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1. Theories, General PrinciplesTheories, General Principles
and Management ofand Management of
ImpactionsImpactions
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education

2. Introduction
Definition
Etiology
Theories
Indications for removal
Classification
Management
Post surgical sequelae

3. DefinitionsDefinitions
Impacted tooth- “Tooth which fails to
erupt to its normal anatomic position
in the arch within its chronological
age of eruption”

4. Malposed tooth- “A tooth,unerupted
or erupted,which is in an abnormal
position in the maxilla or mandible”
Unerupted tooth- “A tooth not having
perforated the oral mucosa”

5. Third Molar AgenesisThird Molar Agenesis
Most Common congenitally missing
tooth
9-20% Incidence
Female/Males = 3:2 ratio

6. Impaction FrequencyImpaction Frequency
1. Mandibular Third Molar
2. Maxillary Third Molar
3. Maxillary Canines
4. Mandibular Premolars

7. ETIOLOGYETIOLOGY
Local causes of impaction (Berger’s list)
• Irregularity in the position & pressure of adjacent tooth.
• Density of the overlying & surrounding bone.
• Long continued chronic inflammation with increase in
density of the overlying mucous membrane.
• Lack of space due to underdeveloped jaws.
• Prolonged retention of the deciduous teeth.
• Acquired diseases such as neurosis due to infection or
abscesses.
• Inflammatory change in the bone due to exanthema to us
disease in children

8. Systemic causesSystemic causes
Prenatal Causes
 Heredity
Post Natal Causes
 Rickets
 Anemia
 Congenital Syphilis
 T.B
 Endocrine dysfunction
 Malnutrition
cleidocranial dysostosis
 Cleft Palate.

9. Theories of ImpactionTheories of Impaction
 Orthodontic theory
 Phylogenic theory
 Mendelian theory

10. Indications for removalIndications for removal
– Pericoronitis
– Caries
– Periodontal disease
– Root resorption
– Eruption under
denture
– Associated
pathology
– Facial pain
– Pre irradiation
– Prophylactic

11. Indications for extractionsIndications for extractions
Orthodontic considerations
Crowding of incisiors ???
Obstruction to treatment
Orthognathic surgery

12. Possible Contraindications to removalPossible Contraindications to removal
of Impacted Teethof Impacted Teeth
Extremes of age
Compromised medical status
Surgical damage to adjacent
structures

13. CLASSIFICATION OF IMPACTEDCLASSIFICATION OF IMPACTED
MAXILLARY MOLARSMAXILLARY MOLARS
Winter (1926)Winter (1926) –– 1st to device classification1st to device classification
1. Vertical1. Vertical –– 38% 2. Mesioangular38% 2. Mesioangular –– 43%43%
3. Horizontal3. Horizontal –– 3% 4. Distoangular3% 4. Distoangular –– 6%6%
5. Buccoangula 6.Linguoangular5. Buccoangula 6.Linguoangular
7.Inverted and Unusual7.Inverted and Unusual

15. II.PELL AND GREGORY:
a) Relation of the tooth to ramus of the
mandible &2nd
molar
Class I:-sufficient amount space for
accommodation of mesiodistal diameter
of the crown of the 3rd
molar.
Class II: - The space between the ramus
and distal side of 2nd molar that is less
than mesiodistal diameter of the 3rd
molar.
Class III: - All most of the 3rd molars is
located within the ramus.

16. b) Relative depth of the third molar in the bone
 Position A: - The highest portion of the tooth
is on a level with/above occlusal line.
 Position B: - The highest portion of the tooth
is below occlusal plane, but above the cervical
line of the 2nd molar.
 Position C: - The highest portion of the tooth
below the cervical line of the 2nd molar teeth
in relation to the long axis of impacted 2nd
molar

18. Nature of Overlying TissueNature of Overlying Tissue
Soft tissue impaction
Partial bony impaction
complete bony impaction
Angular, bony impaction of third molar Soft tissue impaction of third molar

19. ManagementManagement
Diagnosis
– History
– Examination
Radiology
– Periapical
– OPG

20. Assessment of surgical difficultyAssessment of surgical difficulty
– Patient compliance
– Access
– Tooth related factors
• Root pattern
• Degree of eruption
• Depth of impaction
• Angulation
• Associated structures
• Age, gender and race

21. Root MorphologyRoot Morphology
length and width
Number
Curvature
AgeAge
Ideal 16-20 years
Roots 1/3 to 2/3 formed

22. Principles of ManagementPrinciples of Management
 Assess the options &alternatives to treatment
 ACCESS
 Logical steps of incision
 Reflect adequate flaps
 Operations on osseous tissues
 Operations on tooth structures
 Delivery of tooth
 Debridement of wound and closure
 Postoperative care

23. Options and alternatives to treatmentOptions and alternatives to treatment
Exposure of tooth to permit eruption
Removal
Long term observation

24. Perioperative Patient CarePerioperative Patient Care
Anesthetic Technique
Antibiotic Coverage
Steriods

25. Assessment of impacted toothAssessment of impacted tooth
Assessment of impacted tooth is done by
1. Physical evaluation
2. Radiographic evaluation
Physical evaluation
It includes inspection and palpation of
 TMJ and movement of mandible
 Determination of mobility characteristics of lips
and cheeks
 Size and contours of the tongue
 Appearance of soft tissue overlying the impacted
teeth

26. Radiographic evaluation
1. Periapical Radiographs
2. Bite wing radiography
3. Occlussal films
4. Lateral view of the mandible
5. Orthopantmograph

27. Using above radiographs assessment, following are considered
A. Root morphology
a) Length of the root –
Optimal time is when the roots 1/3 -2/3 formed.
When this is the case, the ends of the roots are
blunt and almost never fracture.
If the root development is insufficient less than 1/3
of the tooth, it is difficult to remove.

28. Radiographic assessmentRadiographic assessment…………....
b) Single/conical, separate/distinct roots are
noted.
c) Curvature of roots
d) Total width of the roots in mesiodistal
direction should be compared with the width
of the tooth at the cervical line.
e) Assess the periodontal ligament space. More
the width the periodontal ligament space, is
the easier the tooth is to remove.

29. B. Size of follicular sac
C. Density of the surrounding bone
 Younger patient the bone is less dense, is more
likely pliable and expands and blends somewhat,
which allows the socket to be expanded by
elevators/by luxation forces by itself and easier to
cut with bur.
 Patients who are older than 35 years have dense
bone and thus decreased ability to expand. In
these patients surgeon must remove all
interfering bone, because it is not possible to
expand the bone socket. Bone cutting is difficult
and bone removal process takes longer
Radiographic assessmentRadiographic assessment…………....

30. D. Contact with the 2nd molar
 Take care if 2nd molar has carious/large
restoration/root canal treated.
 Locked against second molar there is no
space for elevation, then sectioning of the
tooth should be planned.
E. Nature of overlying tissues -is considered
 Soft tissue covering
 Soft tissue + Bone covering
 Bone
Radiographic assessmentRadiographic assessment…………....

31. F) Inferior Alveolar Nerve and Vessels
Are usually in true osseous canal in the ramus
and body of the mandible. There may be
multiple branches Inferior Alveolar Nerve,
instead of single combined structure. When
Inferior Alveolar Nerve canal identified
radiographically, determine its relationship
with impacted mandibular 3rd molar. Usually
canal will be inferior/buccal to the third
molars, but variations are common
Radiographic assessmentRadiographic assessment…………....

32. Description of radiographic markers
Superimposition
occurs when the
upper and lower
cortical bone of the
mandibular canal is
superimposed on
the root of the third
molar

33. Description of radiographic markers
Increased
radiolucency
consists of a darker
zone where the
anatomy of both the
root and the
mandibular canal
are less defined

34. Interruption of the
radiopaque border of the
canal by the third molar
consists of interruption of
the cortical bone, which
constitutes the mandibular
canal walls. On the
radiograph, these lines
appear radiopaque and
constitute the roof and
floor of the canal. The top
line is interrupted most
frequently
Description of radiographic markers

35. Description of radiographic markers
Diversion of the
canal is
recognizable on
the radiograph
where the canal
bends in proximity
to the root or the
crown of the third
molar

36. Description of radiographic markers
Narrowing consists of a
narrowing of the
diameter of the canal
resulting from close
proximity to the third
molar. This can be
associated with
deflection of the canal
or deflection of the apex
of the third molar roots

37. This can be determined by a method described by
George winter. Similar to cephalometric
radiographic tracing, three lines are drawn on
IOPA radiograph. Three imaginary lines are
known as WINTERS LINES.
White Line represents the occlusal plane, joining
the white enamel caps of the unerrupted molars.
It is extended posteriorly over the third molar
region.
Position and depth of impaction….WINTERS LINE

38. It is estimated that tooth with
less than 5mm long red line
can conveniently be removed
with ease under local
anesthesia. Increase in the
length of the red line of the
every additional mm renders
the removal of impacted teeth
three times more difficult. If the
line is more than 9mm they can
be safely removed under GA
and if the tooth is below the
apices of second molar.
WINTERS LINE ………..

39. Wharfs assessmentWharfs assessment
The six factors chosen for scoring are:
A) Winters classification
B) Height of the mandible
C) Angulations of the molar
D) Root shape
E) Follicle
F) Path of exit of the tooth during removal.

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41. Factors that make impaction surgery more difficultFactors that make impaction surgery more difficult
1. Distoangular
2. Class 3 ramus
3. Class C depth
4. Long, thin roots
5. Divergent curved roots
6. Narrow periodontal ligament
7. Thin follicle
8. Dense, inelastic bone
9. Contact with second molar
10. Close to inferior alveolar canal
11. Complete bony impaction.

42. Factors that Make Impaction Surgery Less DifficultFactors that Make Impaction Surgery Less Difficult
1. Mesioangular position
2. Class 1 ramus
3. Class A Depth
4. Roots one third to two thirds formed.
5. Fused conic roots
6. Wide periodontal ligament
7. Large follicle
8. Elastic bone
9. Separated from second molar
10. Separated from inferior alveolar nerve.
11. Soft tissue impaction.

43. MANAGEMENT OF IMPACTED TOOTHMANAGEMENT OF IMPACTED TOOTH
The options of treatment plans depend on
the patients presenting complaint, the
history, the physical evaluation,
radiographic assessment, the diagnosis
and the prognosis. The treatment plan will
fall into 4 categories.
I. OBSERVATION
II. EXPOSURE
III. TRANSPLANTATION
IV. REMOVAL OF IMPACTED TOOTH

44. The incisionsThe incisions
Incisions is considered in following sequences (posterior-anterior)
 Posterior to the 2nd molar the usual incision takes advantage
at the lateral flare of the ramus and is angled from lateral to
medial as it passes forward, terminating at the distobuccal
aspect of 2nd molar (ensure avoid cutting of lingual nerve).
 The inferior portion of the incision may terminate in any
location, depending on the indication of regional anatomy and
surgeon’s preference, from the distobuccal area of 2nd molar
to bicuspid area.
 Occasionally, there may be no anterior component to incision,
anterior to distoboccual angle of 2nd molar, however usually
the incision passes anteriorly from distobuccal aspect of 2nd
molar and may terminate at the gingival papilla between 1st
and 2nd molar.

45. Types of Incision
Ward Incision
 Modified ward incision.
Envelope incision.
Inverted L or Bionate Incision.
Extended S incision
Comma incision

46. The incisionsThe incisions………………....

47. SURGICAL PROCEDURESURGICAL PROCEDURE
1.Adequat exposure of area of impacted teeth
2.Assess the need for bone removal and to remove a
sufficient amount of bone to expose tooth for
sectioning and delivery.
3.To divide the tooth with a bur or chisel
4. Sectioned tooth is delivered from the alveolar process
with the appropriate elevator
5.Wound is cleaned with irrigation &mechanical
debridement with a curette & is closed with simple
interrupted sutures

48. REMOVAL OF OVERLYING BONEREMOVAL OF OVERLYING BONE
THE AMOUNT OF BONE THAT NEEDS TO BE
REMOVED VARIES WITH THE DEPTH OF
IMPACTION ,MORPHOLOGY OF ROOTS
&THE ANGULATION OF THE TOOTH.
 BUR:
1.NO 8 rose head round bur - pushing motion
2.NO 703 fissure bur - lateral direction.

49. ADVANTAGES OF USING BUR TO CUT BONEADVANTAGES OF USING BUR TO CUT BONE
1. 50% more effective
2. Apposition of new bone and the rate of repair
enhanced when bur is used.
3. Trauma and postoperative pain reduce to 50%.
Lips are less abraded.
4. Post operative swelling slightly decreased.
5. Post operative bleeding relatively same.
6. The length of time required for surgery decreases
to 60%
7. Ease of operation and less fatigue.

50. POSTAG STAMP METHODPOSTAG STAMP METHOD

51. THE REMOVAL OF TOOTH BY USING TOOTH DIVISION
It can be done with
1.osteotoms/chisel
Advt: quick &clean
Disadvt: does not creates any space for manipulation
2.Bur
More time consuming &creates much more debris,
but creates wide cut through the tooth substances
In many instance it is convenient to be begin tooth
division with a bur & complete it with an osteotome.
The line & level of the cuts dividing the tooth should
be such that no root is left completely embedded in
bone.

56.  REMOVAL OF RESIDUAL TOOTH FOLLICLE
 CLOSURE OF SOFT TISSUE FLAP
Objectives
1. Returning of soft tissue flaps is their original
anatomical position on bone.
2. Stabilizing the soft tissue flap and permit
repair.
3. Restoring the additional gingival
attachments.
SURGICAL PROCEDURESURGICAL PROCEDURE…………....

57. PERIOPERATIVE PATIENTS MANAGEMENTPERIOPERATIVE PATIENTS MANAGEMENT
1. Anxiety Control
2. Prescription of Analgesic
3. Use of Parenteral steroids to minimize
swelling.
4. Use of ice pack on face
5. Use of Antibiotics
6. Postoperative instruction and sequelae of
procedure should be explained.

58. Thank YouThank You