This document discusses impacted and unerupted teeth, with a focus on impacted wisdom teeth. It provides information on: - The frequency of tooth impactions, with wisdom teeth and maxillary third molars being most common. - Factors to consider when deciding whether to remove impacted wisdom teeth, including development stages, potential risks like infection, and possible benefits like occlusion. - Surgical principles for removing impacted teeth, including flap design, suturing techniques, and managing complications like nerve injury. - Alternatives to surgical removal like restoration and the optimal timing for prophylactic removal of wisdom teeth between ages 15-18.

1. Copy Right 2020
Wisdom of wisdoms

3. Impacted teeth
is a tooth that fails to erupt into its
normal functioning position in the
dental arch within the expected
time.
The term Unerupted includes both
impacted teeth and teeth that are
in the process of erupting.

4. Evidence-Based Dentistry
Clinician’s
Clinical
Expertise
Patient’s Needs
and
Preferences
Assessment of
Scientific
Literature
1. mandibular 3rd molar
2. maxillary 3rd molar
3. maxillary cuspid
4. mandibular cuspid
5. Mandibular premolar
6. maxillary premolars
7. maxillary central and lateral incisiorors
frequency of impaction

5. To Remove or Not to Remove
1. Development
2. Wisdom teeth as an asset
3. Wisdom teeth as a liability
4. Alternatives to removal
5. Timing of removal

6. Development
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Initial calcification
■ Occurs as early as 7yrs, more typically age 9.

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Crown Mineralization
■ Usually completed by age 12 to 14.
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Root Formation
■ Usually half-formed by age 16.

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Root Completion
■ Fully formed roots with open apices are usually present by age
18.
Eruption
■ Most teeth that will erupt are
erupted by age 20.
■ 95% of all teeth that will erupt are
erupted by age 24.
■ A limited number of third molars
appear to erupt, at least to some
degree, in young adults.

9. Predicting Eruption –
Who Cares?
■ Does it matter if a wisdom tooth erupts?
■ Does it matter when a
wisdom tooth erupts?

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The Key Issue
Does it affect the
Risk:Benefit Ratio?
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Evaluating Risk:Benefit

11. Evaluating Risk:Benefit
■ Since “Risk of retention” and
“Benefit of removal” are essentially
the same concept, these terms may
be combined.
■ Since “Benefit of retention”
essentially = 0, the equation may
be simplified:
Magnitude
■ Is it major or minor?
■ Does it require hospitalization?
■ Is it permanent?
■ Does it affect your daily routine? If
so, for how long?

12. How Sick Is Patient?
■ Airway most important
■ Mental status
■ Swallowing/ Secretions
■ Trismus
■ Vital Signs
■ Speed of onset
Treat?
■ Your office
■ Oral surgeon’s office (document
referral)
■ Hospital

13. Probability
■ The most overlooked aspect of
most consultations.
■ Fortunately most real bad outcomes
are real uncommon
■ What is the likelihood of certain
problems? How much does
treatment alter this likelihood?
Risk:Benefit
■ Are erupted 3rds more or less
subject to disease?
■ Are erupted 3rds more or less
beneficial?

14. Wisdom Teeth as an
Asset
What Impacts Treatment?
■ Eruption into occlusion should
not be the sole criterion of
usefulness.
■ The issue is not “can you
save it” but “should you save
it.”

15. Benefits of 3rds
■ “Functional occlusion” – what is this?
■ Is it any different than just “occlusion”?
■ Is all occlusion functional?
■ Is all functional occlusion important? If so, is
it all equally important?
■ Without evaluating questions such as these,
how can you determine the true benefit of
3rds?
Benefits of 3rds
■ Orthodontic repositioning to replace
missing or grossly compromised 1st
molars
■ Transplantation – poor long-term
survival
■ With dental implants, these are rarely
reasonable treatment alternatives.

16. Wisdom Teeth as a
Liability
What Impacts Treatment?
■ Failure of eruption should not be the sole
criterion for removal.
■ Successful eruption should not be the sole
criterion for retention.
■ Eruption is not always a “yes” or “no”
proposition.

17. Problem #1 – Soft Tissue
■ Even with adequate arch length and full
eruption, 3rd molars are often surrounded
by thin, unkeratinized, highly distensible
lining mucosa of the buccal vestibule.
■ Encourages pathogenic bacteria retention
■ Poorly withstands hygiene measures

18. Problem #2 – Periodontal Compromise
■ Bone loss distal to the 2rd molar
after removal of the 3rd molar is
controversial, at best. Even with
some loss of bone, the result is
stable and cleansable – the goal of
periodontal therapy.
■ A reduction in pocket depth with
no change in bone height on the
distal of the 2nd molar.
Szmyd and Hester
Groves and Moore
Grondahl and Lekholm
■ Alveolar bone crest healing distal to
the 2nd molar is enhanced in
younger patients with incompletely
developed 3rd molar roots.
Ash, Costich, and Hayward
Ziegler

19. Measuring Bone Height

20. Problem #2 – Periodontal Compromise
■ The role of pathogenic bacteria
retention in 3rd molar pockets is
unknown. How does this affect the rest
of the dentition?
■ Hygenic compromise of the 2nd molar
can result in a difficult to restore
situation if this tooth is lost.

21. How Do You Treat Missing
2nd Molars?
■ If the entire dentition is healthy and a
mandibular 2nd molar needs extraction, what
is the recommended treatment?
■ Cantilevered abutment?
■ Implant?
■ Partial denture?
■ Remove opposing tooth at same time?
■ Nothing. Allow opposing tooth to supererupt.
The Missing 2nd Molar Dilemma
■ Your treatment plan for this scenario
illustrates the value you place on 2nd
molars.
■ Most people will subconsciously do a
cost:benefit analysis and conclude
that restoration is not necessary.

22. Problem #3 – 3rd Molar Caries

23. Problem #4 – 2nd Molar Caries
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24. Problem #5 - Infection
■ Can turn an elective procedure into
an urgent or emergent situation
■ Unscheduled loss of work
■ Increased pain and healing time
■ Compromise of adjacent teeth
■ Compromise of patient’s systemic
health
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25. Types of Infection
1. Simple dental caries
and periodontal
disease
2. Pericoronitis
3. Abscess
4. Cellulitis
5. Abscess extension into
adjacent fascial spaces
5. Abscess spread to
distant sites
6. Recurrent
infections
7. Infections resistant
to initial local and
systemic treatment
measures
The most
common
cause of
therapeutic
3rd molar
removal.
Pericoronitis
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26. Problem #6 - Resorption

27. Problem #7 - Supereruption

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Problem #8 - Cysts
Dentigerous
Cyst
Dentigerous
Cyst

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Dentigerous Cyst
Supernumerary
4th Molar

30. Types of Cysts
■ Follicular cyst (Dentigerous Cyst)
■ OKC (Odontogenic Keratocyst)
■ Ameloblastoma (several varieties)
■ Not all radiolucencies are cysts!
- Lymphoma
- Myeloma
- Metastatic carcinoma
Without the
radiolucency,
would you have
recommended
removal?
Is the removal of
this better or
worse with the
radiolucency?

31. When would you
recommend
removal of this
3rd molar?

32. Problem #9 - Tumors
■ Benign vs. malignant
■ Odontogenic vs. non-odontogenic
■ Primary vs. secondary
■ Each of these factors has important
treatment implications.

34. Problem #10 – Risk of Fracture
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Immediate Pre-extraction

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Immediate Post-extraction
3 Days Post-extraction
8 Days Post-extraction

36. Problem #11 - Fracture

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38. Problem #12 - Orthodontics
■ Prevent loss of post-
retention stability
■ Allow distalization of
2nd molars
■ These are
controversial
indications

39. Alternatives to Removal
1. Restoration
2. Periodontal therapy
3. Operculectomy
4. Removal of another tooth
5. No treatment

40. Timing Removal of 3rds
When is the best time for
prophylactic removal?
Age 15-18

41. Advantages of Early Removal
■ Wide pericoronal
space
■ Incomplete root
development
■ Straight roots
■ Away from IAN
■ Away from sinus
■ Less risk of infection
■ Less risk of fracture
■ Patient more likely in good
health
■ Better chance for primary
closure
■ Smaller teeth require less
bone removal

42. Evaluation
Mesioangular Vertical Distoangular
Horizontal Inverted Transverse

43. Whinters lines

46. Principles of Surgery

48. BASIC NECESSITIES FOR SURGERY
■ Adequate visibility
(1) adequate access
(2) Adequate light, and
(3) a surgical field free of excess
blood and other fluids.
■ Assistance
Never operate through a keyhole

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50. Incisions
sharp blade of the proper size
firm, continuous stroke
vital structures
blade held perpendicular to the epithelial
surface.
should be properly placed
(attached gingiva, healthy bone)

52. Flap design

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56. Types of Sutures
■ Absorbable or non-absorbable (natural or
synthetic)
■ Monofilament or multifilament (braided)
■ Dyed or undyed
■ Sizes 3 to 12-0 (numbers alone indicate
progressively larger sutures, whereas numbers
followed by 0 indicate progressively smaller)
■ New antibacterial sutures
■ Degraded via
inflammatory
response
– Vicryl
– Monocryl
– PDS
– Chromic
– Cat gut
(natural)
Absorbable
Non-absorbable
■ Not biodegradable
and permanent
– Nylon (Ethilon)
– Prolene
– Stainless steel
– Silk (natural, can
break down over
years)

57. Natural Suture
■ Biological
■ Cause
inflammatory
reaction
– Catgut
(connective from
cow or sheep)
– Silk (from
silkworm fibers)
– Chromic catgut
Synthetic
■ Synthetic polymers
■ Do not cause
inflammatory
response
– Nylon
– Vicryl
– Monocryl
– PDS
– Prolene
■ Single strand of
suture material
■ Minimal tissue
trauma
■ Smooth tying but
more knots needed
■ Harder to handle
due to memory
■ Examples: nylon,
monocryl, prolene,
PDS
Multifilament (braided)
■ Fibers are braided or
twisted together
■ More tissue
resistance
■ Easier to handle
■ Fewer knots needed
■ Examples: vicryl,
silk, chromic
Monofilament

58. Suture Selection
■ Do not use dyed sutures on the skin
■ Use monofilament on the skin as multifilament
harbor BACTERIA
■ Non-absorbable cause less scarring but must be
removed
■ Plus sutures (staph, monocryl for E. coli,
Klebsiella)
■ Location and layer, patient factors, strength,
healing, site and availability
Surgical Needles
■ Wide variety with different company’s
naming systems
■ 2 basic configurations for curved
needles
– Cutting: cutting edge can cut through
tough tissue, such as skin
– Tapered: no cutting edge. For softer
tissue inside the body

59. Surgical Instruments

61. Simple Interrupted Suturing
Rule of halves
1 1
1
3 2
Simple Interrupted Suturing
Rule of halves

62. Suturing
■ The needle enters the
skin with a 1/4-inch
bite from the wound
edge at 90 degrees
– Visualize Erlenmeyer
flask
– Evert wound edges
▪ Because scars
contract over time

64. Continous suture

65. mattress suture

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Nerve injury
(1) neurapraxia
(2) axonotmesis
(3) neurotmesis
Types of injury

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70. Treatment and
Management

81. ]

84. Lingual splitting
technique
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86. Impacted Canine

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Tube-Shift Localization (Clark)
SLOB Rule
Same Lingual Opposite Buccal

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Paralleling
Technique

110. Thank you
•Islam Kassem
• ikassem@dr.com
• 00201222209842
• 002034810481
• 00201091472244
• 0097455118606
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