This document provides an overview of impacted teeth and their surgical management. It begins with definitions of impacted, unerupted, and malposed teeth. It then discusses the etiology, theories of impaction, indications for surgery, classifications, and assessments needed prior to surgery. Surgical management involves raising a flap, removing overlying bone, and extracting the tooth. Potential complications during and after surgery are also reviewed.

1. UNDER THE
GUIDANCE OF:
Dr. Akshay Gurha
Dr. Sridhar
Dr. Hemant Bajpai
Dr. Umang Agarwal
PRESENTED BY:
Mausam Tiwari
BDS 4TH Year
(10-11) Batch

2.  INTRODUCTION
 ETIOLOGY
 THEORIES OF IMPACTIONIONS
 INDICATIONS
 CONTRAINDICATIONS
 CLASSIFICATION
 DIFFICULTY INDEX
 PRE-OPERATIVE ASSESSMENT
 RELATIONSHIP OF ROOT TO CANAL
 SURGICAL MANAGEMENT
 COMPLICATIONS
 MANAGEMENT

3.  Embedded or impacted tooth: tooth that has
failed to erupt completely or partially to its correct
position in dental arch and its eruption potential has
been lost.
 Unerupted tooth: tooth that is in the process of
eruption and is likely to erupt based on clinical and
radiographic findings.
 Malposed tooth: an unerupted or erupted tooth
which is in an abnormal position in the maxilla or in
the mandible.

4. Unerupted tooth
Malposed tooth
Impacted tooth

5.  The word impaction has been derived from Latin word
–impactus.
 Impaction is cessation of eruption of a tooth caused by
physical barrier or ectopic positioning of a tooth.
 Following are the most commonly impacted teeth:
1) Mandibular 3rd molars
2) Maxillary 3rd molars
3) Maxillary canine
4) Mandibular premolar
5) Maxillary premolar
6) Mandibular canine
7) Maxillary central incisors
8) Maxillary lateral incisors

6.  Local causes: 1) obstruction for eruption- irregularity
in position and presence of an adjacent tooth.
- Density of the overlying and surrounding bone.
2) Lack of space in dental arch- crowding ,supernumerary
teeth.
3) Ankylosis of primary or permanent teeth.
4) Nonabs0rbing, over retained deciduous teeth
5) Non absorbing alveolar bone
6) Ectopic position of tooth bud
7) Dilacerations of roots
8) Associated soft tissue or bony lesions.
9) Habits involving tongue,finger,thumb, cheek, pencil.

7.  Systemic causes: 1) pre natal causes- heredity
2) Postnatal – rickets, congenital syphilis, malnutrition.
3) Endocrinal disorders of thyroid, parathyroid, pituitary
glands like hypothyroidism, achondroplasia, etc. here
the primary retention of teeth is seen due to lack of
osteoclastic activity, which does not provide resorption
of the bone overlying the developing tooth.
4)Hereditary-linked disorders: down syndrome, hurler’s
syndrome, osteopetrosis,cliedocranial dystosis.

8. By Durbeck
1) Orthodontic theory : Jaws develop in
downward and forward direction. Growth of the jaw and
movement of teeth occurs in forward direction, so any
thing that interfere with such movement will cause an
impaction (small jaw-decreased space).
A dense bone decreases the movement of the teeth in
forward direction.

9. 2) Phylogenic theory: Nature tries to
eliminate the disused organs i.e., use makes the
organ develop better, disuse causes slow
regression of organ.
[More-functional masticatory force – better the
development of the jaw]
Due to changing nutritional habits of our
civilization, use of large powerful jaws have
been practically eliminated. Thus, over centuries
the mandible and maxilla decreased in size leaving
insufficient room for third molars.

10. 3)Mendelian theory: Heredity is most
common cause. The hereditary transmission of small
jaws and large teeth from parents to siblings. This may
be important etiological factor in the occurrence of
impaction.
4) Pathological theory: Chronic infections
affecting an individual may bring the condensation of
osseous tissue further preventing the growth and
development of the jaws.
5) Endocrinal theory: Increase or decrease
in growth hormone secretion may affect the size of the jaws

11. “A strong indication for removal of impacted third
molar should be complemented with a strong
contraindication to its retention”
Indications:
 Recurrent pericoronitis/pain/infection
 Caries
 Root resorption
 Prior to orthodontic treatment
 Formation of follicular cyst, abscess of odontogenic
origin
 Prevention of pathological fractures
 Tumors arising in the follicular (Dentigerous cysts)

12. CONTRAINDICATIONS:
 Medically compromised state – uncontrolled diabetes
 Extremes of age – Old age
 Pregnancy 1st and 3rd trimester.

13. Winter’s classification: According to the long axis of
tooth.

14. Pell & Gregory's classification (1933)
According to the relative depth of third molar in the
bone in relation to the second molar, the third molars
are classified as:
Position A Position B Position C

15. Based on the space available between the distal
surface of second molar and the anterior surface of
ramus of the mandible.
Class I Class II Class III

17. Killey & Kay’s Classification
a) Based on angulation and position:
(Same as Winter’s classification)
b) Based on the state of eruption:- Completely erupted
- Partially erupted
- Unerupted
c) Based on roots: 1) Number of roots - Fused roots
- Two roots
- Multiple roots
2) Root pattern - Surgically favorable
- Surgically unfavorable

18.  soft tissue impaction (incision of overlying soft tissue &
removal of tooth)
 partial bony impaction (incision of overlying soft tissue,
elevation of flap, either removal of bone & tooth or
sectioning & removal of tooth)
 complete bony impaction (incision of overlying soft tissue,
elevation of flap, removal of bone & sectioning of tooth for
removal)
 complete bony impaction with unusual surgical
complication (incision of overlying soft tissue, elevation of
flap, removal of bone, sectioning of tooth for removal &/or
presents unusual difficulties & circumstances)

19.  1) angulation and depth classification is same as
mandibular third molars.
 2) classification of maxillary 3rd molar in relation to
the floor of maxillary sinus:
 A) sinus approximation(SA): no bone or a thin bony
partition present between impacted maxillary 3rd
molar and the floor of the maxillary sinus.
 B) no sinus approximation(NSA): 2mm or more
bone is present between the sinus floor and the
impacted maxillary 3rd molar.

20. Type 1 classification
Type 2 classification

21.  HISTORY
 Patients might be asymptomatic
 when symptomatic- pain, swelling of the face, trismus
 Symptoms of acute pulpitis or abscess
 Presence of trismus.
 General medical history & assessment of physical condition
 EXAMINATION
Clinical
 Extra oral
 Intra oral
Radiographs
• DECISION
Diagnosis
Treatment planning – type of anesthesia
- surgical procedure

22.  EXTRA ORAL:
• Signs of swelling & redness of the cheek(delayed healing)
• LN’s - enlargement & tenderness,
• TMJ
• Anesthesia or paraesthesia of lower lip,
 INTRA ORAL:
• Mouth opening & any evidence of trismus
• State of eruption of tooth, signs of pericoronitis
• Condition of 1st & 2nd molars
• Space present b/w 2nd M & ascending ramus
• Elasticity of oral tissues
• Size of tongue ,hypertrophied buccal pad of fat, excessive gag
reflex may interfere with access and conduct of the procedures

23.  IOPAR
 OPG
 Occlusal radiograph
1. any periapical pathology
2. relation with adjacent tooth,resorption of roots of adjacent tooth.
3. Shape and size of the crown
4. depth of the tooth in bone and its angulations.
5. Position & root pattern of 2nd Molar & impacted tooth(fused, conical,
dilacerated)
6. Inferior alveolar canal
7. External oblique ridge --vertical & ant. to third molar – poor access
-- oblique & post. – good access
Interpretation

24. Relationship of Root to Canal
Related but not involving the canal
Separated
Adjacent
Superimposed
Related to changes in the roots
Darkening of root
Dark and bifid root
Narrowing of root
Deflected root
Related with changes in the canal
Interruption of lines
Converging canal
Diverted canal

25. • White, amber and red lines are given by George Winter –
based on imaginary lines
• White line- it was drawn along the occlusal surface of
mandibular 2nd molars and extend posteriorly over the 3rd
molar region.
• It indicates the depth of impaction and differences in
occlusal level of molars.
• Amber line –distal to 3rd molar and extend anteriorly along
the bone crest of interdental septum between molars.
• Represents the summit of alveolar bone covering the
impacted tooth.
 Red line –imaginary line perpendicular to amber line to an
imaginary point of application of elevator.
 Indicates the depth at which the impacted tooth is located.

27. SURGICAL
MANAGEMENT
Steps in surgical removal
 Anesthesia
 Incision and mucoperiosteal flap
 Removal of bone
 Tooth removal/odontectomy
 Wound debridement
 Arrest of hemorrhage
 Wound closure
 Postoperative follow-up

28. MUCOPERIOSTEAL FLAP
For mandibular molars:
Anterior releasing incision should begin from the
vestibule upwards towards midway of CEJ of 2nd molar at
an angle.
 Incision then continued in gingival sulcus upto the
distal aspect of 3rd molar.
 Distal releasing incision is started from the distal most
point of 3rd molar across the external oblique ridge
into buccal mucosa.

30.  For maxillary molars: -the anterior releasing
incision is started anterior to 2nd molar from the
vestibule and till the mesial interdental papilla of he
second molar.
-the incision should follow the gingival sulcus of 2nd
molar and continue over the tuberosity area from the
distal most point of 2nd molar.

31. Aim
1. To expose the crown by removing the bone overlying it.
2. To remove the bone obstructing the pathway for
removal of the impacted tooth.
Types
1. By consecutive sweeping action of bur (in layers).
2. By chisel or mallet(in sections).
How much bone has to be removed?
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.  Bur technique: -either no,7/8 round bur or straight bur is
used. These could be used either for bone removal or
sectioning of tooth.
 Step 1: bur is used in a sweeping motion around the
occlusal, buccal and distal aspect of the mandibular 3rd
molar crown to expose it and to have its orientation.
 Step 2: once the crown has been located, the buccal surface
of tooth is exposed with bur to the cervical level of the
crown contour and a buccal trough or gutter is created.
- The buccal trough should be made in the cancellous bone.
- The distolingual portion of the tooth should be exposed
without cutting the lingual bony plates to avoid lingual
nerve damage.
-

33. Chisel and mallet technique: -it has *historical
importance.
*very rarely used.
*less bone necrosis than bur technique.
*can cause inadvertent fracture of the bone
*the jaw bone should be supported, while using this
technique.
Step 1: - for mandibular or maxillary molars the first step
is the placement of vertical stop cut, which is made by
placing a 3mm or 5mm chisel vertically at the distal
aspect of 2nd molar with bevel facing posteriorly(5-
6mm).
-the aim is to prevent the force transmission anterior to
the direction of bone removal.

34.  Step 2: - at the base of vertical stop cut, the chisel is
placed at an angle of 45·with the bevel facing upwards
or occlusally, and the oblique cut is made till the distal
most point of 3rd molar.

35. Split Bone / Lingual Split Technique
Sir William Kelsey Fry(1933)
- Quick & clean technique
- Reduces the size of blood clot by means of saucerization
of socket.
-Decreased risk of damage to the peridontium of the 2nd molar.
-Used especially for lingually impacted 3rd molars.
- Less risk of inferior alveolar nerve damage.
- Decreased risk of socket healing problems
- Can use regional anesthesia but endotracheal anesthesia is
preferred one.
- Only suitable for young adults whose bone is elastic
- Support the mandible inferiorly.

37. -splitting of crown of the tooth is called odontectomy.
-it is done to facilitate the removal of tooth into pieces
without excessive bone cutting.
Mesioangular Impaction Horizontal Impaction

38. Vertical Impaction
Disto Angular Impaction

39.  Thorough debridement of the socket by Periapical
curettage.
 Smoothening of sharp bony margins by Bone file / burs.
 Thorough irrigation of the socket Betadine solution +
Saline .
 Initial wound closure is achieved by placing 1stsuture just
distal to 2ndmolar, sufficient number of sutures to get a
proper closure.

40.  A pressure pack is given postoperatively, which should be maintained
for about 1 hr to achieve adequate hemostatis.
 To prevent excessive edema application of cold is instructed.
 Glycerin-magnesium sulfate dressings, given extraorally .
 Liquid or semi-solid diet is recommended.
 Warm saline gargles after 24hrs. Improve the circulation inducing
vasodilatation and facilitate the reabsorption of interstitial fluid.
 The patient is prescribed antibiotics and analgesics along with anti-
inflammatory drugs.
 The oral hygiene and the wound hygiene are maintained by
chlorhexidine mouthwash and povidone irrigation.

41. Intra Operative
1. During incision
a. Injury to facial artery for molars, for lower canine-mental vessels may damage
b. Injury to lingual nerve
c. Hemorrhage – careful history
2. During bone removal
a. Damage to second molar and roots of overlying teeth
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 neighboring tooth/ fractured restoration
b. Soft tissue injury due to slipping of elevator
c. Injury to inferior alveolar neurovascular bundle
d. Fracture of mandible
e. Forcing tooth root into submandibular space or inferior
alveolar nerve canal
f. Breakage of instruments
g. TMJ Dislocation – careful history

42. 4) During debridement: - damage to inferior alveolar
nerve or lingual nerve
- Damage to maxillary sinus.

43. post-operative complications
 Immediate
- Hemorrhage
- Pain and swelling
- Edema ,sensitivity
- Drug reaction
- loss of vitality of neighboring teeth
 Delayed -pocket formation
- alveolar osteitis /dry socket
- Infection
- Trismus
- sinus tract formation, oroantral fistula, oronasal fistula

44.  Inflammation of the alveolar bone
 20% of extraction of mandibular 3rd molar
 2% of routine extraction
 Moderate-severe pain develops generally on 3rd/4th
day.(with no signs of infection)
 Bad odour & taste
 Etiology - unknown
-Possibly excessive fibrinolytic activity
-Subclinical infection
• The dressing of zinc oxide eugenol is usually done.

45.  As the pain is severe patient is given sedative dressings in form
of zinc oxide eugenol on cotton wool or gauze and is loosely
tucked in the socket.
 Curettage of socket to induce fresh bleeding.
 Prophylactic use of antimicrobials drugs like metronidazole and
clindamycin.