IMPACTION IN ORAL SURGERY

detailed description on impaction

1. IMPACTION IMPACTION BY DR. VIGNESH PRABHU.t

2. Introduction Theories for impaction of teeth. Causes of impaction. Order of frequency for impaction of teeth. Complications arising from the retained impacted teeth. Indications & contraindications for removal of impacted teeth. CONTENTS

3. “Third molar tooth has been the most widely discussed tooth in the dental literature, and the debatable question,to extract or not to extract” seems set to run into the next century- Faiez N hattab;joms 57:389-391 ( 1999) Got their name” wisdom teeth ” from the age during which they erupt:17-25 This is the age at which men and women become adults and presumably wiser. INTRODUCTION

4. A tooth which is completely or partially unerupted and is positioned against another tooth and bone or soft tissue, so that it’s further eruption is unlikely , described according to its anatomical position. - ARCHER DEFINITIONS

5. 1954 MEAD – defined an impacted tooth as a tooth that is prevented from erupting into position because of malposition ,lack of space or other impediments. IMPACTED TOOTH

6. PETERSON , characterized impacted teeth as those teeth that fail to erupt into the dental arch within the expected time. In 2004 , FARMAN wrote that impacted teeth are those teeth that are prevented from eruption due to a physical barrier within the path of eruption. IMPACTED TOOTH

7. Cessation of eruption of tooth caused by a clinically or radiographically detectable physical barrier in the eruption path or ectopic eruption. DMFR -2005 DEFINITIONS

8. A tooth, unerupted or erupted, which is in an abnormal position in the maxilla or mandible MALPOSED TOOTH

9. A tooth which has not perforated the oral mucosa . UNERUPTED TOOTH

10. Cessation of eruption of tooth after emergence without a physical barrier in the path of eruption or result of abnormal position . Secondary If no physical barrier can be identified as a explanation for the cessation of a normally placed & developed tooth germ before emergence Primary RETENTIONS

11. causative factors include ankylosis ,Trauma, infection, disturbed local metabolism, and genetic factors Secondary Disturbance in the dental follicle that fails to initiate the metabolic event Primary

12. 19.7 ./. – 25.9./. Third molars shows agenesis. F > m Maxilla > mandible AGENESIS

13. MY OPG

14. Max.3 rd molars Man. 3 rd molars Max. & Man. Canines First evidence of calcification 7-9 yr 8-10 yr 4-6 months Crown completion 12-16 yr 12-16 yr 6 yr Eruption 17-21 yr 17-21 yr 11-13 yr Root completion 18-25 yr 18-25 yr 14-15 yr CHRONOLOGY

15. Orthodontic theory Phylogeneic theory Mendelian theory Pathological theory Endocrinal theory Theories of impaction

16. Growth of jaw , movement of teeth occurs in forward direction , so any thing that interfere with such moment will cause an impaction. i.e small jaw – decreased space BY DURBECK Orthodontic theory

17. Due to changing nutritional habits of our civilization , use of large powerful jaws have been practically eliminated. Phylogenic theory

18. Genetic variations play a major role. Hereditary transmission of small jaw & large teeth from parents to siblings , it may be important etiological factor for impaction . Mendelian theory

19. Increase or decrease in growth hormone Endocrinal Chronic infection may bring the condensation of osseous tissue . Pathological OTHERS

20. According to Archer Causes LOCAL SYSTEMIC

21. Inadequate space Inclination Obstruction Ankylosis Ectopic eruption Dilaceration of roots LOCAL CAUSES

22. Systemic causes Prenatal causes Heredity Miscegenation Postnatal causes Rickets Anemia Congenital syphilis T.B Endocrine dysfunctions Malnutrition Rare conditions Cleidocranial dysostosis . Osteopetrosis Progeria Achondroplasia Cleft palate

23. Maxillary 3 rd molars. Mandibular 3 rd molars. Maxillary cuspids . Mandibular bicuspids. Mandibular cuspids . Maxillary bicuspids. Maxillary central incisors. Maxillary lateral incisors According to Archer

24. 1.Mandibular 3 rd molars 2.Maxillary 3 rd molars 3.Maxillary cuspids . 4.Mandibular bicuspids. 5.Maxillary bicuspids. 6.Mandibular cuspids . 7.Maxillary central incisors. 8.Maxillary lateral incisors According to Malik

25. Trismus Redness and swelling of the gums around the impacted tooth. Swollen lymph nodes   ( occasionally) Signs Pain Difficulty opening the mouth Bad breath Head ache or jaw ache Unpleasant taste Symptoms Signs and symptoms

26. “A strong indication for removal of impacted tooth should be complemented with a strong contraindication to its retention” INDICATION

27. INDICATIONS

28. Pain in the retromolar region without any apparent cause PAIN

29. Pericoronitis

30. CARIES

31. Periodontal pocket

32. Root resorption

33. Abcess formation

34. CYST & TUMOURS Follicular sac cystic degeneration The epithelium contained within the dental follicle leads to Odontogenic T.

35. When to remove ideally..?? more than 1/3 but less than 2/3

36. Extremes of age compromised medical status Excessive risk of damage of adjacent structure Uncontrolled active pericoronal infection Prosthetic considerations Socioeconomic status CONTRA INDICATIONS

37. Intervention …???? Non – intervention…????

38. CLASSIFICATION GEORGE WINTER’S (1926)

39. A. Relation of the tooth to the ramus of the mandible & the second molar Pell & Gregory (1933)

40. B . Relative depth of the third molar in bone . 42 POSITION B POSITION C POSITION A

41. C. The position of the long axis of the impacted Mandibular third molar in relation to the long axis of the second molar. (Winter’s classification.)

42. a) Based on angulation and position: (Same as Winter’s classification) b) Based on the state of eruption: - Completely erupted - Partially erupted - Unerupted c) Based on roots: 1) Number of roots - Fused roots - Two roots - Multiple roots 2) Root pattern - Surgically favorable - Surgically unfavorable killey & kay’s classification-1975

43. Quek et al ( 2003)

44. 46 AAOMS & ADA CLASSIFICATION 07220 - soft tissue impaction. 07230 - partial bony impaction. 07240 - complete bony impaction 07241 - complete bony impaction with unusual complications.

45. Based on angulation Maxillary third molars

46. According to depth of impaction

47. Relationship of tooth to maxillary sinus

48. Clinical Radiographical Psycological Assessment

49. RELATIONSHIP OF THIRD MOLAR WITH THE INFERIOR ALVEOLAR NERVE

50. Related but not involving the canal

51. Related to changes in the canal Rood & Shebab criteria (Rood JP , Shihab BA - British J OMFS 1998:28:20)

52. 57 Position of the molar Mesioangular 1 Horizontal 2 Vertical 3 Distoangular 4 Relative depth Class A 1 Class B 2 Class C 3 Relation with ramus and space available Class 1 1 Class 2 2 Class 3 3 Assessment of difficulty PEDERSON SCALE Difficulty score Total Easy 3–4 Moderate 5–6 Difficult 7–10

53. Wharfe’s assessment

54. 60 Winter’s assessment-WAR lines

55. Surgical anatomy

56. MUSCLES MUSCLES

57. ARTERIES

58. Lingual nerve (Antony Pogrel ,J oral maxillofac Surg 1995:53:1178)

59. 66 Surgical procedure John tomes-1848-extn of 2 nd molar-Impaction Steele-1895- Grinding of distal surface of 2 nd molar NOVITSKY-1890-1 st to raise the flap and remove bone Edmund kells-1918-tooth sectioning. Winter-1926-chisel ( ossisector )

60. Surgical removal of the third molar

61. STEPS TO BE FOLLOWED Premedication Armamentarium and patient preparation Local anesthesia+ sedation/general anesthesia Incision Reflection of mucoperiosteal flap osteotomy odontectomy Elevation Extraction Debridement and smoothening of bone Control of bleeding Closure Medications Follow up

62. 69 Incision and Mucoperiosteal Flap Principles of flap Accessibility Vascularity Base wider than apex Rest on sound bone Full thickness flap Should not extend too far distally

63. PARTS OF INCISION Limb A Limb B Limb C

64. WARD’S INCISION 1956 Ward T.G(1955). The radiographic assessment of the impacted lower wisdom tooth. Dent dezin.6.3-7

65. Modified Ward’s incision - 1968 indicated when lower third molar is completely unerupted and inadequate depth of buccal vestibule

66. Triangular incision: triangular incision for L shaped flap Crevicular with distal releasing incision:

67. ENVELOPE FLAP BY SZMYD (1971)

68. MODIFIED ENVELOPE FLAP BY SZMYD (1971)

69. BAYONET FLAPS Bayonet shaped flap is reflected when Ward I and II incisions are given. This flap provides better blood supply to the flap by providing a broader base.

70. ‘L’ SHAPED FLAP Advantage : Prevents pocket formation distal to second molar. (Mac GregorAJ.the impacted lower wisdom tooth.oxford:oxford university press 1985)

71. VESTIBULAR TONGUE-SHAPED FLAP BY BERWICK (1966)

72. OSTEOTOMY ( BONE REMOVAL)

73. CHISEL TECHNIQUE For bone removal – monobevel chisel For tooth sectioning- bibevel chisel To plane bone with a chisel, the bevel have to be turned towards the bone. To penetrate the bone, turn the bevel away from the bone. To restrict the bony cut to the desired extent a vertical limiting cut is made by placing a 3 mm or 5 mm chisel vertically at the distal aspect of the II molar with the bevel facing posteriorly.

74. LATERAL TREPHENATION TECHNIQUE Was first described by B owdler –henry Modified s-shaped incision is made from retromolar fossa across the external oblique ridge to 1 st molar Buccal cortical plate is trephined over the iii molar crypt. Bur is used to make vertical cuts anteriorly and posteriorly.

75. LATERAL TREPHENATION TECHNIQUE A chisel or an osteotome is applied in the vertical direction over the bur holes. Then the buccal plate is fractured out. Advantages: Partially formed unerupted 3rd molar can be removed. Post-op pain is minimal. Bone healing is excellent and there is no loss of alveolar bone around the 2nd molar.

76. DIFFERENCES BETWEEN BUR & CHISEL TECHNIQUE Sl.No Criteria . Chisel&Mallet t Bur 1. Technique Difficult Easy. 2. Control over bone cutting Uncontrolled & chances of fracture is more . Controlled. 3. Patient acceptance. Not tolerated in L.A. Well tolerated in L.A. 4. Healing of bone. Good Delayed Healing 5. Postoperative edema Less More. 6. Dry socket. Less. More. 7. Postoperative Infection. Less. More.        

77. ODONTECTOMY INDICATIONS : Large bulbous crown. Deep horizontal or Mesioangular impactions. Disto angular impactions with plenty of bone cover. Unfavorable root form like divergent, locking or dilacerated roots. Hypercementosed roots.

78. SECTIONING OF TOOTH Advantages of the tooth division technique (Pell and Gregory , 1942): 1.Bone removal is eliminated or considerably reduced, resulting in less post-operative pain and swelling. 2. There is less chance of damage to the adjacent tooth because no effort is made to force the impacted tooth past the convexity of the second molar, which would tend to elevate it out of the socket. 3. The risk of fracture of the jaw is reduced, since most fractures occur from forced elevation. 4. D anger of injury to the inferior alveolar nerve is reduced. 

79. PATH OF WITHDRAWAL The path of withdrawal defined by Moore is that, along which the tooth would move according to its position and the curvature of its roots , if it was able to erupt unimpeded into the mouth.

80. LINGUAL SPLIT TECHNIQUE ( WARD TG:THE SPLIT BONE TECHNIQUE FOR REMOVAL OF LOWER THIRD MOLAR.BR DENT J 101:297,1956)

81. LINGUAL SPLIT TECHNIQUE A 5-mm chisel and mallet used to place a horizontal cut parallel to the cervix of the tooth. This buccal osteotomy should extend the full mesiodistal width of the crown to allow placement of a Coupland elevator

82. CORONECTOMY

83. CLOSURE—SUTURING . Most important suture is the one placed immediately behind the second molar. It also prevents pocket formation distal to second molar.

84. Recent advances