PREOPERATIVE ASSESSMENT OF IMPACTED MANDIBULAR AND MAXILLARY 3rd MOLARS

Minor oral surgeries can give a false impression that less skill and care are required.

A minor sugery should not produce a major morbidity

Proper assessment prevents or minimise complications

introduction

Origin- Latin -- impactus means something to drive in

Definition a completely / partially unerupted tooth, positioned against a physical barrier,

. Unerupted tooth is a tooth not having perforated the oral mucosa

Introduction

Local causes
Lack of space Retained deciduous teeth Premature loss of deciduous teeth Ectopic position of tooth bud Obstruction of eruption path Cyst, tumors and supernumerary teeth Infection and trauma

ETIOLOGY

Systemic causes

Pre-natal causes Heredity Post-natal causes Rickets, anemia, congenital syphilis, malnutrition Endocrine causes Hypothyroidsm, hypoparathyroidism Rare conditions Cleidocranial dysostosis oxycephaly, cleft palate

THEORIES OF IMPACTION

The Phylogenic theory

Mendelian theory

Orthodontic theory

STRONG INDICATIONS FOR REMOVAL

infection such as pericoronitis, cellulitis, abscess formation Caries in 3rd molar which is unlikely to be usefully restored, or 2nd molar which cannot satisfactorily be treated without the removal Periodontal disease

Cases of dentigerous cyst formation

Cases of external resorption of the third molar or of the second molar.

For autogenous transplantation to a first molar socket. In cases of fracture of the angle of mandible For a tooth involved in tumour resection. Pre-irradiation removals.

When posterior retraction is considered during orthodontic treatment.

Under 25
Pericoronal infection 32.7%

Orthodontic reason 32.7% Pain 30.6

Den cl N A, V38, N2.

Between 25 - 35 Pericoronal infection 46.1% Pain 28.2% Periodontal reasons 19.7%

Above 35
Pericoronal infection 40.6% Pain 29.3% Periodontal reasons 24.8%

CONTRAINDICATION
functional role Orthodontic reasons No symptoms or pathology atrophic jaw Abutment tooth. Medical history Unwilling patient

Preoperative assessment
Clinical assessment
General Local

Radiological assessment

Psychological assessment

General assessment Age Systemic condition Surgical fitness

LOCAL ASSESSMENT
Size of tongue

Mouth opening

Extensibility of lips and cheeks

Intra oral Examination

ASSESSMENT OF IMPACTED TEETH

State of eruption.

Periodontal status.

External and internal oblique ridge in relation to impacted tooth.

Condition of soft tissue covering the impacted tooth.

LINGUAL NERVE

2.28 mm + 1.9

Clinical and anatomical observations on the relationship of the lingual nerve to the mandibular third molar reg1ion. J Oral Maxillofac Surg 41:565,1984

RADIOGRAPHIC ASSESSMENT

Radiographic views

IOPA occlusal OPG lateral radiograph

1.The entire third molar and hence the type of impaction.

2. Entire configuration of the 2nd molar. 3. Immediate surrounding bone and the entire pericoronal space. 4. Relationship of the root to the neuro-vascular canal.

5. Presence and extend of any associated pathological changes

Radiographs of third molars must show the

Which radiograph to prefer?

IOPA fails to meet all the said criteria.

OPG, lateral view meets the requirement

Commonly, used are OPG. IOPA gives better resolution. Any doubt about the relationship of root to IAV canal, IOPA is preferred.

Sensitivity 24% to 38%

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RADIOLOGICAL ASSESSMENT AIDS IN DETERMINING

Classification of impacted tooth
Orientation of impacted tooth Depth of the tooth

Degree of impaction of the tooth

Root shape Bone removal Bone density Localization of impacted tooth Relationship to inferior alveolar canal

CLASSIFICATION
WINTERS (1926)
Based on angulation of long axis of 3rd molar to long axis of 2nd molar

31% MESIOANGULAR
42% Vertical 27% DESTOANGULAR

0% HORIZONTAL

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PELL AND GREGORY CLASSIFICATION (1933)

According to the relation of the impacted tooth to the ramus of the mandible & the 2nd molar

Third-molar impaction classified according to the critieria of Pell and Gregory.

Sensitivity 15% only

ADA NOMENCLATURES

amount of soft and hard tissue over tooth

Soft tissue impactions Complete bony impactions

Partial bony impactions

Combined ADA & AAOMS classification of procedural terminology

07220: removal of impacted tooth - overlying soft tissue

07230: removal of impacted tooth - partially bony impacted

07240: removal of impacted tooth - completely bony 07241: removal impacted tooth - completely bony, with unusual surgical complications

WHARFE ASSESSMENT
Winters classification
Horizontal Distoangular Mesioangular Vertical 2 2 1 0

Height of the mandible

1-30 mm 31-34 mm 35-39 mm 0 1 2

Angulation of 2nd molar

1-59 degrees 60-69 70-79 80-89 90 + 0 1 2 3 4

Root shape and development

favourable curvature unfavourable curvature complex < 1/3 complete 1/3 to 2/3 complete > 2/3 complete 1 2 3 2 1 3

Follicles
normal possibly enlarged enlarged impaction relieved 0 1 2 3

Path of exit
space available distal cusps covered mesial cusp also covered both covered 0 1 2 3

Difficulty Index for removal of impacted mand third molars

CLASSIFICATION
ANGULATION
Mesioangular Horizontal / transverse Vertical Distoangular 1 2 3 4

DIFFICULTY INDEX VALUE

DEPTH
Level A Level B Level C 1 2 3

RAMUS RELATIONSHIP / SPACE AVAILABLE

Class I Class II Class III 1 2 3

Difficulty index for removal of impacted mand.Third molars

Difficulty index Very difficult : 7 to 10 Moderately difficult : 5 to 7 Minimally difficult : 3 to 4

Radiological prediction of inferior alveolar nerve relation ding to J. P. Rood, B. A. A. Nooraldeen Shehab, jc

Darkening of the root (Howe and Poyton, Main).DeflectofMacgregor, Killey and Kay)

Put

Darkening of the root Loss of density of root Shows overlaping 93.1% showed this sign

Deflected roots

Abrubt deviation Roots may be hooked

Narrowing of roots

implies that the greatest diameter involved by cannal

Deep grooving or perforation may be their

Dark & bifid root Nerve cross the apex Double periodontal membrane of bifid apex

Interruption of white line Diappeares as it reaches the tooth

Diversion of cannal Change of direction due to displacement of cannal Nerve may pass through root

Narrowing/ hour glass apperance Downward displacement of cannel

Winters lines / war lines (1926) Using the roots of second molar as a guide

ASSESSMENT OF DEPTH OF TOOTH IN ALVEOLAR BONE

WHITE LINE

*Depth of the third molar in relation to the 2nd molar tooth. *Angulation of the impacted tooth to the second molar.

Amber line

Amount of alveolar bone covering the impacted tooth

Red line

Point of application of elevator Depth -More than 5mm GA Distoangular impactions - red line-distal CEJ of impacted 3rd molar

If 2nd molar roots are smaller in relation to the impacted tooth or if the roots of 2nd molar are fused & conical, surgeon must be careful not to luxate 2nd molar during elevation. Absence of 1st molar leaves 2nd molar Unsupported

Assesment of 2nd molar

LOCALIZATION OF IMPACTED TEETH USING RADIOGRAPHS

Clarks / buccal object / horizontal tube shift rule (1909) Millers right angle rule

Localization techniques

Richards / vertical tube shift rule (1952)

Panorex split-mode panoramic tomograph

Localization of impacted third molar using radiographs

Horizontal tube shift tech For seperating superimposed objects with vertical long axis For buccal / lingual localisation of impacted third molar from roots of erupted teeth vertical tube shift tech For seperating horizontally oriented objects For determining bucco-lingual position of third molar apices that super impose the mand canal

TUBE SHIFT TECHNIQUE

If canal moves upwards then it is bucally placed . If it moves downwards then lies lingual to roots.

CLARKS HORIZONTAL TUBE SHIFT

MAXILLARY THIRD MOLAR IMPACTION

Clinical assessment Eruption position of crown Presence of pericoronitis Periodontal status of 2nd molar Soft tissue over tuberosity Radiological interpretation Crown Root Follicle size Periodontal ligament space Antral position

ASSESSMENT OF IMPACTED MAX 3rd MOLAR

ARCHERS (1975) On anatomic basis similar to mand 3rd molar PELL & GREGORY Based on relative depth in relation to 2nd molar Based on relation of max 3rd molar to max sinus floor

Sinus approximation- no bone / thin partition present No sinus approximation 2mm or more bone is present

ARCHERS ANATOMIC CLASSIFICATION

PELL & GREGORY RELATIVE DEPTH IN RELATION TO 2ND MOLAR

DIFFICULTY FACTORS
ANGULATION OCCURANCE DIFFICULTY
Vertical Distoangular Mesioangular Transverse Horizontal Inverted 63% 25% 12% <1% <1% <1% + + +++ ++ ++ ++

Difficulty factors

Most common thin non fused root with erractic curvature Sinus approximation Fracture of tuberosity

The best way is to manage complication is not to produce in the first place. Few complications are unavoidable in minor surgeries but

most can and should be prevented by proper assessment.

Conclusion

References

IMPACTED TEETH ALLING , HELFRICK CONTEMPORARY ORAL AND MAXILLOFACIAL SURGERY,4TH EDITION-LARRY.J.PETERSON,JAMES.R.HUPP,MYRON.R.TUCKER MINOR ORAL SURGERY- GEOFRY L. HOW TEXT BOOK OF ORAL AND MAXILLOFACIAL SURGERY, BALAJI TEXT BOOK OF ORAL AND MAXILLOFACIAL SURGERY, SHRINIVASAN BR JR OF ORAL AND MAXILLOFACIAL SURGERY 1990; 28: 20-25 J ORAL MAXILLOFAC SURG 2003; 61: 417- 421 J ORAL MAXILLOFAC SURG 2005; 63: 3-7 DENTAL CLINICS OF NORTH AMERICA VOL 38.NO:2 APRIL 1994

Thank you

Condition of the Masticatory mucosa in relation to the adjacent tooth. If planned under GA, other impacted teeth should also be considered for removal.