MANAGEMENT OF IMPACTIONS

DR RAKESH KOSHY ZACHARIAH

PROFESSOR
DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY
P.M.S COLLEGE OF DENTAL SCIENCE AND RESEARCH
INTRODUCTION
• Archer (1975) defines impacted tooth as one
which is completely or partially unerupted and is
positioned against another tooth or bone or soft
tissue so that its further eruption is unlikely,
described according to its anatomic position .
• Got their name ‘Wisdom teeth’ from the age
during which they erupt: 17 to 25. This is the age
at which men and women become adults, and,
presumably wiser.
• According to the American Association of Oral
and Maxillofacial Surgeons, “if there is in-
sufficient anatomical space to accommodate
normal eruption. . . removal of such teeth at an
early age is a valid and scientifically sound
treatment rationale based on medical necessity.”
• The earliest recorded case of impacted wisdom teeth
belongs to the renowned "Magdalenian Girl," a nearly
complete 13,000- to 15,000-year-old skeleton excavated
in France in 1911 and acquired by The Field Museum in
1926.
• The first documented extraction was probably performed
by Hippocrates using an instrument called plumbeum
odontogagon.
• Techniques to extract third molars gained attention at the
end of the 18th century.
• Charles Edmund Kells (1856-1928) was the first to foster
a comprehensive approach to third molar removal.
• In 1918, Kells, an American dentist best known for his
contributions to oral radiology and for the invention of the
surgical aspirator, published a paper in Dental Cosmos in
which he described a more “humane” approach to
removal of third molars.
 INCIDENCE

Mandibular 3rd molar exhibit the highest rate of impaction.. According to Archer
According to different authors:- • Maxillary third molars
DACHI AND HOWELL - 17.5%
• Mandibular third molars
• Maxillary cuspids
HELLMAN-9.5%
• Mandibular bicuspids
BJORK-25%
• Mandibular cuspids
RICHARDSON-50% • Maxillary bicuspids
RICKETTS-35% • Maxillary central incisors
• Maxillary lateral incisors
 ETIOLOGY OF IMPACTION

Berger lists the following local causes of impaction :

• Irregularity in the position and presence of an adjacent tooth.
• Density of the overlying or surrounding bone.
• Long – continued chronic inflammation with resultant Increase in density of the overlying
mucous membrane.
• Lack of space due to underdeveloped jaws.
• Unduly long retention of the primary teeth.
• Premature loss of the primary teeth.
• Acquired diseases, such as necrosis due to infection or abscesses and inflammatory changes in
the bone due to exanthematous diseases in children.
 Prenatal Causes *Rare Causes
Heredity Cleidocranial dysostosis
Miscegenation Oxycephaly
Postnatal Causes Progeria

SYSTEMIC Rickets Achondroplasia

CAUSES Anemia Osteopetrosis

Congenital Syphilis Cleft palate
Tuberculosis
Endocrine Dysfunctions
Malnutrition
 PAIN

Inflammation

Food lodgement

Trauma to adjacent mucosa

Pressure on adjacent tooth

Rule out MPDS& TMDs

Pericoronitis

Unrestorable caries

INDICATIONS Pathologic resorption of adjacent tooth

Pathologies/ prevention of cysts and tumours

Orthodontic treatment

Periodontitis

Autogenous transplant

Teeth under prosthesis

Involvement in fracture

Prophylatic removal – contact sports

Recurrent trauma
 CONTRAINDICATIONS
Extreme of age
Compromised medical status
Probable excessive damage to adjacent structure
(unfavourable risk /benefit ratio)
Third molars needed as abutments
Recently irradiated jaw
Tooth in tumor
Absolute contraindications
Acute pericoronitis.
Acute necrotising ulcerative gingivitis.
Hemangioma, Hemophilia, leukaemia.
Thyrotoxicosis
 THEORIES OF IMPACTION
Orthodontic theory:(BY DURBECK)
• Jaws develop in downward and forward direction. Growth of the jaw and
movement of teeth occurs in forward direction , so any thing that interfere
with such moment will cause an impaction (small jaw-decreased space).
• A dense bone decreases the movement of the teeth in forward direction
Phylogenic theory:

Nature tries to eliminate the disused organs i.e., used makes the organ develop
better, disuse causes slow regression of organ.
[More-functional masticatory force – better the development of the jaw]
Due to changing nutritional habits of our civilization have practically eliminated
needs for large powerful jaws, thus, over centuries the mandible and maxilla
decreased in size leaving insufficient room for third molars.
• Mendelian theory:
Heredity is most common cause. The hereditary transmission of small jaws and large teeth from parents to siblings. This may be
important etiological factor in the occurrence of impaction
• Pathological theory:
Chronic infections affecting an individual may bring the condensation of osseous tissue further preventing the growth and development
of the jaws.
• Endocrinal theory:
Increase or decrease in growth hormone secretion may affect the size of the jaws.
• The Skeletal theory :
Several studies have demonstrated that when there is inadequate bony length, there is a higher proportion of impacted teeth
CLASSIFICATION OF IMPACTED THIRD
MOLAR
WINTER’S CLASSIFICATION (1926)
• According to the position of the impacted third molar to the long
axis of second molar
• Mesioangular
• Horizontal
• Vertical
• Distoangular
These may occur simultaneously in:
• Buccal version
• Lingual version
• Torsoversion
MODIFIED WINTERS CLASSIFICATION
Vertical impaction (10° to -10°)
Mesioangular impaction(11° to 79°)
Horizontal impaction (80° to 100°)
Distoangular impaction ( -11° to -79°)
Others (111° to -80°)
Buccolingual impaction (any tooth oriented in a buccolingual direction with crown overlapping the roots)
Sadeta Šeèiæ et al. Journal of Health Sciences 2013;3(2):151- 158
CLASSIFICATION BY ARCHER
(1975) AND KRUGER(1984)
Based on angulation of 3rd molar

Mesioangular

Distoangular

Vertical

Horizontal

Buccoangular

Lingoangular

Inverted
BASED ON NATURE OF OVER LYING TISSUE

According to contemporary oral and maxillofacial surgery-Peterson

The three types of impactions are:

• Soft tissue impaction
• Partial bony impaction
• Full bony impaction
 PELL AND GREGORY CLASSIFICATION
1. Relation of tooth to the ramus of the mandible

2. Relative depth of the third molar in the bone

 07220- Soft tissue impaction that requires incision of overlying
soft tissue and the removal of the tooth.
07230- Partially bony impaction that requires incision of overlying soft
tissue, elevation of a flap, and either removal of bone and the tooth or
sectioning and removal of tooth.
07240- Complete bony impaction that requires incision of overlying soft
tissue, elevation of a flap, removal of bone, and sectioning of tooth for
removal
COMBINED ADA & 07241- Complete bony impaction with unusual surgical complication
AAOMS that requires incision of overlying soft tissue, elevation of a flap,
removal of bone , sectioning of the tooth for removal, and /or presents
CLASSIFICATION unusual difficulties and circumstances.
KILLEY & KAY'S CLASSIFICATION

Based on angulation and position

• Vertical
• Mesioangular
• Distoangular
• Horizontal
• Transverse
• Buccoangular
• Linguoangular
• Inverted
• Aberrant positions
Based on state of eruption
• Erupted
• Partially erupted
• Unerupted
• Soft tissue impaction
• Complete bony impaction
Based on number of roots

Unfavorable impaction-
• Mesial curvature of roots
• Multiple roots
Favorable impaction-
• Fused roots
• Distal curvature of roots
 Maxillary third
molar Impactions
1. Based on state of eruption
• Fully erupted
• Partially erupted
• Unerupted
 • Based on depth

• POSITION A - highest point of 2nd

molar and highest point of impacted
third molar is in line
• POSITION B - highest point of third
molar is in between plane of occlusion
and cervical line
• POSITION C - highest point of third
molar is below cervical line
 Based on sinus approximation
Sinus Approximation (SA):
No bone or thin partition of bone twixt the impacted maxillary 3rd molar
& the maxillary sinus / antrum.
No Sinus Approximation (NSA):
> 2mm of bone twixt the impacted maxillary 3rd molar & the maxillary sinus /
antrum.
 CANINE CLASSIFICATION
By Archer (1975)
• Class I : Palatally placed maxillary canine
Horizontal
Vertical
Semi-vertical
• Class II : Labially placed maxillary canine
Horizontal
Vertical
Semi-vertical
• Class III : Involving both buccal and palatal bone
• Class IV : Impacted in the alveolar process between the incisors and the first premolar
• Class V : Impacted in the edentulous maxilla
 FIELD AND ACKERMAN CLASSIFICATION

A. Labial position
1.Crown in intimate relationship with incisors. 2.Crown above apices of incisors.

B. Palatal position
1.Crown near surface in close relationship to roots of incisors.
2.Crown deeply embedded in close relationship to apices of incisors

C. Intermediate position
1.Crown between lateral incisors and first premolar roots
2.Crown above these teeth with crown labially placed and root palatally placed or vice versa

D. Unusual position
1.In Nasal or Antral wall
2.In infraorbital region
 PRE- OPERATIVE ASSESSMENT
General assessment Intra oral examination Extra oral examination
• Age/ sex • Soft tissues • Symmetry
• TMJ
• Systemic condition • Position of mandible
• Mouth opening
• Drug history • Tongue size • Cheek bulk
• Anesthesia history • Extensibility of lips & • Swelling
• General physical examination cheeks • Neurologic examination
• Soft tissue trauma • Lymph node
• Hard tissues
• Dentition status
• External oblique ridge
Assessment of impacted teeth

• Status of eruption
• Periodontal status
• External and internal oblique ridge
• Relationship with adjacent teeth
• Soft tissue covering
• Occlusal relationship with opposing tooth
 RADIOGRAPHIC
INVESTIGATIONS

• Intraoral –IOPAR, Bite wing , Occlusal

radiograph

• Extra oral –OPG, Lateral cephalometric

• Digital imaging –CT, CBCT

 • State of eruption level of tooth
• Angulation of tooth
• Relationship with second molar
• Distance between ascending ramus and distal
surface of second molar
RADIOGRAPHIC • Condition of second molar and impacted tooth
ASSESSMENT • The existing pathology
• Root shape
• Bone removal to permit application of elevators
• The relationship with inferior alveolar canal
• WHARFE assessment with OPG
• WAR lines/winters lines with IOPA
• WHARFE ASSESMENT : MACGREGOR 1985

• WINTERS WAR LINE

• PEDERSON DIFFICULTY INDEX

 The surgical procedure for the extraction of
impacted teeth includes the following steps:
• Asepsis and isolation
• Local anesthesia/ general anesthesia
• Incision-flap design
SURGICAL • Reflection of mucoperiosteal flap
• Bone removal
PROCEDURE • Sectioning (division) of tooth
• Elevation and tooth removal
• Debridement and smoothening of bone
• Closure-suturing
 • SHORT ENVELOPE
• LONG ENVELOPE
• L-SHAPED INCISON
• BAYONET SHAPED INCISION
DIFFERENT • TRAINGULAR FLAP

TYPES OF •
•
WARDS INCISION
MODIFIED WARDS INCISION
INCISION • GROOVE AND MOORE INCISION

AND FLAP •
•
S SHAPED INCISION
COMMA SHAPED INCISION
DESIGN • SZMYD FLAP
• MODIFIED SZMYD
• BERWICKS TONGUE FLAP
PARTS OF INCISION
The incision having 3 parts-
• LIMB A: The anterior incision started from buccal sulcus approx. at the junction of posterior and middle
third of 2nd molar, passes upwards extended upto the distobuccal angle of the 2nd molar at the gingival
margin approx 6mm.

• LIMB B:It was carried along the gingival crevice of third molar extending upto the middle of exposed distal
surface of the tooth

• LIMB C: Started from a point where intermediate gingival incision ended and was carried laterally.

• Total length of incision should be approx 25.4mm.or 1inch

 Incision-flap design
• Ward’s incision

• Modified ward’s incision

ENVELOPE FLAP

TRIANGULAR FLAP
 COMMA SHAPED
INCISION

SZMYD INCISION(1971)
 S SHAPED INCISION

VESTIBULAR TONGUE
SHAPED FLAP
 FLAP DESIGNS FOR
MAXILLARY IMPACTIONS
• Envelope flap
• Triangular flap
• Palatal diagonal flap
 REFLECTION OF MUCOPERIOSTEAL
FLAP
• Periosteal elevator or Minnesota or Austin retractors
• Howarth retractor
• Ward killner retractor
• Dyson’s Malleable copper retractor
• Mac gregor periosteal elevator
• Fickling periosteal elevator
• Read periosteal elevator
• Lasters retractor
 BONE REMOVAL

BUR TECHNIQUE
• Postage stamp technique
• Moore and Gillbe’s technique
• Guttering technique
• Bowdler Henry’s( Lateral trephination(1969))

CHIESEL AND MALLET

• Window technique
• Lingual split technique
• Shaving technique
• Distal lingual split technique
 Postage stamp
technique
• In this technique a row
of small holes is made(at
2-3mm equidistance)
with a small bur and
then joined together
either with bur or chisel
cuts.
 Moore & Gillbe’s
Collar Technique
• Conventional technique of using
bur.
• Rosehead round bur no.3 is used to
create a gutter along the buccal
side & distal aspect of tooth.
• A point of elevation (mesial
purchase point) is created with bur.
• Amount of bone sacrificed is less.
• Can be used in old patient.
• Convenient for patient.
 Lateral Trepanation
Technique
Bowlder Henry

• Employed to remove any partially formed

unerupted 3rd molar that has not breached the
overlying hard & soft tissues.
• Age 9-18 yrs
• GA/LA with sedation.
• Excellent PDL healing on distal surface of
2nd molar.
• Bone healing is excellent as there is no
loss of alveolar bone around 2nd molar.
• Disadvantage – increased buccal swelling
LINGUAL-SPLIT TECHNIQUE
• Described by Sir William Kelsey Fry (1933). Later popularized by Terence G ward(1956)
Specially for lingually placed tooth.

• Modified by Dr. Davis & Lewis in 1960

• Removal of buccal plate expose the crown, Chisel is used and section the lingual cortex by
planning 45˚angle to upper border and cutting edge parallel to external oblique ridge.
• Modified Lingual Split Technique For Removal Of Mandibular Third Molar (Dr. Davis 1979)

• Kamanishi modification: Do not raise the lingual flap

• Lewis modification: It is considered as combination of both lingual and buccal approach

 TOOTH DIVISION TECHNIQUE

• Kelsey Fry
• To reduce removal of large amount of bone.
• Avoid damage to adjacent structures.
• Decreases dead space.
• Allows portions of tooth to be removed separately with
elevators.
• Direction depends primarily on angulation of impacted tooth.
• With a bur, tooth is sectioned 3/4th toward lingual aspect.
 SECTIONING OF TOOTH
• Reduces the amount of bone removal required prior to elevation of tooth.

• Reducing the risk of damage to the adjacent tooth.

• The direction in which the impacted tooth should be divided depends primarily on the
angulation of the impacted tooth & root curvature.

• When the bur is used, the tooth is sectioned three- fourth of the way towards the lingual
aspect.

• A straight elevator is inserted into the slot made by the bur and rotated to split the tooth
 CRITERIA FOR
SECTIONING OF TOOTH
• A line is drawn from the mesiolingual cusp till the distal
root of the impacted third molar.
• Half the distance measured is taken as the radius and an
arc is drawn.
• If the arc touches the 2nd molar indicates locking of
tooth, then sectioning is mandatory.
• If mesiodistal diameter of crown and mesiodistal width
of roots are more than the space for exit of the tooth.
 MESIOANGULAR IMPACTION

A. buccal and distal bone are removed
to expose crown of
tooth to its cervical line.
C . A small straight
B. The distal aspect of the crown is then elevator is inserted
sectioned from tooth. Occasionally it is into the purchase
necessary to section the entire tooth into point on mesial aspect
two portions rather than to section the of 3rd molar, & the
distal portion of crown only. tooth is delivered with
a rotational and level
motion of elevator.
 HORIZONTAL
IMPACTION
•A .Removal of distal and buccal
underlying bone

•B. The crown is sectioned from the

roots of the tooth and is delivered from
socket.

•C. The roots are delivered together or

independently with a Cryer elevator used
with a rotational motion. Seperation of
root into 2 parts - occasionally the
purchase point is made in the root to
allow the Cryer elevator to engage it.

•D. The mesial root of the tooth is

elevated in similar fashion
 DISTOANGULAR
IMPACTION
•A. Removal of mesial & distal bone. It is important to
remember that more distal bone must be taken off than
for a vertical or mesioangular impaction.

•B. The crown of the tooth is sectioned off with a bur

and is
delivered with straight elevator

•C. The purchase point is put into the remaining root

portion of the tooth, and the roots are delivered by a
Cryer elevator with a wheel and- axle motion. If the roots
diverge, it may be necessary in some cases to split them
into independent portions
 SMOOTHENING & DEBRIDEMENT
OF SOCKET
• Attention must be given to debriding the wound of all particulate bone chips
and debris.

• Wound should be irrigated with sterile saline, taking special care to irrigate
thoroughly under the reflected soft tissue flap.

• Remove any remaining dental follicle and epithelium.

• The bone file is used to smooth any sharp, rough edges of bone.

• A final irrigation and a thorough inspection should be performed before the

wound is closed.
 SURGICAL CLOSURE
• Closure of soft tissue flap
• Return soft tissue flap to the original position
• Stabilize the flap to permit repair
• Resecure periodontal/ gingival attachments
 Treatment Options for Impacted Canines

1. Observation.
2. Surgical exposure.
3. Surgical exposure and orthodontic traction.
4. Surgical removal.
 Intra Operative
During incision
• Injury to facial artery
• Injury to lingual nerve
• Hemorrhage
During bone removal
• Damage to second molar
• Slipping of bur into soft tissue & causing injury
• Extra oral/ mucosal burns
COMPLICATIONS • Fracture of the mandible when using chisel & mallet
• Subcutaneous emphysema
During elevation or tooth removal
• Luxation of neighbouring tooth/ fractured restoration
• Soft tissue injury due to slipping of elevator
• Injury to inferior alveolar neurovascular bundle
• Fracture of mandible
• Forcing tooth root into submandibular space or inferior alveolar nerve canal
• Breakage of instruments
• TMJ Dislocation
 POST OPERATIVE COMPLICATIONS
• The overall complication rate associated with the removal of third molars is
7% to 10%, and the risk of haemorrhage is 0.2% to 1.4%.

• HEMORHAGE
• PAIN
• SWELLING / ODEMA
 • Exposure of inferior alveolar canal
• Injury to inferior alveolar nerve
• Acute trismus
• Fracture of roots
• Disruption of blood supply
According • Fracture of alveolar process
to Archer • Injury to lips, cheek or mucous membrane
• Fracture of mandible
• Extensive laceration or traumatisation of soft
tissue
• Extensive exposure of root of adjacent tooth
• Forcing an apex through lingual plate into
sublingual space
 • The premolars , first and second molars, and
incisors, however, are far less commonly
impacted than the third molars and canines-
MISCELLANEOUS Bluestone 1951
UNERUPTED • Multiple impactions ,associated with
TEETH supernumerary teeth, are seen in cleidocranial
dystosis - Thoma and Kale 1943
 REFERENCES

• TEXTBOOK OF ORAL AND MAXILLOFACIAL SURGERY , VOL.2. DANIEL M LASKIN

• ORAL AND MAXILLOFACIAL SURGERY- ARCHER
• OUTLINE OF ORAL SURGERY - KILLEY AND KAY
• TEXTBOOK OF ORAL AND MAXILLOFACIAL SURGERY - SM BALAJI
• PRINCIPLES OF ORAL AND MAXILLOFACIAL SURGERY - PETERSON
• MINOR ORAL SURGERY - GEOFFREY L HOWE