Third molar /certified fixed orthodontic courses by Indian dental academy


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Third molar /certified fixed orthodontic courses by Indian dental academy

  1. 1. Impacted third molar INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Impacted third molar
  3. 3. Impacted third molar What its so special about third molar •Frequently encountered surgical problem •Commonly performed oral surgical procedure •General practitioner likely to see first •Need to decide a. Whether to remove or not b. Remove himself/herself or send to a specialist
  4. 4. Impacted third molar How often are teeth impacted? Only 17% of people over 20 years have an impacted tooth Maxillary third molars 22% Mandibular third molars 18% Maxillary canine 0.9% Ref:- Dachi S.F,Hovell oral surgery14:1165.1961
  5. 5. Impacted third molar
  6. 6. Impacted third molar
  7. 7. Impacted third molar
  8. 8. Impacted third molar The exact cause is unclear could be multifactorial 1.Phylogenic theory 2.Mendelian theory 3. Endocrine disorders 4. Skeletal growth disturbances 5.Systemic conditions 6. Local factors
  9. 9. Impacted third molar Indications for removal - Repeated attacks of pericoronitis - Dental caries -Periodontal disease - Resorption of second molar - Prior to orthodontic treatment
  10. 10. Impacted third molar Indications for removal (Continued) - Presence in an edentulous jaw - Involved in cyst formation - Obscure facial pain - In line of fracture of mandible - Prophylactic reasons
  11. 11. Impacted third molar Pericoronitis Infection of the soft tissues around and above the crown of a partially erupted tooth Common condition between ages 17 and 25 Affects males and females equally Highest incidence in spring and autumn Predisposing factors Lowered tissue resistance, Upper respiratory infection Emotional stress, Fatigue, Pregnancy
  12. 12. Pericoronitis Classification Acute, subacute and chronic Acute characterized by -Pain Severe, Throbbing, Radiating, Intermittent, Interferes with sleep, exacerebated by chewing -Extra oral swelling -Limitation of mouth opening -Lymph nodes enlarged & tender
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  15. 15. Acute (continued) Constitutional symptoms Rise in temperature, increased pulse and respiratory rates, looks ill and Leukocytosis Intra-orally Gum pad swollen, tender, red in appearance, pressure causes discharge of pus from beneath the flap and foetor oris
  16. 16. Pericoronitis Management General measures Bed rest is ideal Soft and nourishing diet Relief of pain by analgesics Antibiotic therapy
  17. 17. Pericoronitis Management Local measures Frequent use of hot saline mouth washes Incision and drainage, if pus in buccal sulcus Impinging maxillary third molar removal Removal of third molar after infection has subsided
  18. 18. Dental caries
  19. 19. Periodontal disease
  20. 20. Resorbtion of second molar
  21. 21. Resorbtion of second molar
  22. 22. Impacted third molar Classifications : George Winter’s Pell and Gregory’s Kay’s
  23. 23. George Winter’s classification Based on the relationship of the long axis of impacted 3rd molar with the long axis of 2nd molar:Vertical Mesioangular Distoangular Horizontal Buccoangular Aberrant positons
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  25. 25. Vertical Mesioangular Horizontal Distoangular
  26. 26. Pell & Gregory(1942) Classification Based on three aspects Position & Angulation Space between second molar and ramus Depth of the third molar in the bone
  27. 27. Pell & Gregory classification Position & Angulation George Winter’s Classification is adopted Mesioangular Vertical Distoangular Horizontal
  28. 28. Space between second molar & ramus
  29. 29. Depth of the third molar in the bone
  30. 30. Kay’s Classification ( Based on three aspects) 1.Position & Angulation- Winter’s Classification 2. State of eruption a) Erupted b) Partly erupted c) Unerupted 3. Number & pattern of roots - Fused -Two -Multiple -Favourable -Unfavourable
  31. 31. Difficulty index values (Pederson) Mesioangular 1 Horizontal 2 Vertical 3 Distoangular 4 level A 1 Class I 1 level B 2 Class II 2 level C 3 Class III 3
  32. 32. Difficulty index (Pederson) Minimal 3-4 Moderate 5-7 Very difficult 7-10
  33. 33. Difficulty index (Pederson)
  34. 34. Difficulty index (Pederson)
  35. 35. Difficulty index (Pederson)
  36. 36. Difficulty index (Pederson)
  37. 37. Difficulty index (Pederson)
  38. 38. Difficulty index (Pederson)
  39. 39. Winter’s imaginary lines White Line - Indicates position of 3rd molar Amber Line - Indicates margin of alveolar bone Red Line - Indicates depth of 3rd molar
  40. 40. Assessment of impacted third molar Purpose of assessment Possible difficulties & complications Facilities available Necessary surgical skill Decision to remove or to refer to a specialist
  41. 41. Clinical assessment General factors - Age - Medical condition - Temperament
  42. 42. Clinical Assessment Local factors Small mouth Mandibular retrusion Relationship of external Oblique ridge to the 3rd molar
  43. 43. Radiological assessment - Radiographs required - Periapical film - Lateral oblique view of mandible - Orthopantomogram - Lower occlusal film
  44. 44. Radiological assessment Points to be noticed in radiograph Augulation and depth Number and shape of roots Relationship with mandibular canal Condition of crown & root of 2nd molar Density of the bone Bone loss around the tooth Presence of first molar
  45. 45. Relationship with mandibular canal Normal relationship Variations - Groove - Deep Groove - Perforation
  46. 46. Considerations in predicting difficulty Age Young age old age Easy surgery less morbidity Difficult surgery greater morbidity Facial form Tapering Easy surgery Square & Compact Difficult
  47. 47. Removal of third molar Careful assessment Instruments selection Choice of anaesthesia Operative plan Post operative care
  48. 48. Instrumentation
  49. 49. Choice of Anaesthesia Local Intravenous sedation and local General
  50. 50. Operative plan - Incision - Removal of bone - Removal of tooth - Preparation of the wound - Closure of the wound
  51. 51. Incision Principles of muco periosteal flaps Visibility Vascularity Healing
  52. 52. Impacted third molar Muco periosteal flap Flap consisting mucosa and periosteum Design Visibility Large enough to provide adequate access Viability Broad base wit narrow margin to provide proper blood supply Healing: Line of incision should be placed on sound bone
  53. 53. Impacted third molar Incision Anteriorly starts from the disto-buccal corner of the second molar runs downwards and forwards into the muco-buccal fold Posteriorly starts from middle of the distal aspect of second molar runs backwards and buccally towards external oblique ridge
  54. 54. Incision
  55. 55. Impacted third molar Removal of bone Bone is removed either by using surgical burs or chisel
  56. 56. Complications during surgical removal Incision Hemorrhage Lingual nerve damage Bone removal Injury to soft tissues Damage to 2nd molar Splitting of ramus Damage to bone Elevation of tooth Fracture of tooth Damage to 2nd molar Damage to I.D bundle Fracture of mandible Preparation of the wound Damage to I.D. nerve and vessels
  57. 57. Complications (Postoperative) - Haemorrhage - Haematoma - Oedema - Pain - Trismus
  58. 58. Impacted maxillary canine Classification Labial position Palatal position Intermediate position Unusual position
  59. 59. Impacted maxillary canine Localization-clinical Evidence of eruption Bulge on labial aspect Bulge on palatal aspect
  60. 60. Impacted maxillary canine Localization-radiological Vertex occlusal view Lateral skull radiograph Parallox method of clark
  61. 61. Impacted maxillary canine Management No surgical intervention Surgical exposure & orthodontic alignment Surgical removal & auto transplantation Surgical removal
  62. 62. Thank You