impaction 27.8.6
TRANSCRIPT
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IMPACTION
Dr.V.RAMKUMAR
CONSULTANT DENTALFACIOMAXILLARYSURGEON
REG NO: 4118 TAMILNADU- INDIA(ASIA)
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DEFINITIONImpacted tooth is one that fails to erupt and will not eventually assume its anatomical arch relationship, beyond the chronological eruption date
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ETIOLOGY
* NATURE - LACK OF SPACE IN JAWS
* NURTURE - CHANGE IN DIET
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LACK OF SPACE
ETIOLOGY
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Theories..
Phylogenetic
Mendelian
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DILACERATION
ETIOLOGY
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ETIOLOGY
retained deciduous teeth
OBSTRUCTIONS
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Odontome
ETIOLOGY
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Cyst / Odontogenic tumour
ETIOLOGY
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Thick scar band
Dense bone
Systemic causes – Hormonal imbalance
ETIOLOGY
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INDICATIONS
Recurrent pericoronitis
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Presence of a pathological lesion
INDICATIONS
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Caries Periodontal disease Obscure facial pain Previous attempted extraction Prosthetic considerations Social and economic factors
INDICATIONS
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CONTRA INDICATIONS
Health considerations Prosthetic considerations Availability of adequate
space socio economic reasons
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Mandibular 3rd Molar Impaction
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CLASSIFICATION
Based on the long axis of the impacted tooth in relation to the long axis of the second molar
WINTER’S CLASSIFICATION
Angulation Depth
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Mesioangular
WINTER’S CLASSIFICATIONAngulation
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Distoangular
WINTER’S CLASSIFICATIONAngulation
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Horizontal
WINTER’S CLASSIFICATIONAngulation
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Vertical
WINTER’S CLASSIFICATIONAngulation
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Buccoversion
WINTER’S CLASSIFICATIONAngulation
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Linguoversion
Angulation WINTER’S CLASSIFICATION
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Inverted
Angulation WINTER’S CLASSIFICATION
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Angulation
Unusual / Ectopic
WINTER’S CLASSIFICATION
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ASSESSMENTCLINICAL
RADIOLOGICAL
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CLINICAL ASSESSMENT
AGE
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EXTERNAL OBLIQUE RIDGE
BUCCAL PAD OF FAT
POSITION OF TONGUE
STATUS OF ADJACENT TOOTH
LENGTH OF BOTH ANGLES OF MOUTH
PRESENCE OF ANY ACUTE INFECTION
PRESENCE OF ANY PATHOLOGY
PRESENCE OF ASSOCIATED JAW #
FACIAL FORM
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RADIOLOGICAL ASSESSMENT
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W A R Lines
W A R Lines
W A R Lines
W A R LinesW A R Lines
W A R Lines
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WHITE Line
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Amber Line
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RED Line
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Sl. NO Category Score
1. Winter’s Classification Horizontal Distoangular Mesioangular Vertical
2210
2. Height of the mandible 1-30 mm31-41 mm35-39 mm
012
3. Angulation of III molar 1° - 50°60°-69°70-79°80°-89°90°+
01234
4. Root shape Complex Favourable curvature Unfavourble curvature
123
5. Follicles Normal Possibly enlarged Enlarged
012
6. Path of Exit Space available Distal cusps covered Mesial cusps also covered Both covered
012 3
Total 33
SCORING DETAILS FOR WHARFE ASSESSMENT
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Maxillary 3rd Molar Impaction
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Classification
Archer’s.. Class A
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Class B
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Class C
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Canine Impaction
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Classification
Ackerman (1935):
Maxillary canines
Palatal position Labial position
Class I Class II
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Class III
involve both buccal and palatal bone
Class IV
in the alveolar process between the incisors & 1st premolar
Class V
in the edentulous maxilla
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SURGICAL TECHNIQUE IN IMPACTED TOOTH REMOVAL
FLAPS : L - SHAPE, ENYELOPE, BAYONET
BONE : BUR VS CHISELREMOVAL
TOOTH : TOOTH VS BONE (KELSY FRY RETRIEVAL SPLIT & DAVIS)
WOUND : CONVENTIONAL VS TISSUE ADHESIVES
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Incision
Flap Design
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BONE SPLIT TECHNIQUE
SIR WILLIAM KELSY FRY ?
VS
W.H.DAVIS ?
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ADVANTAGES OF DAVIS
- DECREASED INCIDENCE OF INFECTION IN II MOLAR AREA - OBVIATES LINGUAL BONE REMOVAL
- ↓ LINGUAL NERVE COMPLICATION
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DISADVANTAGES OF KELSY FRY
-↑ LINGUAL NERVE COMPLICATION - BLEEDING - ELEVATION OF LINGUAL
SOFT TISSUE
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POSTOPERATIVE CARE
i) Rest is necessary for the prompt healing of wounds.
ii) Cold applications to the face prevent disfiguring swelling and postoperative edema.
iii) They should be instructed to drink plenty of fluids in the form of milk, juices, Tea, Water etc.,
iv) Proper oral care must not be neglected
v) Should rinse 4 to 6 times daily. Best mouth rinse is a warm saline water.
vi) In take of alcohol and use of smoking should be discontinued for five days.
vii) Antibiotics and analgesic drug should be started.
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During bone removal
jaw #
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During elevationjaw #
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Swelling
Post operative
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Subcutaneous emphysema
Post operative
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Complications of surgical removal of impacted tooth
During LA Intra operative Post operative
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During LA Pain Snycope LA toxicity Role of adrenalin in systemically
compromised pts
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Management: Slow injection Aspiration before injecting Proper case history to rule out systemic
illness Proper DOCTOR-PATIENT rapport..
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Intra operative complicationsIncision Flap elevation Bone
removal
Tooth sectioning Elevation of tooth
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During incision Local inflammation immediately prior to
surgery hemorrhage
Subside the inflammation prior to surgery by anti inflammatory drugs
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Placement of incision:Buccal:
downward & forward placement of incision towards the vestibule
damage to the facial artery or anterior facial vein
Management:Temporary Permanent
extra oral finger pressure ligation
Direct the cut upwards towards the tooth
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Distal:incision directly in line with the
anterior border of ramus Damage the retromolar vessels
Lingual extension Damage lingual nerve
Direct the incision more bucally
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During bone removal
Damage to the distal aspect of 2nd molar
sensitivity
Improper cooling of the bur
Local bone death
Sequestration
slip & embed into the soft tissue
Damage mucosa & lingual nerve
Bur
Mandibular canal openingemorrhage
Hemorrhage Anestheisa
Careful drillingAdequate retractionLingual nerve protection
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Advantage:1. Safe 2. Rapid3. Efficient method
Disadvantage:1. Damage adjacent
structures2. Fracture of the jaw3. Splitting of the
lingual plate
Chisel
Firm controlAnterior vertical limit cutOptimum force of malleting
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During tooth sectioning
Incorrect line of sectioning
Difficult removal of the tooth
Damage to mandibular canal
HemorrhagePost op numbness of
the lower lip on the side of surgery
Bur
Section across the cervical portion at right angle to the long axis of the tooth
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Difficult to achieve correct line of cleavge
More accurate sectioning
Chisel Osteotome
Inadequate control
•Damage to soft tissues•Lingual nerve•2nd molar
Excessive malleting force
•Dislodgement of tooth into the lingual pouch•Fracture of the tooth in unwanted angulation
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Retrieval of the dislodged tooth
Tooth
Lingual pouch
Finger pressure
Manipulation upwards
Retrieval with forceps
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During elevation of the tooth Fracture of the tooth Displacement of the tooth into lingual pouch
or lateral pharyngeal space or tonsillar area (retrieval – finger manipulation or surgical exploration)
Sublux]ation to 2nd molar or complete dislodgement out of its socket
Damage to the disto-occlusion restoration Fracture of the jaw (due to excessive force)
Root apices penetrating mandibular canal – hemorrhage & numbness
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Prevention of dislodgement into the lingual pouch or lateral pharyngeal space
Relieve the tooth from the overlying gingival pad
Finger over the 3rd molar during elevation
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Post operative complicationsImmediate 1. pain2. Hemorrhage 3. Swelling4. Anesthesia5. Trismus6. Pain on swallowing & sore throat pyrexia
Late 1. Infection 2. Hemorrhage 3. Pain in TMJ4. Trismus
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Immediate post op complications
1. Pain: cause:
dry sockethematomatrauma to the adjacent tooth
Pain thershold – varies for each individualJudicious manipulation of the tissues
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2. Hemorrhage:
Injection
Incision
Infection
Hemorrhage
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Reactionary Hemorrhage Occuring during the first 24 hours following surgery
Cause:1. failure to achieve complete
hemostasis during surgery2. wearing of adrenalin action
Management:
source of bleeding is identified
Ligation Pressure pack
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3. Swelling:
Cause: Bleeding under a tight suture
lack of escape of hemorrhage through the sutural line
Seepage into the soft tissues
1. Tongue base 2. Pharyngeal tissue planes
Impairment of airway
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Swelling
Edema
Not painful
Hematoma
Tense & Tender
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