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IMPACTION
Dr. BABURAJ.M
DEFINITION
Latin - Impactus
An organ or structure which because of an abnormal
mechanical condition has been prevented fro...
TOOTH ERUPTION
Eruption stage Eruption mechanism Structures resisting eruption
Pre-eruptive stage - -
Intra-osseous stage ...
TERMINOLOGIES
IMPACTED TOOTH MALPOSED TOOTHUNERUPTED TOOTH
It is the tooth that
has failed to erupt
completely or
partiall...
COMMONLY IMPACTED TEETH
Impacted teeth seen in the following order of
frequency:
1. Mandibular third molars
2. Maxillary t...
THEORIES OF IMPACTION (DURBECK)
Orthodontic theory
Endocrinal theoryPathological theory Mendelian theory
Phylogenic theory...
CAUSES OF IMPACTION - BERGER
LOCAL CAUSES SYSTEMIC CAUSES
1. Obstruction for eruption
2. Lack of space
3. Ankylosis of too...
PROBLEMS OF RETAINED IMPACTED TOOTH
 Pain
 Difficulty in mastication
 Paraesthesia of lip
 Swelling of retro-molar tis...
INDICATIONS CONTRA INDICATIONS
 Tooth in line of fracture
 Recurrent pericoronitis
 Deep periodontal
pocket
 Prior to ...
Tooth in line of fracture
Orthodontic ProblemsTooth adjacent to CystCaries in adjacent tooth
Retained DeciduousRecurrent P...
CLASSIFICATION OF IMPACTIONS
WINTERS CLASSIFICATION OF MANDIBULAR THIRD MOLARS - 1929
BASED ON ANGULATION
Mesioangular Dis...
BASED ON DEPTH
PELLAND GREGORY CLASSIFICATION OF MANDIBULAR THIRD MOLARS - 1933
CLASSIFICATION OF IMPACTIONS
LEVELA LEVEL ...
CLASSIFICATION OF IMPACTIONS
PELLAND GREGORY CLASSIFICATION OF MANDIBULAR THIRD MOLARS - 1933
CLASS I CLASS IIICLASS II
Su...
CLASSIFICATION OF IMPACTIONS
ARCHERS CLASSIFICATION OF MAXILLARY THIRD MOLARS
BASED ON ANGULATION
Mesioangular HorizontalV...
CLASSIFICATION OF IMPACTIONS
PELLAND GREGORY CLASSIFICATION OF MAXILLARY THIRD MOLARS
BASED ON OCCLUSAL PLANE
CLASS A CLAS...
CLASSIFICATION OF IMPACTIONS
CLASSIFICATION OF MAXILLARY THIRD MOLARS
BASED ON RELATION TO MAXILLARY SINUS
NO SINUS APPROX...
CLASSIFICATION OF IMPACTIONS
CLASSIFICATION OF MAXILLARY CANINE
CLASS I CLASS VCLASS IVCLASS IIICLASS II
Impacted
cuspids ...
DIFFICULTY INDICES FOR REMOVAL OF IMPACTED MANDIBULAR THIRD MOLARS
PEDERSON SCALE - 1988
CLASSIFICATION SCORE
SPATIAL
RELA...
DIFFICULTY INDICES FOR REMOVAL OF IMPACTED MANDIBULAR
THIRD MOLARS
PARRANT SCALE
TECHNIQUE USED DIFFICULTY
EXTRACTION REQU...
DIFFICULTY INDICES FOR REMOVAL OF IMPACTED MANDIBULAR THIRD MOLARS
WINTERS LINES / WAR LINES
 Corresponds to occlusal pla...
DIFFICULTY INDICES FOR REMOVAL OF IMPACTED MANDIBULAR THIRD MOLARS
WHARFE ASSESSMENT
CRITERIA SCORE
Winters
Classification...
RADIODGRAPHS IN IMPACTION MANAGEMENT
OCCLUSAL OPG
RADIOGRAPH
CBCT
LATERAL
CEPHIOPA
PA VIEW
USES OF IOPA RADIOGRAPH
Radiological assessment aids in determining
 Classification of impacted tooth
 Orientation & Dep...
ROOT PATTERN
 Limited development (Rolling Tooth) –Difficult
 2/3rd to complete Development – Easy
 Extremely Curved - ...
RELATION TO INFERIOR ALVEOLAR CANAL (HOWE & POYTON – 1960)
DARKENING OF ROOT
DEFLECTION OF ROOT
NARROING OF CANAL
DIVERSIO...
FACTORS THAT MAKE REMOVAL EASIER
MESIO
ANGULAR
CLASS 1
POSITION A
ROOT 1/3RD
TO
2/3RD
FUSED CONICAL
ROOTS
WIDE
PDL
SPACE
L...
FACTORS THAT MAKE REMOVAL DIFFICULT
DISTO
ANGULAR
CLASS 3
POSITION C
LONG
THIN
ROOTS
DIVERGENT
CURVED
ROOTS
NARROW
PERIODO...
RISKS OF NONINTERVENTION RISKS OF INTERVENTION
A. Crowding of dentition
B. Resorption of adjacent
tooth and Periodontal
st...
SURGICAL TECHNIQUES IN
REMOVAL OF IMPACTED
MANIBULAR THIRD MOLARS
SURGICAL PROCEDURES
GENERAL CONSIDERATIONS
ADEQUATE EXPOSURE
ACCESS TO THE TOOTH
SECTIONING OF THE TOOTH(OPTIONAL)
ELE...
INCISIONS AND FLAP DESIGNS
PARTS OF INCISION
Limb A Limb CLimb B
It was carried
along the gingival
crevice of the third
mo...
 The base of the flap must be broader than the free margin to
preserve an adequate blood supply.
 Must be of adequate si...
BAYONET FLAPL SHAPED FLAP
Suits only the buccal approach
since it is difficult to raise a
lingual flap from this approach....
ENVELOPE FLAP TRIANGULAR FLAP
Extends from the mesial papilla of
the mandibular first molar and
passes around the neck of ...
COMMA SHAPED INCISION WARDS INCISION
Provides Large area of access
Indicated In case of deep
Horizontal Impactions
Periodo...
REFLECTION OF FLAP
 Reflection of the flap begins at the papilla.
 The end of the Woodson elevator or the no. 9 perioste...
BONE REMOVAL
Aim:
1. To expose the crown by
removing the bone
overlying it.
2. To remove the Bone
obstructing the pathway ...
A. Preferred method to use a hand piece with adequate speed and high torque
to remove the overlying bone.
B. Ideal length ...
Irrigation Rate
a. 15 mL/min -for intermittent drip
b. 24 mL/min -for continuous flow
A large plastic syringe with a blunt...
A. Mandible should be adequately supported.
B. The mallet is used with a loose, free-swinging wrist motion gives maximum
s...
SECTIONING OF TOOTH
BUR OSTEOTOME
WITH
 Safe and Easy
 Bur Used
Fissured Type
No.8 with larger
cutting surface
 Used wi...
TOOTH DIVISION IS NECESSARY
 IF THE TOOTH IS BISSECTED AT NECK
 ENAMEL IS VERY THIN
 LOWER POSITION
 Distal half of th...
REMOVAL OF DISTOANGULAR IMPACTED III MOLAR
 Distoangular position brings the 3rd molar well under the ascending ramus
 F...
REMOVAL OF VERTICALLY IMPACTED III MOLAR
 Procedure of bone removal and tooth sectioning is similar to
mesioangular impac...
REMOVAL OF HORIZONTALLY IMPACTED III MOLAR
 Superior(Distal) and inferior(Mesial)
cusp sectioned
 Superior crown is remo...
Not so common
Tooth is sectioned horizontally at the cervical region
Crown is first delivered following roots
In case ...
 It is described originally by Sir William Kelsey Fry
 Later popularized by T Ward
 Useful in removal of deeply positio...
1 32 4
5 6 7 8
STEPS:
1. Vertical Stop Cut
2. Horizontal Cut
3. Removal of Buccal Plate
4. Fracturing Distolingual Bone
5....
LINGUAL TREPHENATION TECHNIQUE
This procedure was first described by
Bowdler-Henry to remove any partially
formed and une...
LINGUAL TREPHENATION TECHNIQUE
 A chisel or an osteotome is applied in the vertical
direction over the bur holes. Then th...
WOUND CLOSURE
 The most important suture is the one placed immediately behind the second
molar, ensuring there is accurat...
COMPLICATIONS
INTRA OPERATIVE POST OPERATIVE
During
incision
1. Injury to Facial Nerve or
Vessels
1. Pain
2. Swelling/edem...
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Impaction

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Classification of Impaction and Methods & Techniques of Third molar/Manidibular impaction removal,Flap designs of impaction removal techniques and more

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Impaction

  1. 1. IMPACTION Dr. BABURAJ.M
  2. 2. DEFINITION Latin - Impactus An organ or structure which because of an abnormal mechanical condition has been prevented from assuming its normal position. Rounds (1962) The condition in which a tooth is embeded in the alveolus so that its further eruption is prevented. Andreasen (1997) A cessation of the eruption of a tooth caused by a clinically or radio-graphically detectable physical barrier in the eruption path or by an ectopic position of the tooth. Archer (1975) A tooth which is completely or partially unerupted and is positioned against another tooth or bone or soft tissue so that its further eruption is unlikely. Peterson A tooth is considered impacted when it has failed to fully erupt into the oral cavity within in its expected developmental time period and can no longer reasonably be expected to do so.
  3. 3. TOOTH ERUPTION Eruption stage Eruption mechanism Structures resisting eruption Pre-eruptive stage - - Intra-osseous stage Vascular hydrostatic Pressure Root formation Bone formation Bone Primary predecessors Mucosal stage Vascular hydrostatic Pressure Root formation Bone formation Mucosa Pre-occlusal stage Vascular hydrostatic Pressure Root formation Bone formation Periodontal ligament Mastication Occlusal stage Root elongation Bone formation Periodontal ligament Mastication Occlusion Maturation Root elongation Bone formation Periodontal ligament Mastication Occlusion Movement of a tooth from its site of development within the alveolar bone to its functional position in the oral cavity
  4. 4. TERMINOLOGIES IMPACTED TOOTH MALPOSED TOOTHUNERUPTED TOOTH It is the tooth that has failed to erupt completely or partially to its correct position in the dental arch and its eruption potential has been lost It is a tooth that is in the process of eruption and is likely to erupt based on clinical and radiographic findings A tooth un erupted or erupted which is in an abnormal position in the maxilla or in the mandible
  5. 5. COMMONLY IMPACTED TEETH Impacted teeth seen in the following order of frequency: 1. Mandibular third molars 2. Maxillary third molars 3. Maxillary canine 4. Mandibular premolar 5. Maxillary premolar 6. Mandibular canine 7. Maxillary central incisors 8. Maxillary lateral incisors
  6. 6. THEORIES OF IMPACTION (DURBECK) Orthodontic theory Endocrinal theoryPathological theory Mendelian theory Phylogenic theory Jaws develop in downward and forward direction. Growth of the jaw and movement occurs in forward direction, so any thing that interfere with such moment will cause an impaction (small jaw-decreased space).A dense bone decreases the movement of the teeth in forward direction Nature tries to eliminate the disused organs [More functional masticatory force, better the development of the jaw] Due to changing nutritional habits ,use of large powerful jaws have been practically eliminated.Thus,over centuries the mandible and maxilla decreased in size leaving insufficient room for third molars Heredity is most common cause. The hereditary transmission of small jaws and large teeth from parents to siblings. This may be important etiological factor in the occurrence of impaction Chronic infections affecting an individual may bring the condensation of osseous tissue further preventing the growth and development of the jaws Increase or decrease in growth hormone secretion may affect the size of the jaws
  7. 7. CAUSES OF IMPACTION - BERGER LOCAL CAUSES SYSTEMIC CAUSES 1. Obstruction for eruption 2. Lack of space 3. Ankylosis of tooth 4. Non absorbing, over retained tooth 5. Non absorbing alveolar bone 6. Ectopic position of tooth bud 7. Dilaceration of roots 8. Soft tissue or bony lesions 9. Habits 1. Prenatal causes- Heredity 2. Postnatal-Rickets, Congenital Syphilis, Anaemia,Malnutrition 3. Endocrinal disorders 4. Rare Causes- Cleidocranial disorder,Osteopetrosis, Achondroplasia,Cleft lip and palate
  8. 8. PROBLEMS OF RETAINED IMPACTED TOOTH  Pain  Difficulty in mastication  Paraesthesia of lip  Swelling of retro-molar tissue  Soreness  Erythemia of overlaying soft tissue or operculum  Trismus  Facial swelling of the affected side  Space involvement  Raised temperature  Regional lymphodenopathy  Dental Caries  Risk of Cyst and Tumour development
  9. 9. INDICATIONS CONTRA INDICATIONS  Tooth in line of fracture  Recurrent pericoronitis  Deep periodontal pocket  Prior to orthodontic treatment  Prevention of root resorption and caries  Retained Deciduous teeth  Management of cysts and tumors  Management of preprosthetic concerns  Prophylactic removal  Extremes of age  Compromised medical status  Excessive risk of damage to adjacent structure  When there is question about the future status of the second molar  Uncontrolled active pericoronal infection  Socioeconomic status  Fracture of atrophic mandible may occur  Abutment selection
  10. 10. Tooth in line of fracture Orthodontic ProblemsTooth adjacent to CystCaries in adjacent tooth Retained DeciduousRecurrent Pericoronitis & Deep Pocket
  11. 11. CLASSIFICATION OF IMPACTIONS WINTERS CLASSIFICATION OF MANDIBULAR THIRD MOLARS - 1929 BASED ON ANGULATION Mesioangular Distoangular HorizontalVertical Buccoangular InvertedLinguoangular
  12. 12. BASED ON DEPTH PELLAND GREGORY CLASSIFICATION OF MANDIBULAR THIRD MOLARS - 1933 CLASSIFICATION OF IMPACTIONS LEVELA LEVEL CLEVEL B The highest position of the tooth is on a level with or above the occlusal line Highest position is below the occlusal plane, but above the cervical level of the second molar Highest position of the tooth is below the cervical level of the second molar
  13. 13. CLASSIFICATION OF IMPACTIONS PELLAND GREGORY CLASSIFICATION OF MANDIBULAR THIRD MOLARS - 1933 CLASS I CLASS IIICLASS II Sufficient space available between the anterior border of the ascending ramus and the distal side of the second molar for the eruption of the third molar The space available between the anterior border of the ramus and the distal side of the second molar is less than the mesiodistal width of the crown of the third molar The third molar is totally embedded in the bone from the ascending ramus because of absolute lack of space BASED ON SPACE AVAILABLE DISTAL TO SECOND MOLAR
  14. 14. CLASSIFICATION OF IMPACTIONS ARCHERS CLASSIFICATION OF MAXILLARY THIRD MOLARS BASED ON ANGULATION Mesioangular HorizontalVerticalDistoangular Buccoversion InvertedLinguoversion
  15. 15. CLASSIFICATION OF IMPACTIONS PELLAND GREGORY CLASSIFICATION OF MAXILLARY THIRD MOLARS BASED ON OCCLUSAL PLANE CLASS A CLASS CCLASS B The occlusal plane of the impacted tooth is apical to the cervical line of the adjacent tooth The occlusal plane of the impacted tooth is between the occlusal plane and the cervical line of the adjacent tooth The occlusal plane of the impacted tooth is at the same level as the adjacent tooth
  16. 16. CLASSIFICATION OF IMPACTIONS CLASSIFICATION OF MAXILLARY THIRD MOLARS BASED ON RELATION TO MAXILLARY SINUS NO SINUS APPROXIMATION SINUS APPROXIMATION 2mm or more bone is present between the sinus floor and the impacted maxillary third molar No bone or thin bony partition present between impacted maxillary third molar and the floor of the maxillary sinus
  17. 17. CLASSIFICATION OF IMPACTIONS CLASSIFICATION OF MAXILLARY CANINE CLASS I CLASS VCLASS IVCLASS IIICLASS II Impacted cuspids located in palate a) Horizontal b) Vertical c) Semi Vertical Impacted cuspids located in palatine and maxillary bone e.g.crown is on the palate and root passes through the root of the adjacent teeth and ends in the labial or buccal surface of maxilla Impacted cuspids located in the alveolar process,usually vertically between incisor and first bicuspids Impacted Cuspid located in edentulous maxilla Impacted cuspids located in Labial or buccal surface of maxilla a) Horizontal b) Vertical c) Semi Vertical
  18. 18. DIFFICULTY INDICES FOR REMOVAL OF IMPACTED MANDIBULAR THIRD MOLARS PEDERSON SCALE - 1988 CLASSIFICATION SCORE SPATIAL RELATIONSHIP Mesioangular 1 Horizontal 2 Vertical 3 Distoangular 4 DEPTH Level A 1 Level B 2 Level C 3 RAMUS RELATIONSHIP/ SPACE AVAILABLE Class I 1 Class II 2 Class III 3 DIFFICULTY LEVEL Very Difficult 7 - 10 Moderately Difficult 5 – 7 Minimally Difficult 3 - 4
  19. 19. DIFFICULTY INDICES FOR REMOVAL OF IMPACTED MANDIBULAR THIRD MOLARS PARRANT SCALE TECHNIQUE USED DIFFICULTY EXTRACTION REQUIRING FORCEPS ONLY EASY I EXTRACTION REQUIRING OSTECTOMY EASY II EXTRACTION REQUIRING OSTEOTOMY AND CORONAL SECTION DIFFICULT III COMPLEX EXTRACTION ( ROOT RESECTION) DIFFICULT IV
  20. 20. DIFFICULTY INDICES FOR REMOVAL OF IMPACTED MANDIBULAR THIRD MOLARS WINTERS LINES / WAR LINES  Corresponds to occlusal plane of molar teeth.  Indicates the difference in occlusal level of second and third molar  Represents the bone level.  Denotes the alveolar bone covering the impacted tooth and the portion of tooth not covered by the bone  The red line is an imaginary line drawn perpendicular from the amber line to an imaginary point of application of an elevator  Represents depth of the tooth in bone and the difficulty encountered in removing the tooth. Indicates the amount of bone that has to be removed before elevation  If the length of red line is more than 5 mm then extraction is difficult.  For Every additional 1mm difficulty increases three times(3X). WHITELINEREDLINEAMBERLINE
  21. 21. DIFFICULTY INDICES FOR REMOVAL OF IMPACTED MANDIBULAR THIRD MOLARS WHARFE ASSESSMENT CRITERIA SCORE Winters Classification Horizontal 2 Distoangular 2 Mesioangular 1 Vertical 0 Height of Mandible 1 to 30 mm 0 31 to 34 mm 1 35 to 39 mm 2 Angulation of Third Molar 1 to 59 degrees 0 60 to 69 degrees 1 70 to 79 degrees 2 80 to 89 degrees 3 90 + degrees 4 CRITERIA SCORE Root Shape Complex 1 Favorable Curvature 2 Unfavorable Curvature 3 Follicle Size Normal 0 Possibly Enlarged 1 Enlarged 2 Path of Exit Space Available 0 Distal cusp covered 1 Mesial cusp covered 2 Both covered 3
  22. 22. RADIODGRAPHS IN IMPACTION MANAGEMENT OCCLUSAL OPG RADIOGRAPH CBCT LATERAL CEPHIOPA PA VIEW
  23. 23. USES OF IOPA RADIOGRAPH Radiological assessment aids in determining  Classification of impacted tooth  Orientation & Depth of the tooth (WAR Lines)  Root Pattern  Relation to inferior alveolar canal(Howe & Poyton)  Localization of impacted tooth(Clarks rule/Tube shift)
  24. 24. ROOT PATTERN  Limited development (Rolling Tooth) –Difficult  2/3rd to complete Development – Easy  Extremely Curved - Difficult  Multiple , Fused & Conical – Easy  Multiple & Separated – Moderately difficult  Multiple & Diverged – Difficult
  25. 25. RELATION TO INFERIOR ALVEOLAR CANAL (HOWE & POYTON – 1960) DARKENING OF ROOT DEFLECTION OF ROOT NARROING OF CANAL DIVERSION OF CANAL INTERUPTION OF WHITE LINE OF CANAL DARK BIFID APEX NARROWING OF ROOT RELATEDTOROOT RELATEDTOCANAL
  26. 26. FACTORS THAT MAKE REMOVAL EASIER MESIO ANGULAR CLASS 1 POSITION A ROOT 1/3RD TO 2/3RD FUSED CONICAL ROOTS WIDE PDL SPACE LARGE FOLLICE LESS DENSE BONE SEPRTATED FROM II MOLAR SOFT TISSUE IMPACTION
  27. 27. FACTORS THAT MAKE REMOVAL DIFFICULT DISTO ANGULAR CLASS 3 POSITION C LONG THIN ROOTS DIVERGENT CURVED ROOTS NARROW PERIODONTAL SPACE THIN FOLLICLE DENSE INELASTIC BONE CONTACT WITH II MOLAR COMPLETE BONY IMPACTION
  28. 28. RISKS OF NONINTERVENTION RISKS OF INTERVENTION A. Crowding of dentition B. Resorption of adjacent tooth and Periodontal status C. Development of Pathological conditions such as Infection, Cysts, Tumors A. Minor transient- Sensory nerve alteration, Alveolitis, Trismus and infection. Haemorrhage, Dentoalveolar fracture and Displacement of tooth. B. Minor permanent- Periodontal injury, Adjacent tooth injury, TMJ injury. C. Major – Altered sensation, Vital organ infection, Fracture of mandible, Maxillary tuberosity
  29. 29. SURGICAL TECHNIQUES IN REMOVAL OF IMPACTED MANIBULAR THIRD MOLARS
  30. 30. SURGICAL PROCEDURES GENERAL CONSIDERATIONS ADEQUATE EXPOSURE ACCESS TO THE TOOTH SECTIONING OF THE TOOTH(OPTIONAL) ELEVATION FROM THE ALVEOLAR PROCESS DEBRIDMENT & IRRIGATION REPOSITION OF FLAPS AND CLOSURE POST OPERATIVE FOLLOW UP
  31. 31. INCISIONS AND FLAP DESIGNS PARTS OF INCISION Limb A Limb CLimb B It was carried along the gingival crevice of the third molar extending upto the middle of exposed distal surface of the tooth. Started from a point where intermediate gingival incision ended and was carried laterally towards the cheek at mucosal depth. This arm should be about 25.4 mm long The anterior incision started from a point about 6.4 mm down in the buccal sulcus approximately at the junction of posterior and middle third of the second molar, passes upwards extended upto the distobuccal angel of the second molar at the gingival margin for a distance of 1- 2cm Standard Incision line
  32. 32.  The base of the flap must be broader than the free margin to preserve an adequate blood supply.  Must be of adequate size - sufficient soft tissue reflection - provide necessary visualization of the area.  The flap should be a full-thickness mucoperiosteal flap.  The incisions must be made over intact bone  Should be designed to avoid injury to local vital structures in the area of the surgery.  Incisions should be well away from the lingual aspect of the mandible to preserve lingual nerve.  Vertical-releasing incisions should cross the free gingival margin at the line angle of a tooth and should not be directly on the facial aspect of the tooth nor directly in the papilla. PRINCIPLES OF FLAP DESIGN
  33. 33. BAYONET FLAPL SHAPED FLAP Suits only the buccal approach since it is difficult to raise a lingual flap from this approach. The posterior limb of the incision extends from a point just lateral to the ascending ramus of the mandible into the sulcus.It passes disto-lateral periodontium by avoiding or including it - depending upon the proximity of the third molar with the second molar. The junction bw the limbs may be Curved & incision made in one sweep or it may be angled This incision has three parts a. Distal or Posterior b. Intermediate or Gingival c. Anterior part The posterior part of the incision goes round the gingival margin of the second and even the first molar, before turning into the sulcus
  34. 34. ENVELOPE FLAP TRIANGULAR FLAP Extends from the mesial papilla of the mandibular first molar and passes around the neck of the teeth to the disto buccal line angle of the second molar. Now the incision line extends posteriorly and laterally upto the anterior border of the mandible. Its anterior extension is directly proportional to the depth at which the impacted tooth is present deeper the tooth, longer the Ant extension Advantage Easier to close and heal better This flap is the result of an L-shaped incision with a horizontal incision made along the gingival sulcus and a vertical or oblique incision. The vertical incision begins approximately at the vestibular fold and extends to the interdental papilla of the gingiva. The triangular flap is performed labially or buccally on both jaws and is indicated in the surgical removal of root tips, small cysts, and apicoectomies. Advantages Good blood supply,Satisfactory vision, Good stability& reapproximation Disadvantages Limited access, Tension builds when flap held with retractor, and it causes a defect in the attached gingiva
  35. 35. COMMA SHAPED INCISION WARDS INCISION Provides Large area of access Indicated In case of deep Horizontal Impactions Periodontal Pocketing Distal to 2nd Molar WARDS MODIFIED WARDS The anterior line of the incision runs from the distal aspect of the second molar curving ,downward and forward to the level of the apex of the distal root of the first molar. This second type of incision is used when a linguoverted tooth impaction is present. The posterior part of the incision is the same but the anterior part commences as the junction of the anterior and middle thirds of the second molar and runs down to the apex of the distal root of the first molar
  36. 36. REFLECTION OF FLAP  Reflection of the flap begins at the papilla.  The end of the Woodson elevator or the no. 9 periosteal elevator begins a reflection.  The sharp end is slipped underneath the papilla in the area of the incision and turned laterally to pry the papilla away from the underlying bone. This technique is used along the entire extent of the free gingival incision.  Once the flap reflection is started, the broad end of the periosteal elevator is inserted at the middle corner of the flap, and the dissection is carried out with a pushing stroke, posteriorly and apically. This facilitates the rapid and atraumatic reflection the soft tissue flap.
  37. 37. BONE REMOVAL Aim: 1. To expose the crown by removing the bone overlying it. 2. To remove the Bone obstructing the pathway for removal of the impacted tooth Types: 1. By consecutive sweeping action of bur(in layers). 2. By chisel or osteotomy cut (in sections). Amount to be removed: Bone should be removed till we reach below the height of contour, where we can apply the elevator. Extensive bone removal can be minimized by tooth sectioning. CRITERIA BUR CHISEL&MALLET TECHNIQUE EASY DIFFICULT CONTROL OVER BONE CUTTING CONTROLLED UNCONTROLLED PATIENT ACCEPTANCE WELL TOLERATED UNDER L.A NOT TOLERATED UNDER L.A HEALING OF BONE DELAYED GOOD POST OPERATIVE EDEMA MORE LESS CHANCES OF DRY SOCKET MORE LESS POST OPERATIVE INFECTION MORE LESS
  38. 38. A. Preferred method to use a hand piece with adequate speed and high torque to remove the overlying bone. B. Ideal length – 7mm Diameter – 1.5mm. C. Large rose head bur (size 12) or fissure bur (no.7) used for gross bone removal. D. The bur should rotate in correct direction and at maximum speed. E. Cutting instruments that induce air should not be used. F. Handpiece should not rest on the tissues of the cheek and lips to avoid burning. G. Bone removed: a. Mesially – to create a point of application b. Buccaly – cutting a trough or gutter around the tooth to the root furcation c. Distolingually – lingual plate should not be breached to protect the lingual nerve H. Copious amount of normal saline is irrigated to avoid thermal necrosis of bone. I. To keep the operator field clean an efficient suction should be used. J. In the mesial side adequate bone must be removed so that the elevator stands up an angle of 45° to the mandible without any support. BUR TECHNIQUE
  39. 39. Irrigation Rate a. 15 mL/min -for intermittent drip b. 24 mL/min -for continuous flow A large plastic syringe with a blunt & angled I8-gauge needle is used Solutions Used a. Saline b. Sterile water c. Ringer’s lactate. d. 1% Povidone iodine Advantages of Irrigation a. Irrigation cools the bur b. Prevents bone-damaging heat buildup c. Increases the efficiency of the bur IRRIGATION TECHNIQUE
  40. 40. A. Mandible should be adequately supported. B. The mallet is used with a loose, free-swinging wrist motion gives maximum speed to head of the mallet without introducing the weight of the arm or body into the blow. C. 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. D. 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. Its approximate height is 5-6 mm. E. Then the chisel is placed at an angle of 45° at the lower edge of the limiting cut in an oblique direction. This will result in the removal of a triangular piece of buccal plate distal to the II molar. F. If necessary, bony cut can be enlarged to uncover the impacted tooth to the desired level. G. Finally distal bone must be removed so that when the tooth is elevated, there is no obstruction at the distobuccal aspect. CHISEL & MALLET TECHNIQUE
  41. 41. SECTIONING OF TOOTH BUR OSTEOTOME WITH  Safe and Easy  Bur Used Fissured Type No.8 with larger cutting surface  Used with sufficient amount of Coolant  Quicker but Hazardous  Osteotome Used Width: 6.4 mm(1/4 in) Length: 17.5cm(7 in)  When splitting a tooth longitudinally through the root bifurcation the osteotome blade should be placed in the buccal anatomical groove between the mesial and distal coronal cusps at an angle of 450 to the vertical axis of the tooth A D V A N T A G E S  Amount of bone to be removed is reduced. The time of operation is reduced.  The field of operation is small and therefore damage to adjacent teeth and bone is reduced.  Risk of jaw fracture is reduced.  Risk of damage to the inferior alveolar nerve is reduced
  42. 42. TOOTH DIVISION IS NECESSARY  IF THE TOOTH IS BISSECTED AT NECK  ENAMEL IS VERY THIN  LOWER POSITION  Distal half of the crown is sectioned off at the buccal groove just below the cervical line  Position of elevator under cemento enamel junction on mesial surface  Tooth is moved upward and backward as far as distal rim of bone will allow  Upward movement of roots REMOVAL OF MESIOANGULAR IMPACTED III MOLAR
  43. 43. REMOVAL OF DISTOANGULAR IMPACTED III MOLAR  Distoangular position brings the 3rd molar well under the ascending ramus  Frequently distally curved roots are encountered  After sufficient bone removal, the crown is sectioned horizontally from the roots just above the cervical line  The entire crown is first removed  If roots if fused then a elevator can be straight used to elevate the roots into the space previously occupied by the crown  If roots are divergent sectioning of roots is necessary and individual removal  Extraction of this type of impaction is difficult, because more distal bone has to be removed and the tooth tends to be elevated distally and into the ramus portion of the mandible
  44. 44. REMOVAL OF VERTICALLY IMPACTED III MOLAR  Procedure of bone removal and tooth sectioning is similar to mesioangular impaction tooth sectioned vertically  Distal part removed first,followed by the mesial half  It is more difficult than mesioangular impaction because the access around 2nd molar is less and requires more removal of bone on the buccal and distal sides
  45. 45. REMOVAL OF HORIZONTALLY IMPACTED III MOLAR  Superior(Distal) and inferior(Mesial) cusp sectioned  Superior crown is removed first  Followed by bulk of tooth and then the inferior crown fragment  If sufficient space is not available then a split is made near the anatomic neck of tooth  If divergent roots then spitting of roots is necassery and then each root is delivered individually  Requires maximum bone removal  Bone should be removed down to the cervical line to expose the superior aspect of the distal root and the majority of buccal surface of crown
  46. 46. Not so common Tooth is sectioned horizontally at the cervical region Crown is first delivered following roots In case of linguoangular impaction retraction of the lingual mucosa is important REMOVAL OF BUCCO/LINGUO ANGULAR IMPACTION BUCCOANGULAR IMPACTION LINGUOANGULAR IMPACTION
  47. 47.  It is described originally by Sir William Kelsey Fry  Later popularized by T Ward  Useful in removal of deeply positioned horizontal distoangular impactions (Rud, 1970). 1. First, a vertical stop cut about 5 mm in height is made with a 3 mm width chisel in the buccal cortex immediately distal to the second molar. A second vertical stop cut will be made about 4 mm disto-buccal to the third molar crown. 2. With the chisel bevel downward, a horizontal cut is made backward from the lower end of the vertical limiting stop cut. 3. The buccal bone plate is removed above the horizontal cut. 4. Thedistolingual bone is then fractured inward by placing the cutting edge of the chisel along the dotted line A. Bevel side of the chisel is facing upward and cutting edge is parallel to the external oblique ridge. The chisel is held at 45º to the bone surface. 5. Finally small wedge of bone, which then remaining distal to the tooth and between the buccal and lingual cut, is excised and removed. 6. A sharp straight elevator is then applied and minimum force is used to elevate the tooth. As the tooth moves upward and backward, the lingual plate gets fractured and facilitates the delivery of the tooth. 7. After the tooth is removed, the lingual plate is grasped with the hemostat and freed from the soft tissue and removed. 8. Smoothening of the edges is done with bone file. Wound irrigated and sutured. LINGUAL SPLIT/ KELSEY FRY TECHNIQUE
  48. 48. 1 32 4 5 6 7 8 STEPS: 1. Vertical Stop Cut 2. Horizontal Cut 3. Removal of Buccal Plate 4. Fracturing Distolingual Bone 5. Removing Bony wedge 6. Elevation of Tooth 7. Repositioning of flap 8. Suturing LINGUAL SPLIT/ KELSEY FRY TECHNIQUE ADVANTAGES  Faster tooth removal.  Less risk of inferior alveolar nerve damage.  Reduces the size of residual blood clot by means of saucerization of the socket  Decreased risk of damage to the periodontium of the second molar.  Decreased risk of socket healing problems. DRAWBACKS  Risk of damage to the lingual nerve. The incidence of lingual nerve and inferior alveolar nerve damage has been reported as 1- 6.6% .  Increased risk of postoperative infection  Patient discomfort due to the use of a chisel and mallet for lingual bone removal or fracturing.  Only suitable for young patients with elastic bone
  49. 49. LINGUAL TREPHENATION TECHNIQUE This procedure was first described by Bowdler-Henry to remove any partially formed and unerupted third molar in the age group of 9-16 years. Modified S-shaped incision is made from retromolar fossa across the external oblique ridge. It then curves down to the I molar anteriorly in the vestibule. The mucoperiosteal flap is elevated and buccal cortical plate is trephined over the III molar crypt. bur is used to make vertical cuts anteriorly and posteriorly.
  50. 50. LINGUAL TREPHENATION TECHNIQUE  A chisel or an osteotome is applied in the vertical direction over the bur holes. Then the buccal plate is fractured out, exposing the third molar crypt completely.  Elevator is applied to deliver the tooth out of the crypt. Any follicular remnant present in the crypt is carefully scooped out, avoiding injury to the inferior alveolar (dental) canal at the lower part of the crypt.  Flap repositioned and Suturing done Advantages: a. Partially formed unerupted 3rd molar can be removed. b. Can be preformed under general or regional anesthesia with sedation. c. Post-op pain is minimal. d. Bone healing is excellent and there is no loss of alveolar bone around the 2nd molar. Disadvantages : a. Virtually every patient has some post operative buccal swelling for 2-3 days after surgery
  51. 51. WOUND CLOSURE  The most important suture is the one placed immediately behind the second molar, ensuring there is accurate apposition of wound edges .  It is also useful to place a suture across the distal incision where the soft tissue thickness and potential bleeding source is greatest.  Many clinicians often do not place sutures across the buccal relieving incision, which permits a dependent area of drainage.  Watertight closure is unnecessary and may in some cases increase postoperative pain and swelling.  Primary closure of the wound should not be attempted unless – atleast 5mm of a band of buccal attached mucoperiosteum is present. DRAIN BY TUBE  When using primary wound closure, a small surgical tube drain or gauze strip may be inserted in buccal incision before suturing to facilitate drainage. Small surgical tube inserted with Primary Closure WOUND CLOSURE AND MANAGEMENT  It should be removed after 24-72 hours.  With this technique, the postoperative problems are expected to be less severe.
  52. 52. COMPLICATIONS INTRA OPERATIVE POST OPERATIVE During incision 1. Injury to Facial Nerve or Vessels 1. Pain 2. Swelling/edema 3. Hematoma 4. Bleeding 5. Trismus 6. Infection 7. Dry socket  Incidence between 3% and 25%.  Higher in smokers and Females taking oral contraceptives.  Occurs during the 3rd – 4th post operated day  Goal of treatment is relief of pain  Irrigation of extraction site & Placement of eugenol dressing  Pain usually resolves within 3-5 days but up to 10 to 14 days 8. TMJ Pain 9. Paraesthesia 10. Sensitivity During bone removal 1. Damage to second molar 2. Slipping of bur into soft tissue & causing injury 3. Fracture of the mandible when using chisel & mallet During elevation 1. Luxation of neighbouring tooth. 2. Soft tissue injury due to Slipping of elevator. 3. Fracture of mandible. 4. Forcing tooth root into submandibular space or inferior alveolar canal. 5. Breakage of instruments. 6. TMJ Dislocation During debridement 1. Injury to inferior alveolar neurovascular bundle.

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