Impacted teeth /certified fixed orthodontic courses by Indian dental academy

The Management of
Impacted Teeth
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INDIAN DENTAL ACADEMY
Leader in continuing dental education

Impacted Teeth
 The aim of this lecture is to explain the
principles relating to the management
of commonly encountered impactions
 It is a guide to further study and an
introduction to topics that will be
addressed elsewhere in your course

Impacted Teeth
 The third molars
 The canines
 The premolars
 The supernumerary or mesdiodens
 The submerged deciduous tooth or
teeth
 Others

The Mandibular Third Molar
 Introduction
 Evolution
 Preservation of teeth
 Eruption variability
 Incidence

 Indications for removal
 Pericoronitis
 Caries
 Periodontal disease
 Eruption under denture
 Associated pathology
 Facial pain
 Previous unsuccessful surgery
 Prophylacticwww.indiandentalacademy.com

 Diagnosis
 History
 Examination
 Special tests

Radiology
 Periapical
 OPT
 Lateral Oblique

 Assessment of surgical difficulty
 Patient compliance
 Access
 Tooth related factors

Root pattern

Degree of eruption

Depth of impaction

Angulation

Associated structures

Age, gender and race

 Classification
 Soft tissue
 Hard tissue
 Vertical
 Mesioangular
 Distoangular
 Horizontal
 Aberrant

 Structures at risk
 Contents of inferior alveolar canal
 Lingual nerve
 Mandibular second molar
 Soft tissue

Flap

Lips and cheek

Tongue
 Jaw fracture

 Radiological assessment of the
proximity of the tooth to the inferior
alveolar canal

Decrease in width of the canal as it crosses
the roots

Relative radiolucency of the roots as they
are crossed by the canal

Divergence of the canal as it crosses the
roots

Loss of the lamina dura of the canal

 Results of damage to the inferior
alveolar canal
 Haemorrhage

Arterial

Venous

Intraneural
 Nerve damage

Anaesthesia

Paraesthesia

Dysaesthesiawww.indiandentalacademy.com

 Neurological Damage
 Neuropraxia

Paraesthesia

Rapid recovery
 Axonotmesis

Anaesthesia / Dysaesthesia

Slow and unpredictable recovery
 Neurotmesis

Anaesthesia

Little chance of recovery

 Surgical Process
 Diagnosis
 Explanation
 Consent
 Surgical treatment
 Post operative care
 Discharge

 Surgical Management
 Anaesthesia

Local

General
 Raising the flap

Distal relieving incision

Envelope

Buccal relieving

Lateral trepanation
 Flap retraction

Lingual nerve protectionwww.indiandentalacademy.com

 Bone removal
 Hand instruments

Chisels
 Lingual split technique of Sir William Kelsey-Fry

Gouges

Rongeurs
 Rotating instruments

Round bur

Fissure bur
 NO LINGUAL TISSUE TRANSGRESSED

 Tooth division
 To convert into a single rooted tooth

Osteotome

Fissure bur
 To provide space to relieve the impaction

Fissure bur
 Axial
 Decoronation
 Combination

 Elevation
 Point of application
 Controlled force with elevators

Couplands

Warwick James

Cryers
 Debridement

 Wound closure
 Postoperative care
 Prevention of infection
 Analgesia
 Patient instructions
 Follow up
 Discharge

 Complications
 Prior to surgery

Syncope
 During surgery

Failure of anaesthesia

Fractured crown/roots

Damage to associated structures
 After surgery

Haemorrhage

Infectionwww.indiandentalacademy.com

The Maxillary Third Molar
 As for mandibular third molar except
 Often removed as non-functional in a
prophylactic manner
 Classification by height rather than
angulation

 Surgical Technique
 Erupted teeth

Usually an elevator better than forceps

Can also be used with relieving incision for
partly erupted teeth
 Unerupted teeth

Buccal and distal flap

Retraction of flap to prevent dislodgment of
tooth

Bone removal with hand instruments prior to
elevationwww.indiandentalacademy.com

 Complications as for mandibular molar
except
 No inferior alveolar canal
 Fracture of tuberosity
 Oro antral communication
 Dislodgement into infra temporal fossa

The Impacted Maxillary
Canine
 Causes
 Incorrect eruption pathway
 Crowded maxillary arch
 Non-resorbing deciduous teeth
 Presence of pathology
 Trauma

Canine
 Sequelae
 Resorbtion of tooth roots
 Dentigerous cyst formation
 Infection
 Nothing

Canine
 Clinical presentation
 Non appearance of tooth at appropriate
age
 As incidental finding on OPT
 Buccal or palatal swelling
 Inclination or rotation of lateral incisors

Canine
 Radiology
 Periapical (especially parallax technique)
 Occlusal

Anterior

Vertex
 OPT
 Lateral skull

Canine
 Localisation
 Aim to be able to decide on whether the
tooth lies buccal or palatal to the arch
 Obtain films at right angles to each other
 Hint

On OPT Buccal tooth often looks larger

Canine
 Treatment planning
 Age, attitude and oral hygiene
 Crowding or spacing
 Degree of displacement/impaction
 Associated pathology
 Root morphology

Canine
 Treatment options
 Do nothing

Elderly, sick and asymptomatic

Risk to surrounding structures

Informed refusal of treatment
 Surgical exposure

To allow orthodontic treatment to align the tooth
in the arch

Only in favourable cases

Canine
 Surgical removal

In cases of pathology or tissue damage

Impossible to expose or transplant

very crowded arch (with orthodontic agreement
only)

poor patient cooperation
 Transplantation

Last resort

Overtaken by use of implantology

Canine
 Similar basic principles

Buccal or palatal flaps

Bone removal

Tooth division

Elevation

Debridement

Closure

Canine
 Complications

As for other surgery

Include
 Flap necrosis
 Palatal haematoma
 Reactionary haemmorhage
 Oro Nasal Communication

The Impacted Mandibular
Second Premolar
 Commonly crowded out from the arch
 Crown displaced lingually or buccally
 Radiology
 Periapicals
 OPT

Second Premolar
 Surgical options
 Masterly inactivity
 If suitable arch space, orthodontic
treatment
 If crowded arch, extraction of first premolar
and orthodontic treatment

Second Premolar
 Surgical technique
 Buccal mucoperiosteal flap
 Identification and protection of mental
nerve
 Bone removal
 Tooth division
 Elevation
 Debridement
 Repair

Further Reading
 MacGregor: The Third Molar Tooth
 Petersen: Contemporary Oral and
Maxillofacial Surgery
 Moore and Gillbe: Principles of Oral
Surgery

Thank you
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Impacted teeth /certified fixed orthodontic courses by Indian dental academy

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Impacted teeth /certified fixed orthodontic courses by Indian dental academy