This document provides an overview of the management of impacted third molars and maxillary canines. It discusses the causes and prevalence of impacted teeth, classifications of impactions, indications and contraindications for extraction, surgical procedures, and complications. Impacted third molars are the most common impacted teeth, with mandibular molars more prevalent than maxillary. Classification systems describe angulation, depth of impaction, and root morphology. Extraction is indicated for pathology but not for asymptomatic teeth. Surgical procedures involve exposure, bone removal if needed, tooth sectioning or elevation, and closure. Post-operative issues may include pain, swelling, and nerve injury.

1. MANAGEMENT OF IMPACTED
Third Molars
Dr. Hadi Munib
Oral and Maxillofacial Surgery Resident

2. OUTLINE
 Impacted vs. Unerupted
 Causes of impaction
 Prevalence.
 Indications for extraction of impacted teeth.
 Contraindications for extraction of impacted teeth
 Classification systems of mandibular third molar impactions
 Root morphology
 Classification systems for maxillary third molar impactions
 Surgical procedure
 References

3. Impacted vs. Unerupted
 An impacted tooth is one that fails to erupt into the dental arch within the
usual range of expected time.
 The term unerupted teeth includes impacted teeth and teeth that are in the
process of erupting.

4. Causes of impaction
 Adjacent teeth
 Dense overlying bone
 Excessive soft tissue
 Genetic abnormality
 Most commonly: inadequate space in the dental arch.

5. Prevalence
 Maxillary and mandibular third molars are the most commonly impacted
teeth, the Mandibular ones are more common] [reason? Age of eruption?]
 Followed by Maxillary canine and mandibular premolars

6. Normal development
 The lower third molar begins in a horizontal angulation, then angulation
changes from horizontal to mesioangular to vertical.
 Failure of rotation from the mesioangular to the vertical direction is the
most common cause of lower third molars becoming impacted.
 The second major factor is space

7. Indications for removal of impacted teeth
 Prevention of caries
 Prevention of periodontal disease
 Prevention of Pericoronitis
 Prevention of root resorption
 Prevention of odontogenic cysts and tumors
 Facilitation of orthodontic treatment

8. General rule
 all impacted teeth should be removed
unless removal is contraindicated.
 The practice of prophylactic removal of
pathology-free impacted third molars
should be discontinued in the NHS. [NICE
GUIDELINES 2015]

9. NICE GUIDELINES 2015
 Surgical removal of impacted third molars should be limited to patients with
evidence of pathology:
 Unrestorable caries
 Non-treatable pulpal and/or periapical pathology
 Cellulitis
 Abscess and osteomyelitis
 Internal/external resorption of the tooth or adjacent teeth
 Fracture of tooth
 Disease of follicle including cyst/tumor
 Tooth/teeth impeding surgery or reconstructive jaw surgery
 When a tooth is involved in or within the field of tumor resection.

13. Contraindications of Removal of Impacted Teeth
 Extremities of age
 Compromised Medical status
 Probable excessive damage to vital structures
 No pathology caused by the presence of the tooth.

14. Classification of mandibular third molar impactions
 Type of overlying tissue
 Winter’s Classification
 Pell and Gregory Classification

15. Type of overlying tissue Classification
 Soft tissue impaction.
 Bony impaction can be either:
 Partial Bony impaction
 Full Bony impaction

16. Winter’s Classification – Based on angulation

17.  Relationship to Anterior Border Of The Ramus:
 Class I
 Class II
 Class III
 Relationship to Second Molar’s Occlusal surface
 Class A
 Class B
 Class C
Pell And Gregory Classification

18. Relationship to Anterior Border Of The Ramus

19. Occlusal Plane Relationship

20. WAR

21. Modified Parant Scale

22. Root Morphology
 Indicators for easier or harder extraction of the impacted tooth:
 Roots Length, distance and curvature
 Size of the Follicular Sac
 Density of the Surrounding Bone
 Contact with the Mandibular Second Molar
 Distance to the ID nerve
 Nature of the overlying tissue

25. Classification For Maxillary Third Molar Impaction
 Angulation:
 Vertical impaction (63%)
 Distoangular impaction (25%)
 Mesioangular 12% of the time.
 Transverse, Inverted, or Horizontal impactions; less than 1%.

26. Degree of Difficulty
 Vertical vs. Distoangular vs. Mesioangular
 Buccopalatal position of the tooth
 Roots length, distance and curvature.
 Follicle size
 Bony Density
 Relationship to adjacent Second Molar.
 The structure and position of the maxillary sinus. ONLY IN MAXILLARY
 Maxillary Tuberosity. ONLY IN MAXILLARY

27. Steps of Management
 Consent Form [ID nerve risk]
 Chief Complaint and History taking
 Clinical Examination.
 Radiographic Examination.
 L.A.
 Flap exposure
 Bone Removal?
 Tooth Sectioning
 Elevation
 Extraction
 Suturing.

28. Surgical Procedure
(1)Adequate exposure of the area of the impacted tooth.
(2)Is bone removal needed?
(3)Is tooth division with a bur needed?
(4)The sectioned or unsectioned tooth is delivered from the alveolar process with
the appropriate elevators.
(5)Bone in areas of elevation is smoothed with a bone file, the wound is thoroughly
irrigated with a sterile, physiologic solution and the flap is re-approximated with
sutures.

35. Post-Operative Complications
 Pain
 Swelling
 Redness
 Dry Socket
 Mandibular Third Molars: ID nerve risk and Trismus
 Maxillary Third Molars: Sinus injury.

36. Impacted Maxillary Canine
 Maxillary canines are second only to wisdom teeth to be impacted
 3 : 1 palatal to labial maxillary canine impactions
 Maxillary impactions are 20X more common than mandibular ones
 8% are bilateral impactions

37. Aetiology
 Long Path of eruption
 Sequence of eruption
 Thick Palatal mucosa
 Missing Lateral Incisor
 Space Considerations
 Delayed Resorption of Primary Canine
 Pathology
 Syndrome
 Trauma
 Supernumeraries

38. Diagnosis
 Clinical Examination
 Maxillary Canine should be palpable in the buccal sulcus by 10 years of
age.
 Presence of Deciduous canine
 Symmetry
 Colour of Adjacent teeth
 Space Availability
 Radiographic Evaluation

39. Radiographic Evaluation
 2 – 3 Periapical X-Rays
 Panoramic X-Ray
 Occlusal X-Ray
 CBCT
 Combination

43. Management
 Consultation
 Leave and Observe
 Extraction
 Exposure
 Exposure and Orthodontic Traction
 Auto-Transplantation

44. Extraction
 Well-Aligned teeth
 Good Contact between Lateral and First Premolar
 Uncooperative patient
 Patient Willingness

45. Surgical Exposure +/- Traction
 Enough space in the arch
 Unobstructed, suitable path of eruption
 Normal apex position by the end of eruption
 Compliant patient
 Orthodontist willing to treat
 Techniques
 Open: Window or Apically Positioned Flap
 Closed

46. Window Exposure

48. Closed Technique

50. Supernumerary teeth
 The supernumerary tooth in the midline of the maxilla, called a mesiodens.
 The supernumerary tooth situated buccally or palatally to one of the maxillary molars
is called a paramolar.
 The supernumerary tooth situated distally to third molars is called Distomolar.

52. References
Chapter 9: Management of
impacted teeth

53. THANK YOU