principles of management of impacted teeth impacted lower third molar impacted upper third molar

1. Principles Of Management Of
Impacted Teeth
Chapter one
DR. HAYDAR MUNIR SALIH
BDS, PHD (BOARD CERTIFIED)

2. Definitions
 An unerupted tooth: is a tooth that is in the process
of eruption and is likely to erupt based on clinical
and radiographic findings.
 Malposed tooth: A tooth unerupted or erupted
which is in an abnormal position in the maxilla or in
the mandible
 Impaction is cessation of eruption of a tooth caused
by a physical barrier or ectopic positioning of a
tooth.

3. 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.

4. Causes of impaction of Teeth
Lack of space in the dental arch (main cause)

5. Causes of impaction of Teeth
Development in abnormal position

6. Causes of impaction of Teeth
Odontogenic tumors and cysts

7. Impacted lower third molar

8. Impacted lower third molars
 The surgical removal of impacted third molars is the most
common oral surgical procedure performed.
 The mandibular third molar tooth germ is usually visible
radiographically by age 9 years, Crown formation is usually
complete by the age 14 years, and they are completely
formed with open apex by age 18 years.
 The eruption of lower third molar is complete at the average
age of 20 years but it can occur up to age 25 years.

9. Indications for removal of impacted lower
third molars
Interference with orthodontic treatment.

10. Indications for removal of impacted
lower third molars
Internal/ External
resorption of the impacted
tooth or adjacent teeth.

11. Indications for removal of impacted
lower third molars
Infection; including
pericoronitis, cellulitis,
abscess and
osteomyelitis.

12. Indications for removal of impacted
lower third molars
Tooth in the line of bone fracture

13. Indications for removal of impacted
lower third molars
Teeth associated with cysts or tumors.

14. Winter & kruger classification of
impacted lower third molars
Based on the relationship of the impacted tooth to the
long axis of the second molar

15. Pell and Gregory classification of
impacted lower third molars
they classified the depth of impaction into two categories

16. Clinical examination
 The mouth opening.
 Oral hygiene.
 General state of the
dentition
 The external and
internal oblique ridges
of mandible
 if there are signs of
pericoronitis

17. Radiographic examination
 The radiographic examination should
demonstrate:
 The whole impacted tooth.
 The investing bone.
 The adjacent tooth.
 The inferior dental (alveolar) canal.
 The anterior border of the ascending ramus

18. Removal of impacted lower third
molar:
Dr. Haydar Munir Salih

19. Radiographic examination: periapical
view

20. Radiographic examination:
Orthopantomogram (OPG)

21. Radiographic Examination: CBCT

22. Radiographic assessment
 Angulation of the impacted tooth.
 The depth of the impacted tooth
 Crown features.
 Root morphology
 Bone density.
 Any associated pathology like cysts or tumors.
 The state of the second molar

23. Relationship of the root of the lower third
molar with the inferior dental (alveolar) canal

24. Removal of impacted lower third
molar:
Dr. Haydar Munir Salih

25. Removal of impacted lower third
molar:
Dr. Haydar Munir Salih

26. Removal of impacted lower third
molar: The incision design
Triangular flap Envelope flap

27. Removal of impacted lower third
molar: bone removal

28. Removal of impacted lower third
molar: tooth sectioning

29. Postoperative care
 bite on a gauze pad for about one hour,
 not to rinse during the first 24 hours,
 the use of ice bag on the face for about 15 minutes on and 15
minutes off for the rest of the day.
 Antibiotics (e.g. Amoxicillin) and analgesics are prescribed,
some clinicians use corticosteroids preoperatively or
postoperatively to reduce the inflammatory response.
 Chlorhexidine mouth wash, twice daily, starting the next
postoperative day.
 Sutures are removed 7 days after surgery.

30. Complications
 Pain, edema and trismusPostoperative hemorrhage.
 Infection and abscess formation.
 Alveolar osteitis (dry socket), Smoking history.
 Preexisting infection.
 Excessive surgical trauma.
 Localized osteomyelitis.
 Temporal or permanent nerve dysfunction of the inferior
dental nerve
 Fracture mandible,
 Loss of the tooth or the root into the lingual space

31. Other lines of treatment :
Coronectomy

32. Other lines of treatment :
Operculectomy

33. Other lines of treatment :
Orthodontic extraction

34. Other lines of treatment :
Surgical transplantation

35. Impacted upper third molars
The main indications for removal include:
Non-functional teeth
Those associated with a cyst or tumor.
Pericoronitis of the partially erupted teeth,
Resorption of the second molars (rare).
Preparation for the provision of prosthesis.

36. Radiographic examination
OPG is the radiograph of choice

37. Archer classification of impacted
upper third molar: Angulation

38. Archer classification of impacted
upper third molar: Depth

39. Surgical technique
Incision flap

40. Surgical technique
After bone removal to expose the crown (if
needed) a Warwick James’ elevator or a straight
elevator is used to elevate the tooth

41. Complications
 Hemorrhage, hematoma formation and periorbital edema.
 Oroantral fistula.
 Infection.
 Dry socket is uncommon in the maxilla
 Displacement of the tooth or root into the maxillary
antrum, this may be retrieved by Caldwell-Luc approach.
 Displacement of the tooth into the infratemporal fossa
 Fracture of tuberosity

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