This document discusses impacted teeth. It begins by defining an impacted tooth and listing some of the main theories for why teeth become impacted, including lack of space, obstruction of eruption, and hereditary factors. It then classifies impacted teeth based on their location, angle, and depth. The document outlines indications and contraindications for removal of impacted teeth as well as techniques for surgical extraction. Specific procedures for impacted canines and techniques to reduce risk of injury to the inferior alveolar nerve during removal of impacted lower third molars are also described. Potential complications of impacted tooth removal are listed.

1. IMPACTED TEETH
Dr SamreenYounas
PGR FCPS OMFS
King Edward Medical University
Lahore

2. OUTLINE
 Definition
 Theories of impaction
 Classifaction
 Indicatiions and contraindications
 Steps of extracton
 Canine impaction
 Complications

3. DEFINITION :-
 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. THEORIES OF IMPACTIONTHEORIES OF IMPACTION
ORTHODONTIC
Jaw growth and
movement of
teeth
PHYLOGENIC
Disuse causes
slow atrophy of
organ
MANDELIAN
Heredity
PATHOLOGICAL
Chronic
infections
ENDOCRINE
Growth
Hormone

5. LOCAL CAUSES
1. Inadequate space
2. Inclination
3. Obstruction of tooth eruption – Irregularity in position &
presence of an adjacent tooth , Density of the overlying &
surrounding bone , Cysts & tumours, Odontomes, Supernumerary
teeth
4. Retained deciduous teeth
5. Ankylosis of primary or permanent teeth
6. Dilaceration of roots(trauma)
7. Ectopic position of tooth bud
8. Non absorbing alveolar bone

6. SYSTEMIC CAUSES
Prenatal causes -Hereditary
Postnatal causes – Rickets, anaemia, tuberculosis,
congenital syphilis,
malnutrition
Endocrinal disorders – Hypothyroidism, hypopituitarism,
achondroplasia (Due to lack of osteoclastic activity)
Hereditary linked disorders – Osteopetrosis,
Cleidocranial dysostosis, Cleft palate.Down syndrome, Hurlers
syndrome, Gardner’s syndrome, Aarskog syndrome,
Zimmerman-Laband syndromeand Noonan’s syndrome,

7. FREQUENCY OF IMPACTION
Mandibular 3rd molar
Maxillary 3rd molar
Maxillary cuspid
Mandibular cuspid
Mandibular premolar
Maxillary premolars
Maxillary central and
lateral incisors

8. CLASSIFICATION

10. MAANDIBLE
Mesioangular
43%
Horizontal
3%
Vertical
38%
Distoangular
6%
Disangular
25%
Vertical
63%
Mesioangular
12%
MAXILLA

11. PELL AND GREGORY
Class 1
Class 2 Class 3
Relation to anterior
Ramal border

12. PELL AND GREGORY
Relation to occlusal plane Class A
Class B
Class C

14. ADA-AAOMS CLASSIFICATION
 07220-
Soft tissue impaction.
 07230-
Partially bony impaction.
 07240-
Completely bony impaction.
 07241-
Completely bony impaction with unusual
surgical complications.

15. DIFFICULTY INDEX

16. WINTER’S LINES
 White line: It indicates the difference in occlusal
level of second and third molars.
 Amber line; This line denotes the alveolar bone
covering the impacted tooth and the portion of
the tooth not covered.
 Red Line: It indicates the amount that will have
to be removed before elevation. Red line <5mm:
extraction - easy, there after every 1mm increase
in depth increases the difficulty three folds & if it
is >9mm then plan the surgery under GA.

17. WHARFE’S ASSESMENT
 W… Winter’s classification
 H….Hight of mandible
 A…Angulation of 2nd molar
 R… Root shape and morphology
 F….Follicle development
 Path of Exit of tooth during extraction

18. PEDERSON DIFFICULTY INDEX
DIFFICULTY
INDEX
Minimal difficult
3-4
Mod. Difficult
5-7
Very difficult
7-10

19. Factors that Make Surgery More
Difficult
 Disto-angular impaction
 Class 3 ramus
 Class C depth
 Long thin roots (present in the older patient)
 Divergent curved roots
 Narrow periodontal ligament (present in the
older patient)
 Dense, inelastic bone (present in the older patient)
 Contact with 2nd molar
 Close to IDN
 Complete bony impaction

20. INDICATONS FOR REMOVAL

21. NICE(NATIONALINSTITUTE FOR CLINICAL
EXCELLENCE) GUIDELINES ON EXTRACTION
OFWISDOM TEETH.
 The practice of prophylactic removal of pathology-free
impacted third molars should be discontinued .
 Surgical removal of impacted third molars should be
limited to patients with evidence of pathology, or
teeth impending surgery or within field of tumor.
 The evidence suggests that a first episode of
pericoronitis, unless particularly severe, should not be
considered an indication for surgery. Second or
subsequent episodes should be considered the
appropriate indication for surgery.
https://www.nice.org.uk/guidance/GID-TAG525/.../final-protocol

22. CONTRAINDICATIONS
1. Extremes of age
2. Compromised medical status
3. Excessive risk of damage to adjacent
structures
4. When there is question about future status
of 2nd molar
5. Fracture risk of atrophic mandible
6. Abutment selection

23. Pre-Operative Assessment
 History
 Clinical examination
 Radiographic examination
INTRAORAL
Periapical
Occlusal
EXTRAORAL
For Mandible, OPG, Lateral oblique
For Maxilla, OPG, Water’s view
CBCT

24. TUBE SHIFT LOCALIZATIION(Clark)
SLOB Rule
Same Lingual Opposite Buccal
Identify buccal or lingual location of impacted
teeth.

25. SEQUENCE OF PROCEDURE
1) Isolation.
2) Anaesthesia
3) Incision- Flap design.
4) Removal of overlying bone.
5) Sectioning of tooth.
6) Delivery of sectioned tooth.
7) Smoothening & debridement of socket.
8) Arrest of haemorrhage
9) Closure of wound.
10) Follow up

26. ENVELOPE FLAP

27. INCISIONS AND FLAPS
 L – shaped flap
(2nd molar para
marginal Flap with
vestibular extension
 Bayonet – shaped flap
 (2nd molar sulcus incision
 With vestibular extension)

28. Buccal extension Triangular
Ward’s Modified Ward’s

29. Coma shaped incision
‘S’ shaped incision

30. VESTIBULAR TONGUE SHAPED FLAP
(Berwick,1966)
Extend onto the buccal shelf of the mandible
Incision line doesnt lie over the bony defect
created by the removal of the impacted teeth
Its base is distolingual aspect of the
second molar

31. BONE REMOVAL
The bone on the occlusal aspect of the tooth is removed first .
Then bone on the buccal aspect of the tooth is.
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.

32. SECTIONING OF TOOTH

33. DELIVERYOF SECTIONED TOOTH

34. Debridement of Wound & Closure
 Thorough debridement of the socket .
 Smoothening of sharp bony margins by Bone file / burs.
 Thorough irrigation of the socket .
 Initial wound closure is achieved by placing 1stsuture just
distal to 2ndmolar, sufficient number of sutures to get a
proper closure.

35. IMPACTED CANINE

36. INCIDENCE
 Maxillary canine impaction occurs in
approximately 2% of the population.
 More common
In females than in males
Maxillry than mandibular
Palatally placed than labially in maxilla
Labially placed than lingual in
mandible

38. CLASSIFICATION OFIMPACTED
MANDIBULAR CANINE
Labial Aberrant
Vertical At inferior border
Oblique On the opposit side
Horizontal

39. DEPTH OF IMPACTED CANINE
 Grade 1:
 Grade 2:
 Grade 3:
 Grade 4:

40. MANAGEMENT OF IMPACTED
CANINE
(1) No treatment except monitoring
(2) Interceptive removal of primary canine
(3) Surgical removal of the impacted canine
(4) Surgical exposure with orthodontic
alignment
(5) Autotransplantation of the canine

41. Surgical removal of the impacted
canine
 If it is ankylosed .
 Root resorption.
 Dilacerated root.
 If the impaction is severe ,e.g., the canine is lodged
between the roots of the central and lateral incisors.
 If the occlusion is acceptable, with the first premolar in the
position of the canine.
 Pathologic changes (e.g., cystic formation, infection)

42. .
FLAP DESIGN:
canine is located buccally- Angulated flap
canine is high & buccally – Semilunar flap

43. Palatally impacted

45. INTRA OPERATIVE
1. During incision
a. Injury to facial artry
b. Injury to lingual nerve
c. Hemorrhage
2. During bone removal
a. Damage to second molar
b. Slipping of bur into soft tissue & causing injury
c. Extra oral/ mucosal burns
d. Fracture of the mandible when using chisel & mallet
e. Subcutaneous emphysema
3. During elevation or tooth removal
a. Luxation of neighbouring tooth/ fractured restoration
b. Soft tissue injury due to slipping of elevator
c. Injury to inferior alveolar neurovascular bundle
d. Fracture of mandible
e. Tooth displacement
f. Breakage of instruments
g.TMJ Dislocation – careful history

46. POST OPERATIVE COMPLICATIONS
 Pain
 Trismus
 Periodontal defect
 Echymosis/hematoma
 Wound dehiscence
 Infection
 Dry socket
 Oroantral fistula
 Oronasal fistula
 Loss of vitality of neighboring teeth

47. NERVE INJURY
 IAN: immediate disturbance 1-5%
 Lingual N: immediate - 0.4-1.5%
 96% IAN injuries show spontaneous recovery
within 9 months, better than lingual nerve
which is about 87%
 Beyond 2yrs recovery is unlikely

48. DRY SOCKET(2-20%)
DEFINITION
“postoperative pain in and around the
extraction site, which increases in severity
at any time between 3 and 4days after the
extraction accompanied by a partially or
totally disintegrated blood clot within the
alveolar socket with or without halitosis.”

49. .
First described by CRAWFORD
SYNONYMS
 Alveolar osteitis(ao)
 Alveolitis
 Localized osteitis
 Alveolitis sicca dolorosa
 Localized alveolar osteitis
 Fibrinolytic alveolitis
 Septic socket
 Necrotic socket
 Alveolalgia

50. ETIOLOGY
Suggested factors include
-Oral micro organisms(Trepanoma denticola)
-Traumatic surgery
-Roots or bone fragments remaining in the wound
-Excessive curettage of the alveolous after
extraction
-Physical dislodgement of the clot
-Oral contraceptives-estrogens, like pyrogens, will
activate the fibrinolytic system indirectly
-Smoking

51. SIGNS AND SYMPTOMS
 Moderate to severe pain without signs of
infection.
 Frequently radiates to ear.
 Exposed bone is necrotic.
 Socket has a bad odor.
 Unpleasant taste.
 Regional lymphadenopathy(occasionally)
 Trismus

52. PREVENTION
 Use of good quality current preoperative radiographs
 Careful planning of the surgery
 Use of good surgical principles
 Extractions should be performed with
minimum amount of trauma and maximum amount of care
 Confirm presence of blood clot subsequent to extraction (if absent,
scrape alveolar walls gently)
 Pre and post op antimicrobial mouth rinses.
 Topical antibiotics(Tetracyclines)

53. . Encourage the patient to stop (or)limit smoking in t
he immediate postoperative period
 Advise patient to avoid vigorous mouthrinsing for
the first 24 hr post extraction & to use gentle tooth
brushing.
 For patients taking oral contraceptives
extractions should ideally be performed
during days 23 through 28 of the menstrual cycle
 Comprehensive pre- and postoperative
verbal instructions.

54. MANAGEMENT
 Gentle irrigation with warm saline.
 Pack iodoform gauze socked with medications change
every other day for 3-6 days.
 Intra-alveolar medicaments(controversial)
-eugenol
-topical LA
-Balsam of Peru
-antifibrinolytic agents.
Analgesics.

55. IANI-RISK REDUCING
PROCEDURES

56. RODE’S CRITERIA
Darkening Deflection Narrowing Dark and bifid
Radiological changes in roots
Calcification of inferior
alveolar canal is completed
before the roots of 3rd molar
are formed. Thus growing
roots may impinge upon the
canal or get deflected.

57. RODE’S CRITERIA
Radiological changes in canal
Loss of lines Diversion of canal Narrowing

58. Coronectomy – oral surgery’s answer to modern
day conservative dentistry
 A method of removing the crown of a tooth but leaving
the roots untouched, which may be intimately related
with the inferior alveolar nerve, so that the possibility
of nerve injury is reduced.
 first proposed in 1984 by Ecuyer and Debien.
 Also known as intentional partial odontoectomy, partial
root removal and deliberate vital root retention
BASIS FOR CORONECTOMY
It is common practice for broken fragments of the root of
vital teeth to be left in place and most heal uneventfully.

59. CORONECTOMY
Coronectomy:A, cutting crown below cement-enamel junction
(arrow); B, trimming cutted surface to less than 3 to 4 mm
below alveolar crest.

60. FATEAFTER CORONECTOMY
 Bone formation over the retained root fragment.
 In all cases the root fragments move into a safer position with
regard to the nerve and it can be envisaged that should removal
become necessary the nerve would not then be at high risk.
 Root migration is more in distoangular impaction.
 Dry socket can be treated in the conventional manner with
irrigation and dressing, if it occurs.
 There does not appear to be any need to treat the exposed pulp
of the tooth.

61. CASES TOAVOID
Teeth
1) infected
2) mobile
3) horizontally impactedalong the course of the inferior
alveolar nerve
DRAWBACKS OFCORONECTOMY
Root walk out duringsurgery(FAILED CORONECTOMY)
Deep periodontal pockets on the distal of the second molar,
Delayedpostoperative root migrationwith the possibleneed of a
second procedure
Postoperative pain
Dry socket
Infection

63. Postoperative radiograph after
the right mandibular third
molar was surgically sectioned.
The space distal to the second
molar would allow mesial
migration of the impacted
tooth.
Three months after odontectomy.
The third molar moved mesially.
However, the mesial root was still
in contact with the alveolar canal.
A second sectioning was required.

64. Postoperative radiograph after second
sectioning of the right mandibular third
molar. A pulpotomy has been performed.
More space was created distal to the right
mandibular second Molar to allow further
migration
Periapical radiograph obtained 2 months
after second sectioning.At that time, the
roots were away from the alveolar canal,
and a riskless extraction could be
scheduled.

65. ORTHODONTIC EXTRUSION
1. Risk of direct trauma to IAN is eliminated
2. A potential problem with this technique is soft tissue
damage.
3. Difficult in working in this area
4. no applicable for ankylosed teeth.
5. It is time consuming and not
always successful

66. PERICORONALOSTECTOMY
 The removal of the overlying bone to allow for the tooth
to erupt away from the IAN,in cases of incomplete root
formation in younger patients 14 to 18 years old

67. THANKYOU
