1. Impacted teeth
Islam Kassem
Level 8

2. Definition :-
is a tooth that fails to erupt into its normal
functioning position in the dental arch within
the expected time.
The term Unerupted includes both
impacted teeth and teeth that are in the
process of erupting.
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3. Causes of impaction
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4. Systemic Causes
A. a hereditary syndrom of
cliedocranial dysistosis termed
primary Retention.
B. endocrinal deficiency
(hypothyrodism,
hypopituitarism).
C. febrile disease, down
syndrom, irradiation (all cause
multiple teeth impaction).
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5. Local Factors
A. prolonged deciduous tooth retention
B. malposed tooth germ
C. arch length deficiency
D. odontoginic tumors abnormal eruption
path
E. cleft lip and palate
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6. frequency of impaction
- The order of frequency of impacted
teeth is as follow:-

7. frequency of impaction
1. mandibular 3rd molar
2. maxillary 3rd molar
3. maxillary cuspid
4. mandibular cuspid
5. Mandibular premolar
6. maxillary premolars
7. maxillary central and lateral incisors
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8. Evaluation

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10. 1. Include clinical inspection to disclose tooth
not in position or absent in place and
radiographic assessment Showing the
unerupted position of the tooth
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11. 2. Standard radiographic techs used to localize
the unerupted teeth, these include:
 The tube shift method
 Periapical & occlusal films
 Panoramic view
 CT
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12. The tube shift method
• Uses two periapical radiographs, shifting the
tube horizontally between exposures.
• If the unerupted teeth moves in the same
direction in which the tube is shifted, its
located on the lingual or palatal side
• A facial or buccally located tooth moves in the
opposite direction to the tube shift.
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13. The periapical &occlusal method
• Uses the periapical radiograph taken with
standard technique and an occlusal
radiograph to give different views of the
impacted tooth.
• Panoramic film can be used to assess
maxillary canine position
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15. Complication of
impacted teeth
(indication for removal):

16. • the presence of impacted teeth in the jaw can
create a variety of problems, so it should be
removed as soon as diagnosis is made:
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17. A. Pericoronitis

18. • when a tooth is partially
impacted with a large
amount of soft tissue over
the axial and occlusal
surfaces, the patient
frequently has one or more
episodes of pericronitis.
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19. Definition of pericoronitis
• is an infection of the soft
tissue around the crown of
partially impacted tooth and is
caused by the normal oral
flora.
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20. Causes
1. If the patient experience a mild transient decrease in
host defense, pericoronitis may result.
2. pericronitis may arise secondary to minor trauma
from maxillary third molar. The soft tissue that covers
the occlusal surface of the partially erupted
mandibular third molar known as the operculum can
be traumatized and become swollen this can be
treated by removal of maxillary third molar.
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21. 3. entrapment of food under operculum, in the pocket under
operculum and impacted teeth ,this pocket can not be
cleaned ,bacteria invade it and pericoronitis begins.
4. streptococci and anaerobic bacteria (the usual bacteria
inhabit the gingival sulcus) cause pericronitis.
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22. Treatment and Management

23. • pericronitis can present as a very mild infection or
as a sever infection that requires hospitalization of
the patient .
A. In its mildest form:-
- Percronitis is present as a localized swelling and
soreness.
- Mild irrigation and curettage by dentist and home
irrigation by pt is suffice.
B. In sever infection with local tissue swelling:
that is traumatized by maxillary third molar ,the dentist
should consider the maxillary third molar and local
irrigation .
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24. • for the patient who have in addition to local swelling
and pain, mild facial swelling ,mild trismus secondary
to inflammation extending into muscle of
mastication ,and a low grade fever, the dentist
should consider administration of antibiotics along
with irrigation and extraction, (penicillin is the
antibiotic of choice).
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25. • the mandibular third molar shouldn't be removed
until sign and symptoms of pericronitis have been
completely resolved
• the incidence of post operative complication as dry
socket and post operative infection ,increases if
tooth is removed during time of active infection.
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26. B. Dental Caries
• When third molar is
impacted or partially
impacted ,the bacteria
that cause dental caries
can be exposed to the
distal aspect of the 2nd
molar, as well as to
third molar
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27. C. Periodontal Disease
• Erupted teeth adjacent to
impacted teeth are
predisposed to periodontal
disease.
• As it decrease amount of bone
on the distal aspect of adjacent
2nd molar, with deep
periodontal pocket on the
distal aspect of the 2nd molar.
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28. D. Root Resorption
• Impacted teeth cause
sufficient pressure on
the root of an adjacent
tooth to cause root
resorption.
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29. E. Pain of unexplained origin:
• Pain in the retro
molar region with no
obvious reason.
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30. F. Odontogenic cyst and Tumors
• The dental follicle may
undergo cystic
degeneration and
become a dentigerios
cyst or keratocyst.
• A meloblastoma may
developed from
epithelium within the
dental follicle
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31. G. Fracture of the jaw
• impacted third molar
occupies space that is
usually filled with bone,
this weaken the
mandible and render
the mandible to
fracture.
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32. H. impacted teeth under dental
prosthesis:
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33. I. Facilitation of orthodontic
treatment
• to relief crowding of
mandibular anterior
teeth.
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34. Contraindication for
removal of impacted
teeth:

35. 1. extreme of age:
- as the bone become highly calcified, less flexible,
less likely to bend under force of tooth extraction
the result ,bone more surgically removed to
displace tooth from its socket and less post
operative sequla
2. compromised medical status:
3. probable excessive damage to adjacent
structure:
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36. Classification system
of impacted teeth
- this is done to help dentist in evaluation of the
extent of the surgical procedure and in the
planning of this procedure.

37. Whinters lines
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38. 1-Classification of impacted
mandibular third molar:
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39. A - Relation of the tooth to the ascending
ramus of the mandible and to the distal
surface of the 2nd molar: (Pell &Gregory)
– this show the anterioposterior relationship of the
tooth to the arch and the amount of resistance
offered by the bone of the ascending ramus that may
influence the tooth removal
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40. Class1
• the space between the
anterior part of the
ascending ramus and
the distal surface of the
2nd molar is sufficient
to accommodate the
mesiodistal diameter of
the crown of the third
molar.
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41. Class2
• the space between the
anterior part of the
ascending ramus and
distal surface of the 2nd
molar is less than the
mesiodistal diameter of
the crown of the third
molar (part of the tooth
located within the
ramus)
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42. Class3
• all the third molar is
located within the
ascending ramus of the
mandible.
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43. B - Relative depth of the third molar in
bone:
- this show the superior inferior
relationship of the tooth in
relation to the occlusal plan. (Pell
& Gregory)
• Position A:
the highest portion of the tooth is on level
with or above the occlusal plane.
• Position B:
the highest portion is below the occlusal
plane but above the cervical margin of the 2nd
molar
• Position C:
the highest point of the tooth is below the
cervical margins of the 2nd molar (deep
impaction)
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44. C - the position of the long axis of the impacted tooth in
relation to the long axis of the 2nd molar (winter's
classification):
1-vertical: the long axis of the third molar
is parallel to that of the 2nd molar.
2-horizontal:the long axis of the third
molar is at right angle to that of the
2nd molar .
3-mesioangular impaction.
4-destoangular impaction:
all the previous four classes can come in:
a - lingual deflection.
b - buccal deflection.
5-inverted impaction
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55. 2 -Classification of impacted
maxillary third molar:

56. 1. The relationship of the tooth to occlusal plane of the 2nd
molar (as before)
2. The relationship of tooth to maxillary sinus :
a-sinus approximation :
(s.a) where no bone or very thin bone exist
between the impacted teeth and floor of sinus.
b-no sinus approximation :
(n.s.a) where 2 mm or more of bone exist
between the floor of sinus and impacted teeth.
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57. 3-Classification of impacted
maxillary cuspids:

58. • Class1:
palatally impacted cuspids ,these could be in vertical,
horizontal, semivertical position.
• Class2:
labialy impacted cuspide which could be in vertical,
horizontal, semivertical.
• Class3:
impacted cuspid located both in the palatal and labial
surfaces.
• Class4:
impacted cuspid that are present in an edentulous maxilla
and may assume any of the previous three classes.
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59. Surgical removal of
impacted teeth:

60. 1- Proper radiographic and clinical evaluation of the
condition:
A- periapical radiograph
B- occlusal radiograph
C- panoramic radiograph
2- Classification of impaction to help in planning the
surgical procedure:
3- Selection of the time for surgical procedure:
 surgical removal of impacted third molar is not as a
surgical emergency, it is an elective procedure which
shouldn't be postponed for along period of time until
several complication arises.
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61. 4- The condition should be explained to patient in a
simple easy way directing his attention to possible
complication that may arise from leaving tooth in
position
5- Surgical removal can be made under local anesthesia
as well as general anesthesia the choice of the
anesthetic technique depends on:
a- general condition of the patient and his ability
psychologically and physically take the procedure. in very
apprehensive patient, general anesthesia is preferred.
b- position of impaction and extent of surgical procedure
c- patient co-operation
d- number of impaction that will be removed in the setting
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62. the surgical procedure is divided into
following stages:

63. 1- gaining access to impacted tooth:
A- elevation of an adequate
mucoperosteal flap to expose the field
of surgery:
 Pyramidal flap used in all third molar
impaction, the anterior incision of the flap
could extend from the distal aspect to 2nd
molar running at 45 degree angel and
extend to the mucobucal fold.
 In deep impaction ,a bigger flap is
advisable. the anterior incision could start
from the mesial aspect of 2nd molar
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64. Envelope Incision and
reflection
When more
accessibility is needed ,
a releasing incision is
made.
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65. Envelope Flap Incision and Reflection
Triangular Flap Incision and Reflection
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67. with palatally impacted maxillary cuspid
- exposure of the field of surgery can be
done by gingival incision extending from
the palatal side of premolar in one side to
other side all around the palatal gingiva of
the present teeth.
with labially placed impaction
- a labial pyramidal flap is adequate
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68. 2- bone removal
This is done for :-
A- exposure of impaction
B- reduction of resistance
C- making a point for application of the elevator
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69. Bone Removal With a
Fissure Surgical Bur
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71. 3- tooth delivery
1- total delivery by application of force using elevators:
a- mesial application of force :straight elevators and pot's elevators.
b- buccal application of force :winter elevator
2-delivery of the tooth after tooth division :
- division is indicated to reduce resistance ,create a space or remove
interlocked cusps of the tooth
a- decapitation:- division of the crown of the tooth at cervical margin
level .
- indicated in horizontal mandibular and maxillary third molar impaction
and pallataly impacted maxillary cuspid
b- longitudinal tooth division:
- indicated when the impacted tooth has a widely divergent straight
roots, or when one root is straight and the other is curved
c- division of the interlocking cusp:
- this is done with mesioangular impaction ,removal of the inter locking
segment of the tooth usually located under the distal surface of 2nd
molar
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72. Bone is removed with the surgical bur to Decapitation is then performed
expose the whole crown
A purchase point is prepared in the root, The second root is removed in the same
which is then removed with an elevator way
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75. Preparation for wound closure:
- after removal of the tooth from it's socket the wound
is gently irrigated with sterile normal saline solution
and inspected for:
a- any remnant of the residual tooth sac is removed
b- remnant of tooth structure or fragments of bone debris is
gently removed
c- small fragments of the detached bone
d- sharp edges of interseptal or alveolar bone is trimmed and
smoothed
- then final irrigation and wound now is ready for
closure.
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76. closure of the wound:
• well designed and properly reflected flap fall back easily into
place. using have circle a traumatic needle and 000 black silk
suture to hold flap into place
• post operative care:
1. a pressure pack is held in place for 1hour
2. post operative instruction given to pt:
3. cold packs on outside of face 20 min/h 5 time daily
4. proper antibiotic therapy
5. mouth wash
6. soft diet
7. patient return back for check up after two days
8. suture removal after 5 days
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77. Complication associated with
surgical removal of impacted tooth

78. 1- laceration of the soft tissue flap:
a-improper incision
b-improper elevation of the flap and improper retraction this
leads to delayed healing and sever discomfort
2- affection of the alveolar bone:
3- fracture of the jaw:
- in angle of mandible ,improper use of elevator with
uncontrolled force
4- fracture of tuberosity:
this occurs with erupted rather than unerupted tooth due
to improper use of force
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79. 5-comlication related to injury of adjacent structure:
a-injury to inferior alveolar canal:
- occurs in deeply seated vertical impaction, the nerve pass between roots
of impacted tooth .permanent numbness and heamorraghe
b-damage to nasal floor:
- during surgical removal of impacted maxillary cuspid, profuse bleeding from nasal
mucosa
c- involvement of maxillary sinus:
- during removal of impacted maxillary third molar. oro anntral fistula
results
d- pushing of impacted tooth into maxillary sinus:
e- pushing of impacted maxillary molar into pterigopalatine fossa:
- uncontrolled mesial application of force in deep impaction
f- pushing impacted mandibular third molar into sub-mandibular space:
- uncontrolled buccal application pf force and fracture of the lingual plate
g-aspiration or swallowing of impacted tooth:
- with general anesthesia ,
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80. post operative complication:
1. pain.
2. infection
3. heamoraghe
4. anesthesia or parenthesis of the lingual or inferior alveolar
nerve
5. trismus,limitation of jaw movement
6. osteomylitis
7. pain at tmj
8. pain on swallowing due to edema of pharynx and hematoma
formation.
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81. Study source?
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82. • Contemporary Oral &
maxiallofacial surgery
• Page 185-199
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83. • You can get it form
• http://www.slideshare.net/islamkassem
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84. •Thank you
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