This document provides an overview of impacted teeth and their surgical removal. It begins with definitions of impacted and malposed teeth. It then discusses theories of tooth impaction and common causes. The document outlines the typical order of impaction by tooth type and potential complications. Factors influencing difficulty of removing impacted third molars are examined. The document provides classifications and assessments for impacted third molars along with surgical techniques and considerations for their removal.
2. CONTENTS
1. INTRODUCTION
2. Definitions.
3. Theories for impaction of teeth.
4. Causes of impaction.
5. Order of frequency for impaction of teeth.
6. Complications arising from the retained impacted teeth.
7. Indications & contraindications for removal of Impacted
teeth.
8. Impacted Mandibular third molars.
a. Classification.
b. Radiological examination.
c. Factors responsible for increasing the difficulty
score for removal of impacted 3rd molars.
d. Surgical plan for removal of impacted tooth.
e. Instruments and Principles of Elevators.
f. Surgical removal of impacted teeth.
g. Complications.
. Impacted Maxillary third molar.
. Impacted Maxillary Canine. Impacted Mandibular Canine.
3. DEFINITIONS.
Impacted tooth
A tooth which is completely or partially unerupted
and is positioned against another tooth and bone or
soft tissue, so that it’s further eruption is unlikely
described according to its anatomical position.
Malposed tooth.
A tooth, unerupted or erupted, which is in an
abnormal position in the maxilla or mandible.
Unerupted tooth.
A tooth which has not perforated the oral mucosa.
* American society of oral surgeons 1971
4. THEORIES FOR IMPACTION OF
TEETH.
Phylogenic theory:
Due to evolution, the human jaw size is becoming
smaller & since the third molar tooth is last to
erupt, there may not be room for it to emerge in the
oral cavity.
Mendelian theory:
Here genetic variations play a major role. If the
individual genetically receives a small jaw from one
of the parents &or large teeth from the other
parent, then impacted teeth can be seen, because of
lack of space.
5. CAUSES OF IMPACTION
ACCORDING TO BERGER
Local causes
1. Irregularity in the position & pressure of an
adjacent tooth.
2. Density of the overlying or surrounding bone.
3. Chronic inflammation with resultant increase in
density of the overlying mucosa.
4. Lack of space.
5. Over retained primary teeth.
6. Premature loss of primary teeth,habits and
trauma.
7. According to Archer impacted teeth occur in
the following order of frequency.
Maxillary 3rd molars.
Mandibular 3rd molars.
Maxillary cuspids.
Mandibular bicuspids.
Mandibular cuspids.
Maxillary bicuspids.
Maxillary central incisors.
Maxillary lateral incisors.
8. According to Malik impacted teeth occur in the
following order of frequency.
1.Mandibular 3rd molars
2.Maxillary 3rd molars.
3.Maxillary cuspids.
4.Mandibular bicuspids.
5.Maxillary bicuspids.
6.Mandibular cuspids.
7.Maxillary central incisors.
8.Maxillary lateral incisors.
9. Complications arising from the retained
impacted teeth.
Infection.
Pain.
Fracture of the jaw.
Trismus.
Chronic cheek biting.
Resorption of adjacent tooth.
10. Indications for removal of Impacted
teeth.
Recurrent pericoronitis/infections.
To prevent damage to adjacent tooth.
Prior to Orthodontic treatment.
Prior to or during Orthognathic surgeries.
Before fabrication of dental prosthesis.
11. CONTRAINDICATIONS FOR
REMOVAL OF IMPACTED TEETH.
Extremes of age.
Compromised medical status.
Probable extensive damage to adjacent
structures.
14. Classification suggested by Pell & Gregory, which
includes portion of George B Winter’s
classification:
A. Relation of the tooth to the ramus of the mandible & the
second molar.
Class I
There is sufficient space between the ramus of the mandible
& the distal side of the second molar for the accommodation
of the mesiodistal diameter of the crown of the third molar.
Class II
The space between the ramus of the mandible & the distal
side of the second molar is less than the mesiodistal
diameter of the crown of the third molar.
Class III
Complete or most of the third molar is located within the
15. B. Relative depth of the third molar in bone.
Position A
The highest portion of the tooth is on a level with
or above the occlusal plane.
Position B
The highest portion of the tooth is below the occlusal
plane, but above the cervical line of the second molar.
Position C
The highest portion of the tooth is below the
cervical line of the second molar.
16. C. The position of the long axis of the impacted
Mandibular third molar in relation to the long axis of
the second molar. (Winter’s classification.)
1. Vertical.
2. Horizontal.
3. Inverted.
4. Mesioangular.
5. Distoangular.
6. Buccoangular.
7. Linguoangular.
These may also occur simultaneously in
a. Buccal version.
b. Lingual version.
c. Torso version.
17. Class I position A Horizontal
Class I position B Vertical
Class II position A Vertical
Class II position B
Distoangular
Class III position C
Mesioangular Class III position C horizontal
18. Radiological examination.
1. To study the relation with adjoining tooth.
2. To study the configuration of the roots &
status of the crown.
3. To know the buccoversion or
Linguoversion of Impacted tooth.
4. Shadow of the external oblique ridge.
If vertical & anterior to the Impacted tooth
– Poor access.
If oblique & posterior to the Impacted
tooth—Good access.
21. RELATIONSHIP OF INFERIOR ALVEOLAR NERVE
TO THE ROOTS OF THE THIRD MOLAR.
Darkening of root Deflection of root Narrowing of root Dark & Bifid apex
Interruption of white line of canal Diversion of canal Narrowing of canal
22. DARKENING OF ROOT:Density of root is the same throughtout its
length &this is not disturbed when the image of tooth & inferior alveolar
canal overlap.When there is impingement of the canal on the tooth root,
there is loss of density of the root and appears darker.
DEFLECTED ROOTS: Roots hooked around the canal are seen as an
abrupt deviation of the root, when it reaches the inferior alveolar canal.
Root may deflected to the buccal or lingual side or both side so that it may
completely surround the canal or it may deflect to mesial or distal side.
NARROWING OF THE ROOT: seward(1963), if there is a narrowing of
the root where the canal crosses it. Indicates greatest diameter of the root
has been involved by the canal, or deep grooving or perforation of the root.
DARK & BIFID ROOT:This sign appears when the inferior alveolar canal
crosses the apex and is identified by the double periodontal membrane
shadow of the bifid apex.
INRUPPTION OF THE WHITE LINE: The white line are the two radio-
-paque lines or tram lines that constitute the roof & floor of the inferior
alveolar canal,radiographically these lines appears due to dense structure
of the canal walls, these white lines considered to indicate deep grooving of
the root if it appears alone or perforation of the rootif it appears with the
narrowing of the inferior alveolar canal.
23. DIVERTION OF THE INFERIOR ALVEOLAR CANAL: The canal is
considered to be diverted if when it crosses the mandibular third molar, it
changes its direction. Seward (1963) attributed an upward displacement of
the inferior alveolar canal during eruption of the third molar, the contents
are dragged upwards with it.
NARROWING OF THE INFR. ALVEOLAR CANAL: When the canal
crosses the root of the mandibular third molar,there is reduction of its
diameter. This narrowing could be due to the downward displacement of the
upper border of the canal.
Out of these 3 radiological sign are significantly related to inferior
alveolar nerve injury:
1.darkening of the canal
2.diversion of the canal
3.interruption of the white line
26. WINTER’S LINES OR WAR LINES.
White line
It corresponds to the ocllusal plane. The line is drawn
touching the occlusal surfaces of first & second molars
& is extended posteriorly over the third molar region.
It indicates the difference in occlusal level of second &
third molars.
27. WINTER’S LINES OR WAR LINES.
Amber line.
A line is drawn from the crest of the interdental
septum between the molars & extended posteriorly
distal to the third molar along the anterior border of
the ramus.
This line denotes the alveolar bone covering the
impacted tooth & the portion of the tooth not covered
by the bone.
28. WINTER’S LINES OR WAR LINES.
Red line.
It is drawn perpendicular from the Amber line to an imaginary
point of application of the elevator.
It indicates the amount of bone that will have to be removed
before elevation i.e. the depth of tooth in bone & the difficulty
encountered in removing the tooth.
If the length of the red line is more than 5mm then the
extraction is difficult.
Every additional millimeter renders the removal of the
Impacted tooth three times more difficult.
29. DIFFICULTY INDEX FOR REMOVAL OF
IMPACTED LOWER 3rd MOLARS
Class I – 1
Class II – 2
Class III- 3
Mesioangular - 1
Horizontal – 2
Vertical - 3
Distoangular - 4
30. Position A - 1
Position B - 2
Position C - 3
INTERPRETATION
Relatively difficult 3-4
Moderately difficult 5-7
Very Difficu1t 7-10
33. WHARFE’S ASSESMENT
3. Angulation of 2nd molar
1- 59° 0
60 -69° 1
70 -79° 2
80 -89° 3
90° & above 4
4. Root shape- Root development
a) Less than 1/3 complete 2
b) 1/3 to 2/3 complete 1
c) More than 2/3 complete:
Favourable curve 1
Unfavourable curve 2
Complex 3
34. WHARFE’S ASSESMENT
5. Follicle
Normal 0
Possible enlarged -1(NEGATIVE)
Enlarged -2(NEGATIVE)
Impaction relieved -3(NEGATIVE)
6. Exit path.
Space 0
Distal cusp covered 1
Mesial cusp covered 2
All covered 3
35. FACTORS RESPONSIBLE FOR INCREASING THE
DIFFICULTY SCORE FOR REMOVAL OF
IMPACTED 3rd MOLRAS.
1. Difficult access to the operative field because of
a. Small orbicularis oris muscle.
b. Inability to open mouth wide enough.
c. Trismus due to infection.
d. Oral sub mucous fibrosis.
e. A large uncontrollable tongue.
f. External oblique ridge ahead of impacted
tooth & vertical.
36. 2. As per the angulation.
3. As per the depth.
4. As per the space available for the
eruption.
5. Dilacerated roots.
6. Hypercementosis.
7. Extremely dense bone.
8. Proximity to mandibular canal.
9. Ankylosed impacted tooth.
10. Large bulbous crown.
11. Long slender roots.
37. SURGICAL PLAN FOR REMOVAL OF
IMPACTED TOOTH.
1. Plan the soft tissue flap for adequate accessibility &
visibility.
2. Decide how the impaction is to be removed i.e. by only
bone removal or by sectioning the tooth or by combination
of the two.
3. Estimate the bone surrounding the tooth to be removed to
give an adequate exposure & facilitate the removal.
4. Plan the method of removal of bone whether with a bur or
with a chisel or combination of both.
5. Select the best direction of removal of the tooth from its
bed & instruments required for the purpose.
6. Consider other factors like Dilacerated roots,
Hypercementosis, Ankylosis, Proximity to inferior alveolar
canal.
38. INSTRUMENTS
.B.P blade Handle- No.3
.No.10 blade-Skin incision
.No.11 blade-Stab incision( To drain abscess)
.No.12 blade-Mucogingival incision
.No.15 blade-Intraoral surgery
.Dissecting Scissors
i to iv) periosteal elevator- Flap elevation
v) moon’s probe- Mucoperiosteum elevation
around tooth
39. i)Osteotome- Various osteotomy
procedures,Biopsy of bony
lesion,Recountouring of bone.
ii,iii,iv) chisel- To remove chips of
bone,to split the tooth.
v)bone gouge
vii) mallet
Warwick-James Straight elevator:
for removal of anterior apical root
pieces.
40. Straight elevators- For luxation of
teeth.
i) straight elevator- For luxation of
teeth.
ii) hockey stick elevator(London
hospital elevator)-For removal of root
stumps of mand.molars.
iii) apexo elevator- For removal of root
stumps of both maxillary and
mandibular teeth .
41. Winter cryer’s elevators- For removal of
root stumps of mandibular molars.
i)Cryer’s elevators- For removal of root
stumps of mand.molars.
ii)Crane pick-To establish insertion of
other elevators & removal of impacted
third molars.
42. PRINCIPLES OF ELEVATORS
Lever Principle:This is the most commonly used
principle.the elevator is a lever of the first order,in
this the fulcrum is between the effort and the
resistance.In order to gain mechanical advantage,
the effort arm must be longer than the resistance
arm.
Wedge Principle:The wedge elevator is forced
between the root and the bone,parallel to the long
axis of the tooth.The wedge is a movable inclined
plane which overcomes a large resistance at right
angle to the applied effort and it is usually used in
conjunction with the lever principle.
Wheel and Axle: The wheel and axle principle is
actually a modified form of lever principle.The
effort is applied to circumference of wheel which
turns the axle so as to arise weight.The principle is
used with wedge and sometimes with the lever
principle.The principle is applicable to the
crossbar elevators.
43. SURGICAL REMOVAL OF IMPACTED TEETH
1. Isolation of surgical site.
2. Anesthesia: Local Anesthesia/general
anesthesia.
Depending on
a. Length & technical difficulty of the
procedure.
b. Patients acceptance of the procedure.
c. Patients apprehension level.
d. The patients systemic condition.
e. Economic factor.
44. 3. INCISION-FLAP DESIGN
WARDS INCISION MODIFIED WARDS INCISION
For superficial tooth
impactions)
(For deep tooth impactions)
Parts of incision:ANTERIOR LIMB,with or without INTERMEDIATE LIMB,POSTERIOR LIMB
Anterior releasing incision begins from vestibule upwards towards midway of
CEJ and anterior to second molar then incision is continued in the gingival
sulcus upto the distal aspect of third molar. Distal releasing incision begins from
distal most point of the third molar across external oblique ridge in to the buccal
mucosa, to avoid damage to bleeding from buccal vessels, anastomosing branches
of lingual and facial arteries and fibers of the temporal muscle(trismus) and
Herniation of buccal fat pad into the surgical field.
49. 4. 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).
How much bone has to be removed?
1. Bone should be removed till we reach below the height
of contour, where we can apply the elevator.
2. Extensive bone removal can be minimized by tooth
sectioning.
50. DIFFERENCES BETWEEN BUR &
CHISEL TECHNIQUE
Sl.No Criteria. Chisel&Mallet Bur
1. Technique Difficult Easy.
2. Controll over bone cutting Uncntrolled&cha
nces of fracture is
more.
Controlled.
3. Patient acceptance. Not tolerated in
L.A.
Well tolerated in
L.A.
4. Healing of bone. Good Delayed Healing
5. Postoperative edema Less More.
6. Dry socket. Less. More.
7. Postoperative Infection. Less. More.
51. 5. TOOTH SECTIONING, ELEVATION &
EXTRACTION.
Advantages of the tooth division technique (Pell and
Gregory , 1942):
1.Bone removal is eliminated or considerably reduced,
resulting in less post-operative pain and swelling.
2. There is less chance of damage to the adjacent tooth
because no effort is made to force the impacted tooth
past the convexity of the second molar, which would
tend to elevate it out of the socket.
3. The risk of fracture of the jaw is reduced, since most
fractures occur from forced elevation
4. Danger of injury to the inferior alveolar nerve is
reduced.
53. HENRY’S GERMECTOMY PROCEDURE
Flap design Bone removal Tooth germ removal
(Tech.for tooth germ removal before or immediately after initiation of tooth mineralization)
54. Advantage: Facilitate certain type of orthodontic
treatment such as distal movement of premolars,
molars, to prevent ectopic eruption of second molar
and also reduces the extensive surgical procedure due
to the smaller size of the developing third molar.
Disadvatage: Prediction of removal and preservation
of third molar indicated at such early stage.
55. LATERAL TREPANATION TECHNIQUE
(BOWDLER HENRY).
Flap design Bone removal Tooth sectioning
(partially formed mandibular third molar)
‘٭S’ shaped incison abt 25mm from retromandibular fossa
٭ across external oblique ridge to anterior border of
٭1st permanent molar,leaving cuff of attached mucoperio-
٭-steam 5mm width distobaccally to second molar is the
٭advantage.
56. INCISION VERTICAL STOP CUT
HORIZONTAL CUT DISTAL CUT
REMOVAL OF DISTAL
& BUCCAL BONE
REMOVAL OF
LINGUAL BONE CLOSURE
ELEVATION
Split bone technique of Sir William Kelsey Fry1933
57. •supporters claim following
advantages.
Faster tooth removal.
Less risk of inferior alveolar nerve damage.
Lessened risk of damage to the periodontium of
the second molar.
Lessened risk of socket healing problems.
58. CRITICISM OF THIS TECHNIQUE HAS
RELATED TO
• Risk of damage to the lingual nerve.
• Increased risk of postoperative infection
and greater danger of spread.
• Patient discomfort due to the use of a
chisel and mallet for lingual bone
removal or fracturing.
59. INCISION VERTICAL STOP CUT DISTAL CUT
TOOTH ELEVATION CLOSURE
MODIFIED LINGUAL SPLIT TECHNIQUE FOR REMOVAL OF
MANDIBULAR THIRD MOLAR (Dr.DAVIS 1979)
65. 6. DEBRIDEMENT AND
SMOOTHENING OF BONE MARGINS.
• Irrigation of the socket
• Curreting to remove any remaining dental
follicle & epithelium
• check for pieces of tooth, bone granulation
tissue & bleeding points.
• Round off the margins of the socket with
vulcanite round bur or bone file.
• Irrigate the socket again.
66. 7. CLOSURE—SUTURING.
Soft tissue flap immediately posterior to
second molar should be sutured first &
should be water tight to prevent pocket
formation.
67. COMPLICATIONS.
* Intra operative complications.
1. During incision
a.Injury to facial artery.
b.Injury to lingual nerve.
2. During bone removal
a. Damage to second molar.
b. Slipping of bur into soft tissue & causing
injury.
c. Fracture of the mandible when using chisel &
mallet.
68. 3. DURING ELEVATION OR TOOTH
REMOVAL.
a. Luxation of neighboring tooth.
b. Soft tissue injury due to Slipping of elevator.
c. Injury to inferior alveolar neurovascular
bundle.
d. Fracture of mandible.
e. Forcing tooth root into submandibular space
or inferior alveolar canal.
f. Breakage of instruments.
g. TMJ Dislocation.
69. POST OPERATIVE COMPLICATIONS
a. Pain.
b. Swelling.
c. Trismus.
d. Infection.
e. Paresthesia of Lingual or Inferior alveolar nerve.
f. Dry socket.
71. CLASSIFICATION
A) Relative depth of the impacted maxillary third molar in
bone.
Class A: lowest portion of the crown is on a line with the
occlusal plane of 2nd molar.
Class B: lowest portion of the crown is between the occlusal
plane of 2nd molar and cervical line.
Class C: lowest portion of crown is at or above the cervical line
of the 2nd molar
B) Position of the long axis of the impacted maxillary 3rd
molar in relation to the long axis of the 2nd molar.
1. Vertical 2. Horizontal 3. Mesioangular 4. Distoangular
5.Inverted 6. Buccoangular May also occur simultaneously
in .:. Buccal version .:.Lingual version .:. Torso version
72. C) Relationship of the impacted maxillary 3rd
molar to the maxillary sinus
1 Sinus Approximation (SA) -no bone or a thin
partition of bone between the impacted 3rd
molar and the maxillary sinus.
2 No Sinus Approximation (NSA) -2mm or more
bone between maxillary 3rd molar and the
maxillary sinus.
73. FACTORS COMPLICATING
THE REMOVAL
1. Approximation to maxillary sinus.
2. Presence of impacted 3rd molar partly within
immediately above roots of 2nd molar.
3. Fusion of roots of 3rd molar with roots of 2nd
molar.
4. Abnormal root curvature.
5. Hypercementosis.
80. FRACTURE OF THE MAXILLARY
TUBEROSITY.
1. Immediate excision of the tuberosity.
2. Removal of the third molar from the
mobile tuberosity.
3. Immobilization until bony healing and
tooth removal.
82. ETIOLOGY FOR IMPACTED
MAXILLARY CANINE.
• Space loss.
• Ectopic position of the tooth germ.
• Delayed resorption of the primary
canine.
• Hereditary causes.
• Cleft lip and palate deformity.
83. CLASSIFICATION OF IMPACTED
MAXILLARY CANINES.
Class I- Impacted canine located in palate.
1. Horizontal.
2. Vertical.
3. Semi vertical.
Class II- Impacted cuspids located in labial or
buccal surface of maxilla .
1 .Horizontal
2. Vertical
3. Semi vertical.
84. Class III- Impacted cuspids located in both
palatal process and labial or buccal
maxillary bone.E.g., crown is on palate and
root passes through between roots of
adjacent teeth in alveolar process, ending in
sharp angle on labial or buccal surface of
maxilla.
Class IV - Impacted cuspids located in alveolar
process, usually vertically between incisor
and first bicuspid.
Class V - impacted cuspids located in an
edentulous maxilla.
87. REMOVAL OF IMPACTED
MAXILLARY CANINE IN CLASS III
POSITION
I
FE
BR
RR
PI
FE
Palatally crown removal
Palatal flap
Closure
Buccal flap Closure
Only Root portion
Removal
89. Classification of impacted mandibular canine
LABIAL ABERRANT
_Vertical _at inferior border
_Oblique _On opposite side
_Horizontal
90. REMOVAL OF IMPACTED MANDIBULAR
CANINE
I
I
FR
Labial
Drilling Holes
Window with
Crown exposed
Flap Closure
Removal of crown portion
Removal of root portion
91. CONCLUSION
We discussed varies impacted tooth in the oral
cavity of their aetiology,classifications,
indications and contraindications for removal of
tooth,diagnosis, treatment plan with surgical
and post surgical complications.
