155

155

F. D. Fragiskos

Impacted maxillary third molars may also be classified (Archer 1975), according to the depth of
impac- tion compared to the second molar, into three
Impacted
catego- ries:
Class A: The occlusal surface of the impacted tooth is
at approximately the same level as the occlu7.8.
sal surface of the second molar (Fig. 7.101 a).
1
Class B: The occlusal surface of the impacted tooth is
Impacted
Third
at the middle of the crown of the adjacent
Molar
sec- ond molar (Fig. 7.101 b).
Class C: The occlusal surface of the crown of the imRemoval of an impacted maxillary third molar is
pacted tooth is below the cervical line of the
dif- ficult, because of insufficient visualization of the
adjacent molar or even deeper, contiguously
area and limited access. Furthermore, other factors
or even above its roots (Figs. 7.101 ce).
(re- duced aperture of the mouth, close proximity of
the impacted tooth to the maxillary sinus, etc.) may Impacted teeth belonging to the third category are
make the surgical procedure even more difficult.
very difficult cases, because their extraction entails
the removal of large amounts of bone, limited access,
Classification. Impaction of the maxillary third and the risk of displacing the impacted tooth into the
mo- lar (according to Archer 1975) may be maxillary sinus (Fig. 7.102).
classified as: mesioangular, distoangular, vertical,
horizontal, buc- coangular, linguoangular, or
Fig. 7.100. Classification of
inverted (Fig. 7.100). The tooth usually presents with
impaction of maxillary third molars
a mesial or distal inclina- tion, with the occlusal
according
surface positioned buccally.
to Archer (1975). (1 Mesioangular,

7.
8
Extraction
of
Maxillary Teeth

2 distoangular, 3 vertical, 4 horizontal,

5 buccoangular, 6 linguoangular,
7 inverted)

Fig. 7.101 ae. Classification of

impacted maxillary third molars
according to Archer (1975), depending on
the depth
of impaction compared to the adjacent
second molar

Fig. 7.102 a, b. Maxillary third molars with deep, complete bone impaction. Their removal is considered difficult,
because of the closeness to the maxillary sinus and insufficient visualization of the area

Types of Flaps. The types of f laps used are

triangular and horizontal:

Triangular f lap:
The incision for creating the f lap begins at the
max- illary tuberosity and extends as far as the
distal as- pect of the second molar, continuing
obliquely up- wards and anteriorly (vertical
incision) to the

vestibular fold (Fig. 7.103). In rare cases, when

im- paction is deep and a satisfactory surgical
field is necessary or when the impacted tooth
covers the roots of the second molar buccally, then
the vertical incision may be made at the distal
aspect of the first molar (Fig. 7.104).

Incisions and Types of Flaps for Extraction of Impacted Third Molar

Fig. 7.103 a, b.
Diagrammatic
illustrations showing
the triangular incision
(a) and ref lection of
the f lap (b), indicated
in certain cases of
extraction of impacted
maxillary third molars

Fig. 7.104 a, b. Variation of the triangular incision

and f lap shown in Fig. 7.103 (the vertical incision extends
as far as the distal aspect of the first molar). The mesial
extension

of the incision is necessary due to the position of the third

molar compared to the second molar

Fig. 7.105 a,
b. Dia- grammatic
illustrations showing the
horizontal incision
(a) and envelope f
lap (b), for removal
of impacted
maxillary
third molars

Horizontal (envelope) f
lap:
The incision for creation of this f lap also begins
at the maxillary tuberosity and extends as far as
the distal aspect of the second molar, continuing
buc- cally along the cervical lines of the last two
teeth, and ending at the mesial aspect of the first
molar (Fig. 7.105).
Often, after ref lection of
the f lap, part of the crown of the impacted tooth is
visible or there is bone protuberance over the
crown. Because the bone in this case is thin and
spongy, it may be re- moved from the buccal surface
using a sharp instru- ment. If the buccal bone is
dense and thick, then its removal is achieved using a
surgical bur.
Removal of Bone.

7.8.1
.1
Extraction
of
Third Molar

Impacted

The procedure for removing the impacted third molar

(Fig. 7.106) is as
follows.
After making a triangular incision (Fig. 7.107), the
mucoperiosteal f lap is ref lected (Fig. 7.108) and the
buccal bone is then removed until the entire crown of
the impacted tooth and part of its roots are exposed.
Because extraction of the tooth in segments is not indicated, sufficient space must be created around its
crown to be able to luxate the tooth. Thus, using a
straight or double-angled elevator on the mesial aspect
of the tooth, always buccally, the tooth is luxated carefully, posteriorly, outwards and downwards (Figs.
7.109,
7.110). Care of the wound and suturing are
performed in the same way as described for all other
cases of im- pacted teeth (Fig. 7.111).

Fig. 7.106 a, b. a Radiograph showing a maxillary third molar with distoangular impaction. b Clinical

photograph of the case shown in a

Fig. 7.107 a, b. Triangular incision completed. a Diagrammatic illustration. b Clinical photograph

Fig. 7.108 a, b. Ref lection of the f lap and

exposure of the crown of the impacted tooth. Placement of
the broad end of the periosteal elevator in the posterior
position is indicated

to protect the tooth from becoming accidentally displaced

into the infratemporal fossa or into soft tissues. a
Diagram- matic illustration. b Clinical photograph

Fig. 7.109 a, b. Luxation of the impacted tooth using double-angled elevator. Extraction movements depend
largely upon the relationship between the tooth and the maxillary sinus. a Diagrammatic illustration. b Clinical
photograph

Fig. 7.110 a, b. Final luxation of the tooth. a Diagrammatic illustration. b Clinical photograph

Fig. 7.111 a, b. Surgical field after placement of sutures. a Diagrammatic illustration. b Clinical photograph

7.8.
2
Impacted
Canines
Impacted maxillary canines are quite common, and
approximately 12%15% of the population present
with impacted canines. They are localized palatally
more often than labially.
Even though positions vary, the impacted canine
presents five basic localizations (contralateral or
ipsi- lateral and deep in the bone) as follows:
1. Palatal localization
2. Palatal localization of crown and labial
localization of root
3. Labial localization of crown and palatal localization of root
4. Labial localization
5. Ectopic positions
In young people aged 20 years or slightly older, impacted maxillary canines may be correctly aligned in

the dental arch after surgical exposure and orthodontic treatment. In older patients, especially after the age
of 30 years, the above procedure is not a method of
choice, because the risk of failure is greater. In such
cases, surgical removal is preferred, if deemed necessary of course.
The technique for removing impacted canines depends on the position of impaction (palatal or labial),
the relationship of the impacted tooth to adjacent
teeth, as well as the inclination of its crown. These
fac- tors should be assessed before planning the
surgical procedure.
The localization of impacted canines is achieved
using various radiographic techniques together with
careful clinical examination. The most commonly
used intraoral projections are occlusal projections,
periapical radiographs and panoramic radiographs,
while the technique employed for exact localization
of the labial or palatal position of the impacted tooth
is based on the tube shift principle, as described
in Chap. 2. As far as the clinical examination is
con-