Management for mandibular 3rd molar impaction

Vertically impacted

Mesio - angularly impacted

A. buccal and distal bone are removed to

expose crown of tooth to its cervical line.

B. The distal aspect of the crown is then sectioned from tooth. Occasionally it is necessary to

section the entire tooth into two portions rather than to section

the distal portion of crown only.

C . A small straight elevator is inserted into the purchase point on

mesial aspect of 3rd molar, & the tooth is delivered

with a rotational and level motion of elevator.

PETERSON‘S PRINCIPLES OF ORAL AND MAXILLOFACIAL SURGERYSecond Edition

A. Removal of mesial & distal boen. It is important

to remember that more distal bone must be taken off than for a vertical or mesioangular impaction.

distoangular impaction

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

straightelevator

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-axlemotion. If the roots diverge, it may be

necessary in some cases to split them into

independent portions

PETERSON‘S PRINCIPLES OF ORAL AND MAXILLOFACIAL SURGERYSecond Edition

Horizontally impacted

A. Removal of distal and buccal underlying bone

B. The crown is sectionedfrom 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. Saperation 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

fashionPETERSON‘S PRINCIPLES OF ORAL AND MAXILLOFACIAL SURGERYSecond Edition

A. When removing a vertical impaction, the bone on the occlusal,

buccal, and distal aspects of the crown is removed,

and the tooth is sectioned into

mesial and distal portions.

B. The posterior aspect of the crown is elevated first

with a Cryer elevator inserted into a small purchase point in the distal portion of the

tooth.

C. A small straight no. 301 elevator is then

used to lift the mesial aspect of the tooth with

a rotary and levering motion.

Vertically impactedPETERSON‘S PRINCIPLES OF ORAL AND MAXILLOFACIAL SURGERYSecond Edition

Mandibular 3rd molar removal!

Impaction of teeth other than 3rd molar

Impaction of teeth other than 3rd molar

Max. canine Premolars 2nd molar

Systemic

• Hypothyroidism, Febrile disease , Down syndrome

Local

• Malposed tooth germ, arch-length def, superneumerary, clef lips +palate, prolonged decisous retention

Hereditary

• Cleidocranial dysplasia

Etiology

• Labially : Arch-length deficiency• Palatally : Extra space owing to

excessive growth, agenesis, peg shape lateral incisor

canine

• Ectopic eruption

1st molar

•Arch -length deficiency

2nd molar

Clinical problem : malocclusion, loss of arch length, migration/ loss of adjacent tooth, periodontal disease, root resorption (internal & external) of impacted tooth, dentigerous csyt & pericoronitis.

Management for impacted tooth other than 3rd molar

Exposure Uprighthing

transplantation Removal

a) Exposure (with/ without ortho band)

• Allow natural eruption of impacted teeth • Most appropriate technique • Most common : bonded orthodontic bracket to

1. Conserve exposure of the tooth2. Remove only enough soft tissue + bone to place

bracket3. Avoid exposure of CEJ

PETERSON‘S PRINCIPLES OF ORAL AND MAXILLOFACIAL SURGERYSecond Edition

Labially impacted canine exposed important part of this surgical procedure using an apically repositioned flap

Palatally impacted canines

Maxillary Palatal cuspid Maxillary Labially cuspid

• Full thickness palatal cuspid•Conservative exposure of the tooth•Bonding of a bracket to its palatal surface

• A position in the arch must be established by preliminary orthodontic treatment prior to cuspid exposure

If the tooth near the free edge of the flap :1. Soft tissue may be removed to

leave the crown expose2. Wound packed gently during initial

healing period

•Preservation of attached mucosa adjacent to the cervical line of the tooth

If the tooth deeply impacted :1. Replace the tissue flap2. Bringing a wire attached to the

bonded bracket through the soft tissue near the crest of the ridge

b) Uprighting

• Commonly for impacted MOLARS

• Remove 3rd molar for 2nd molar to erupt normally

• Normal time for uprighting molar teeth : 2/3 of the root has formed

• If root fully formed poor prognosis

• If 3rd molar : Remove bone to ensure occlusal force, antibiotic

Molar uprighting is frequently needed to treat a malocclusion bad bite that occurs years after the extraction of the lower first molar tooth

Third molar in path of second molar eruption

c) Transplantation• For adult : undergo conventional

ortho movement of canine / premolar

• how?1. Expose the impacted tooth2. Move into position + stabilize with

ortho app.3. Endo treatment : calcium hydroxide

paste (antimicrobial effect & bone-regeneration stimulant) 6-8 weeks after surgical procedure

4. Conventional root canal filing at 1 year following surgery

• Extraction possible : transalveolar transplantation (max. canines)

PETERSON‘S PRINCIPLES OF ORAL AND MAXILLOFACIAL SURGERYSecond Edition

iv. Removal• Last choice! : canines / premolar / molar• Surgical + Radiographic assessment• Conservation of bone through conservative

exposure + removal with sectioning

Impacted canines

• Approach from surface of maxilla which they are closely related

Labially impacted canines

• Frequently removed with an elevator technique

Palatal impacted canines

• Removal of crown by sectioning the root (longitudinal sectioning)

• Large palatal flap : palatal splint

• May be removed likely like caninesImpacted Maxillary bicuspid

• General approach from labial surface• Careful!!! Preserve mental nerve

Impacted Mandibular bicuspid

• Identify the tooth through a lingual exposure• a labial flap - raised & a small hole placed in

the labial surface of the bone allow the bicuspid to be pushed through to the lingual

Lingually position

* Molar tooth similar to 3rd molar!

Indication for removal of impacted tooth

Pericoronitis Prevention

or Treatment

Prevention of Dental Disease

Orthodontic Consideratio

n

Prevention of

Odontogenic Cysts and Tumors

Teeth under Dental

ProsthesesPrevention of Jaw Fracture

Management of

Unexplained Pain

Root Resorption of adjacnet teeth

i. Pericoronitis Prevention or Treatment

The most cases for removal of impacted tooth! Usually mandibular – partially erupt Microbes : Peptostreptococcus, Fusobacterium, and Bacteroides

(Porphyromonas)

Initial treatment :i.Débridement

ii. Disinfection with irrigation solution (hydrogen peroxide or chlorhexidine)

iii. surgical management – extract opposing max 3rd

molar.iv. Severe cases with systemic effect – antibiotic

• Recurrent – Removal of involved tooth

ii. Prevention of Dental Disease

• Caries! – At mand 3rd molar / adjacent tooth(mostly at cervical line)

• unable to clean effectively & inaccessible to the restorative dentist advanced periodontal disease : Extract!

iii. Orthodontic Considerations•Controversional•Anterior incisor crowding associated with deficient arch length rather than presence of impacted teeth.

Crowding of Mandibular Incisors

•facilitate treatment and allow predictable outcomes.

Obstruction of Orthodontic Treatment

•For mand. Ostoetomies - delaying removal : the thickness & quality of lingual bone at the proximal aspect of the distal segment where fixation screws are usually applied.•If removed – sufficient time for the extraction site to fill with mature bone.

Interference with Orthognathic Surgery

iv. Prevention of OdontogenicCysts and Tumors

Follicular sac (formation of the crown) cystic degeneration dentigerous cyst --> odontogenic tumor (rare)

Reason for removal of asymptomatic teeth because pathology occurs, it may pose a serious health threat!

v. Root Resorption of Adjacent Teeth

Misaligned erupting teeth may resorb the roots of adjacent teeth just like succedaneous teeth resorb the roots of primary teeth during normal eruption.

Most cases - adjacent tooth recalcified (deposition of a cementum over the resorbed area) & formation of 2o dentin.

If severe resorption & the mandibular 3o molar displaces significantly into the roots of the second molar REMOVE.

vi. Teeth under Dental Prostheses

Removable tissueborne prosthesis – is constructed on a ridge where an impacted tooth is covered by only soft tissue or 1 or 2 mm of bone overlying bone resorbed, mucosa perforate & the area become painful and inflamed. So ----> Extract!

In older patients with tooth- or implant-borne fixed prostheses asymptomatic deeply impacted teeth can be safely left in place.

vii. Prevention of Jaw Fracture

Patients engage in contact sports (football, rugby, martial arts) & noncontact sports (basketball) remove to prevent jaw fracture

An impacted third molar - resistance to fracture in mandible common site for fracture

increased complications in the treatment of the fracture.

viii. Management ofUnexplained Pain

Jaw pain in the area of an impacted third molar but clinical or radiographic signs of pathology.

the surgeon must make sure that all other sources of pain are ruled out before suggesting surgical removal of the third molar.

Patient must be informed that removal of the third molar may not relieve the pain completely

Contraindication for removal of impacted tooth

Extremes of Age

• Healing • Greater bony defect

postoperatively• Difficult - more

densely calcified bone (less flexible & likely fracture)

• Tolerated less easily and the recuperation period grows longer.

• If no complication - extraction

Surgical Damage to adjacent Structures

• Removal may compromise adjacent nerves, teeth & other vital structures (sinus), making it

• If benefits than complication, don’t extract

Compromised Medical Status

• In older : pulmonary disease

• younger people : congenital coagulopathies asthma &epilepsy.