Impaction

Presented by
Binod adhikary
Bds 2004
Rolll no 214
Contents :
1. Introduction
2. Etiology
3. Classifications
4. Indications for removal
5. clinical and radiographic assessment
6. Management
7. Complications


Definition :-
The word impaction comes from the Latin word
impactus.
Impacted tooth is the tooth that fails to erupt to its
normal position due to obstruction by a physical barrier
(adjacent tooth, bone or soft tissue overlying it) OR
ectopic positioning of the tooth itself .
A tooth should be termed as impacted only if the root
formation is complete & yet it has not erupted fully up
to the final position.
Also known as the embedded tooth
Its the one that is erupted, partially erupted or un
erupted & will not eventually assume a normal arch
relationship with the other teeth & the tissues.

Order of frequency:
1. Mandibular 3
rd
molars
2. Maxillary 3
rd
molars
3. Maxillary canine
4. Mandibular premolars
5. Maxillary premolars
6. Mandibular canine
7. Maxillary central incisors
8. Mandibular lateral incisors




Etiology:
Multifactorial etiology (local & systemic)
Two theories impaction are:
1. Phylogenetic theory
2. Mendalian theory
o Local causes:
1. Obstruction for eruption
2. irregularity in position & presence of adjacent tooth
3. density of the overlying bone
4. Lack of space in the arch crowding, supernumerary
teeth
5. Ankylosis of primary or the permanent tooth
6. Non resorbing or over retained deciduous tooth.
7. Non absorbing alveolar bone
8. Ectopic position of the tooth bud
9. Dilacerated roots
10. Tongue thrusting or thumb sucking habits







o Systemic causes:
1. Prenatal hereditary
2. Postnatal rickets, anemia, TB, malaria,
congenital syphilis
3. Endocrine disorders: hypothyroidism,
achondroplasia
4. Hereditary disorders : downs syndrome,
hurlers syndrome, cleidocranial
dysostosis, cleft lip and palate etc.
Classification :
1. Classification of impacted mandibular third
molars
a)Based on angulation
a) mesioangular
b) distoangular
c) vertical
d) horizontal
e) buccoangular
f) linguoangular
g) Inverted.


B) Based on depth :
as per relation to the occlusal surface of the adjacent
2
nd
molar
1. Position A: highest position of the tooth is on a level or
below the occlusal plane
2. Position B: highest position is below the occlusal plane ,but
above the cervical level of the 2
nd
molar.
3. Position C: highest position of the tooth is below the
cervical level of the 2
nd
molar.

C) Pell & Gregorys classification:
based on the space available distal to the 2
nd
molar
1. Class1: sufficient space is available between the anterior
border of the ascending ramus & distal side of the 2
nd
molar
for the eruption of 3
rd
molar.
2. Class2: the space available between the anterior border of
ramus & the distal side of the 2
nd
molar is less than the MD
width of the crown of the 3
rd
molar
3. Class 3: the third molar is totally embedded in the bone on
the ascending ramus, because of absolute lack of space .

Classification of impacted maxillary 3
rd

molar
1. Angulation and depth classification:
mesioangular, distoangular, vertical, horizontal,
buccoversion ,linguoversion inverted
..position A,B, C
2) Classification in relation to the floor of
maxillary sinus :
a) Sinus approximation (SA):
no bone or a thin bony portion is present
between the impacted maxillary 3
rd
molar and
floor of the maxillary sinus
b) No sinus approximation (NSA):
2mm or more bone is present between the sinus floor
& the impacted maxillary 3
rd
molar.
Classification of impacted maxillary canine
Class1:
palatally placed horizontal, vertical,
semivertical
Class2:
labially/bucally placed horizontal, vertical,
semivertical
Class3:
involving both buccal and palatal bone eg
crown is placed in the palatal aspect & the
root is towards the buccal alveolar process.



Class4:
vertically impacted canine between the roots of
lateral incisor and the 1
st
premolar.
Class5:
canine impacted in the edentulous maxilla
Class6:
maxillary canine in unusual position eg. nasoantral
wall or infraorbital margin


When to remove impacted tooth?
1. All impacted teeth should be removed as soon as the
diagnosis is made.
2. Early removal reduces the postoperative morbidity &
allows for best healing
3. Younger patients tolerate the procedure better &
recover more quickly because of the more complete
regeneration of the periodontal tissues.
4. Ideal time for the removal of impacted 3
rd
molar is
when the roots of the teeth are 1/3
rd
formed and before
they are 2/3
rd
formed, usually between the age of 17-
20 years.

Indications for the removal of impacted
teeth:
1. Prevention of periodontal disease
2. Prevention of dental caries
3. Prevention of pericoronitis
4. Prevention of root resorption
5. Impacted tooth under a denture or prosthesis
6. Prevention of odontogenic cyst and tumors
7. Treatment of pain of unknown origin
8. Facilitation of orthodontic treatment
9. Optimal periodontal healing
10. If involved To prevent crowding of dentition
11. in a fracture
12. Preparation for orthognathic surgery.


Clinical and radiographic assessment of
impacted teeth
Purpose:
I. possible difficulties and
complications.
II. facilities available
III. necessary surgical skills
IV. to decide whether to remove or not .





CLI NI CAL EXAMI NATI ON :
A conscious assessment of the general condition of the pt
including his attitude.
Age of the patient
Size of the oral cavity , size of the tongue, the degree of
mouth opening & the extensibility of the lips and cheeks all
contribute to the surgical access.
Large crowns , inlays or amalgam restorations in the second
molar can dislodge during elevation of the third molar
The amount of crown visible clinically.
If no part of 3
rd
molar is visible clinically ,the gingival
crevice distal to the 2
nd
molar should be probed for pockets .
Note the condition of the soft tissue above the impacted
molar
Palpate the related lymph nodes to determine the extent of
any infection.
RADI OGRAPHI C ASSESSMENT :
A) Intraoral radiographs
possible if the tooth is in the
alveolus and not in the ramus
if the oral opening is adequate
if no gagging
useful to study the relation to the adjoining structure
like the IAN canal.
useful to study the status of the crown &
configuration of the roots

The position and depth of the tooth can
be assessed using three imaginary
lines (winters lines), they are:
White line:
corresponds to the occlusal plane
a line touching the occlusal plane of the 1
st
& 2
nd
molar &
extended posteriorly over the third molar.
indicates the difference in the occlusal level of the 2
nd
& 3
rd

molars
Amber line:
represents the bone level
a line is drawn from the crest of the interdental septum between the
molars & extend posteriorly distal to the 3
rd
molar
it denotes the amount of alveolar bone covering the impacted tooth .
Red line:
is drawn perpendicular to the amber line
indicates the amount of bone to be removed before
elevation.
if length>5mm .extraction is difficult
every additional mm renders the extraction 3 times
more difficult .
if >9the 3
rd
molar is below the apices of 2
nd
molar
extraction under GA indicated.
Very difficult: 7-10
Moderately difficult: 5-7
Minimal difficult: 3-4.
Extraoral radiographs :
1. OPG






2. lateral oblique for mandible

3. Waters (PA)view for maxilla.

Radiographic prediction for the proximity
of inferior alveolar nerve canal.
o Darkening of root
o Deflection of root
o Narrowing of root
o Interruption of the white line of the canal
o Narrowing of canal
o Divergence of canal



Management :
1. Asepsis and isolation
2. Anesthesia
3. Incision-flap design
4. Reflection of mucoperiosteal flap
5. Bone removal
6. Sectioning of tooth
7. Elevation, extraction
8. Debridement & smoothening the bone .
9. Control of bleeding
10. Closure suturing
11. Medications-antibiotics, analgesics etc..
12. Follow up


Isolation of surgical site:
Scrubbing +painting the skin & oral mucosa
with cetrimide+ povidone +iodine/absolute
alcohol. OR cetrimide + abs alcohol
+CHX(providone iodine 5% for skin & 1% for
oral mucosa , CHX 0.2% for oral mucosa &7.5%
for skin.
Drape the patient with sterile drape to cover
upper part of face to isolate the oral cavity .
Local anesthetic:
IAN + lingual+long buccal nerve block for
mandibular molars
PSA nerve block + greater palatine nerve block
for maxillary molars
Infraorbital +nasopalatine nerve block for
maxary canines.
Local infiltration for homeostasis.
Incision (mucoperiosteal flap design):
For adequate access
Incision for flap has an anterior limb , a posterior limb
, connected with/out a intermediate limb .
Incision for mandibular 3
rd
molar extends anteriorly to
midway of CEJ of 2
nd
molar at an angle & posteriorly
to distal most point of the 3
rd
molar.
-incision shouldnt extend too far upward distally.

Bone removal
Aim to expose the crown & to create a path for the
removal of the tooth .
Adequate amount of bone should be removed ,but can be
minimized by sectioning the tooth
2 ways of bone removal;
-high speed hand piece & bur technique
-chisel and mallet technique.
Lingual split bone technique:
Described by Sir William Kelsey fry
Quick and clean technique
Causes saucerization of the socket thereby reduces the
size of the residual blood clot.
Used for lingually impacted mandibular 3
rd
molars
Incidence of transient lingual anesthesia post
operatively .
Tooth sectioning :
Reduces the amount of bone removal
Reduces the risk of damage to the adjacent teeth
Planned sectioning permits the parts to be removed
separately in an atraumatic way.
The direction in which the impacted tooth should be
sectioned depends upon the angulation of impaction ,based
on line of withdraw of the segment.
Can be done with bur/chisel ,bur is preferred.



Elevation & extraction:
1. Coupland elevator :
placed at the base of the crown
2. Winter cryer :
may be used for wedging action /buccal elevation.
buccal elevation can be done in molars & canine
by creating a purchase point in the roots just
below the CEJ.
support inferior border +lingual alveolar bone
during elevation.


Debridement & smoothening of bone :
1. Irrigate the socket
2. Curette the socket to remove any remaining dental
follicle and epithelium.
3. Check for pieces of coronal portion ,remnants of
bone ,granulation tissue &bleeding points .
4. Check for caries (crown/root) ,erosion damage of
the adjacent tooth.
5. Round off the margins of the socket with large
vulcanite round bur or bone file .
6. Irrigate the socket again and control bleeding before
suturing .

Closure:
3-0 black silk suture used
Interrupted sutures placed & maintained for 7
days
In case of 3
rd
molars sutures distal to 2
nd
molar
should be placed first & should be water tight to
prevent pocket formation.


o Factors making impaction surgery more
difficult:
1. Distoangular
2. Class3 ramus
3. Class C depth
4. Long thin roots
5. Divergent curved roots
6. Narrow pdl
7. Thin follicle
8. Dense inelastic bone
9. Contact with 2
nd
molar
10. Close to IAN canal
11. Complete bony impaction.


o Factors making impaction surgery less
difficult
1. Mesioangular position
2. Class1 ramus
3. Class A depth
4. Roots 1/3-2/3
rd
formed
5. Fused conical roots
6. Wide periodontal ligament
7. Large follicle
8. Elastic bone
9. Separated from 2
nd
molar, IAN canal
10. Soft tissue impaction
COMPLICATIONS :
Hemorrhage
Injury to the inferior alveolar nerve .
During bone removal:
damage to 2
nd
molar
damage to the root of the overlying tooth
slipping of the bur into the soft tissue
fracture of mandible when chisel & mallet are used.
During elevation:
luxation of the neighboring/overlying tooth
fracture of adjoining bone
displacement of the bone into the nearby space.
injury to the IAN ,lingual nerve etc.






Post operative complications:
pain,
swelling,
trismus,
hypoesthesia,
sensitivity,
loss of vitality of the nearby tooth,
pocket formation etc.

1. Textbook of oral and maxillofacial surgery-

Neelima Anil Malik
2. Contemporary oral &maxillofacial surgery-
Peterson.
3. Oral & maxillofacial surgery Laskin
4. www.google.com