1. BY-RITIKA GUPTA
IMPACTION

2. CONTENTS
 Defination
 Order of frequency of impacted teeth-
 Causes of impaction of teeth
 Indications of removal of impacted teeth
 Classification of Impacted teeth
 Winter” s Line
 Surgical removal of impacted tooth
 Complications

3. Defination
 An embedded or impacted tooth- is the tooth that
has failed to erupt completely or partially to its
correct position in the dental arch and its eruption
potential has been lost.
 The word impaction is from latin origin-impactus
 Impaction is cessation of eruption of tooth caused
by a physical barrier or ectopic positioning of a
tooth.

4. Order of frequency of impacted
teeth-
 Mandibular third molars
 Maxillary third molars
 Maxillary canine
 Mandibular premolars
 Maxillary premolars
 Mandibular canine
 Maxillary canine
 Maxillary cenral incisors
 Maxillary lateral incisors

5. Causes of impaction of
teeth
 The phylogenic theory-Due to evolution , the
human jaw size is becoming smaller and since
the third molar tooth is last to erupt,there may not
be space for it to emerge in the oral cavity.
 Mendelian theory-Here genetic variations plays a
major role.If the individual genetically receives a
small jaw from one parent and / or large teeth
from other parent,then impacted teeth can be
seen, because of lack of space.

6. Causes of impaction of tooth
Local causes Systemic causes
 Obstruction for eruption
 Lack of space in dental
arch
 Ankylosis of primary or
permanent tooth
 Nonabsorbing over
retained decidous teeth
 Ectopic position of tooth
bud
 Dilaceration of roots
 Heredity
 Postnatal-
rickets,anaemia,tb,cong
enital syphilis.
 Endocranial disorder of
thyroid ,parathyroid etc
 Hereditary linked
disorders-Down
syndrome,Hurler
syndrome,osteoporosis,
cleft palate,cleidocranial
dystosis.

7. Indications of removal of impacted
teeth
 Recurrent pericronitis
 Deep periodontal pocket associated with partially
erupted tooth
 Prior to orthodontic treatment
 Prevention of root resorption and caries
 Management of cyst,tumors,abcess
 Preperation of orthognathic surgery
 Impacted teeth in line of fracture

8. Classification of Impacted
teeth
Maxillary and mandibular third molars are classified
radiographically by angulation,depth and arch
length or relationship to the anterior aspect of the
ascending mandibular ramus.
Classification is helpful for the following-
Describes the general position of the impacted third
molar.
Aids in estimating the difficulty in removing the
tooth.

9. Winter”s Classification
 Angulation-According to
the position of the
impacted third molar to
the long axis of the
second molar.The winter”s
classification is
suggested:
 Mesioangular
 Distoangular
 Vertical
 Horizontal
 Buccoangular
 Linguoangular

10. Winter”s Classification
 Depth-As per relationship to
the occlusal surface of the
adjoining second molar of
the impacted maxillary or
mandibular third molar,the
depth can be judged:
 Position A- The highest
position of the tooth is on a
level with or above the
occlusal line.
 Position B-The highest
position is below the occlusal
plane,but above the cervical
level of the second molar.
 Position C-The highest
position of the tooth is below
the cervical level of the
second molar.

11. Pell and Gregory”s
Classification:
 Relationship of the impacted
lower third molar to the ramus of
the mandible and second molar(
based on th space available
distal to the second molar).
 Class I-Sufficient space
available between the anterior
border of the ascending ramus
and distal to the second molar).
 Class II-The space available
between the anterior border of
the ascending ramus and the
distal side of the second molar
is less than the mesiodistal
width of the crown of the third
molar.
 Class III-The third molar is
totally embedded in the bone
from the ascending ramus
because of absolute lack of
space.

12. Difficulty Index-
 Very difficult: 7 to 10
 Moderately difficult:5 to
7
 Minimally difficult:3 to 4

13. Maxillary third molar
classification:
 Angulation and depth
classification is same as
mandibular third molars:
 Classification of the
maxillary third molar in
relation to the floor of
the sinus-
 Sinus approximqation-
(SA)-No bone or a thin
bony partition present
between impacted
maxillary third molar
and floor of the mouth.
 No sinus approximation-
(NSA)-2mm or more
bone is prresent
between the sinus floor

14. Classification of impacted maxillary
canine-
 Impacted canines lie in
the maxillary sinus or
nasal cavity-
 Class I-Palatally placed
 ClassII-Labially placed
 Class III-Involving both
buccal and palatal bone
 Class IV-Impacted in
the alveolar process
between the incisors
and first premolar.
 Class V-Impacted in the
edentulous maxilla

15. Classification of impacted mandibular
canine
 Vertical
 Oblique
 Horizontal
 On opposite side
 At inferior border.

16. Winter”s Line
 The position and depth of the tooth can be
assesed by taking intraloral X-ray or even lateral
extraoral X-ray and tracing can be done,which
was orginally advocated by George Winter-
 Three imaginary lines are drawn which are known
as-
 1. White Line
 2. Amber Line
 3. Red Line

17. Winter”s Line
 White Line-corresponds to
occlusal plane.the line is
drawn touching the occlusal
surfaces of first and second
molar and is extended
posteriorly distal to third
molar region.It indicates the
difference in occlusal level
of second and third molars.
 Amber Line-Represents the
bone level.The line is drwan
from the crest of interdental
septum between the molars
and extende posteriorly
distal to third molar or to the
ascending ramus.This line
denotes the alveolar bone
covering the impacted tooth
and the portion of the tooth
not covered by the bone.

18. Winter”s Line
 Red Line-is drawn
perpedicular from amber line
to an imaginary point of
application of the elevator.It
indicates the amount of bone
that will have to be removed
before elevation,i.e the depth
of the tooth in bone and the
difficulty encountered in
removing the tooth.
 If the length of red line is
more than 5mm then the
extraction is difficult.Every
additional mm renders the
removal of the impacted
tooth three times more
difficult (more than 9mm-
below the level of the apices
of the second molar).

20. Surgical removal of impacted
tooth
 1- Isolation of surgical site:Scrubbing+ painting of
skin and oral mucosa
 Povidone iodine 5% for skin,1% for for oral
mucosa
 It acts topically to inhibit further growth of
microbes
 Drape the patient with sterile drapes to cover
upper part of the face to isolate the oral cavity.

21. Surgical removal of impacted
tooth
 2-Local Anaesthesia-
 For Mandibular molar and canine-Inferior alveolar
block
 For maxillary molars-posterior alveolar nerve
block and greater palatine block or infiltration.
 For maxillary canine-Infraorbital nerve block and
palatal infiltration of incisive canal and bilateral
palatine nerve blocks

22. Surgical removal of impacted
tooth
 3-Incision(Flap design)-For mandibular molars-
 Ward’s incision-
 Anterior releasing incision should begin from the
vestibule upwards towards midway of the CEJ of
second molar at an angle,
 Incision is continued in the gingival sulcus (over
the alveolar crest,if the tooth is fully embedded)
upto the distal aspect of the third molar.
 Distal releasing incision is started from the distal
most point of the third molar across the external
oblique ridge into the buccal mucosa.

23. Surgical removal of impacted
tooth
 The sharp point of periosteal elevator is used to
carefully elevate a mucoperiosteal flap beginning
at the point of the incision behind the second
molar.
 The elevator isbrought forward to elevate the
periosteum around the second molar and down
the releasing incision.
 The other flatter end of the periosteal elevator is
then used to elevate the periosteum posteriorly to
the ascending ramus of the mandible.

24. Surgical removal of impacted
tooth
 For maxillary molars-The anterior releasing incion is
started anterior to second molar from the vestibule and till
the mesial interdental papilla of the second molar.
 The incision must follow the gingival sulcus of second
molar and continue over the tuberosity area from the distal
most point of second molar.
 For maxillary canines-If buccaly placed-flap with anterior
releasing incision ,trapezoidal flap,Semilunar flap.
 If canine is palatally placed-The incision is taken in the
gingival sulcus on the palatal side from the mesial aspect
of the first molar of the same side.Releasing incision is
given obliquely across the palate and sould be deflected
away from the palatine foramen.
 For mandibular canines-Crevicular incision from the
midline is taken upto the first molar.Anterior releasing
incision is given close to the midline.

25. Surgical removal of impacted
tooth
 Bone Removal-
 Aim-
 1.To expose the crown by removing the bone
overlying it.
2.To remove the bone obstructing the pathway
for removal of a tooth.
Adequate amount of bone should be removed to
enable for elevation.
But extensive bone removal can be minimized by
sctioning bthe tooth.

26. Surgical removal of impacted
tooth
 Two ways of Bone removal-
 1.High speed,high torque handpiece and bur
technique
 2.Chisel and mallet technique
 Bur technique-Either no.7/8 round bur or a straight
no.703 fissurw bur is used.Burs should be used with
copious saline irrgation to avoid thermal trauma to the
bone.
 The bur is used in sweeping motion around the
occlusal,buccal and distal aspect of the mandibular
third molar
 Once the crown is located, the buccal surface of the
tooth is exposed with the bur to the crevical level of
the crown contourband a buccal trogh or gutter is
created in the cancellous bone.

27. Surgical removal of impacted
tooth
 It is important that adequate amount of trough is
created to remove any bony obstruction for
exposure and delivery of the tooth,especially
around distal aspect of the crown.
 The distolingual portion of the tooth should be
exposed without cutting through the lingual bony
pkate to prevent damage to lingual nerve.
 For canine removal gutter is created around the
surface of the crown free from contact with
neighburing teeth.
 The bone removal around the crown is done till
CE junction and to expose the crown beyond the
greatest width.

28. Surgical removal of impacted
tooth
 Chisel and mallet technique-
 1-For mandibular/maxillary molars-vertical stop cut is
made by placing a 3mm or 5 mm chisel vertically at distal
aspect of the second molar with bevel facing posteriroly.
 At the base of vertical stop cut,the chisel is placed at n
angel of 45 degree with bevel facing upwardsor
occlusally,and oblique cut is made till the distal most point
of third molar.
 This will result in triangular piece of buccal plate distal to
second molar.
 Additional triangular piece of bone is removed at the
junction of vertical and oblique bone to gain entery of the
elevator tip.
 Finally distal bone is removed so that when tooth is
elevated there should be no obstruction at the distobuccal
aspect.
 In case of canine removal bone is cut till the level of CEJ
and to expose the entire crown.

29. Surgical removal of impacted
tooth
 Lingual Split bone technique-
 Described by Sir William Kelsey Fry
 Later popularised by T.Ward
 Vertical stop cut is made placing the chisel with the
bevel facing posteriorly,distal to the second molar.
 With chisel bevel downward a horizontal cut is made
backward from the lower end of the vertical limiting
stop cut.
 The distolingual bone is then fractured inward by
placing the cutting edge of the chisel along the dotted
line.Bevel side of the chisel is facing upward and
cutting edge is parallel to the rexternal oblique
ridge.The chisel is held at 45 degree to the bone.

30. Surgical removal of impacted
tooth
 Finally small wedge of bone which then remaining
distal to the tooth and between the buccal and
lingual cut is excised and removed.
 A sharp straight elevator is then applied and
minmum force is used to elevate the tooth.As the
tooth moves upward and backward,the lingual
plate gets fractured and facilitates the delivery of
the tooth.
 After the tooth is removed,the lingual plate is
grasped with haemostat and freed from the soft
tissue and removed.
 Smoothening of the edges is done with bone
file.Wound irrigated and sutured.

31. Surgical removal of impacted
tooth
Tooth sectioning-

32. Surgical removal of impacted
tooth
 Elevation-Coupland elevator-placed at the base
of the crown
 Winter cryer’s-used in wedging action.Buccal
elevation may be done in molars and canines by
drlling a purchase point in the roots just below the
CEJ.
 Wedging action is useful when molar crown is
split vertically down to bifiurcation of roots.

33. Surgical removal of impacted
tooth
 Debridement and smoothening of bone margins
 Irrigation of the socket
 Curetting to remove any remaining dental follicle
and epithelium.
 Round off the margins of the socket
 Control bleeding before suturing
 Closure-3-0 mersilk is used,interrupted sutures
given and maintained for 7 days.
 Molars-suture distal to second molar should be
placed first.
 Palatally placed Canine-incisive papilla should be
sutured carefully .

34. Complications
 During incision-for molars facial vessel or buccal
vessel may be cut.
 For lower canines-mental vessels and for upper
canines-incisive canal or greater palatine vessel may
be damaged.
 During bone removal-damage to 2nd molar,damage to
roots of overlying teeth,slipping of bur in soft
tissue,fracture of mandible when using chisel mallet.
 During Elevation-luxation of neighbouring tooth
 Fracture of adjoining bone
 Fracture of tuberosity
 Slipping of tooth in
pterygomandibular,temporal,sublingual space or
maxillary sinus.

35. Complications
 During debridement- Damage to inferior alveolar
nerve/lingual nerve.
 Damage to maxillary sinus.
 Post operatively-
Pain,swelling,trismus,hypoesthesia,senstivity,loss
of vitality of neighbouring teeth.Pocket
formation.Sinus tract formation,oroantral
fistula,oronasal fistula.

36.  ARTICLES

37. 1.Incidence of impacted mandibular and maxillary
third molars: a radiographic study in a Southeast
Iran population
 Med Oral Patol Oral Cir Bucal >v.18(1); Jan 2013 >PMC3548634
 Maryam A. Hashemipour,1 Mehrnaz Tahmasbi-Arashlow,2 and
Farnaz Fahimi-Hanzaei3
 1DDS, MSc. Member of Kerman Dental and Oral Diseases
Research Center. Department of Oral Medicine, School of
Dentistry, Kerman University of Medical Sciences, Kerman, Iran
 2DDS. Member of Kerman dental and oral diseases research
center. Kerman University of Medical Sciences, Kerman, Iran
 3DDS, MSc. Department of Radiology, University of Medical
Sciences, Kerman, Iran
 Corresponding author.
 Department of Oral Medicine School of Dentistry Kerman
University of Medical Sciences Kerman, Iran , E-mail:
m_hashemipoor@kmu.ac.ir
 Author information ► Article notes ► Copyright and License
information ►

38. Abstract
 Objectives: The aim of this study is to evaluate the
position of impacted third molars based on the
classifications of Pell & Gregory and Winter in a
sample of Iranian patients. Study design: In this
retrospective study, up to 1020 orthopantomograms
(OPG) of the patients who were referred to the
radiology clinics from October 2007 to January 2011
were evaluated. Data including the age, gender, the
angulation type, width and depth of impaction were
evaluated by statistical tests. Results: Among 1020
patients, 380(27.3%) were male and 640(62.7%) were
female with the sex ratio was 1:1.7. Of the 1020
OPGs, 585 cases showed at least one impacted third
molar, with significant difference between males (205;
35.1%) and females (380; 64.9%) (P = 0.0311). Data
analysis showed that impacted third molars were 1.9
times more likely to occur in the mandible than in the
maxilla (P =0.000).

39. Abstract
 The most common angulation of impaction in the
mandible was mesioangular impaction (48.3%) and
the most common angulation of impaction in the
maxilla was the vertical (45.3%). Impaction in the
level IIA was the most common in both maxilla and
mandible. There was no significant diffe-rence
between the right and left sides in both the maxilla
and the mandible. Conclusion: The pattern of third
molar impaction in the southeast region of Iran is
characterized by a high prevalence of impaction,
especially in the mandible. Female more than male
have teeth impaction. The most common angulation
was the mesioangular in the mandible, and the
vertical angulation in the maxilla. The most common
level of impaction was the A and there was no any
significant difference between the right and left sides

40. 2- Variations in impacted mandibular
permanent molars: Report of three rare
cases
 Contemp Clin Dent. 2011 Apr-Jun; 2(2): 124–126.
 doi: 10.4103/0976-237X.83079
 PMCID: PMC3180835
 Manjiri Joshi and Vikrant Kasat

41. Abstract
 The impaction of permanent teeth is not
uncommon, but few permanent teeth are rarely
impacted like mandibular first and second molars.
Though third molars are commonly impacted,
inversely impacted mandibular third molars are
very rare. Here, we report three unusual cases of
impacted mandibular molars accidentally
diagnosed on conventional radiographs

42. Case 1
 A 44-year-old man patient
reported to the
department for complaint
of pain and swelling on
the left side of face since
1 week. Clinical
examination revealed
extraoral diffuse swelling
on the left side of face
which was tender on
palpation. Patient had
trismus. Intraoral
examination revealed
inflamed pericoronal flap
with partially seen 38 and
distal periodontal pocket
with 37. Radiographs
revealed inversely
impacted 38 in ramus on
left side

43. Case 2
 A 28-year-old man reported to
the department for complaint of
pain and swelling in upper right
back region of jaw since 3 days.
Also, there was previous history
of pain and swelling in lower
right back region of jaw three
months back, for which patient
was on medication and got
symptomatic relief.
 Intraoral examination revealed
root pieces with 17, with
intraoral swelling in buccal
vestibule. Clinically, 47, 48, and
38 were missing. There was no
history of extraction with the
abovementioned teeth.
Radiographs
[Figures ​[Figures33 and ​and4]4]
revealed root pieces with 17,
with periapical rarefaction and
horizontally impacted 47 and 48,
overlying one above other

44. Case 3
 A young man aged 21
years reported to the
department of Oral
Medicine and Radiology
for complaint of
malaligned teeth.
Clinical examination
revealed missing 36,
mesioangularly inclined
37. There was no
history of extraction or
exfoliation with 36.
Intraoral periapical
radiograph revealed
impacted 36 in between
35 and mesioangularly
placed 37 below
cemento-enamel

45. 3-A case of impacted maxillary central incisor and
its management
 J Pharm Bioallied Sci. 2012 August; 4(Suppl 2):
S174–S176.
 doi: 10.4103/0975-7406.100263
 PMCID: PMC3467902
 Prem Kumar Karupanna Pillai Subbiah Kannan,
Senthil Kumar Kullam Palayam Palanisamy,1 and
Tamizharasi Senthil Kumar1

46.  Impaction of maxillary permanent central incisor
is not a frequently reported case in dental
practice, but its treatment is challenging because
of its importance to facial esthetics. Early
detection of such teeth is most important if
complications are to be avoided. We report a
case of a 14-year-old female with an impacted
central incisor tooth in the maxillary anterior
region. The impacted supernumerary tooth which
was preventing the eruption of permanent incisor
was surgically removed. Combined approach with
surgical exposure and the application of an
orthodontic force brought the impacted left
maxillary central incisor down to its proper
position in the dental arch

47.  Abstract
 INTRODUCTION:
 "Kissing" or "rosetting" of molars refers to contacting
occlusal surfaces of impacted permanent mandibular
second, third, and, very rarely, fourth molars. It is a
rare phenomenon.
 AIM:
 The aim of this study was to assess the incidence,
dental involvement type, associated pathologies and
treatment outcomes of kissing molars in all patients
who underwent lower third molar surgery between
March 2008 and October 2011, at a military hospital in
Turkey.

48.  METHODS:
 The panoramic radiographs of the patients who underwent extraction of lower
third molars at Marmara University Faculty of Dentistry, Gulhane Military Medical
Academy and Surgical Infirmary at Commando Troop No. 5 Gokceada between
March 2008 and October 2011 were analysed retrospectively. The patients found
to have kissing molars (KM), were classified according to the teeth involved and
associated pathologies were evaluated.
 RESULTS:
 Among nine patients (five female, four male) with a mean age of 27.4 years who
were found to have KM, one presented with rosetting of first and second lower
molars (Class I), six with rosetting of second and third lower molars (Class II),
and two with rosetting of lower third and fourth molars (Class III). Three of the
KM presented with dentigerous cyst formation and two with granulamatous
changes of the adjacent dental follicle. Following surgical removal, three patients
presented with mild paraesthesia of the lower lip, which resolved 3 to 6 months
after the operation.
 CONCLUSIONS:
 KM is a rare phenomenon. Early surgical therapy is essential as this condition
can cause serious complications, including formation of pathologies such as
dentigerous cyst or destruction of the adjacent bone.

49.  J Craniofac Surg. 2013 Mar;24(2):531-3. doi:
10.1097/SCS.0b013e31826463f7.
 Pippi R, Alvaro R.
 Source
 From the Department of Oral and Maxillo-Facial
Sciences, Faculty of Medicine and Dentistry,
"Sapienza" University of Rome, Rome, Italy.
.
Piezosurgery for the lingual split technique
in mandibular third molar removal: a
suggestion

50. Abstract
 BACKGROUND:
 The lingual split technique is a surgical procedure for
extraction of impacted mandibular third molar
throughout a lingual approach. The main
disadvantage of this technique is the high rate of
temporary lingual nerve injury mainly because of the
trauma induced by the lingual flap retraction. The
purpose of this paper is to suggest the use of
piezosurgery in performing the lingual cortical plate
osteotomy of the third molar alveolar process.
 METHODS:
 Surgical procedure was performed under general
anesthesia, and it lasted approximately 60 minutes.
After the buccal and lingual full-thickness flaps were
incised and elevated, a piezosurgical device was
used for osteotomy.

51. Abstract
 A well-defined bony window was then removed, and it
allowed the entire tooth was extracted in a lingual
direction. The patient did not show any neurological
postoperative complication. Lingual and inferior
alveolar nerve functionality was normal before as well
as after surgery.
 CONCLUSIONS:
 The use of piezoelectric surgery seems to be a good
option in removing lower third molars when a lingual
access is clearly indicated. The only disadvantage of
this technique can be represented by an operating
time lengthening possibly because of a lower power
cut of the piezoelectric device, to the high
mineralization of the mandibular cortical bone and to
the use of inserts with a low degree of sharpening

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