Impaction 27.8.6

IMPACTION

Dr.V.RAMKUMAR

CONSULTANT DENTALFACIOMAXILLARYSURGEON

REG NO: 4118 TAMILNADU- INDIA(ASIA)

DEFINITIONImpacted tooth is one that fails to erupt and will not eventually assume its anatomical arch relationship, beyond the chronological eruption date

ETIOLOGY

* NATURE - LACK OF SPACE IN JAWS

* NURTURE - CHANGE IN DIET

LACK OF SPACE

ETIOLOGY

Theories..

Phylogenetic

Mendelian

DILACERATION

ETIOLOGY

ETIOLOGY

retained deciduous teeth

OBSTRUCTIONS

Odontome

ETIOLOGY

Cyst / Odontogenic tumour

ETIOLOGY

Thick scar band

Dense bone

Systemic causes – Hormonal imbalance

ETIOLOGY

INDICATIONS

Recurrent pericoronitis

Presence of a pathological lesion

INDICATIONS

Caries Periodontal disease Obscure facial pain Previous attempted extraction Prosthetic considerations Social and economic factors

INDICATIONS

CONTRA INDICATIONS

Health considerations Prosthetic considerations Availability of adequate

space socio economic reasons

Mandibular 3rd Molar Impaction

CLASSIFICATION

Based on the long axis of the impacted tooth in relation to the long axis of the second molar

WINTER’S CLASSIFICATION

Angulation Depth

Mesioangular

WINTER’S CLASSIFICATIONAngulation

Distoangular

WINTER’S CLASSIFICATIONAngulation

Horizontal

WINTER’S CLASSIFICATIONAngulation

Vertical

WINTER’S CLASSIFICATIONAngulation

Buccoversion

WINTER’S CLASSIFICATIONAngulation

Linguoversion

Angulation WINTER’S CLASSIFICATION

Inverted

Angulation WINTER’S CLASSIFICATION

Angulation

Unusual / Ectopic

WINTER’S CLASSIFICATION

ASSESSMENTCLINICAL

RADIOLOGICAL

CLINICAL ASSESSMENT

AGE

EXTERNAL OBLIQUE RIDGE

BUCCAL PAD OF FAT

POSITION OF TONGUE

STATUS OF ADJACENT TOOTH

LENGTH OF BOTH ANGLES OF MOUTH

PRESENCE OF ANY ACUTE INFECTION

PRESENCE OF ANY PATHOLOGY

PRESENCE OF ASSOCIATED JAW #

FACIAL FORM

RADIOLOGICAL ASSESSMENT

W A R Lines

W A R Lines

W A R Lines

W A R LinesW A R Lines

W A R Lines

WHITE Line

Amber Line

RED Line

Sl. NO Category Score

1. Winter’s Classification Horizontal Distoangular Mesioangular Vertical

2210

2. Height of the mandible 1-30 mm31-41 mm35-39 mm

012

3. Angulation of III molar 1° - 50°60°-69°70-79°80°-89°90°+

01234

4. Root shape Complex Favourable curvature Unfavourble curvature

123

5. Follicles Normal Possibly enlarged Enlarged

012

6. Path of Exit Space available Distal cusps covered Mesial cusps also covered Both covered

012 3

Total 33

SCORING DETAILS FOR WHARFE ASSESSMENT

Maxillary 3rd Molar Impaction

Classification

Archer’s.. Class A

Class B

Class C

Canine Impaction

Classification

Ackerman (1935):

Maxillary canines

Palatal position Labial position

Class I Class II

Class III

involve both buccal and palatal bone

Class IV

in the alveolar process between the incisors & 1st premolar

Class V

in the edentulous maxilla

SURGICAL TECHNIQUE IN IMPACTED TOOTH REMOVAL

FLAPS : L - SHAPE, ENYELOPE, BAYONET

BONE : BUR VS CHISELREMOVAL

TOOTH : TOOTH VS BONE (KELSY FRY RETRIEVAL SPLIT & DAVIS)

WOUND : CONVENTIONAL VS TISSUE ADHESIVES

Incision

Flap Design

BONE SPLIT TECHNIQUE

SIR WILLIAM KELSY FRY ?

VS

W.H.DAVIS ?

ADVANTAGES OF DAVIS

- DECREASED INCIDENCE OF INFECTION IN II MOLAR AREA - OBVIATES LINGUAL BONE REMOVAL

- ↓ LINGUAL NERVE COMPLICATION

DISADVANTAGES OF KELSY FRY

-↑ LINGUAL NERVE COMPLICATION - BLEEDING - ELEVATION OF LINGUAL

SOFT TISSUE

POSTOPERATIVE CARE

i) Rest is necessary for the prompt healing of wounds.

ii) Cold applications to the face prevent disfiguring swelling and postoperative edema.

iii) They should be instructed to drink plenty of fluids in the form of milk, juices, Tea, Water etc.,

iv) Proper oral care must not be neglected

v) Should rinse 4 to 6 times daily. Best mouth rinse is a warm saline water.

vi) In take of alcohol and use of smoking should be discontinued for five days.

vii) Antibiotics and analgesic drug should be started.

During bone removal

jaw #

During elevationjaw #

Swelling

Post operative

Subcutaneous emphysema

Post operative

Complications of surgical removal of impacted tooth

During LA Intra operative Post operative

During LA Pain Snycope LA toxicity Role of adrenalin in systemically

compromised pts

Management: Slow injection Aspiration before injecting Proper case history to rule out systemic

illness Proper DOCTOR-PATIENT rapport..

Intra operative complicationsIncision Flap elevation Bone

removal

Tooth sectioning Elevation of tooth

During incision Local inflammation immediately prior to

surgery hemorrhage

Subside the inflammation prior to surgery by anti inflammatory drugs

Placement of incision:Buccal:

downward & forward placement of incision towards the vestibule

damage to the facial artery or anterior facial vein

Management:Temporary Permanent

extra oral finger pressure ligation

Direct the cut upwards towards the tooth

Distal:incision directly in line with the

anterior border of ramus Damage the retromolar vessels

Lingual extension Damage lingual nerve

Direct the incision more bucally

During bone removal

Damage to the distal aspect of 2nd molar

sensitivity

Improper cooling of the bur

Local bone death

Sequestration

slip & embed into the soft tissue

Damage mucosa & lingual nerve

Bur

Mandibular canal openingemorrhage

Hemorrhage Anestheisa

Careful drillingAdequate retractionLingual nerve protection

Advantage:1. Safe 2. Rapid3. Efficient method

Disadvantage:1. Damage adjacent

structures2. Fracture of the jaw3. Splitting of the

lingual plate

Chisel

Firm controlAnterior vertical limit cutOptimum force of malleting

During tooth sectioning

Incorrect line of sectioning

Difficult removal of the tooth

Damage to mandibular canal

HemorrhagePost op numbness of

the lower lip on the side of surgery

Bur

Section across the cervical portion at right angle to the long axis of the tooth

Difficult to achieve correct line of cleavge

More accurate sectioning

Chisel Osteotome

Inadequate control

•Damage to soft tissues•Lingual nerve•2nd molar

Excessive malleting force

•Dislodgement of tooth into the lingual pouch•Fracture of the tooth in unwanted angulation

Retrieval of the dislodged tooth

Tooth

Lingual pouch

Finger pressure

Manipulation upwards

Retrieval with forceps

During elevation of the tooth Fracture of the tooth Displacement of the tooth into lingual pouch

or lateral pharyngeal space or tonsillar area (retrieval – finger manipulation or surgical exploration)

Sublux]ation to 2nd molar or complete dislodgement out of its socket

Damage to the disto-occlusion restoration Fracture of the jaw (due to excessive force)

Root apices penetrating mandibular canal – hemorrhage & numbness

Prevention of dislodgement into the lingual pouch or lateral pharyngeal space

Relieve the tooth from the overlying gingival pad

Finger over the 3rd molar during elevation

Post operative complicationsImmediate 1. pain2. Hemorrhage 3. Swelling4. Anesthesia5. Trismus6. Pain on swallowing & sore throat pyrexia

Late 1. Infection 2. Hemorrhage 3. Pain in TMJ4. Trismus

Immediate post op complications

1. Pain: cause:

dry sockethematomatrauma to the adjacent tooth

Pain thershold – varies for each individualJudicious manipulation of the tissues

2. Hemorrhage:

Injection

Incision

Infection

Hemorrhage

Reactionary Hemorrhage Occuring during the first 24 hours following surgery

Cause:1. failure to achieve complete

hemostasis during surgery2. wearing of adrenalin action

Management:

source of bleeding is identified

Ligation Pressure pack

3. Swelling:

Cause: Bleeding under a tight suture

lack of escape of hemorrhage through the sutural line

Seepage into the soft tissues

1. Tongue base 2. Pharyngeal tissue planes

Impairment of airway

Swelling

Edema

Not painful

Hematoma

Tense & Tender