacted tooth and is caused by the normal oral flora

It can be mild to very severe associated with trismus, high fever, pain, swelling, bad breath.

Prevention of pericoronitis can be achieved by removing the impacted third molars before they penetrate the oral mucosa and are visible.

Prevention of Root Resorption  Occasionally, an impacted tooth causes

sufficient pressure on the root of an adjacent tooth to cause root resorption

 Impacted Teeth under a Dental Prosthesis After teeth are extracted, the alveolar process

slowly undergoes resorption.The denture may compress the soft tissue on the impacted tooth, which is no longer covered with bone; the result is ulceration of the overlying soft tissue and initiation of an odontogenic infection

Removal of impacted tooth must occur before prosthesis construction,otherwise, the alveolar ridge may be so altered by the extraction that the prosthesis becomes unattractive and less functional

Prevention of Odontogenic Cysts and Tumors

Although in most patients the retained dental follicle associated with impacted tooth maintains its original size, its cystic degeneration may occur and become a dentigerous cyst or keratocyst

odontogenic tumors can arise from the epithelium contained within the dental follicle e.g ameloblastoma.

Fig showing radiolucencies

Prevention of Fracture of the Jaw

  An impacted third molar in the mandible occupies space that is usually filled with bone. This may weaken the mandible and render the jaw more susceptible to fracture

Facilitation of Orthodontic Treatment Lack of room in the arch is possibly the most

common indication for extraction, primarily of impacted and semi-impacted third molars of the maxilla and mandible.

It is recommended that impacted third molars be removed before orthodontic therapy is begun, since they may interfere with treatment..

Obstruction of the Normal Eruption of Permanent Teeth. Impacted teeth and supernumerary teeth

often hinder the normal eruption of permanent teeth, creating functional and esthetic problem

Prevention of pain of unexplained origin. Impacted teeth may be responsible for a

variety of symptoms related to headaches and various types of neuralgias

Symptoms may subside after the removal of the offending tooth, which basically involves ectopic impacted teeth, pressurizing the nerve endings.

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