ISRAA UNIVERSITY COLLEGE

Department of dentistry

Effect of Impacted teeth on occlusion

and their causes

Submitted By
‫حسن علي نبأ‬
4th stage/Group D

Supervised By
Dr.Hiba Mohamed

June 2020
1. Introduction

Impaction of a tooth is retardation or halt in the normal process of eruption, Tooth

impaction is a common dental condition ranging from 0.8–3.6% of the general
population . A tooth normally erupts when half to three-quarters of its final root length
has developed. Impaction is usually diagnosed well after the tooth should have erupted.
The most commonly impacted teeth are, consecutively, third molars, maxillary canines,
mandibular premolars and maxillary central incisors. The prevalence of third molar
impaction ranges from 16.7% to 68.6%. Most studies have reported no sexual
predilection in third molar impaction. However, some studies found a higher frequency
in females than in males.The prevalence of
maxillary canine impaction ranges from 0.8–2.8%
. Upper canines can be impacted palatally,
buccally or in line with the dental arch. Palatal
impaction is the most frequent type(Fig.1) The
ratio of palatal to buccal impaction varies from
2:1 or 3:1 to 6.6:1.Some studies indicate that
0.42–2.1% of patients suffer from central incisor
impaction due to the presence of supernumerary
(Fig.1) 15-year old boy with palatally
teeth. impacted maxillary right canine: A -panoramic
view

Etiology of Impacted Teeth

Local Causes Systemic Causes

1. Irregular position or pressure of adjacent teeth. Inflammatory

Impactions changes
are found in thedue to of local
absence
exanthematous disease.
predisposing factors:
2. Greater density of overlying or
surrounding bone. 1. Prenatal causes: heredity.
3. Fibrosis of overlying mucous 2. Postnatal causes: conditions that interfere with
membrane.
growth and development of the child such as
4. Lack of space due to under developed Rickets, Anemia, Congenital syphilis,
jaws.
Tuberculoses, Endocrine dysfunction,
5. Over retained deciduous teeth.
Malnutrition, Irradiation.
6. Premature loss of deciduous teeth. 3. Rare conditions Cleidocranial dysplasia,
7. Changes due to infections or abscesses. Oxycephaly, Progeria, Achondroplasia,
Cleftpalate
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9.

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 or palatal) (Fig.2), delayed eruption of
permanent teeth, prolonged retention of
D
deciduous teeth and the mesial and distal
i
tipping or migration of adjacent teeth.
a Palpation compounds our understanding as a
g widening of labiolingual plates indicates
n presence of tooth at this level and narrowing
o indicates absence at this level. Moreover,
s hard swelling in the place where a shallow
depression on either side of the anterior nasal
i
spine is expected in case of dilacerated or
s
impacted incisor. Palpation of a dilacerated
central incisor is often made in two places,
O
one being high in
f the upper labial
sulcus and the other
I as a small and hard
m lump in the palate.
p
a (Fig.2) Mucosal bulge on the
palate depicting impacted
c Radiographic examination:
canine
t 1. Periapical films(Tube shift technique
or Clark's rule or SLOB method)(Fig.3) :
i
is the 2D picture of an area of dentition.
o To obtain
n 3D

is made by evaluation of case history, clinical

and radiographic examinations.

I. Case History: Prior history of any

episode of trauma especially to the region visualization, two periapical films are
of the mouth should be carefully recorded taken of the same area, when the second
with approximate dates of occurrence. film is taken.
2. Occlusal films also help in visualizing
II. Clinical examination:The following the buccolingual position of the impacted
clinical signs are indicative of impactionstooth concurrent with the periapical films.
3. Extraoral films:
which are presence of mucosal bulge (buccal
(Fig.3)Clark’s method of
Page | 2 buccolingual location of
impacted object.
 a. Frontal and lateral cephalograms. tooth, either at surgery or shortly thereafter the
presence of an orthodontist during the surgical
b. Panoramic films are also used to localize
exposure may be useful for bonding an
impacted teeth in all three planes of space.
attachment to
4. Cone Beam Computed Tomography later apply an orthodontic force in the
is a novel method, which provides appropriate
the direction and to bring the impacted
orientation of the impacted tooth tooth into the dental arch . The last step is to
in all the
three planes of space along withobtain
the 3Da normal position and orientation of the
roots. of the teeth in the alveolar process.
relationships with adjacent structures
Treatment options

Observation Orthodontic\Interven Relocation Extraction

tion

1.Preimpaction Periods. 1.Remove of physical barrier. 1.surgical assisted orthodontic.

2.Postimpaction Periods. 2.extraction of retained 2.surgical auto-plantation.
primary tooth.

 There are 3 main options in the

management of impacted teeth:

o extraction of an impacted tooth

o extraction of an adjacent tooth or
o non- -extraction treatment involving
orthodontic space opening and surgical exposure.

When non-extraction treatment is performed, the

orthodontic treatment is often initiated before the
surgical exposure in order to align the teeth, to
open the space for the impacted tooth and to
enhance the natural eruption process. At the
surgery, any hard or soft tissue obstruction is
removed and the unerupted tooth is exposed.
Then, an attachment is placed on the impacted

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e
t
h

1. Appliance selection: The appliance selected

should have the capability to level and rotate all
the teeth with controlled crown and root
movements to open adequate space to
accommodate the impacted tooth. This stage
requires the use of fine leveling and aligning
arch wires.

2. Preparation of anchorage unit: With the

initial alignment achieved and no further
movement of individual erupted teeth needed,
these teeth are transformed into a

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composite and rigid anchorage unit, this is done by substituting the flexible archwires
with a heavier wire.

3. Space regaining for impacted tooth: Space for the impacted tooth should be created
before surgical exposure by closure of existing incisor spacing, improving the arch form
or by extraction of teeth. Space for the impacted tooth can be maintained by vertical
stops bent in arch wire, stainless steel hollow tubing, coil spring, and tissue guards.

4. Surgical exposure: The surgical exposure of the crown of the impacted tooth should
be performed in a manner that will achieve a good periodontal prognosis of the treated
result. An attachment is bonded to it and the flap fully closed, with only a fine ligature
wire leading through the gingival tissue to the recovered tooth.

5. Active eruption of impacted tooth: Using an auxiliary means of traction from the
rigid orthodontic appliance, a gentle and continuous light force (about 60 gms), with a
wide range of activation is applied to the tooth, and is aimed at erupting the impacted
tooth.

6. Final detailing - There should be final detailing of the position of the formerly
impacted tooth.

 There are three main surgical techniques applied for impacted teeth:

1) the open eruption technique. 2)the apically repositioned flap.

3) the closed eruption technique.

Open Eruption Technique

1)The open eruption technique (Fig.5) involves the surgical removal of a circular
section of the overlying mucosa and the alveolar bone, covering the impacted tooth.
After wards, an attachment, such as an eyelet or button, can be bonded and orthodontic
traction may be performed immediately .The Ballista spring which is an auxiliary
stainless steel arch wire attached to the main arch wire, may be used in order to bring
the impacted tooth into the dental arch.

Advantages: a) simple and direct method, b) orthodontist’s presence during surgery is

not needed. c)in case of bonding failure, there is no need for a second surgical exposure.

Disadvantages: a)can result in poorer periodontal outcome,b)increased risk of

infection, c)greater discomfort to the patient, d) more extensive removal of alveolar

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bone, e) bad taste and breath in the mouth, f) risk of closure of the exposure, g)
increased bonding failure, h) additional visits to change the surgical dressing.

2)Apically Repositioned Flap: The apically repositioned flap is a modification of the

open exposure technique. It includes the raising of a labial flap, including the attached
gingiva, which is taken from the crest of the alveolar ridge and relocated higher up, and
then is followed by suturing it on the buccal side of the crown of the newly exposed
tooth. The main advantage of this method is the improved periodontal outcome
compared to the open eruption technique by ensuring that the attached gingiva covers
the labial aspect of the erupted tooth. This method is well-known and generally
accepted in the periodontal management of buccally displaced teeth. The apically
repositioned flap is performed when the tooth is located mesio-distally fairly close to its
final position and a bulging of the oral mucosa appears at its junction with the attached
gingiva.

Advantages: a) good access for attachment bonding, b) faster eruption, c) easy follow-
up.

Disadvantages: unfavorable gingival contour.

3)Closed Eruption Technique(Primary Full Flap Closure: (Fig.6) involves bonding

an attachment at the time of the exposure. The tissues are fully replaced and sutured to
their former places, to re-cover the impacted tooth. In a case when a canine is very high
up and following the raising of a palatal flap, the canine will be revealed together with
the thin bone covering the palatal aspect of the roots of the adjacent teeth. Below and
distally to the canine is the vertical wall of the alveolar process. Bonding of the eyelet
attachment is performed in the usual manner on the palatal side of the tooth.

Advantages: a) fast healing, b)less discomfort, c)good postoperative homeostasis,

d)less intense functional disturbances, e)less extensive removal of alveolar bone,
f)possibility of an immediate traction, g)applicable close to resorbing root.

Disadvantages: a)presence of an orthodontist may be needed during the surgery, b)in

case of a bonding failure, re-exposure is needed.

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(Fig.5)Second surgical exposure (open eruption technique) performed by Prof. Arye Shteyer

(Fig.6)First surgical exposure (closed eruption technique) performed by Prof. Arye Shteyer.
Complications

The most frequent complications associated with untreated impacted teeth

include :

1) morbidity of the deciduous predecessor and migration of the adjacent teeth.

2) development of a dental cyst.

3) resorption of a crown of an impacted tooth.

4) resorption of the roots of adjacent teeth.

5) ankyloses.

6) infra-occlusion.

7) pain and/or discharge (related to infected cysts, tumors).

8) displacement of the adjacent teeth and shortening of the dental arch.

Conclusion

The etiology of tooth impaction is multifactorial. Patients with impacted teeth are often
referred for orthodontic help by general dentists.

Successful and untroubled management of impaction depends on comprehension of

mechanism of impaction, which depends on detailed knowledge of the development and
eruption paths and patterns of the teeth. Usually management of impacted tooth requires
the collaborative efforts of the orthodontist, periodontist and oral surgeon. But early
recognition and keen understanding of impaction sometimes is sufficient to correct or
check the development of malocclusion by interceptive treatment alone.
REFERENCES

 Om P. Kharbanda, ORTHODONTICS Diagnosis and Management of

Malocclusion and Dentofacial Deformities; THIRD EDITION.
 Indian Journal of Orthodontics and Dentofacial Research, April-June
2017;3(2):59-63.
 Becker A: Orthodontic treatment of impacted teeth. Wiley-Blackwell 2012, 3rd
edition.
 Peterson LJ: Principles of management of impacted teeth. In Contemporary
oral and maxillofacial surgery. Edited by Peterson LJ, Ellis EIII, Hupp JR,
Tucker MR. St Louis: CV Mosby 1988, 223–256.
 Chu FCS, Li TKL, Lui VKB, Newsome PRH, Chow RLK, Cheung LK:
Prevalence of impacted teeth and associated pathologies – a radiographic study
of the Hong Kong Chinese population. Hong Kong Med J 2003, 9, 158–163.
 Kokich VG: Surgical and orthodontic management of impacted maxillary
canines. AmJ  Orthod Dentofacial Orthop 2004, 126, 278–283.