contentscontents Definition of impaction Definition of impaction Classification of impacted teeth by their Classification of impacted teeth by their

orientationorientation List the indications and contraindications for List the indications and contraindications for

the removal of impacted teeththe removal of impacted teeth List the risks of intervention and non-List the risks of intervention and non-

intervention with respect to impacted teethintervention with respect to impacted teeth Radiographic analysisRadiographic analysis

chronologychronology Tooth germ-9 yearsTooth germ-9 years Cusp mineralization-2 Cusp mineralization-2

years lateryears later 11 years-tooth located in 11 years-tooth located in

anterior border of anterior border of ramus,occlusal suface ramus,occlusal suface facing anteiorlyfacing anteiorly

Crown formation-14 yearsCrown formation-14 years Root-50% formed by 16 Root-50% formed by 16

yearsyears Root formation with open Root formation with open

apex-18 yearsapex-18 years 24 years-95% of 324 years-95% of 3rdrd molars molars

completed eruptioncompleted eruption

11 years 14 years

18 years 25 years

TerminologiesTerminologies

impacted teethimpacted teeth

unerupted teethunerupted teeth

Malposed teethMalposed teeth

DefinitionDefinition

– Origin- Latin -- impactusOrigin- Latin -- impactus– Cessation of eruption of teeth cause by Cessation of eruption of teeth cause by

physical barrier or ectopic eruptionphysical barrier or ectopic eruption– DefinitionDefinition

a completely / partially unerupted and is a completely / partially unerupted and is positioned against another tooth, bone / positioned against another tooth, bone / soft tissue, so that its further eruption is soft tissue, so that its further eruption is unlikely,described according to anatomic unlikely,described according to anatomic position.(Archer)position.(Archer)

Unerupted tooth-not having Unerupted tooth-not having perforated oral mucosaperforated oral mucosa

Malposed tooth-a tooth,erupted or Malposed tooth-a tooth,erupted or unerupted which is in abnormal unerupted which is in abnormal position in maxilla or mandibleposition in maxilla or mandible

Causes of impaction of teethCauses of impaction of teeth

– Theories of impaction (Durbeck)Theories of impaction (Durbeck) The Phylogenic theory The Phylogenic theory The Mendelian theoryThe Mendelian theory The Endocrine theory The Endocrine theory The Pathological theory The Pathological theory The Orthodontic theory The Orthodontic theory The Skeletal theoryThe Skeletal theory

Local causesLocal causes

– Lack of space Lack of space – Retained deciduous teethRetained deciduous teeth– Premature loss of deciduous teethPremature loss of deciduous teeth– Ectopic position of tooth budEctopic position of tooth bud– Obstruction of eruption pathObstruction of eruption path– Cyst tumor and supernumery teethCyst tumor and supernumery teeth– Infection and traumaInfection and trauma– Abnormality of jawAbnormality of jaw– Dilaceration : abnormal path of eruption of tooth Dilaceration : abnormal path of eruption of tooth

due to traumatic forces during the eruption perioddue to traumatic forces during the eruption period

Systemic causesSystemic causes

– Pre-natal causesPre-natal causes HeredityHeredity miscegenationmiscegenation

– Post-natal causesPost-natal causes Rickets, anemia, congenital syphilis,Rickets, anemia, congenital syphilis, tuberculosis, malnutritiontuberculosis, malnutrition

– Endocrine causesEndocrine causes Hypothyroidism, hypoparathyroidismHypothyroidism, hypoparathyroidism

– Rare conditionsRare conditions Cleidocranial dysostosis, oxycephaly, Cleidocranial dysostosis, oxycephaly, progeria, achondroplasia, cleft palateprogeria, achondroplasia, cleft palate

mandibular third molarsmandibular third molars maxillary third molars maxillary third molars maxillary cuspidsmaxillary cuspids mandibular bicuspidsmandibular bicuspids mandibular cuspidsmandibular cuspids maxillary bicuspidsmaxillary bicuspids maxillary central incisiormaxillary central incisior maxillary lateral incisormaxillary lateral incisor supernumerary teeth mainly mesiodenssupernumerary teeth mainly mesiodens

Commonly impacted teeth

Indications for removalIndications for removal

prevention of pericoronitis prevention of pericoronitis

Dental caries or prevention of dental cariesDental caries or prevention of dental caries Periodontal disease or its prevention Periodontal disease or its prevention Prevention of root resorptionPrevention of root resorption Odontogenic cysts & tumours – dentigerous cystOdontogenic cysts & tumours – dentigerous cyst Pain of unexplained originPain of unexplained origin autogenous transplantation to first molar socketautogenous transplantation to first molar socket

Indications for removalIndications for removal Fracture of the jaw/tooth in the line of Fracture of the jaw/tooth in the line of

fracturefracture Prosthetic problems e.g. under prosthesisProsthetic problems e.g. under prosthesis Orthodontic relapse/facilitation of Orthodontic relapse/facilitation of

orthodontic tooth movementorthodontic tooth movement Tooth interfering with orthognathic and/or Tooth interfering with orthognathic and/or

reconstructive surgeryreconstructive surgery Prophylactic removalProphylactic removal - Patients with - Patients with

medical or surgical conditions requiring medical or surgical conditions requiring removal of third molar (e.g. organ removal of third molar (e.g. organ transplants, alloplastic implants, transplants, alloplastic implants, chemotherapy, radiation therapy)chemotherapy, radiation therapy)

Definition of pericoronitisDefinition of pericoronitis

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

CausesCauses

1.1. If the patient experience a mild transient If the patient experience a mild transient decrease in host defense, pericoronitis decrease in host defense, pericoronitis may result.may result.

2.2. pericoronitis may arise secondary to minor pericoronitis may arise secondary to minor trauma from maxillary third molar. The trauma from maxillary third molar. The soft tissue that covers the occlusal surface soft tissue that covers the occlusal surface of the partially erupted mandibular third of the partially erupted mandibular third molar known as the operculum can be molar known as the operculum can be traumatized and become swollen this can traumatized and become swollen this can be treated by removal of maxillary third be treated by removal of maxillary third molar.molar.

3.3. entrapment of food under entrapment of food under operculum, in the pocket operculum, in the pocket under operculum and under operculum and impacted teeth ,this pocket impacted teeth ,this pocket can not be can not be cleaned ,bacteria invade it cleaned ,bacteria invade it and pericoronitis begins.and pericoronitis begins.

4.4. streptococci and anaerobic streptococci and anaerobic bacteria (the usual bacteria bacteria (the usual bacteria inhabit the gingival sulcus) inhabit the gingival sulcus) cause pericronitiscause pericronitis . .

When third molar is When third molar is impacted or impacted or partially partially impacted ,the impacted ,the bacteria that cause bacteria that cause dental caries can dental caries can be exposed to the be exposed to the distal aspect of the distal aspect of the 2nd molar, as well 2nd molar, as well as to third molar as to third molar

B.B.Dental CariesDental Caries

Erupted teeth adjacent Erupted teeth adjacent to impacted teeth are to impacted teeth are predisposed to predisposed to periodontal disease.periodontal disease.

As it decrease amount of As it decrease amount of bone on the distal bone on the distal aspect of adjacent 2nd aspect of adjacent 2nd molar, with deep molar, with deep periodontal pocket on periodontal pocket on the distal aspect of the the distal aspect of the 2nd molar.2nd molar.

C.C. Periodontal DiseasePeriodontal Disease

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

D.D. Root ResorptionRoot Resorption

E.E. Pain of unexplained origin:Pain of unexplained origin:

Pain in the retro Pain in the retro molar region molar region with no obvious with no obvious reason.reason.

F.F. Odontogenic cyst and TumorsOdontogenic cyst and Tumors

The dental follicle The dental follicle may undergo cystic may undergo cystic degeneration and degeneration and become a become a dentigerous cyst or dentigerous cyst or keratocyst.keratocyst.

Ameloblastoma Ameloblastoma may developed may developed from epithelium from epithelium within the dental within the dental folliclefollicle

G.G. Fracture of the jawFracture of the jaw

impacted third impacted third molar occupies molar occupies space that is space that is usually filled with usually filled with bone, this weaken bone, this weaken the mandible and the mandible and render the render the mandible to mandible to fracture.fracture.

I.I. Facilitation of orthodontic Facilitation of orthodontic treatmenttreatment

to relief to relief crowding of crowding of mandibular mandibular anterior teeth.anterior teeth.

H.H. impacted teeth under dental impacted teeth under dental prosthesis:prosthesis:

Contraindications for removalContraindications for removal

Extremes of ageExtremes of age Compromised medical statusCompromised medical status Excessive risk of damage to adjacent structuresExcessive risk of damage to adjacent structures When there is a question about the future status When there is a question about the future status

of the second molarof the second molar Uncontrolled active pericoronal infectionUncontrolled active pericoronal infection Socioeconomic statusSocioeconomic status fracture of atrophic mandible may occur fracture of atrophic mandible may occur

Risk of Intervention: Minor transientRisk of Intervention: Minor transient

Sensory nerve alterationSensory nerve alteration Alveolitis Alveolitis Trismus Trismus Infection Infection Hemorrhage Hemorrhage Dentoalveolar fracture Dentoalveolar fracture Displacement of toothDisplacement of tooth

Risk of Intervention: Minor PermanentRisk of Intervention: Minor Permanent

Periodontal injuryPeriodontal injury Adjacent tooth injuryAdjacent tooth injury TMJ injuryTMJ injury

Risk of Intervention: MajorRisk of Intervention: Major

Altered sensationAltered sensation Vital organ infectionVital organ infection Fracture of the mandible and Fracture of the mandible and

maxillary tuberositymaxillary tuberosity injuryinjury

Risk of Non-interventionRisk of Non-intervention

Crowding of dentition based on growth Crowding of dentition based on growth predictionprediction

Resorption of adjacent tooth and Resorption of adjacent tooth and periodontal statusperiodontal status

Development of pathological condition Development of pathological condition such as caries, infection, cyst, tumorsuch as caries, infection, cyst, tumor

Assessment of mandibular third molar Assessment of mandibular third molar impactionimpaction

ClassificationClassification

BASED ON NATURE OF OVERLYING BASED ON NATURE OF OVERLYING TISSUE IMPACTIONTISSUE IMPACTION

SOFT TISSUE IMPACTIONSOFT TISSUE IMPACTION

HARD TISSUE IMPACTIONHARD TISSUE IMPACTION

Winter’s classification(1926)

Based on long axis of 3rd molar in relation to 2nd molar

Pell and Gregory classification (1933)Pell and Gregory classification (1933)

According to the relation of the impacted tooth According to the relation of the impacted tooth to the ramus of the mandible & the 2to the ramus of the mandible & the 2ndnd molar molar

Based on relationship to occlusal plane of 2nd molar

Acc to A. Garcia & co workers, Pell-Acc to A. Garcia & co workers, Pell-Gregory classification is not a reliable Gregory classification is not a reliable predictor of surgical difficulty in predictor of surgical difficulty in vertical impacted lower 3vertical impacted lower 3rdrd molars, and molars, and classification of non-vertical molars on classification of non-vertical molars on Pell-Gregory scales is difficult.Pell-Gregory scales is difficult.

Br J Oral Maxillofac Surg 2000; 83:585-Br J Oral Maxillofac Surg 2000; 83:585-587587

ADA code on procedures & ADA code on procedures & nomenclaturesnomenclatures

Describes the amount of soft and Describes the amount of soft and hard tissue over the coronal surface hard tissue over the coronal surface of an impacted toothof an impacted tooth

Soft tissue impactionsSoft tissue impactionsComplete bony impactionsComplete bony impactionsPartial bony impactionsPartial bony impactions

CombinedCombined ADA & AAOMSADA & AAOMS classification ofclassification of procedural procedural

terminologyterminology 0722007220: removal of impacted tooth - : removal of impacted tooth -

overlying soft tissueoverlying soft tissue 0723007230: removal of impacted tooth - : removal of impacted tooth -

partially bony impactedpartially bony impacted 0724007240: removal of impacted tooth - : removal of impacted tooth -

completely bonycompletely bony 0724107241: removal impacted tooth - : removal impacted tooth -

completely bony, with unusual surgical completely bony, with unusual surgical complications complications

Difficulty Index for removal of impacted mand Difficulty Index for removal of impacted mand third molars - Pedersen 1988third molars - Pedersen 1988

CLASSIFICATION CLASSIFICATION DIFFICULTY INDEX DIFFICULTY INDEX VALUEVALUE

ANGULATIONANGULATION Mesioangular 1Mesioangular 1 Horizontal / transverse 2Horizontal / transverse 2 Vertical 3Vertical 3 Distoangular 4Distoangular 4

DEPTHDEPTH Level A 1Level A 1 Level B 2Level B 2 Level C 3Level C 3

RAMUS RELATIONSHIP / SPACE AVAILABLERAMUS RELATIONSHIP / SPACE AVAILABLE Class I 1Class I 1 Class II 2Class II 2 Class III 3Class III 3

Difficulty index Difficulty index

– Very difficult : 7 to 10Very difficult : 7 to 10– Moderately difficult : 5 to 7Moderately difficult : 5 to 7– Minimally difficult : 3 to 4Minimally difficult : 3 to 4

WHARFE assessment - Macgregor 1985WHARFE assessment - Macgregor 1985

Winters classificationWinters classification– Horizontal Horizontal 33– DistoangularDistoangular 22– MesioangularMesioangular 11– VerticalVertical 00

Height of the mandibleHeight of the mandible– 1-30 mm1-30 mm 0 0– 31-34 mm31-34 mm 1 1– 35-39 mm35-39 mm 22

Angulation of 3rd molarAngulation of 3rd molar– 1-59 degrees1-59 degrees 00– 60-6960-69 1 1 – 70-7970-79 22– 80-8980-89 33– 90 +90 + 44

WHARFE assessmentWHARFE assessment

Root shape and developmentRoot shape and development– favourable curvaturefavourable curvature 1 1– unfavourable curvatureunfavourable curvature 2 2– complexcomplex 3 3– < 1/3 complete 2< 1/3 complete 2– 1/3 to 2/3 complete 11/3 to 2/3 complete 1– > 2/3 complete 3> 2/3 complete 3

FolliclesFollicles– normalnormal 0 0– possibly enlargedpossibly enlarged 1 1– enlargedenlarged 2 2– impaction relieved 3 impaction relieved 3

Path of exitPath of exit– space availablespace available 0 0– distal cusps covereddistal cusps covered 1 1– mesial cusp also coveredmesial cusp also covered 2 2– both coveredboth covered 3 3

Maxillary third molar impactionMaxillary third molar impaction

Clinical assessmentClinical assessment– Eruption position of crownEruption position of crown– Presence of pericoronitisPresence of pericoronitis– Periodontal status of 2Periodontal status of 2ndnd molar molar– Soft tissue over tuberositySoft tissue over tuberosity

Radiological interpretationRadiological interpretation– Crown Crown – RootRoot– Follicle sizeFollicle size– Periodontal ligament spacePeriodontal ligament space– Antral positionAntral position

Assessment of impacted max third molarAssessment of impacted max third molar

ClassificationClassification– ARCHER’S (1975)ARCHER’S (1975)

On anatomic basis similar to mand 3On anatomic basis similar to mand 3rdrd molar molar– PELL & GREGORYPELL & GREGORY

Based on relative depth in relation to 2Based on relative depth in relation to 2ndnd molar molar– Based on relation of max 3Based on relation of max 3rdrd molar to max molar to max

sinus floorsinus floor Sinus approximation- no bone / thin partition Sinus approximation- no bone / thin partition

presentpresent No sinus approximation – 2mm or more bone is No sinus approximation – 2mm or more bone is

presentpresent

Archer’s anatomic classificationArcher’s anatomic classification

Pell & Gregory – relative depth in relation to 2nd molar

Ectopic maxillary 3Ectopic maxillary 3rdrd molar impaction molar impaction

ANGULATION OCCURANCE DIFFICULTYANGULATION OCCURANCE DIFFICULTY– Vertical 63% +Vertical 63% +– Distoangular 25% +Distoangular 25% +– Mesioangular 12%Mesioangular 12% +++ +++– Transverse <1% ++Transverse <1% ++– Horizontal <1% ++Horizontal <1% ++– Inverted <1% ++Inverted <1% ++

Difficulty factorsDifficulty factors– Most common – thin non fused root with Most common – thin non fused root with

erractic curvature erractic curvature – Sinus approximationSinus approximation– Fracture of tuberosity Fracture of tuberosity

Difficulty factors

Maxillary canine impactionMaxillary canine impaction

Clinical assessmentClinical assessment– Presence of retained deciduousPresence of retained deciduous– Presence of crowding in max archPresence of crowding in max arch– Palpate for the presence of bulgePalpate for the presence of bulge

Radiological interpretationRadiological interpretation– The crown The crown – The root The root – Surrounding structuresSurrounding structures

Assessment of maxillary canine impactionAssessment of maxillary canine impaction

MAXILLARY CANINEMAXILLARY CANINE– Labial positionLabial position

Crown in intimate relationship with incisorsCrown in intimate relationship with incisors Crown well above apices of incisorsCrown well above apices of incisors

– Palatal positionPalatal position Crown near surface in close relation to roots of incisorsCrown near surface in close relation to roots of incisors Crown deeply embedded in close relation to apices of incisors Crown deeply embedded in close relation to apices of incisors

– Intermediate positionIntermediate position Crown between lateral incisor & 1Crown between lateral incisor & 1stst premolar root premolar root Crown above lat incisor & 1Crown above lat incisor & 1stst premolar with crown labially premolar with crown labially

placed and root palatally placed or vice versaplaced and root palatally placed or vice versa– Unusual positionUnusual position

In nasal or antral wallIn nasal or antral wall In infraorbital regionIn infraorbital region

FIELD & ACKERMAN (1935)

Class I : PALATALLY PLACED Class I : PALATALLY PLACED MAXILLARY CANINEMAXILLARY CANINE

a) horizontala) horizontal b) verticalb) vertical c) semiverticalc) semivertical

Class II: LABIAL OR BUCCAL PLACED Class II: LABIAL OR BUCCAL PLACED MAX. CANINEMAX. CANINE

a) horizontala) horizontal b) verticalb) vertical c) semiverticalc) semivertical

Class III: INVOLVING BOTH BUCCAL Class III: INVOLVING BOTH BUCCAL AND PALATAL BONEAND PALATAL BONE

Class IV: IMPACTED IN THE Class IV: IMPACTED IN THE ALVEOLAR PROCESS ALVEOLAR PROCESS

BETWEEN THE INCISORS AND BETWEEN THE INCISORS AND FIRST PREMOLARFIRST PREMOLAR

CLASS V: IMPACTED IN EDENTULOUS CLASS V: IMPACTED IN EDENTULOUS MAXILLAMAXILLA

CLASSIFICATION FOR IMPACTED MANDIBULAR CLASSIFICATION FOR IMPACTED MANDIBULAR CANINECANINE

LABIALLABIAL : VERTICAL, OBLIQUE , HORIZONTAL : VERTICAL, OBLIQUE , HORIZONTAL

ABBERANT ABBERANT : AT INFERIOR BORDER: AT INFERIOR BORDER

ON THE OPPOSITE SIDE ON THE OPPOSITE SIDE

Radiographic assessment of impacted toothRadiographic assessment of impacted tooth

Radiographic views Radiographic views – intraoral periapicalintraoral periapical– occlusalocclusal– orthopontamographorthopontamograph– lateral radiographlateral radiograph– Linear cross sectional Linear cross sectional

tomographytomography A diagnostic A diagnostic

technique for technique for determining the determining the buccolingual buccolingual relationship of relationship of impacted mandibular impacted mandibular third molar and third molar and inferior alveolar inferior alveolar neurovascular bundleneurovascular bundle

Radiological assessment aids in Radiological assessment aids in determiningdetermining

Classification of impacted toothClassification of impacted tooth Orientation of impacted toothOrientation of impacted tooth Depth of the tooth Depth of the tooth Root shapeRoot shape Bone removalBone removal

– For path of elevationFor path of elevation– For application of elevatorsFor application of elevators

Bone densityBone density Relationship to inferior alveolar canalRelationship to inferior alveolar canal Localization of impacted tooth Localization of impacted tooth

Radiographic interpretationRadiographic interpretation

Assessment of lower third molarAssessment of lower third molar

– AngulationAngulation– The crownThe crown– The rootsThe roots– Relationship of apices with inf alveolar canalRelationship of apices with inf alveolar canal– Depth of tooth in alveolar boneDepth of tooth in alveolar bone– Buccal / lingual obliquityBuccal / lingual obliquity

Assessment of lower second molarAssessment of lower second molar Assessment of surrounding boneAssessment of surrounding bone

Winter’s WAR linesWinter’s WAR lines

Localization of impacted teeth using Localization of impacted teeth using radiographsradiographs

Localization techniquesLocalization techniques

– Clark’s / buccal object / horizontal tube shift rule Clark’s / buccal object / horizontal tube shift rule (1909)(1909)

– Millers right angle ruleMillers right angle rule– Richard’s / vertical tube shift rule (1952)Richard’s / vertical tube shift rule (1952)– Panorex split-mode panoramic tomographPanorex split-mode panoramic tomograph

Localization of impacted third molar using Localization of impacted third molar using radiographsradiographs

Horizontal tube shift techHorizontal tube shift tech– For seperating superimposed objects with For seperating superimposed objects with

vertical long axisvertical long axis– For buccal / lingual localisation of impacted For buccal / lingual localisation of impacted

third molar from roots of erupted teeththird molar from roots of erupted teeth

vertical tube shift techvertical tube shift tech– For seperating horizontally oriented objectsFor seperating horizontally oriented objects– For determining bucco-lingual position of For determining bucco-lingual position of

third molar apices that super impose the third molar apices that super impose the mand canalmand canal

Clark’s horizontal tube shiftClark’s horizontal tube shift

Clark’s horizontal tube shift techClark’s horizontal tube shift tech

Miller’s right angle techniqueMiller’s right angle technique

Radiological prediction of inferior Radiological prediction of inferior alveolar nerve injuryalveolar nerve injury

According to J. P. Rood, B. A. A. Nooraldeen Shehab,According to J. P. Rood, B. A. A. Nooraldeen Shehab,– Diversion of mandibular canal-changed directionDiversion of mandibular canal-changed direction– Darkening of root-decr.amnt of tooth substance or loss Darkening of root-decr.amnt of tooth substance or loss

of cortical lining of canalof cortical lining of canal– Interruption of white lines-dense canal wall structureInterruption of white lines-dense canal wall structure– Narrowing of roots-greates diam.inv.by canalNarrowing of roots-greates diam.inv.by canal– Deflection of roots-deviation of root to b,l,m,d sideDeflection of roots-deviation of root to b,l,m,d side– Narrowing of mandibular canal-cross the root of 3Narrowing of mandibular canal-cross the root of 3rdrd m m– Dark and bifid root-canal cross the root apex,double Dark and bifid root-canal cross the root apex,double

periodontal membrane shadow of bifid apex.periodontal membrane shadow of bifid apex.

Br Jr of Oral and Maxillofacial Surgery 1990; 28: 20-25Br Jr of Oral and Maxillofacial Surgery 1990; 28: 20-25J Oral Maxillofac Surg 2003; 61: 417- 421J Oral Maxillofac Surg 2003; 61: 417- 421J Oral Maxillofac Surg 2005; 63: 3-7J Oral Maxillofac Surg 2005; 63: 3-7

Relationship with inf alv canalRelationship with inf alv canal

Position of root to inferior alveolar canalPosition of root to inferior alveolar canal

Assessment of impactionAssessment of impaction

Preoperative assessmentPreoperative assessment

– Clinical assessmentClinical assessment

GeneralGeneral

Local Local

ERUPTION STATUS OF IMPACTED TOOTHERUPTION STATUS OF IMPACTED TOOTH

RESORPTION OF SECOND MOLARRESORPTION OF SECOND MOLAR

PRESENCE OF LOCAL INFECTION- PERICORONITISPRESENCE OF LOCAL INFECTION- PERICORONITIS

ORTHODONTIC CONSIDERATIONORTHODONTIC CONSIDERATION

CARIES IN OR RESORPTION OF THIRD MOLAR OR ADJACENT CARIES IN OR RESORPTION OF THIRD MOLAR OR ADJACENT

TEETHTEETH

PERIODONTAL STATUSPERIODONTAL STATUS

Local assessmentLocal assessment

– Mouth openingMouth opening– Size of tongueSize of tongue– Extensibility of lips and cheeksExtensibility of lips and cheeks– Status of dentitionStatus of dentition– Assessment of teeth in particular Assessment of teeth in particular

ORIENTATION AND RELATIONSHIP TO IDCORIENTATION AND RELATIONSHIP TO IDC

OCCLUSAL RELATIONSHIP OCCLUSAL RELATIONSHIP

REGIONAL LYMPH NODESREGIONAL LYMPH NODES

TMJ FUNCTIONTMJ FUNCTION If planned under GA, other impacted teeth should also beIf planned under GA, other impacted teeth should also be

considered for removalconsidered for removal

SURGICAL REMOVAL OF IMPACTED TOOTHSURGICAL REMOVAL OF IMPACTED TOOTH

ASEPSIS AND ISOLATION ASEPSIS AND ISOLATION LOCAL ANAESTHESIA /SEDATION , LA/GALOCAL ANAESTHESIA /SEDATION , LA/GA INCISION AND FLAP DESIGNINCISION AND FLAP DESIGN REFLECTION OF MUCOPERIOSTEAL FLAPREFLECTION OF MUCOPERIOSTEAL FLAP BONE REMOVAL BONE REMOVAL SECTIONING (DIVISiON ) OF TOOTHSECTIONING (DIVISiON ) OF TOOTH ELEVATIONELEVATION EXTRACTIONEXTRACTION DEBRIDEMENT AND SMOOTHENING OF BONEDEBRIDEMENT AND SMOOTHENING OF BONE CONTROL OF BLEEDINGCONTROL OF BLEEDING CLOSURE – SUTURING CLOSURE – SUTURING MEDICATIONS – ANTIBIOTICS, ANALGESICSMEDICATIONS – ANTIBIOTICS, ANALGESICS FOLLOW UPFOLLOW UP

Asepsis and isolationAsepsis and isolation

Painting solution Painting solution

povidine –iodine 5% for skin, 1% for oral mucosapovidine –iodine 5% for skin, 1% for oral mucosa

chx – 7.5% for skin, 0.2%for rinsing oral mucosachx – 7.5% for skin, 0.2%for rinsing oral mucosa

Drape the patientDrape the patient

AnaesthesiaAnaesthesia Mostly procedure performed under local anaesthesiaMostly procedure performed under local anaesthesia

GA is indicated when impacted tooth situated deep in GA is indicated when impacted tooth situated deep in jaw bone ( red line > 5 mm )jaw bone ( red line > 5 mm )

and more than two impacted tooth have to be and more than two impacted tooth have to be removed at one timeremoved at one time

Indication of GA- Indication of GA- emotional inabilityemotional inabilityFear of pain & apprehensionFear of pain & apprehensionMedical condition req.alleviation of anxietMedical condition req.alleviation of anxietLengthy procedureLengthy procedureUnco op. patientUnco op. patientLA may not achieved desired effectLA may not achieved desired effect

General anesthetic agentsGeneral anesthetic agents

Premedication-Premedication- Pentobarbital(100 mg oral or 1-2 ml Pentobarbital(100 mg oral or 1-2 ml

IV)IV) Diazepam(5-15 mg.oral,3-20 mg.IV)Diazepam(5-15 mg.oral,3-20 mg.IV) Sedative & hypnotic Sedative & hypnotic

agents(methohexital(0.5-1.5mg/kg agents(methohexital(0.5-1.5mg/kg body wt)body wt)

Surgical anatomySurgical anatomy Situation of 3Situation of 3rdrd molar in molar in

respect to ant.boder of respect to ant.boder of ramusramus

Lingual positionLingual position Incisions and nerves and Incisions and nerves and

vesselsvessels Retromolar triangle & fossaRetromolar triangle & fossa Incisions & facial vesselsIncisions & facial vessels Lingual nerveLingual nerve Lingual sockets(root Lingual sockets(root

fenestration)fenestration) Spaces-sublingual and Spaces-sublingual and

submandibilar spacesubmandibilar space

Flap designFlap design

Adequate exposure of the operative siteAdequate exposure of the operative site Base of the flap should be wideBase of the flap should be wide Full thickness mucoperiosteal flap should be elevatedFull thickness mucoperiosteal flap should be elevated Flap should not be extended too far distally Flap should not be extended too far distally

injure the vesselinjure the vessel

trismustrismus

herniate the buccal pad of fat into the operating herniate the buccal pad of fat into the operating fieldfield

Incision should be designed so that flap can be closed Incision should be designed so that flap can be closed over solid boneover solid bone

Incision should not damage the vital st. Incision should not damage the vital st.

Different types incision and flap designDifferent types incision and flap design

Short envelopeShort envelope Long envelopeLong envelope L shaped incision(L shaped flap)L shaped incision(L shaped flap) Bayonet shaped incisionBayonet shaped incision Triangular flapTriangular flap ward’s incisionward’s incision Modified Ward’s incisionModified Ward’s incision Groove and Moore(1970)Groove and Moore(1970) Comma shaped incisionComma shaped incision S shaped incisionS shaped incision Szmyd flapSzmyd flap Modified szmydModified szmyd Berwick’s tongue flapBerwick’s tongue flap Guralnik horizontal incisionGuralnik horizontal incision Donlon trintaDonlon trinta motamedimotamedi

Envelope flapEnvelope flap Adv-Adv- VisibilityVisibility Easy to sutureEasy to suture Less post op.painLess post op.pain Osseous defect can b Osseous defect can b

coveredcovered Adequate blood supply Adequate blood supply

to wound marginto wound margin Disadv:Disadv: Cuts insertion of Cuts insertion of

temporalis tendontemporalis tendon

Triangular flapTriangular flap

Bayonet flapBayonet flap

DistalDistal IntermediateIntermediate gingivalgingival

Grooves & moore(1970)Grooves & moore(1970)

Didn’t involve gingival margin-Didn’t involve gingival margin-decrease pocketingdecrease pocketing

Involve marginInvolve margin Wolffe etal(1978) compared effects Wolffe etal(1978) compared effects

of removing a wedge of soft tissue of removing a wedge of soft tissue distal to m2 with primary closuredistal to m2 with primary closure

Former-allow dainageFormer-allow dainage Later-prevents ingress of infectionLater-prevents ingress of infection

Sir Terence ward’s incisionSir Terence ward’s incision Ant-distobuccal corner of Ant-distobuccal corner of

crown of m2ends along crown of m2ends along mesiobuccal cusp of teethmesiobuccal cusp of teeth

Any epithelium present in Any epithelium present in gingival crevice must be gingival crevice must be excised with reverse bevel excised with reverse bevel incision with no.12 bladeincision with no.12 blade

Primary closure should not Primary closure should not be attempted unless a be attempted unless a band of buccal attached band of buccal attached mucoperiosteum of 5 mucoperiosteum of 5 mm.is presentmm.is present

Better results-allow for Better results-allow for secondary intentionsecondary intention

Barwick’s tongue flap(1966)Barwick’s tongue flap(1966)

Szmyd incisions(1971)Szmyd incisions(1971)

Szmyd incision Modified szmyd

comma shaped incisioncomma shaped incision Adv:Adv: No part of wound lies No part of wound lies

o resultant bone o resultant bone defectdefect

No approach to No approach to temporalis muscle temporalis muscle tendontendon

No distal extensionNo distal extension Ind:Ind: Total soft tissue Total soft tissue

impactionimpaction Partially impacted 3Partially impacted 3rdrd

molarmolar

Criteria for success of incisionCriteria for success of incision

Surgical accessSurgical access Healing both in terms of lack of Healing both in terms of lack of

discomfort,pd healthdiscomfort,pd health Schow(1974) extending the flap Schow(1974) extending the flap

beyond EOR incr.chances of dry beyond EOR incr.chances of dry socketsocket

ReferencesReferences

Oral and maxillofacial surgery:ArcherOral and maxillofacial surgery:Archer Impacted teeth:AllingImpacted teeth:Alling Oral & maxillofacial surgery:Neelima Oral & maxillofacial surgery:Neelima

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