Impacted Teeth

IMPACTED TEETH
Definition
A tooth which is completely or partially
unerupted & is positioned against
another tooth, bone or soft tissue, so that
further eruption is unlikely, described
according to its anatomic position.
 Etiological theories
1. PHYLOGENIC THEORY --
Civilization has eliminated the human
need for large & powerful jaws which
leads to decreases the size of jaws. Due
to this IIIrd molar occupies an abnormal
position & may be consider a vestigial
organ( with out purpose or function).
 . 2. MENDELIAN THEORY
HERIDIETRY OR GENETIC INFLUNCE LEADS TO SMALL
JAWS & RESULTING IMPACTED TEETH.

3.ENDOCRINE THEORY
Due to lack of function of anterior lobe of pituitary gland,
leads to hampering the growth of jaws.

4. PATHOLOGICAL THEORY
As a result of early diseases of adjacent molars leads to
existence of osteosclerosis in IIIrd molar area.
 4. ORTHODONTIC THEORY
• Supported by constricted & narrowed
dental arches of early mouth breathers
• Depend on Position & alignment of
permanent teeth.
 Causes of Impaction
LOCAL CAUSES --
1.Irregularity in position & pressure of an
adjacent tooth.
2. Density of overlying or surrounding
bone.
3.Long continued chronic inflammation
with resultant increase in density of
overlying mucous membrane.
4. Premature loss of primary teeth.
 Systemic causes
• Prenatal Cause :-
Heredity
• Post Natal Cause – Rickets, Anemia
• Congenital Syphilis ,Tuberculosis, Malnutrition,
endocrine dysfunction.
• RARE CONDITION –
Cleidocranial dysostosis
Oxycephaly (Steeple head-pointed head)
Progeria - Premature old age
Achondroplasia (Cartilage fails to develop)
Cleft Palate
 INDICATIONS
1 Recurrent pericoronitis – 70 – 80% of
patients are adults with impacted teeth.
2 Root resorption – It may occur due to
pressure effect from 3rd molar to 2nd
molar.
 3.Caries or periodontal
problems-It occurs in impacted
teeth
4 Recurrent infection around pericoronal flap may lead
to TMJ problems

5 Preventive dentistry- Extraction of impacted tooth can

be done as a preventive measure.

6. Paresthesia or Nonspecific pain may sometimes be

relieved by removal of impacted teeth.
7.Impacted teeth are sometimes removed when they
become foci of infection.
8. Trauma – Impacted teeth are extracted to avoid
recurrent cheek bite.
9.Orthodontic problems- Impacted teeth may lead to
malocclusion or overcrowding in adolescent period.
10.Cyst or ameloblastic changes – Impacted
teeth are sometimes associated with cysts.
11Autotransplantation – Impacted third
molar can be used to replace the lost 1
molar.
12 Prosthetic consideration- An unerupted
Teeth may cause ulceration under the
denture or later denture failure may occur.
 CONTRAINDICATION
• Health consideration – Due to systemic
disorder patient is not fit for minor surgery.
• Prosthetic consideration- Partially erupted
tooth has to be retained sometimes for utilization
as an abutment for fixed partial denture.
• Availability of adequate space – Sometimes if
there is an adequate space between 3 rd molar
and ascending border of ramus operculectomy
can be done.
• Socioeconomic reason -
 IMPACTED MANDIBULAR 3RD MOLAR

• One of the most common impaction in all

impacted teeth

– Dense bone

– Last to erupt
 CLASSIFICATION

WHY WE HAVE TO STUDY?

• Methodical approach to surgical procedure

• Difficulty assessment in intra – op and post - op

complications

• Type of instrument needed

• Correct information to the patient about likely

complications
Classification is based on:

• Angulation

• of long axis of impacted tooth is compared to

long axis of adjacent erupted tooth.

• importance – to know the path of withdrawal

• to decide – tooth splitting or removal of bone or

both, which obstructs the path of withdrawal of
tooth
 RELATIONSHIP TO ANTERIOR BORDER OF
RAMUS

• amount of bone covering the impacted tooth

RELATIONSHIP TO OCCLUSAL PLANE

• depth of impacted tooth in bone when compared to

height of adjacent 2nd molar

• importance - degree of difficulty for removal

assessed by thickness of bone overlying the tooth or
depth of tooth in bone.
 George Winter’s classification – 1926
• classified impacted 3rd molar according to
relationship of their long axis to 2nd molar.
• Mesioangular
• Vertical
• Distoangular
• Horizontal
• Transverse
• Buccoangular
• Linguoangular
• Inverted
• Mesioangular – crown of tooth is tilted towards
the 2nd molar mesially
• it is most common and least difficult to remove
MESIOANGULAR IMPACTION
Vertical : long axis of impacted tooth runs in same
direction of 2nd molar.
 VERTICAL
IMPACTION
Distoangular: long axis of impacted tooth is
angulated distally or posteriorly away from 2nd molar.
This is most difficult to remove because path of
withdrawal is into the ramus.
DISTOANGULAR IMPACTION
Horizontal : severe mesial inclination of 3rd molar
towards the 2nd molar
HORIZONTAL IMPACTION
 Bull’s Eye Sign
TRANSVERSE IMPACTION
 Pell’s Gregory Classification
In 1933 Pell’s Gregory classified impacted
mandibular 3rd molar.
• Class I : space between the ramus and the distal
side of 2nd molar is more than mesiodistal diameter
of crown of impacted 3rd molar.
Class II: space is less than mesiodistal diameter of
crown of impacted 3rd molar
Class III: most of the 3rd molar is located within the
ramus, no space between 2nd molar and ascending
border of ramus.
Position: relative depth of 3rd molar in the bone
Position A: Highest portion of impacted tooth is on a
level with or above the occlusal plane of 2nd molar.
Position B: highest portion of impacted tooth is below
the occlusal plane but above the CEJ of 2nd molar.
Position C: highest portion of tooth is below the CEJ
of 2nd molar.
Long axis of impacted tooth in relation to that of
2nd molar:
• Mesioangular
• Vertical
• Distoangular
• Horizontal
• Transverse
• Buccoangular
• Linguoangular
• Inverted
Kay’s Classification:
1. Based on angulation and position:
• Mesioangular
• Vertical
• Distoangular
• Horizontal
2. Based on state of eruption:
• Fully erupted
• Partially erupted
• Embedded
3. Based on number of roots
• Fused roots
• Two roots
• Multiple roots

FUSED ROOTS MULTIPLE ROOTS

4. Based on root pattern:
• Favorable roots
• Unfavorable roots
UNFAVOURABLE ROOTS
Preoperative assessment:

1. History : medical problems must be weighed

against the danger of leaving the tooth.

2. Age: older age group more difficult then younger

age group.
3. Facial form:

1. Tapered facial form: such patient have a high

zygomatic arch and flexible Orbicularis Orris

muscle, therefore access is better.

2. Compact facial form: more challenging,

because such patient have small mouth,

mandibular retrusion, limited opening and

access to operating site is poor.

4. Extraoral:

1. swelling

2. redness of the cheek

3. submandibular lymphadenopathy

4. lower lip tested for anesthesia or

parasthesia
5. Intraoral:

1. mouth opening

2. lateral surface of body of mandible in close

alignment with ramus with little flare makes
procedure difficult

3. relationship of external oblique ridge to 3rd

molar

1. if ridge is posterior to tooth access is good

2. if ridge is alongside the tooth or anterior to

it access is poor
4. General inspection – oral hygiene
5. Adjacent 2nd molar
1. crown
2. Inlay
3. Fillings – which can be dislodged during
elevation
6. Condition of overlying soft tissue
1. fibrosis
2. inclination of upper third molar
3. active pericoronitis
4. pus beneath the flap
 RADIOGRAPHIC EVELUATION
IOPA should show entire tooth structure, investing
structures, as well as adjacent tooth

• How to take an ideal IOPA?

• patient is seated such that occlusal plane is

parallel to the floor

• anterior edge of the film should be in line with

mesial surface of 1st permanent molar.
CENTRAL RAY DIRECTION
a. Average case – distal part of 2nd molar
b. Horizontal impaction – through crown of 3rd molar
• X ray tube positioned in such way that central beam
is parallel to occlusal surface of 2nd molar and should
pass through distal cusp of 2nd molar at right angle to
film packet.
•lingual and Buccal cusp of 2nd molar should

superimpose on each other giving an enamel cap

appearance.

• entire length of 2nd molar and impacted 3rd molar

should be visible.
 Occlusal films:

•occlusal view provides an alternative to periapical

view in case of horizontally impacted tooth for a

clearer picture of the root pattern.

• Important role in buccolingually placed teeth to

identify which way the crown is pointing.

• helpful in showing the thickness of lingual cortical

plate
• Lateral oblique projection

• provides greater periapical coverage

• shows amount of bone below an

impacted tooth in a thin mandible

•OPG:

• difficult access for positioning of the film or

when patient cannot tolerate IOPA film.

• where the tooth is so far below that it cannot

be projected on to the periapical film.

• when there is associated pathological process

larger than the film to exclude any other
pathology of the jaw.
CLASS I
CLASS I
CLASS II
CLASS II
CLASS III
CLASS III
UNCOMMON IMPACTIONS
UNCOMMON IMPACTIONS
RADIOLOGICAL

ASSESSEMENT
1. TECHNIQUE

2. TYPES OF IMPACTION

3. ACCESS: External Oblique Ridge – position

1. Horizontal – access is good

2. Vertical – access is poor

3. behind the tooth – access is good

4. along or in front of impacted tooth – access is poor

4. EXISTING PATHOLOGY:

1. Dental caries in 2nd or 3rd molar

2. Periodontal disturbances

3. Presence or absence of 1st molar

4. Any fusion of crowns between 2nd and 3rd molars

5. Conical or fused roots of 2nd or third molars

6. Any associated dental pathology like odontome, cyst or

neoplasm

7. Flexibility of the orofacial muscles.

5. SCORING DETAILS FOR WHARF ASSESSMENT

Contd-
6. POSITION AND DEPTH – George Winter
1. WHITE LINE: - represents the occlusal plane
a) Joining the white enamel caps of the erupted
molars it is extended posteriorly over the 3rd molar.
b) The maximum contour of the impacted tooth and its
relation to the white line will indicate the relative
depth of its location.
2. AMBER LINE: - represents the bone level, distal to the 3rd
molar and extended anteriorly along the crests of
intrdental septum between the molars. Represents the
amount of bone covering the impacted tooth which will
have to be removed

3. RED LINE: indicates depth at which impacted tooth is

located. It is a line drawn perpendicular from the amber
line to point of application of the elevator. If red line is less
than 5 mm long – tooth can be conveniently removed
under L.A. for each mm increase in length difficulty
increases by 3 times. Length > 9mm and tooth below
apices of 2nd molar then G.A. case
 Amber line
White line

Red line
6. BUCCOVERSION AND LINGUOVERSION:

can be identified – more radioopacity of the

tooth overlapped by the 2nd molar and the

portion of tooth nearer to the film.

7. CROWN OF IMPACTED TOOTH: large

bulbous crown with prominent cusps – difficulty

in delivery – tooth division technique indicated.

8. CONFIGURATION OF THE ROOTS OF THE
IMPACTED 3RD MOLAR: point of application of the
elevator and the path of delivery of the tooth vary
greatly with the configuration of the root of the
impacted molar. Radiograph to be examined for

1. Fused or separate roots

2. Number of roots

3. Straight or curved roots

1. if curved – favorable or unfavorable

4. Long and slender or short and stout roots

5. Convergent or divergent

6. Texture and type of investing bone e.g.

hypercementosis

7. Root of the 2nd molar:

a) smaller in relation to 3rd molar

b) fused and conical

8. Absence of 1st molar

8. BONE TEXTURE: texture and density of the

investing bone varies with:

1. Individuals

2. Age

3. Sex

4. Systemic constitution
9. RELATIONSHIP WITH INFERIOR ALVEOLAR
CANAL: if root apices closely related to the canal
then warn patient about possible impairment of
labial sensations, and better to use tooth division
technique.
RELATIONSHIP OF THE ROOT TO THE CANAL

a) Related but not involving the canal

i. Seperated

ii. Adjacent

iii. Superimposed
b) Related to changes in the roots

i. Darkening of the root

ii. Dark and bifid root

iii. Narrowing of the root

iv. Deflected root

c) Related to changes in the canal

a) Interruption (loss) of lines

b) Converging canal (narrowing)

c) Diverted canal
DARKENING OF
ROOT
DARK AND BIFID
APEX OF ROOT
NARROWING OF
ROOT
DEFLECTION OF
ROOT
INTERRUPTION
OF WHITE LINE
OF CANAL
NARROWING OF

THE CANAL
DIVERSION OF
THE CANAL
10. OTHER RADIOGRAPHIC TECHNIQUES:

1. IOPA is a 2-dimensional view, another view in

the 3rd dimension can be helpful.

2. Tube shift technique:

a) 2 IOPAs : first at normal position, second at

mesiocentric or distocentric position. The
movement is – same side lingual and
opposite side Buccal (SLOB) ie if the tube
and the object in question both move in the
same direction – object is on lingual side.
 TRANS - ALVEOLAR EXTRACTION

Some teeth are unsuitable for removal using

forceps and the technique of intra - alveolar
extraction.

Surgical or trans – alveolar technique gives the

operator a direct access to the alveolar bone and
tooth roots after raising the mucoperiosteal flap,
and bone removal and sectioning of the roots is
under direct vision.
INSTRUMENT TRAY
 Principles of flap design

• access : large enough to allow clear access

without stretching or risk of tearing soft tissues.

• blood supply : base of all flaps should be wider

than free margin to maintain unimpeded blood
supply to the tissues of the flap

• avoiding vital structures: the position of the

relieving incision must take into account the
proximity of vital structures. Contd-
• suture over bone: the margins of flap should be
placed away from site of bone removal so that,
incision line is supported by firm bone on suturing
• ease of closure: edges of flap should be
positioned to make their accurate replacement
simple
• extending flaps: when extracting two teeth flap
should be so designed that if needed the flap can be
extended
• oro - antral communication: when removing a
tooth in posterior maxilla then a thought should be
given for inadvertent oro – antral communication and
flap so designed that it can be closed.
 FLAP DESIGNS

one sided flap: incision along the gingival margin –

provides restricted access.

Two – sided flap: one incision along the gingival

margin and another relieving incision angled
obliquely across the attached buccal gingiva into lax
vestibular mucosa.

Three – sided flap: have a second relieving

incision at the distal end of the flap, allows greater
mobilization and exposure of the underlying bone
and roots.
ENVELOPE INCISION
• SHORT
• LONG
Ward’s incision

OCCLUSAL VIEW
 MODIFIED WARD’S

L – SHAPED INCISION
 BONE REMOAVAL

• CHISEL MALLET

• postage stamp method

• lingual split technique

• ROTARY CUTTING INSTRUMENT – buccal

guttering technique. { GILBE MOORE TECHNIQUE }

 INDICATIONS OF USE OF BUR
• Old patient – brittle, sclerotic bone
• Position of internal oblique ridge
• Operation under L.A.
INDICATIONS FOR CHISEL & MALLET
• Young patient
• Procedure under G.A.
• Tooth sectioning is not required
• Position of external / internal oblique ridge
 INDICATIONS FOR SECTIONING

• Tooth lock

• Unfavourable root pattern

• To protect important structures (nerve, vessel,

adjacent tooth)
 ROTARY CUTTING INSTRUMENTS
• 1000 – 30, 000 RPM
• Straight hand piece – optimal control
• Plentiful irrigation- to prevent rise in temperature
as, as little as 10 degrees – lethal to osteocytes
• round burs –
• versatile and efficient
• difficult to control lateral cuts
• once bur head is inside bone difficult to gauge
depth
• fissure burs:
• cut neatly and precisely in lateral direction
• less good at cutting than round bur
• greater feel than round bur
• burs can be used to:
• drilling bone around the tooth or tooth root on
the buccal side – buccal guttering – to make
space for elevator
• bone is shaved off or block of bone outlined
and removed, then tooth or tooth root is
removed (postage stamp method).
BUCCAL GUTTERING
 CHISEL AND MALLET

• Postage stamp method : a whole block of bone is

removed to facilitate the removal of the tooth. In

case of mandible a posterior stop cut (vertical) is

given so that the horizontal cut does not extend

beyond that point.

POSTAGE STAMP
METHOD
• Lingual approach:{ Introduced by William
Kelsey Fry in 1933 & described in detail
by Warwick james in 1936 & later by
Terence ward in 1956 }
• bone covering Buccal & distal surface of 3rd
molar removed
• chisel at 45° to sagittal plane, bevel placed
lingually, facing parallel to opposite bicuspid &
driven through distal part of molar shelf, twisted to
fracture a part of lingual shelf.
•
 LINGUAL APPROACH
• elevator placed on Buccal side & crown lifted
in lingual & coronal direction.

• after tooth removal, the loosened fragments on the

lingual plate are repositioned by finger pressure
lingually.
FRACTURE THE LINGUAL PLATE

LINGUAL SPLIT TECHNIQUE

 REMOVE BONE COVERING THE ROOT ON
DISTAL AND BUCCAL ASPECTS AND ELEVATE
THE TOOTH
 LATERAL TREPANATION
{Low Buccal approach}
Advocated by BOWDLER HENRY [ 1969] & HOWE [1973]

• INDICATION ---1.unerupted iiird molar in

9-16 years of age group for orthodontic purpose.
• 2. auto transplantation.
• 3.Prophylactic removal in unfavorable pattern-
• [a] vertical axis of 3rd molar is inclined at angle of more
than 30 degree to long axis of 2nd molar.
[b] space between distal margin of 2nd molar & ramus is
less than one-half of crown width of 3rd molar.

• PROCEDURE -- S shape incision from retro molar

fossa across external oblique ridge.5 mm. Cuff of attach
mucosa at distobuccal region of 2nd molar.
 Tooth splitting
TOOTH BELONGS TO DENTIST & BONE
BELONGS TO THE PATIENT
 COMPLICATIONS OF TOOTH EXTRACTION
1. Haemorrhage - intraoperative
a) facial artery
b)Retromolar vessels
c) inferior alveolar vessels
2. Fracture
a) dentoalveolar
b) angle
3. Displaced root / tooth
4. Luxation or damage to adjacent tooth
4. TMJ dislocation

5. Damage to soft tissue

6. Parasthesia / anaesthesia

7. Trismus

8. Alveolar osteitis ( dry socket)

9. Infection

10. Hypersensitivity of 2nd molar or distal pocket

formation

11.Emphysema