1) The document discusses impacted teeth, which are teeth that fail to fully erupt. It describes common causes and locations of impactions as well as classification systems. 2) Surgical removal of impacted teeth involves asepsis, anesthesia, incisions, bone removal, tooth sectioning, elevation and extraction while protecting surrounding structures. 3) Radiographs aid in determining the depth, orientation and relationship to nearby anatomy to assess difficulty prior to surgery. Careful treatment planning is important for safe and effective removal of impacted teeth.

1. IMPACTION
Presented by
-Tanvi Koli

2. TERMINOLOGIES
 Impacted tooth
 Unerupted tooth
 Malposed tooth

3. IMPACTED TOOTH
 It is the tooth that has
failed to erupt
completely or
partially to its correct
position in the dental
arch and its eruption
potential has been
lost.

4. UNERUPTED TOOTH
 It is a tooth that is in
the process of
eruption and is likely
to erupt based on
clinical and
radiographic findings.

5. MALPOSED TEETH
 A tooth unerupted or
erupted which is in
an abnormal position
in the maxilla or in
the mandible.

6. COMMONLY IMPACTED TEETH
1. Mandibular third molar
2. Maxillary third molar
3. Maxillary canine
4. Mandibular premolar
5. Maxillary premolar
6. Mandibular canine
7. Maxillary central incisor
8. Maxillary lateral incisor.

7. THEORIES OF IMPACTION
1. Phylogenic theory
2. Mendelian theory
3. Orthodontic theory.

8. CAUSES OF IMPACTION
 LOCAL CAUSE
 Obstruction for eruption
 Lack of space
 Ankylosis of primary or permanent tooth
 Nonabsorbing, over retained tooth
 Nonabsorbing alveolar bone
 Ectopic position of tooth bud
 Dilaceration of roots
 Soft tissue or bony lesions- fibrosis
 Habits.

9.  SYSTEMIC FACTOR
 Prenatal causes- heredity
 Postnatal-tuberculosis, anaemia, ricketts,
malnutrition.
 Endocrinal disorders of thyroid, parathyroid,
pit.gland.
 Hereditary- linked disorders- osteoporesis, cleft
palate.

10. INDICATION
for removal of impacted teeth
 Tooth in line of
fracture.
 Tooth in line of
fire.

11.  Recurrent
pericoronitis
- is the
inflammation of the
gingiva
surrounding a
crown of a partially
erupted tooth.

12.  Deep periodontal
pocket
- associated with
partially erupted
tooth.
 Prior to
orthodontic
treatment
- to control the tooth
crowding in the
mandible.

13.  Prevention of root
resorption and
caries
 Prevention of
pathological
fractures.

14.  Management of
cysts and tumors.
Abscess of
odontogenic
origin
 Management of
preprosthetic
concerns
 Prophylactic
removal

15. CONTRAINDICATION
 Extremes of age
 Compromised medical status
 Excessive risk of damage to adjacent structure
 When there is question about the future status of the
second molar
 Uncontrolled active pericoronal infection
 Socioeconomic status
 Fracture of atrophic mandible may occur
 Abutment selection

16. SIGN AND SYMPTOMS
 Pain
 Difficulty in mastication
 Paraesthesia of lip
 Swelling of retro-molar tissue
 Soreness
 Erythemia of overlaying soft tissue or operculum
 Trismus
 Facial swelling of the affected side
 Raised temperature
 Regional lymphodenopathy.

17. RISK OF NONINTERVENTION
 Crowding of dentition
 Resorption of adjacent tooth and
periodontal status
 Development of pathological conditions
such as infection, cysts, tumors.

18. RISK OF INTERVENTION
 Minor transient- sensory nerve alteration,
alveolitis, trismus and infection. Haemorrhage,
dentoalveolar fracture and displacement of
tooth.
 Minor permanent- periodontal injury, adjacent
tooth injury, temporomandibular joint injury.
 Major – altered sensation, vital organ infection,
fracture of mandible, maxillary tuberosity.

19. CLASSIFICATION OF IMPACTED
TOOTH
1. WINTER’S CLASSIFICTION
 Acc to angulation
1. mesioangular
2. horizontal/ transverse/ inverted
3. vertical
4. distoangular
5. buccoangular
6. linguoangular

20. Winter’s classification
acc to angulation

21.  Acc to depth
1. Position A : highest position of the tooth
is on a level with or above the occlusal line.
2. Position B : highest position is below the
occlusal plane, but above the cervical level of
the second molar.
3. Position C : highest position is below the
cervical level of the second molar.

22. acc to depth
Position A
Position B
Position C

23.  Pell and Gregory’s classification
relationship of the impacted lower third molar to ramus
of the mandible and the second molar.
1. Class I : sufficient space available between the anterior
border of the ascending ramus and the distal side of
the second molar for the eruption of the third molar.
2. Class II : the space available between the anterior
border of the ramus and the distal side of the second
molar is less than the mesiodistal width of the crown of
the third molar.
3. Class III : the third molar is totally embedded in the
bone from the ascending ramus because of absolute
lack of space.

24. Pell and Gregory’s classification
Class I
Class II
Class III

25.  Maxillary third molar classification
acc to relation to the floor of maxillary sinus.
1. Sinus approximation (SA)- no bone or thin
bony partition present between impacted
maxillary third molar and the floor of the
maxillary sinus.
2. No sinus approximation (NSA)- 2mm or more
bone is present between the sinus floor and the
impacted maxillary third molar.

26. Maxillary third molar classification
NSA SA

27.  Classification of impacted maxillary
canines
1. class I : palatally placed maxillary canine
a. Horizontal
b. Vertical
c. semivertical
2. class II : labially or buccally placed maxillary
canine
a. Horizontal
b. Vertical
c. semivertical

28. 3. class III : involving both buccal and palatal
bone
4. class IV : impacted in the alveolar process
between the incisors and first premolar.
5. class V : impacted in edentulous maxilla.

29. Classification of impacted maxillary
canines

30. DIFFICULTY INDEX
 Pederson difficulty index
angulationangulation
- mesioangular : 1
- horizontal-transverse : 2
- vertical : 3
- distoangular : 4
depthdepth
- level A : 1
- level B : 2
- level C : 3

31. ramus relationship/ space available
- class I : 1
- class II : 2
- class III : 3
Difficulty index
 Very difficult : 7 to 10
 Moderately difficult : 5 to 7
 Minimally difficult : 3 to 4

32.  Wharfe assessment
six factor chosen for scoring are
 Winter’s classification
- horizontal : 3
- distoangular : 2
- mesioangular : 1
- vertical : 0
 Height of mandible
- 1 to 30 mm : 0
- 31 to 34 mm : 1
- 35 to 39 mm : 2

33.  Angulation of third molar
- 1 to 59 degrees : 0
- 60 to 69 : 1
- 70 to 79 : 2
- 80 to 89 : 3
- 90 + : 4
 Root shape
- favorable curvature : 1
- unfavorable curvature : 2
- complex : 3

34.  Follicle
- normal : 1
- possibly enlarged : 2
- enlarged : 3
 Path of exit
- space available : 0
- distal cusp covered : 1
- mesial cusp covered : 2
- both covered : 3

35. Radiographic examination
 Radiographic views
 Intraoral
- IOPA
- Occlusal view
 Extraoral
- OPG
- Lateral oblique view
- PA Water’s view

36. Radiological assessment aids in
determining
 Classification of impacted tooth
 Orientation of impacted tooth
 Depth of the tooth
 Root shape
 Relation to inferior alveolar canal
 Localization of impacted tooth

37. 1. Darkening of root
2. Deflection of root
3. Narrowing of root
4. Dark and bifid
apex
1
2
3
4

38. 5. Interruption of
white line of the
canal
6. Diversion of canal
7. Narrowing of canal
5
6
7

39.  Winter’s lines

40. Winter’s lines
 White line – corresponds to occlusal plane.
- indicates the difference in occlusal level of second and third molar.
 Amber line – represents the bone level.
- denotes the alveolar bone covering the impacted tooth and the
portion of tooth not covered by the bone.
 Red line – represents depth of the tooth in bone and the difficulty
encountered in removing the tooth.
- indicates the amount of bone that has to be remover before
elevation.
- if the length of red line is more than 5 mm then extraction is
difficult.
- every additional mm renders the removal of the impacted tooth
three times more difficult.

42. Assessment of third molar
 Case history
 Intraoral and Extraoral examination
 Examination of site of impacted tooth
 Analysis- IOPA and OPG
 Structure
-inferior alveolar nerve
-Lingual nerve
-Pterygomandibular space
-Facial artery
-External oblique ridge
-Retromolar pad
-Retromolar triangle

43. SURGICAL REMOVAL OF IMPACTED
TEETH
1. Asepsis and isolation
2. Local anaesthesia/ sedation+ LA/ general anaesthesia.
3. Incision – flap design.
4. Reflection of mucoperiosteal flap.
5. Bone removal.
6. Sectioning (division) of tooth.
7. Elevation.
8. Extraction.
9. Debridement and smoothening of bone.
10. Control of bleeding.
11. Closure – suturing.
12. Medication – antibiotics, analgesics, etc.
13. Follow-up.

44. Instruments
 Mouth mirror
 Probe
 No 15 blade on a Bard Parker handle.
 Mosquito artery forceps
 Retractors
 Chisel
 Bur: rose head, straight fissure
 Elevators
 forceps
 Bone file
 Needle holder
 Tissue forceps
 Scissors
 Drape
 Syringe

45. Instruments

46. Asepsis and Isolation
 Scrubbing + painting of skin and oral mucosa
- Cetrimide + absolute alcohol or cetrimide + povidine+ iodine
- Cetrimide + absolute alcohol + chlorhexidine.
 Cleaning solution- used on skin to remove residual soap solution.
- Normal saline
-Alcohol – spirit
 Painting solution – act topically to inhibit further growth of microbes
- Povidine – iodine 5% for skin, 1% for oral mucosa
- Chlorhexidine gluconate - 7.5% for skin, 0.2% for rinsing oral
cavity.
 Drape the patient

48. Local anaesthesia
 For mandibular molar and canines – pterygomandibular
nerve block.
 For maxillary molars – posterior superior alveolar nerve
block and palatine nerve block or infiltration.
 For maxillary canines – infraorbital nerve block + palatal
infiltration of incisive canal and bilateral palatine nerve
blocks.

49. Infraorbital nerve block
Posterior superior
alveolar nerve block

50. Incision
(flap design)
 Incision should be away from surgical site.
 Not on vital structure.
 Should be perpendicular to tissue
 Triangular flap recommended for
adequate blood supply.

51. For Mandibular Molars
Vertical mucoperiosteal flap Envelope flap

52. For Maxillary Molars

53. For Maxillary Canine
Gingival crevicular incision
Palatally placed canine

54. For Mandibular Canine

55. 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 a tooth.
 Two ways of bone removal
1. High speed, high torque handpiece and technique
2. Chisel and mallet technique.
 Adequate amount of bone should be
removed to enable for elevation

56. Bur technique
 No. 7/8 round bur or a straight no. 703 fissure bur is
used.
 Sealed bearing handpieces or surgical handpieces with
extra ball bearing must be used.
 Medium speed drills(12000- 20000r.p.m) are preferred
for dento -alveolar surgery.
 The bur is used in sweeping motion around the occlusal ,
buccal and distal aspect of the crown to exposed it.
 Once the crown has been located, the buccal surface of
the tooth is exposed with the bur to the cervical level of
the crown and a buccal trough or gutter is created.
 Continuous irrigation with 1% povidine -iodine or with
normal saline to reduce the thermal necrosis of bone.

57. MOOR AND GLIBSON’S COLLAR TECHNIQUE

58. Lingual split bone technique
 It is described by Sir William Kelsey Fry.
 Later popularized by T. Ward.
 Quick and clean technique.
 Creates saucerization of the socket, thereby
reduces the size of residual blood clot.
 Used for mandibular third molar especially those
are placed lingually.

59. Steps
1. 3mm wide or 5mm wide chisel is used
2. Vertical stop cut is made by placing the chisel with the
bevel facing posteriorly, distal to second molar.
3. With the chisel bevel downward, a horizontal cut is
made backward from the lower end of vertical limiting
stop cut.
4. The buccal bone plate is removed above the horizontal
cut.
5. The distolingual bone is then fractured inward by
placing the cutting edge of the chisel. Bevel side of
chisel facing upward and cutting edge is parallel to the
external oblique ridge.
6. Finally small wedge of bone , which then remaining
distal to the tooth and between the buccal and lingual
cut, is excised and removed.

60. 6. A sharp straight elevator is then applied and minimum
force is used to elevate the tooth, as the tooth moves
upward and backward, the lingual plate gets fractured
and facilitates the delivery of the tooth.
7. After the tooth is removed , the lingual plate is grasped
with the hemostat and freed from the soft tissue and
removed
8. Smoothening of the edges is done with bone file.
9. Wound irrigated and sutured

61. Lingual split bone technique

62. Tooth sectioning, elevation and
extraction
 Reduces amount of bone removal required prior to
elevation of the tooth.
 Reduces the risk of damage to the neighboring teeth.
 The direction in which impacted tooth should be
sectioned is dependent on the angulation of the
impacted tooth, based on line of draw of the segments.
 Can be performed either with bur or chisel.
 The bur is used in controlled fashion to avoid damage to
the vital structures and surrounding teeth and soft issue.
 The tooth is sectioned one-half to three-fourths with bur
and then it is completely sectioned with the elevator.

63. Tooth sectioning, elevation and
extraction
Sectioning of the
1. Horizontally placed
lower third molar
2. Mesiobuccally placed
molar
3. Vertically placed molar
4. Distobuccally placed
molar

64. Elevation
1. Coupland elevator- placed at the base of
the crown.
2. Winter cryer’s – may be used in wedging
action/ buccal elevation.
 Wedging action is useful, when molar crown is
split vertically down to bifurcation of roots

65. Coupland elevator
Winter cryer’s elevator

66. Debridement and smoothening of
bone margins
 Irrigation of the socket.
 Curetting to remove any remaining dental follicle and
epithelium.
 Look for piece of coronal portion, check for remnants of
bone /granulation tissue, bleeding points.
 Check for caries/ erosion/damage to the adjacent teeth.
 Round off the margins of the socket with large vulcanite
round bur or bone file.
 Irrigate the socket again.
 Control bleeding before suturing.

67. closure
 3-0 black silk and 21or 22mm half circle or 1 25 mm, 5/8
circle cutting needle is commonly used.
 Interrupted sutures given and maintained for 7 days.
 In case of molars, suture distal to second molar should
be placed first and should water tight to prevent pocket
formation.
 In case of palatally placed canines, incisive papilla
should be sutured carefully to reduce postoperative
bleeding.

68. Principle of suturing
 Use few suture as possible
 Should not be excessively tight.
 Suture should penetrate the lingual flap
close to and behind the third molar and
the buccal flap further distally

69. Interrupted sutures

70. Post Operative instruction
 Pressure pack for 1hr.
 Ice application
 Soft diet for 1st
two days
 1st
dose of analgesic should be taken before the
anesthetic effect of LA wears off
 Avoid gargling / spitting / smoking / drinking with straw
 warm water saline gargling after 24 hrs + mouth wash
regularly thereafter
 Suture removal after 7 days.

71. COMPLICATION
 Intraoperative complications
During Incision
- for molars- facial vessel or buccal vessel may be cut.
- for lower canines- mental vessel may e damaged.
- for upper canines- incisive canal or greater palatine
vessel may be damaged.
During Bone Removal
- damage to the second molar, damage to the roots of
overlying teeth, slipping of the bur into soft tissues,
fracture of the mandible when using chisel and mallet

72. During Elevation
- Luxation o neighboring/ overlying tooth
- Fracture of the adjoining bone
- Fracture of the tuberosity
- Slipping of the tooth into pterygomandibular/ temporal
spaces, sublingual pouch and/ maxillary sinus
- Damage to nasal wall/ overlying teeth/ lingual, inferior
alveolar or mental nerve.
During Debridement
- damage to inferior alveolar nerve /lingual nerve
- damage to maxillary sinus.

73.  Postoperative Complications
- pain
- swelling
- trismus
- sensitivity
- loss of vitality of neighboring teeth
- pocket formation
- sinus tract formation
- oroantral fistula
- oronasal fistula

74. Thank you