EXCISION OF MAXILLARY AND MANDBULAR IMPACTED TEETH
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CONTENTS
Definitions Theories of Impactions Orthodontic Theory Indications Classifications Pre - operative assessment Armamentarium Patient preparation Operative procedure Complications Conclusion www.indiandentalacademy.com
DEFINITION
Tooth which is completely or partially unerupted and is placed against adjacent tooth, bone or soft tissue in such a way that its further eruption is unlikely within arch within expected time
The term “Impacted teeth” includes teeth whose normal eruption is prevented by adjacent teeth or bone, malposed teeth, such as lingually or buccaly to normal arch or in infraocclusion, unerupted teeth past their normal time of eruption - ARCHER (1975)
An impacted tooth is one that fails to erupt into the dental arch within the expected time. The tooth becomes impacted because eruption is prevented by adjacent teeth, dense overlying bone, or excessive soft tissue PETERSON (1982) www.indiandentalacademy.com
IMPACTED TOOTH Which is completely or partially unerupted and is placed in the arch in such a way that its further eruption is unlikely.
UNERUPTED TOOTH Which is in the process of eruption and likely to erupt based on clinical and radiological findings.
EMBEDDED TOOTH Which is completely surrounded by bone and there are no chances of eruption. www.indiandentalacademy.com
THEORIES OF IMPACTIONS ORTHDONTIC THEORY Normally growth of jaws and movement of teeth are in forward direction, anything interfering with such development will cause impactions. Dense bone, pathological conditions causing condensation of osseous tissues interfere with forward movement of jaws Early loss of deciduous teeth cause malposition of permanent tooth and impactions www.indiandentalacademy.com
MENDELIAN THEORY The hereditary plays a role such as transmission of small jaws from one parent and large teeth from other. PHYLOGENIC THEORY OR EVOLUTIONARY THEORY Nature tries to eliminate which is not used and civilization with its changing nutritional habits has practically eliminated The need for large powerful jaws as a result maxilla and mandible size is decreased www.indiandentalacademy.com
CAUSES OF IMPACTIONS
Obstruction in the path of eruption Irregularity in position and presence of adjacent tooth Density of the overlying and surrounding bone Lack of space Ankylosis of primary or permanent teeth Non resorption and over retention of primary teeth Non absorption of alveolar bone Ectopic position of tooth bud Dilacerations of roots (trauma) www.indiandentalacademy.com
Associated soft tissue or bony tumors Habits Systemic diseases prenatal-hereditary diseases post natal- rickets, anemia, TB, syphilis, malnutrion Endocrinal disorders of thyroid parathyroid and pituitary Hereditary linked disorders, Downs syndrome, Hurlers syndrome, cleft palate, cledocranial dysostosis
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INDICATIONS FOR REMOVAL CARIES PERICORNITIS FOOD IMPACTION TMJ DISORDERS PREVENTIVE DENTISTRY NONSPECIFIC PAIN www.indiandentalacademy.com
INDICATIONS FOR REMOVAL FOCI OF INFECTION TRAUMA ORTHODONTIC CONSIDERATION PROSTHETIC CONSIDERATION PATHOLOGY SOCIAL AND ECONOMIC FACTORS
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CONTRAINDICATIONS
HEALTH CONSIDERATIONS EXTREMES OF AGE
PROSTHETIC CONSIDERATION SURGICAL DAMAGE TO ADJACENT STRUCTURES AVAILABILITY OF ADEQUATE SPACE ASYMPTOMATIC DEEPLY IMPACTED TOOTH SOCIOECONOMIC REASONS OR FEAR www.indiandentalacademy.com
CLASSIFICATIONS A) Based on space available between distal surface of second molar and anterior border of ramus of mandible‌ PELL & GREGORY (1933)
Class 1 Impaction Sufficient amount of space is present between the anterior border of ramus and distal surface of the second molar
Class 2 Impaction Space between the anterior border of ramus and distal surface of second molar is less than mesiodistal www.indiandentalacademy.com diameter of crown of third molar.
Class 3 Impaction Most of the third molar is located in the ramus.
B) Based on relative depth of mandibular third molar‌ PELL & GREGORY (1933).
Position A Impaction
Position C Impaction
Occlusal plane of impacted tooth is at the same level as Occlusal plane of second molar
Impacted tooth is below cervical line of second molar
Position B Impaction Occlusal plane of impacted tooth is between Occlusal plane and cervical line of www.indiandentalacademy.com second molar
C) Based on angulations of third molar with respect to long axis of Second molar‌.. WINTER (1926).
Horizontal impaction
Vertical impaction
www.indiandentalacademy.com Distoangular impaction Mesioangular impaction
Buccoangular impaction Winter’s Lines
3
Linguoangular impaction 1
2
1. White line:- Indicate the relative depth of the third molar. 2. Amber line:- Represents thewww.indiandentalacademy.com bone level covering the impacted tooth. 3. Red line:- Indicates amount of resistance & difficulty during impaction.
PRE-OPERATIVE ASSESSMENT A thorough assessment of the difficulties and possible complications which might occur during tooth removal is required. Factors influencing removal of the impacted third molar are: • Age of the patient:-It is difficult to carry out the lingual split technique in patients of higher age group due to the dense and inelastic nature of bone. • Temperament of the patient. • General medical condition. • Presence of infection:--
Infection in the form of pericoronitis should be treated before surgery. Probing with a sterile silver probe under the flap on buccal side for the release of pus, antibiotic therapy may aid in treatment. www.indiandentalacademy.com
• Relation of external oblique ridge to third molar:-If the external oblique ridge is situated behind the tooth access is good, but if the ridge is either alongside or in front of the third molar access is poor and extraction is more difficult. • Radiographic assessment:-To plan impactions accurate radiographs are required to assess the position of whole tooth and its investing structures. - I.O.P.A. radiograph is most suitable film for preoperative assessment. - Extra-Oral lateral oblique view & O.P.G. are also useful in some cases
Position of film packet and angulations of central ray seen from above. www.indiandentalacademy.com a). Average case, b). In presence of a horizontal impaction.
Interpretation of the standardized intra-oral radiograph
Most of local factors causing difficulty during impaction can be diagnosed:-• Access: If radio-opaque line cast by external oblique ridge is vertical access is poor, whilst if it is horizontal access is excellent.
• Shape of crown: Teeth with large square crowns and prominent cusps are more difficult to remove than teeth with small conical crowns and fl cusps. www.indiandentalacademy.com
Texture of investing bone: Size of cancellous spaces and density of bone should be noted. If the spaces are large and bone structure is fine, bone is usually elastic whilst if spaces are small and bone is dense, bone is sclerotic ď Ź Position and root pattern of second molar: ď Ź
A distal tilt of long axis of the second molar may either create or increase tooth impaction of the buried tooth.
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Root pattern of an impacted mandibular third molar: • This may affect both the line of withdrawal of the tooth and point of application of elevator. The presence of roots with conflicting lines of withdrawal may indicate the need of tooth division.
disto-angularly impacted mandibular third molar has hooked roots.
The roots of the tooth have conflicting lines www.indiandentalacademy.com of withdrawal.
‘Tooth impaction’ of three-rooted mesioangularly impacted mandibular third molar
• Inferior dental canal:
A band of decreased radio-opacity crossing the roots and coinciding with the outline of the inferior dental canal indicates that the tooth root is grooved by the inferior dental canal and its contents. If the tooth is seen in close proximity to inferior dental canal, the patient should be warned preoperatively of possible impairment of labial sensation which can be a complication of the extraction.
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In case of close proximity of canal to the apex of tooth, division of the tooth minimizes the risk of damage to canal contents. When preservation of continuity is not possible, the cut ends of canal contents are placed close to each other in the bottom of socket, normal sensation is normally restored to lower lip within 6 months of operation.
a. Mesio-angular impaction of a notched Γ . b. Mesial application of force crushes canal contents. www.indiandentalacademy.com c. Tooth division minimizes the risk of damage to the canal contents.
Scoring details for Wharfe’s assessment
Category
a). Winter’s classification Horizontal Distoangular Mesioangular Vertical
b). Height of mandible 1-30 mm c). Angulations of 3rd molar
31-34 mm 35-39 mm 1-50° 60-69° 70-79°
80-89° www.indiandentalacademy.com 90° +
Score 2 2 1 0
0 1 2 0 1 2 3 4
d). Root shape
Normal Favorable curvature Unfavorable Complex
0 1 2 3
e). Follicles
Normal Possibly enlarged Enlarged
0 1 2
f). Path of exit
Space available Distal cusps covered Mesial cusps covered Both covered TOTAL
0 1 2 3 33
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Pedersen’s difficulty index Classification Value Spatial relationship Mesioangular 1 Vertical 2 Horizontal/transverse 3 Distoangular 4 Position Position A Position B Position C
1 2 3 www.indiandentalacademy.com
Ramus relationship/space available Class I Class II Class III
1 2 3
Total Easy impaction Moderate impaction Difficult impaction
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3-5 5-7 7 - 10
ARMAMENTARIUM
• 5ml. Disposable syringe with 24 gauge hypodermic need
• Injection lignocaine hydrochloride 2% with 1: 2,00,000 adrenalin
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Bard parker knife handle no. 3 with a no. 15 blade. Tongue depressor. Round bur (No. 8). Straight fissure bur Micro motor with straight hand piece. Chisel (4mm and mallet). Howarth periosteal elevator. • Dial’s mucoperiosteal elevator. • Austin’s retractor. www.indiandentalacademy.com
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Browne’s lingual flap retractor. Set of Cryer’s elevators. Coupland’s elevator. Halstead’s curved mosquito artery forceps. Allis tissue forceps. Molt’s curettes. Bone roungers and bone files. Straight and curved scissors. Mayo’s needle holder. 3 - 0 silk suture. Suction apparatus. Indelible marker. www.indiandentalacademy.com
PATIENT PREPARATION Premeditation :-Premeditation of the patient is done with the help of antibiotics, analgesics and sedation.
Chair position:-Should be low enough so that the operator’s right elbow is opposite the patient’s mandible.
Preparation of patient:--
a). Intra oral rinse - preparation of patient starts with a mouthwash to reduce the intraoral bacterial count. b). Draping - drapes in the form of sterile towels under patient head and a towel clip. Exposed portion of face and chin are washed with antiseptic solution. www.indiandentalacademy.com
Sponges:-A curtain sponge is placed to isolate the field of operation if chisel technique is used. Sponge keeps saliva away from the field and fragments and blood away from the throat and eliminates the time loss.
Retractor:--
The assistant should be trained to hold the retractor in the right hand. The tip of retractor is held under the mucoperiosteal flap
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OPERATIVE PROCEDURE 1. Anesthesia 2. Incision and elevation of mucoperiosteal flap 3. Bone removal 4. Tooth removal 5. Wound debridement 6. Arrest of hemorrhage 7. Wound closure 8. Postoperative follow-up www.indiandentalacademy.com
1) Anesthesia:--
Operations for impacted third molars may be performed unde local anesthesia, intravenous sedation or general anesthesia. I case the patient is highly anxious, background sedation with diazepam may be used as an adjunct to local anesthesia.
Intraoral photograph of a horizontally impacted mandibular third molar. www.indiandentalacademy.com
2a). Incision:-- Types of incision which can be given 1. Second molar sulcus incision / envelop flap :
The incision starts on the ascending ramus, following the center of the third molar shelf to the disto buccal surface of the second molar and then extends as a sulcular incision to the mesio buccal corner of the second molar. • It provides adequate exposure for Mesioangular and soft tissue impactions. •
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ď Ź
Incision:-- Types of incision which can be given
2. Second and first molar sulcus
incision / extended envelop flap : ď Ź
This incision differs from the former in that it is extended to the mesio buccal surface of the first molar. Due to this reason, it provides better visibility. It is given where the third molar shelf is well developed and the tooth is lingually placed. www.indiandentalacademy.com
3. Ward’s incision and modified ward’s incision / triangular (three cornered flap) given for partially erupted third molar. 4. L shaped incision / Para marginal flap gives an intact marginal attachment distal to second molar.
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2b). Mucoperiosteal flap:-Flap design should fulfill the following criteria: a) Flap should be full thickness mucoperiosteal flap b) Flap must be of adequate size for access and visualization. c) Should have broad base for adequate blood supply. d) Margins should rest on sound bone after repositioning. e) Should be designated to avoid any injury to local vital structures
Giving the incision www.indiandentalacademy.com
Flap elevation :-A periosteal elevator is inserted in the Mesial relieving incision down to the bone and flap reflected distally to include the papilla between the 2nd and 3rd molar. After buccal flap elevation, lingual soft tissues should be reflected so that at least 5mm. of bone lying behind the tooth must be seen.
Flap elevation www.indiandentalacademy.com
3) Bone removal:-Once an adequate mucoperiosteal flap is raised, bone removal should be accomplished. here are mainly three criteria for bone removal: Bone should be removed to expose the height of contour f the crown of impacted tooth. Bone obstructing the path of elevation should be removed. Enough bone should be removed to create a fulcrum for the engagement of an elevator
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Bone removal
b). Bone removal by bur : --
It is an easy procedure. Patient’s acceptance is good under L.A. The chances of bone fracture are less. Bone healing may be delayed due to over heating and inefficient cooling leading to thermal necrosis. Postoperative edema is more. Chances of developing dry socket are more. Chances of developing postoperative infection are more. It is a relatively easy procedure in case of deeply buried teeth, elderly patients and edentulous jaws. www.indiandentalacademy.com
4)Toothremoval: Once adequate amount of bone is removed, an elevator is applied on the Mesial surface of the tooth or furcation are and the tooth is removed along the path of removal. Care must be taken to support the lower border of the mandibl and cause minimal damage to second molar. But tooth sectioning may be required in some cases.
Tooth elevated
Empty socket www.indiandentalacademy.com
Indications of tooth sectioning: a) When there is a tooth impaction and path of exit is interrupted by the crown of second molar b) When there is unfavorable root morphology resulting in conflicting path of removal. c) To prevent injury to adjacent anatomical structures like inferior alveolar nerves and vessels. d) To avoid the removal of large amount of bone. www.indiandentalacademy.com
Sectioning and removal in various types of impactions :
A) Vertically impacted third molars: After exposure of buccal and lingual bone, a careful inspection is made as to the amount of bone impinging on the distal surface of the tooth. In case: The tooth has straight roots, it can be elevated in a vertical direction and there for it’s only necessary to create space a little larger than the perimeter of the crown. www.indiandentalacademy.com
b) If the roots are curved distally, a considerable amount of bone in the ramus behind the tooth should be removed to tilt the crown or to remove the distal part of the crown to create enough space for turning the tooth distally. ď Ź c) If the roots are curved mesially, the mesial part of the crown should be sectioned to permit the application of an elevator between the alveolar bone and distal surface to tilt the tooth forward. The buccal leverage method can be used by drilling a hole into the buccal surface, over the bifurcation of the roots. ď Ź
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B) Mesioangular impacted third molars: -a) If the tooth has non-fused roots and is in close proximity to the second molar, it is generally split along its long axis with a bibevel chisel inserted in the buccal groove directing the force parallel to the long axis. The distal half of the tooth is then removed with an elevator placed between the split sections, using the buccal plate as a fulcrum.
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b) When the roots are fused, a bur can be used to divide the tooth horizontally at the cementoenamel junction. The crown is removed by inserting a straight elevator under the medial aspect. A Cryer's elevator placed between the roots and the buccal plate is used to luxate them into the space created by the removal of the crown.
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ď Ź
C) Horizontally impacted third molars: -Most third molars in horizontal position require sectioning. The tooth is divided horizontally from the superior aspect. Care must be taken not to penetrate the mandibular canal, which often lies close to the tooth. After the tooth has been sectioned, the crown is removed with an elevator. An apexo elevator may be inserted to disengage the roots but if the roots are firm, it may be required to divide them with a bur and remove each of them separately.
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5) Wound debridement: -• The follicle which surrounds the tooth should be curetted out from the surrounding tissue. • Infected or any granulation tissue if present should be removed. • Any bone or tooth chips, if present should be removed. • Sharp irregular edges and interradicular bone should be trimmed with bone roungers and file.
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6) Wound closure: -Excessive tissue is trimmed from the flap margins soft tissue scissors before suturing. Primary closure is accomplished using 3-5 sutures with 3-0 silk.
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Wound closure and suturing
7) Postoperative follow up: -Proper postoperative care after the removal of impacted third molar is essential to obtain a successful end result. The instructions given to the patient are: • To apply firm pressure on the gauze for minimum fifteen minutes. • Limit activity for remainder of the day. • Patients may not be able to eat properly for 1-2 days.
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No vigorous rinsing for minimum 8-12 hrs. Warm saline rinses to be used after 24hrs. for 4 - 5 days. Pain, swelling and trismus are a common sequelae of the third molar surgeries and the patients should be made aware about them. To report for suture removal on day 7 th of surgery.
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COMPLICATIONS
1 Operative: --
a) Damage to vessels emerging from retro molar foramina can occur if the incision is carried upwards and towards the coronoid process instead of outwards into the cheek. b) Severing of facial artery and anterior facial vein the blade might slip and severe the facial artery and anterior facial vein. c) Damage to lingual nerve may occur while using scalpel on the lingual side of the mandible. www.indiandentalacademy.com
Damage to adjacent soft tissues may occur due to slipping of the instruments. e) Damage to distal aspect of adjacent second molar may occur if it’s used as a fulcrum f) Hemorrhage severing of the inferior alveolar artery vessel walls may cause profuse bleeding.
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2 Post-operative: -a) Pain:-Dry socket, haematoma, trauma to adjacent tooth, undue retraction of tissues and careless handling of the soft and hard tissues are the causes of pain. b) Swelling: -Edema or infection may lead to swelling. c) Trismus: -Haematoma formation, bone removal and stripping of the temporalis tendon presence of infection in the submassetric space may lead to trismus.
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Nerve involvement: -ď Ź Inferior alveolar nerve damage causes paraesthesia of the lower lip and chin. Lingual nerve damage causes numbness of the lingual mucosa on that side and paraesthesia of that half of the tongue.
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e) Pain on swallowing: -May occur due to the tearing of the superior constrictor muscle of the pharynx.
f) Pocket formation: -Commonly seen on the distal aspect of second molar.
g) Secondary hemorrhage: -Infection or disruption of the clot lead to secondary hemorrhage
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TMJ pain: Can occur due to prolonged opening of the mouth or improper use of the chisel and mallet. Infection: -If proper asepsis is not followed, dry socket can occur. www.indiandentalacademy.com
CLASSIFICATION OF IMPACTED MAXILLRY CANINE Labial or palatal placement intermediate position Crown between lateral incisors and pre molars crown above the root tip with labial or palatal orientation of lateral incisors and premolars. Aberrant position- impacted canine lies in maxillary sinus or nasal cavity.
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Class I - palatally positioned maxillary canine can be horizontal semi vertical or vertical. Class II –labially or buccally placed, horizontal , semi vertical or vertical Class III –involving both palatal and buccal. Class IV-impacted in alveolar process between incisors and first premolars Class V-impacted in edentulous mandible
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Classification of Impacted Mandibular Canines Labial Vertical Oblique
Aberrant At inferior Border On the opposite side Horizontal
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Classification of maxillary third molar Based on sinus approximation Sinus approximation-when thin bone or no bone is present between sinus and tooth No sinus approximation- when 2mm or more bone is present between the tooth and floor of the sinus
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MAXILLARY THIRD MOLAR IMPACTION COMPARED WITH LOWER MOLAR
Favorable factors
Tooth is usually not so malformed more porous Anatomy helps in displacing tooth distally Rapid healing due to better blood supply
Unfavorable factors
Accessibility Maxillary sinus is close
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TECHNIQUE ď Ź
Incisions similar to lower molars except that the distal component passes straight back from 2nd molar splitting the Tuberosity
ď Ź
The order of bone removal is from behind to forward, so that greatest margin of safety will be maintained for the disto buccal root of 2nd molar
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ď Ź
When sufficient overlying bone is removed the inclined plane elevator is inserted on the mesial,at the neck of the tooth, with an intruding , wedging, slight levering action, the tooth is removed in downward, outward and back ward direction.
ď Ź
No inadvertent vertical upward vector of force must be allowed, tooth can get displaced into maxillary sinus, it is for this reason that extraction forceps is not advised www.indiandentalacademy.com
UPPER CUSPIDS
Probably most difficult Orthodontic consultation required
RADIOGRAPHIC LOCALIZATION
3/4th of them are located on to the lingual to other teeth. SLOB method is applied to localize the unerupted tooth Two periapical films in different angulations or Occlusal radiograph can be employed to locate them accurately. www.indiandentalacademy.com
PROCEDURE OF REMOVAL
A large palatal flap devoid of vertical incisions is raised Gingival attachments are incised from the region of 1st molar of the side to be operated upon around the bicuspid region of the opposite side. Flap is raised towards mid line from each side
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Nasopalatine nerve and terminal portion of sphenopalatine artery, which is clamped and cut close to the flap. Traction suture is placed and flap drawn and towards the opposite side. If tooth is not visible a disc of bone is removed by circle drill technique. Occasionally it is possible to elevate tooth intact with inclined plane, otherwise odontectomy has to be done. Judicious use of elevators and bur used to remove the tooth. www.indiandentalacademy.com
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UPPER AND LOWER PREMOLARS Buccal approach is to be preferred whenever possible However when embedded tooth is readily accessible from the lingual side, lingual approach is to be used. THE BROKEN INSTRUMENT TECHNIQUE A hole is drilled from the buccal side in the line directly with the tooth to be removed. Then a shank of broken instrument of same diameter is inserted and by levering or rotating with instrument an effective bodily moment is attained
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CONCLUSION Before any impaction is carried out assessment of the tooth position is very important. It makes the surgical procedure less traumatic and prevents undue injury. With help of radiographs proper positioning of tooth can be determined. After impaction proper instructions should be given to patient. Proper antibiotic coverage is necessary to prevent any infection and to help accelerate healing. Recalling of the patients after seven days should be done to assess the condition of the socket. www.indiandentalacademy.com
REFERENCES Geoffry.L.Howe KRUGER B.Srinivasan Co lour Atlas of Impactions Neelima Anil Malik. Charles Rounds Clark
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