IMPACTED TEETH

T.PRAVALIKA
• According to WHO : An impacted tooth is the one that is unable to fully erupt in its normal
functional occlusion / location by its expected age of eruption, because it is blocked by overlying
soft tissue or bone or another tooth.
• Impacted teeth

Fully impacted : completely encased in jaw

Partially impacted : not completely encased in jaw bone and communication in

oral cavity
 CAUSES OF IMPACTION OF TEETH: (THEORIES)

• Durbeck orthodontic theory: inadequate space in dental arch for eruption.

• Phylogenic theory (Nodine 1943): evolution- jaw size- 3rd molar last to erupt so no room to
emerge; modern food habits- donot require forceful mastication which offers less stimulation for
jaw growth- DISUSE THEORY
• Mendelian theory: genetic variations- small jaw- one parent; large teeth: another parent ,
impacted teeth because of lack of space.
 ORDER OF FREQUENCY OF IMPACTION

• Impacted teeth seen in the following order of frequency:

1. Mandibular third molars
2. Maxillary third molars
3. Maxillary canine
4. Mandibular premolar
5. Maxillary premolar
6. Mandibular canine
7. Maxillary central incisors
8. Maxillary lateral incisors.
 INDICATIONS FOR REMOVAL:

• Recurrent pericoronitis/ pain/infection

• Impacted 3rd molar-lead to periodontal defect in 2nd molar
• Prevention of root resorption and caries
• Prior to orthodontic treatment
• Associated lesions
• Prevention of pathological fractures/jaw angle fractures
• Preparation of orthognathic surgery
• Management of preprosthetic concerns
 CLASSIFICATION OF IMPACTED 3RD MOLARS

• Winter’s classification (1926)

 Angulation : 1) mesioangular
2) horizontal
3) verical
4) distoangular
5) transverse
6) inverted
 PELL AND GREGORY CLASSIFICATION (1933)
CLASS 1:
Sufficient space available
between the anterior border
of the ascending ramus and
the distal side of the second
molar for the eruption of the
third molar.
CLASS 2:
The space available between the anterior
CLASS 3:
border of the ramus and the distal side of he third molar is totally
the second molar is less than the
mesiodistal width of the crown of the third embedded in the bone from
molar. It denotes that the distal portion of the ascending ramus because
the third molar crown is covered by the
bone from the ascending ramus
of absolute lack of space.
 CLASSIFICATION OF THE MAXILLARY THIRD MOLAR
IN RELATION TO THE FLOOR OF MAXILLARY SINUS.

• a. Sinus approximation (SA)—no bone or a thin bony partition present between impacted
maxillary third molar and the floor of the maxillary sinus.
• b. No sinus approximation (NSA)—2 mm or more bone is present between the sinus floor and
the impacted maxillary third molar.
 CLASSIFICATION OF IMPACTED MAXILLARY
CANINES
• Labial or palatal placement of impacted maxillary canine
• Intermediate position:
a. Crown between the lateral incisors and premolar.
b. Crown above the root tip with labial/palatal orientation of the lateral incisor or premolar
 Aberrant position: Impacted maxillary canines lie in the maxillary sinus or nasal cavity.

• Class I: Palatally placed maxillary canine

a. Horizontal
b. Vertical
c. Semivertical
• Class II: Labially or buccally placed maxillary canine
a. Horizontal
b. b. Vertical
c. c. Semivertical
• Class III: Involving both buccal and palatal bone, e.g. crown is placed on the palatal aspect and the root is toward the buccal
alveolar process
• Class IV: Impacted in the alveolar process between the incisors and first premolar.
• Class V: Impacted in the edentulous maxilla.
RADIOLOGICAL EXAMINATION: WINTER’S LINES
White line

• corresponds to the occlusal plane. The line is drawn touching the occlusal surfaces of first and second molar and is
extended posteriorly over the third molar region. It indicates the difference in occlusal level of second and third molars.

Amber line
• represents the bone level. The line is drawn from the crest of the interdental septum between the molars and extended
posteriorly distal to third molar or to the ascending ramus. This line denotes the alveolar bone covering the impacted
tooth and the portion of tooth not covered by the bone.

Red line

• is drawn perpendicular from the 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.
 EXTRAORAL X-RAYS

• For mandibular teeth For maxillary teeth

• OPG • OPG
• Lateral oblique view mandible • PA view Water’s position
Indicated in
• Patients with restricted oral opening/trismus/ excessive gagging
• Impacted tooth in an aberrant position
• For ruling out associated pathology
• To study the relationship of the tooth to inferior alveolar nerve inferior border. For maxillary teeth—relationship to the
maxillary sinus.
 SURGICAL REMOVAL OF IMPACTED TEETH
• 1. Asepsis and isolation
• 2. Local anaesthesia/sedation + LA/ general anaesthesia
• 3. Incision—flap design
• 4. Reflection of mucoperiosteal flap
• 5. Bone removal
• 6. Sectioning (division) of tooth
• 7. Elevation
• 8. Extraction
• 9. Debridement and smoothening of bone
• 10. Control of bleeding
• 11. Closure—suturing
• 12. Medications – antibiotics, analgesics, etc.
• 13. Follow-up
 ISOLATION OF SURGICAL SITE
• Cetrimide + absolute alcohol + chlorhexidine
• cetrimide + povidone + iodine
Scrubbing • Cetrimide + absolute alcohol

• Normal saline
Cleaning • Alcohol—spirit
solutions

• Povidone-iodine 5 per cent for skin, 1 per cent for oral mucosa
• Chlorhexidine gluconate—7.5 per cent for skin, 0.2 per cent for
Painting rinsing oral cavity.
solution
 LOCAL ANAESTHESIA

• For mandibular molars and canines—pterygomandibular nerve block.

• For maxillary molars—posterior superior alveolar nerve block and palatine nerve block or infiltration
• For maxillary canines—infraorbital nerve block + palatal infiltration of incisive canal and bilateral
palatine nerve blocks
• Saline adrenaline in concentration of 1:400000
• Plain saline (in case of hypertensive patients)
• LA solution with adrenaline.
REFLECTION OF MUCOPERIOSTEAL FLAP
• for mand. Molars:
• Ant. Releasing incision- vestibule towards CEJ of 2nd molar at an angle gingival sulcus upto
distal aspect of 3rd molar
• Distal releasing insertion-distal most point of 3rd molar across ext. oblique ridge into buccal
mucosa. Lingual side- -lingual nerve
• 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 is brought 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.
• For max molars:
• Ant. Releasing insertion- ant. To 2nd molar from vestibule –till mesial interdental papilla of 2nd molar
• The incision should follow the gingival sulcus of second molar and continue over the tuberosity area from the
distal most point of second molar.
• For max. canines:
• buccally placed: • Flap with anterior releasing incision • Trapezoidal flap • Semilunar flap.
• If the 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 should be
deflected away from the palatine foramen. If unilateral—an incision is restricted to the canine region of the
opposite side. If bilateral—an incision is extended to the first molar of the opposite side.
• For Mandibular Canines:
• If buccally placed then crevicular incision from the midline is taken upto first molar. Anterior releasing incision
is given close to the midline. Care should be taken to protect the mental nerve. If the canine is placed on the
lingual side, then lingual envelop flap is taken.
 BONE REMOVAL

• Aim:
• i. To expose the crown by removing the bone overlying it.
• ii. To remove the bone obstructing the pathway for removal of a tooth.
• Two Ways of Bone Removal : a. High speed, high torque handpiece and bur technique b. Chisel
and mallet technique
• Bur technique Either no. 7/8 round bur or a straight no. 703 fissure bur is used.
 BUR TECHNIQUE
• 7/8 round bur or straight no. 702 or 703 carbide fissure bur
• First step: The bur is used in a sweeping motion around the occlusal, buccal and distal aspect of the
mandibular third molar crown to expose it and to have its orientation.
• Second step (Moore Gillbe Collar technique): Once the crown has been located, the buccal surface of the
tooth is exposed with the bur to the cervical level of the crown contour and a buccal trough or gutter is
created. The buccal trough should be made in the cancellous bone. It is important that the adequate amount of
trough is created to remove any bony obstruction for exposure and the delivery of the tooth, especially around
the distal aspect of the crown. The distolingual portion of the tooth should be exposed without cutting through
the lingual bony plate to prevent damage to the lingual nerve.
 CHISEL AND MALLET TECHNIQUE

• First step: For mandibular/maxillary molars,the first step is the placement of vertical stop cut, which is made
by placing a 3 mm or 5 mm chisel vertically at the distal aspect of the second molar with bevel facing
posteriorly (5 to 6 mm height). prevent the force transmission anterior to the direction of the bone removal.
• Second step: At the base of the vertical stop (limiting) cut, the chisel is placed at an angle of 45° with the
bevel facing upwards or occlusally, and oblique cut is made till the distal most point of third molar. This will
result in the removal of a triangular piece of buccal plate distal to second molar. Additional triangular piece
of bone is removed at the junction of vertical and oblique bone cut to gain the entry of the elevator tip.
Finally the distal bone must be removed, so that when the tooth is elevated, there should be no obstruction at
the distobuccal aspect.
LINGUAL SPLIT BONE TECHNIQUE

Vertical stop cut is made by placing the chisel with the bevel
facing posteriorly, distal to the second molar.

With the chisel bevel downward, a horizontal cut is made

backward from the lower end of the vertical limiting stop cut.

The buccal bone plate is removed above the horizontal cut.

The distolingual bone is then fractured inward by placing the

cutting edge of the chisel along the dotted line A. Bevel side
of the chisel is facing upward and cutting edge is parallel to
the external oblique ridge. The chisel is held at 45° to the
bone surface.
 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

minimum 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 the haemostat and freed from the
soft tissue and removed.

Smoothening of the edges is done with bone

file. Wound irrigated and sutured.
 ODONTECTOMY
• Reduces the amount of bone removal (conserves the bone) required prior to elevation of the tooth
• Reduces the risk of damage to the neighbouring teeth
• Planned sectioning permits the parts of the tooth to be removed separately in an atraumatic manner by
creating space into which it is displaced and the remaining crown or root segments removed.
• The direction in which the impacted tooth should be sectioned is dependent on the angulation of the
impacted tooth, based on the line of draw of the segments
• Can be performed either with a bur or chisel. Bur use is preferable. Mallet blows may give psychological
discomfort to the patient
• The bur is used in a controlled fashion to avoid damage to the vital structures and surrounding teeth and soft
tissues
• The tooth is usually sectioned one-half to 3/4th with the bur and then it is completely sectioned with the
elevator.
 INDICATIONS:

• Deep impacted teeth

• Large bulbous crown
• Unfavorable rt anatomy
• Roots close proximity to IAN
• Extensively carious tooth
• Narrow pdl space
• Bulbous root
sectioning procedure
 DEBRIDEMENT AND SMOOTHENING OF BONE
MARGINS
• Irrigation of the socket
• Curetting to remove any remaining dental follicle and epithelium
• Look for pieces of coronal portion (especially in carious teeth/sectioned teeth), check for remnants of
bone/granulation tissue, bleeding points
• Check for caries (root/crown)/erosion/damage to the adjacent teeth
• Round off the margins of the socket with large vulcanite round bur or bone file
• Irrigate the socket again
• Control bleeding before suturing
 CLOSURE

• 3-0 black silk is used. Interrupted sutures given and maintained for 7 days. In case of molars,
suture distal to second molar should be placed first and should be water tight to prevent pocket
formation. In case of palatally impacted canines, incisive papilla should be sutured carefully to
reduce postoperative bleeding.
 COMPLICATIONS

 Intraoperative 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 vessels may be damaged
• During Bone Removal : Damage to the second molar, damage to the roots of overlying teeth, slipping of the bur into
the soft tissues, fracture of the mandible when using chisel and mallet.
• During Elevation :
 Luxation of neighbouring/overlying tooth
Fracture of the adjoining bone
Fracture of the tuberosity
Slipping of the tooth into pterygomandibular/ temporal spaces , sublingual pouch and / maxillary sinus.
Damage to nasal wall/overlying teeth/ lingual, inferior alveolar or mental nerve.
• During Debridement :
Damage to inferior alveolar nerve/lingual nerve.
Damage to maxillary sinus
 Postoperative Complications
Pain, swelling, trismus, hypoesthesia, sensitivity, loss of vitality of neighbouring teeth. Pocket
formation. Sinus tract formation, oroantral fistula, oronasal fistula.