Impacted teeth , examination, diagnosis and treatment

Impactions , classification and management

1. IMPACTIONS Presented by ; Asiimwe Edgar Mulungi Deborah Ssali Henry Tamale

2. OUTLINE Introduction Incidence Etiology Theories and Classification Evaluation Surgical management

3. INTRODUCTION An impacted tooth is that which is completely or partially unerupted, its usually positioned against another tooth, bone or soft tissue hence forth no further eruption is unlikely and described according to its anatomic position. Partially erupted : When the tooth has failed to erupt into a normal functional position but has crossed the bone barrier and has not reached the occlusal line. An unerupted tooth is one that hasntperforated the oral mucosa. Impactions can be identified clinically or radiographically.

4. ILLUSTRATIONS

5. INCIDENCE OF OCCURENCE Mandibular third molars Maxillary third molars Maxillary cuspids Mandibular bicuspids Mandibular cuspids Maxillary bicuspids Maxillary central incisors Maxillary lateral incisors

6. ETIOLOGY OF IMPACTION LOCAL FACTORS; • Irregularity in the position and pressure of the adjacent tooth. • Density of the overlying or surrounding bone. • Localised chronic inflammation with resultant increase in density of the overlying mucous membrane. • Lack of space due to underdeveloped jaws. Arch length and tooth size discrepancy. •Dilaceration: Abnormal path of eruption of the tooth due to traumatic forces during eruption period.

7. CONTINUATION... Ectopic position of tooth buds over retained deciduous teeth 2. SYSTEMIC FACTORS A . Prenatal causes : Heredity B. Postnatal causes : All those conditions that may interfere with the development of the child, such as:Rickets, Anaemia, Congenital syphilis Tuberculosis,endocrine dysfunction C. Rare conditions : 1. Cleidocranial dysostosis, Oxycephaly,Osteopetrosis,Cleft palate,Pericoronitis.

8. THEORIES OF MANDIBULAR IMPACTIONS Most popular theory is insufficient growth of the retromolar pad . ORTHODONTIC THEORY; Jaws develop in downward and forward direction, while as the teeth move in a forward direction Interference with the proper movements cause impaction A dense bone decreases the movement of the teeth in forward direction.

9. PHYLOGENIC THEORY The more-functional masticatory force,the better the development of the jaw. Nature tries to eliminate the disused organs. This causes elimination of the unused teeth which causes congenital absence of third molars. Due to changing nutritional habits ,there is elimation of the need for poerful jaws,this causes the mandible and maxilla size to reduce over years leaving insufficient room for thirtd molars

10. MENDELIAN THEORY Heredity is the most common cause. An individual may inherit small jaws from one parent and a complement of large teeth from the other. Hereditary transmission of small jaws and large teeth from parents to children. This may be an important etiological factor in the occurrence of impactions.

11. CONTINUATION.. PATHOLOGICAL THEORY ; Osteosclerosis in the third molar area, caused by the early disease of adjacent molars, cause chronic infections. It may bring the condensation of osseous tissue further preventing the growth and development of the jaws ENDOCRINAL THEORY; Increase or decrease in the growth hormone secretion may affect the size of the jaws. An imbalance of endocrine activity leads to the lack of growth of the jaws, this lack provides a cause for impaction.

12. EVALUATION Clinical examination (present or absent) Radiographic assessment. This shows the position of the unerupted tooth. Periapical radiograph Occlusal radiograph Panoramic radiograph CT

13. THE TUBE SHIFT METHOD Employs the use of two PA radiographs, shifting the tube horizontally between exposures. If the unerupted tooth moves in the same direction in which the tube is shifted, its located on the lingual or palatal side. A facial or buccally located tooth moves in the opposite direction to the tube shift

14. PERIAPICAL AND OCCLUSAL METHOD Uses the PA radiograph taken with standard technique and an occlusal radiograph to give different views of the impacted tooth. Panoramic film can be used to assess maxillary canine position.

15. CLASSIFICATION OF MANDIBULAR IMPACTIONS Classification of the position of the impacted teeth helps in assessing the best possible path of removal of the impacted teeth and also in determining the amount of difficulty which would be encountered. Based on nature of overlying tissues; Hard tissue impacions Soft tissue impactions 2. Winter’s Classification ;Basedon the inclination of impacted 3rd molar to the long axis of second molar Mesioangular ;the long axis of 2nd molar is bissected at or above the occlusal plane by the long axis of 3rd molar.

16. CONTINUATION ... Distoangular ; : Long axis of 3rd molar is away from long axis of 2nd molar at the level of occlusal plane . Horizontal : Long axis of 3rd molar bisect long axis of 2nd molar at right angle Vertical ;The long axis of the impacted tooth runs parallel to the long axis of the second molar Buccal or lingual: In combination to the above described impaction, the tooth can also be buccally or lingually impacted.

17. PELL AND GREGORY’S CLASSIFICATION Based on their relationship with anterior border of the mandible; Class 1 ; The anteroposterior diameter of the tooth is equal to the space between the anterior border of ramus of the mandible and distal surface of the second molar tooth Class 2 ; mesiodistal diameter of the tooth is greater than the space available Class 3 ; Tooth is located completely within the ramus of the mandible–least accessible

18. ILLUSTRATION...

19. CONTINUATION... 2. Based upon the amount of bone covering the impacted tooth and relation to occlusal plane. Position A ; Occlusal plane of the impacted tooth is nearly in the same level as the occlusal level of the adjacent second molar tooth Position B ; Occlusal plane of the impacted tooth is in the midway between the cervical line and the occlusal plane of the adjacent second molar tooth. Position C ; Occlusal plane of the impacted tooth below the level of cervical line of the second molar tooth

20. ILLUSTRATION...

21. CLASSIFICATION OF MAXILLARY MOLARS Based on relative depth of impacted molar in thebone; Class A : The lowest portion of the crown of the impacted maxillary third molar is on a line with the occlusal plane of the second molar Class B : The lowest portion of the crown of the impacted maxillary third molar is between the occlusal plane of the second molar and the cervical line Class C: The lowest portion of the crown of the impacted maxillary third molar is at or above the cervical line of the second molar

22. CONTINUATION.... Based on position of the tooth to the sinus.. a -sinus approximation : where no bone or very thin bone exist between the impacted teeth and floor of sinus. b -no sinus approximation : where 2 mm or more of bone exist between the floor of sinus and impacted teeth.

23. CLASSIFICATION OF IMPACTED CUSPIDS... . Class I Impacted cuspids in palate 1. Horizontal 2. Vertical 3. Semivertical Class II Impacted cuspids on buccal surface 1. Horizontal 2. Vertical 3. Semivertical Class III Impacted cuspids located both in the palatal process and labial maxillary bone Class IV Impacted cuspids located in the alveolar process usually vertically between the incisor and bicuspid. Class V Impacted cuspid located in an edentulous maxilla .

24. MANAGEMENT OF IMPACTIONS Pre surgical evaluation Surgical management Post surgery

25. Pre surgical management Radiological and clinical evaluation. Classification of the impaction Surgical management Give LA or GA depending on: General condition of the patient and their ability to psychologically or physically to withstand the procedure. Position of the impaction and extent of the surgical procedure Number of impactions to be removed in a single procedure

26. STAGES OF SURGICAL DISIMPACTION Access to the impacted tooth. Elevation of an adequate mucoperiosteal flap to expose the field of operation. A pyramidal flap incision is used in all third molar impactions, with the anterior incision of the flap extending from the distal aspect to 2 nd molar at a 45 degree angle, extending to the mucobuccal fold. In deep impactions, a bigger flap is advisable, the anterior incision could start from the mesial aspect of the 2 nd molar

27. 2. Surgical extraction

28. Extraction of impacted maxillary 3 rd molars With palatally impacted maxillary: exposure of the surgical field is done by a gingival incision extending from the palatal side of the molar on one side to the other side all around the palatal gingiva of the present teeth. With labially placed impaction: use a pyramidal flap incision is adequate.

29. 3. Bone Removal. This is done for: Exposure of the impaction Reduction of resistance Making a point for application of the elevator

30. 4. Tooth Delivery Done by use of elevators. Mesial application: straight elevators and pot’s elevators. Buccal application: winter elevator

31. Delivery of the tooth after tooth division. Indicated to reduce resistance, create space or remove interlocked cusps of the tooth. Decapitation is the division of the crown of the tooth at cervical margin level and is indicated in horizontal impactions. Longitudinal tooth division is indicated in widely divergent straight roots or when one root is straight and the other is curved. Also in division of interlocking cusp mesioangular impaction

32. Prepare for wound closure. Irrigate with NS. Inspect for any remnants of the tooth sac, bone debris, sharp edges of interseptal or alveolar bone. Final irrigation

33. Wound closure. Reflect the flap back in to place and use absorbable sutures. Post operative care. Pressure pack held in place for 1 hour Post op instructions given to the patient Cold packs on outside of face 20min per hour 5 times daily Antibiotic therapy Mouth wash Soft diet Patient returns for check up

34. COMPLICATIONS Laceration of the soft tissue flap Improper incision Improper elevation of the flap and improper retraction. 2. Fracture of the jaw 3. Complication related to injury of adjacent structure. Injury to the inferior alveolar canal as with deeply seated impactions where the nerve passes between roots of impacted tooth. Damage to the nasal floor as with maxillary impacted 3 rd molars. Involvement of the maxillary sinus. Aspiration of the tooth, as with GA

35. Post-operative complications. Pain Hemorrhage Infection Parasthesia of the lingual or inferior alveolar nerve Trismus Osteomyelitis Odynophagia due to edema of the pharynx

36. REFERENCES Peterson LJ. Rationale for removing impacted teeth: when to extract or not to extract. J Am Dent Assoc 1992; 123: 198-204. Robinson PD. The impacted wisdom tooth: to remove or to leave alone? Dental Update. 1994; 21: 245-8. Venta I, Turtola L, Ylipaavalniemi P. Change in clinical status of third molars in adults during 12 years of observation. J Oral Maxillofac Surg 1999; 57: 386-9. Anatomy Journal of Africa. 2023. Vol 12 (1): 2296-2302 Google images