This document discusses impacted teeth, including definitions, causes, classifications, and surgical removal procedures. It notes that an impacted tooth fails to erupt within the expected time frame due to issues like inadequate arch space. Impactions are classified based on factors like angulation, depth, and relationship to surrounding structures. Mandibular third molars are most commonly impacted. Surgical removal indications include preventing complications, while contraindications include medical issues or risk of damage. The procedure involves raising flaps, removing bone, sectioning and delivering the tooth, then closing the site. Potential complications are also outlined. Pre- and post-operative management include use of anesthesia, antibiotics, and measures to reduce swelling and pain.

1. Submitted by :
ARAVIND NAIR
IV PART II BDS
Departmentof Oral & Maxillofacial Surgery
TOOTH IMPACTION

2. IMPACTED TOOTH
 Impacted tooth is one that fails to erupt in the dental arch
within the expected time.
CAUSES
 Inadequate dental arch length.
 Inadequate space to erupt.
 Dense overlying bone.
 Excessive soft tissue.

3.  Completely impacted-When the tooth is
entirely covered by soft tissues & bone, within
the bony alveolus, beyond the chronological
age of eruption of particular tooth, even after
root apex closure.
 Partially erupted-When the tooth has failed to
erupt into a normal functional position but has
crossed the bone barrier& has not reached the
occlusal line.

4.  Impacted tooth may be-
1. Completely impacted
2. Partially erupted
3. Ankylosed
4. Unerupted tooth
5. Malposed tooth
6. Ectopic/Displaced teeth

5.  Ankylosed- When the cementum of the tooth
is fused to the bone.
 Unerupted tooth-Tooth not having perforated
oral mucosa.

6.  Malposed tooth- Abnormal position in the
maxilla or mandible.
 Ectopic/Displaced teeth-
causes
congenital factors
due to pathology

7.  Most commonly impacted teeth
Mandibular III molars
Maxillary III molars
Maxillary Cuspids
Mandibular Bicuspids
Mandibular Cuspids
Maxillary Bicuspids
Maxillary Central incisors
Maxillary Lateral incisors

8. INDICATIONS FOR EXTRACTION OF
IMPACTED TEETH
 Removal of impacted teeth becomes difficult with
age.
 Early removal reduces post operative morbidity&
best healing.
 Ideal time for removal of impacted III molars is
between 17-20 years.

9. INDICATIONS
 TO PREVENT
Periodontal disease.
Dental caries.
Pericoronitis.
Root resorption.
Fracture of jaw
Odontogenic cysts & tumors
 For dental prosthesis.
 For orthodontic treatment

10. CONTRAINDICATIONS
 Extremes of age .
 Medical compromised state.
 Probability of excessive damage to adjacent
structures.

11. Extremes of age
 Bone is highly calcified,
 Less flexible under forces of tooth extraction.
Medical Compromised state
 Cardiovascular disease.
 Respiratory disease.
 Compromised immune status.
 Acquired or Congenital coagulopathy.

12. Probable excessive damage to
adjacent structures
 If the impacted tooth lies in close proximity to adjacent
nerves, teeth or previously constructed bridges.

13. CLASSIFICATION
BASED ON-
Angulation.
Relationship to anterior border of ramus.
Relationship to occlusal plane.

14. Based on Angulation-
Winter’s classification
Relation of long axis of impacted III molar to long axis of second molar.
Mesioangular impaction
Horizontal impaction
Vertical impaction
Distoangular impaction
Buccal impaction
Lingual impaction
Transverse impaction

15. Mesioangularimpaction
 Most common
 Easiest to remove.
 In close proximity to
II molar.

16. Horizontal impaction
 Uncommon.
 More difficult to
remove
 Occlusal surface.
immediately adjacent
to II molar.
 Early severe
periodontal disease.

17. Vertical impaction
 2nd most common.
 2nd most difficult to remove.
 Posterior aspect frequently
covered with bone of anterior
ramus of mandible.

18. Distoangularimpaction
 Uncommon.
 Most difficult to remove.
 Occlusal surface embedded in
ramus of mandible

19.  Buccal impaction- Tooth is buccally impacted.
 Lingual impaction- Tooth is lingually impacted.
 Transverse impaction- Tooth is completely
impacted in buccolingual direction.

20. BASEDONRelationshipto anteriorborderof ramus
 Based on amount of impacted tooth covered with bone of
mandibular ramus.
 Pell and Gregory classification.
Class 1
Class 2
Class 3

21. PellandGregoryClass1 Impaction
Mandibular 3rd molar has sufficient
anteroposterior room to erupt.
Pell and Gregory Class 2 Impaction
APPROXIMATELY HALF IS COVERED BY
ANTERIOR PORTION OF RAMUS OF
MANDIBLE.

22. Pell and Gregory Class 3 Impaction
Impacted 3rd molar completely embedded
in bone of ramus of mandible.

23. Based on relationship to occlusal plane
 Based on comparing the depth of impacted tooth compared with
height of adjacent 2nd molar
Pell and Gregory Classification
Class A
Class B
Class C

24. Pell and Gregory Class A Impaction
Occlusal level of impacted tooth is at same level
as occlusal plane of 2nd molar.

25. Pell and Gregory Class B Impaction
Occlusal plane of impacted tooth is between
occlusal plane and cervical line of 2nd molar.

26. Pell and Gregory Class C Impaction
Impacted tooth is below cervical line of 2nd
molar.

27. ROOT MORPHOLOGY
 Size of follicular sac.
 Density of surrounding bone.
 Contact with mandibular second molar.
 Relationship inferior alveolar nerve.
 Nature of overlying tissue.

28. Size of follicular sac
 It determines the difficulty of extraction.
 Wide – less bone removed – easier to extract
seen in young patients
 Narrow – space needed to be created –
difficult to remove.

29. Density of surrounding bone
 Determines difficulty of extraction.
 It is determined by patient’s age.
 18 yrs or above – bone density favorable for tooth removal.
 Less dense – pliable, bends, expanded by elevators.
 More dense – more difficult to remove with dental drill and bone
removal takes longer.

30. Contact with mandibular
second molar
 Extraction is easier if space exists between 2nd and impacted
3rd molar.
 Commonly in Mesioangular or horizontal impaction. So care
should be taken not to exert pressure on 2nd molar.
 Care should be taken if the 2nd molar has caries, large
restoration or root canal.

31. Relationship to inferior alveolar
nerve
 The roots of impacted mandibular 3rd molars may lie in close
proximity to inferior alveolar canal.
 There may be damage or bruising of inferior alveolar nerve during
extraction, that lead to paresthesia or anesthesia of lower lip of
injured side.
 Care must be taken to avoid injury to nerve.

32. Based on Nature of overlying tissue
3 types
1. Soft tissue impaction – height of tooth’s contour is above level of alveolar
bone and superficial portion of tooth is covered only by soft tissue. Easiest of
all impactions.
2. Partial bony impaction – superficial portion of tooth is covered by
soft tissue, but the height of tooth’s contour is below the level of surrounding
alveolar bone.
3. Full bony impaction – completely encased in the bone. Extensive
amounts of bone must be removed and tooth must always be sectioned. Most
difficult to remove

33. Factors that Make
Impaction Surgery Less
Difficult
Factors that Make
Impaction Surgery More
Difficult
Mesioangular position Distoangular
Class 1 ramus Class 3 ramus
Class A depth Class C depth
Roots 1/3 to 2/3 formed. Long, thin roots
Fused conic roots Divergent curved roots
Wide periodontal ligament Narrow periodontal ligament
Large follicle Thin follicle
Elastic bone Dense, inelastic bone
Separated from 2nd molar Contact with 2nd molar
Separated from inferior alveolar
nerve
Close to inferior alveolar canal
Soft tissue impaction Complete bony impaction

34. MODIFICATIONOF CLASSIFICATIONSYSTEMS FOR
MAXILLARY
IMPACTED TEETH
BASED ON-
Angulation.
Relation to occlusal plane.

35. Based on ANGULATION
 Vertical impaction- 63% of impactions.
 Distoangular impaction- 25% of impactions.
 Mesioangular impaction- 12% of impactions.

36. RELATION TO OCCLUSAL PLANE-Pell &Gregory
classification
 Class A- Occlusal surface of III molar is at same level than
II molar.
 Class B- Occlusal surface of III molar is located between
occlusal plane & cervical line of II molar.
 Class C- Impacted maxillary III molar is deep to cervical
line of II molar.

37. Difficulty of Removal of Other Impacted Teeth
 The most important consideration in the removal of impacted maxillary
canine is buccolingual position of tooth.
 LABIALLY POSITIONED IMPACTED MAXILLARY CANINE-
 Tooth should be uncovered with apically positioned flap procedure to
preserve attached gingiva.
 Mucoperiosteal flap is outlined, allowing for repositioning of keratinized
mucosa over exposed tooth.
 When flap is reflected thin overlying bone is removed.
 Tissue is retracted and bonded to tooth with a wire or with a gold chain.
 Flap is apically sutured to tooth.

38.  PALATALLY POSITIONED IMPACTED MAXILLARY
CANINE-
 Tooth may be repositioned or removed.
 Repositioned, then surgically exposed & moved into position
orthodontically
 Overlying soft tissue is excised
 Bur is necessary to remove underlying bone.
 Exposed tooth is managed similar to labially positioned tooth.

39.  REMOVAL OF MESIODENS- Supernumerary tooth
in the midline of the maxilla.
Almost always found on the palate.
It is approached in a palatal direction during
removal.

40. Surgical Procedure
5 basic steps are :
Reflecting adequate flaps for accessibility
Removal of overlying bone
Sectioning the tooth
Delivery of the sectioned tooth with elevator
Debridement of wound and wound closure.

41. Reflecting adequate flaps for accessibility
 Envelope incision is most commonly used to reflect soft tissue
for removal of impacted 3rd molar. Posterior extension of
incision should laterally diverge to avoid injury to lingual
nerve.
 Envelope excision is laterally reflected to expose bone
overlying impacted tooth.
 When three-cornered flap is made, a releasing incision is
made at mesial aspect of second molar.
 When soft tissue flap is reflected by means of a releasing
incision, greater visibility is possible, especially at apical aspect
of surgical field.

42.  Envelope flap is the most commonly used flap for
removal of maxillary impacted teeth.
 When soft tissue is reflected, bone overlying 3rd
molar is easily visualized.
 If tooth is deeply impacted, a releasing incision can
be used to gain greater access.
 When three-cornered flap is reflected, the bone’s
more apical portions become more visible.

43. Removal of overlying bone
 After soft tissue has been reflected, bone overlying
occlusal surface of tooth is removed with a fissure
bur.
 Bone on buccodistal aspect of impacted tooth is
then removed with bur.

44. Mesioangular impaction
 Buccodistal bone is removed to expose crown of tooth
to cervical line.
 Distal aspect of crown is then sectioned from tooth.
Occasionally, it is necessary to section entire tooth into
2 portions rather than to section distal portion of crown
only.
 After distal portion of crown has been delivered, small
straight elevator is inserted into purchase point on
mesial aspect of III molar ,& tooth is delivered with
rotational & lever motion of the elevator.

45. Horizontal Impaction
 Bone on distal & buccal aspect of tooth is removed with bur.
 Crown is then sectioned from roots of teeth & delivered from
socket
 Roots are then delivered together or independently by
CRYER elevator used with rotational motion. Roots may
require separation into 2 parts; occasionally purchase point
is made in root to allow CRYER elevator to engage it.
 Mesial root of tooth is elevated in similar fashion.

46. Vertical impaction
 When removing vertical impaction, bone on the occlusal,
buccal and distal aspects of crown is removed, and the tooth
is sectioned into mesial and distal sections. If the tooth has a
single-fused root, the distal portion of crown is sectioned off
in a manner similar to that depicted for mesioangular
impaction.
 Posterior aspect of crown is elevated first with CRYER
elevator inserted into small purchase point in distal portion
of tooth.
 Small straight elevator no.301 is then used to elevate the
mesial aspect of the tooth by rotary-and-lever type of motion.

47. Distoangular impaction
 Occlusal, buccal & distal bone is removed with bur.
More distal bone must be taken off than for vertical or
mesioangular impaction.
 Crown of tooth is sectioned with bur,& crown is
delivered with straight elevator.
 Purchase point is put into remaining root portion of
tooth & roots are delivered by CRYER elevator with
wheel-and-axle type of motion. If roots diverge, it may
be necessary in some cases to split them into
independent portions.

48. Delivery of impacted maxillary III molar
 Once soft tissue has been reflected, small amount of buccal
bone is removed with bur or hand chisel.
 Tooth is delivered by small straight elevator, with rotational
and lever types of motion. Tooth is delivered in distobuccal
and occlusal direction.

49. COMPLICATIONSARISINGDURINGOR AFTER REMOVAL OF IMPACTED
THIRDMOLAR
 Neurosensory injuries- Injury to inferior alveolar
nerve, lingual nerve, buccal nerve, mylohyoid nerve
& the resultant numbness of the areas supplied by
these nerves.
 Infections.
 Injury to the surrounding soft tissue.
 Disturbance of normal blood supply due to injury to
the local blood vessels resulting in necrosis of the
surrounding soft tissue or flap.

50.  Acute trismus.
 Fracture of root or accidental displacement of the
fractured root into maxillary sinus or other spaces.
 Oro antral fistula.
 Displacement of adjacent teeth out of the socket thus
rendering it non-vital.
 TMJ problem.

51.  Alveolar osteitis.
 Fracture of maxilla or mandible.
 Excessive hemorrhage.
 Adjacent teeth rendered non-vital.
 Subcutaneous emphysema as a result of frequent use
of air driven hand pieces.

52.  Postoperative sequelae like excessive swelling,
severe dysphagia, severe pain, trismus.
 Teeth may get displaced into maxillary sinus,
submandibular space or may be accidentally
swallowed or aspirated by the patient.

53. PRE OPERATIVE
MANAGEMENT
POST OPERATIVE
MANAGEMENT
 Removal of impacted tooth
is associated with anxiety.
 Surgeons recommend local
anesthetic, general
anesthetic or deep IV
sedation.
 Use of long acting local
anesthetic in mandible.
 Oral analgesic for 3-4 days.
 Use of ice packs to reduce
swelling.
 Antibiotics to prevent
infection.
 Patient may have mild to
moderate trismus.
 Sequelae of extraction is of
less intensity in young
individual compared to
older individuals.

54. Reference
Contemporary Oral and Maxillofacial
Surgery [Fourth Edition] -Larry J.
Peterson

55. THANK
YOU