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Management for mandibular 3rd molar impaction
Vertically impacted
Mesio - angularly impacted
A. buccal and distal bone are removed to
expose crown of tooth to its cervical line.
B. The distal aspect of the crown is then sectioned from tooth. Occasionally it is necessary to
section the entire tooth into two portions rather than to section
the distal portion of crown only.
C . A small straight elevator is inserted into the purchase point on
mesial aspect of 3rd molar, & the tooth is delivered
with a rotational and level motion of elevator.
PETERSON‘S PRINCIPLES OF ORAL AND MAXILLOFACIAL SURGERYSecond Edition
A. Removal of mesial & distal boen. It is important
to remember that more distal bone must be taken off than for a vertical or mesioangular impaction.
distoangular impaction
B. The crown of the tooth is sectioned off with a bur and is delivered with
straightelevator
C, The purchase point is put into the remaining
root portion of the tooth, and the roots are
delivered by a Cryer elevator with a wheel
and-axlemotion. If the roots diverge, it may be
necessary in some cases to split them into
independent portions
PETERSON‘S PRINCIPLES OF ORAL AND MAXILLOFACIAL SURGERYSecond Edition
Horizontally impacted
A. Removal of distal and buccal underlying bone
B. The crown is sectionedfrom the roots of the tooth and
is delivered from socket.
C, The roots are delivered together or independently with
a Cryer elevator used with a rotational motion. Saperation of root into 2 parts - occasionally the purchase point is made in
the root to allow the Cryer elevator to engage it.
D, The mesial root of the tooth is elevated in similar
fashionPETERSON‘S PRINCIPLES OF ORAL AND MAXILLOFACIAL SURGERYSecond Edition
A. When removing a vertical impaction, the bone on the occlusal,
buccal, and distal aspects of the crown is removed,
and the tooth is sectioned into
mesial and distal portions.
B. The posterior aspect of the crown is elevated first
with a Cryer elevator inserted into a small purchase point in the distal portion of the
tooth.
C. A small straight no. 301 elevator is then
used to lift the mesial aspect of the tooth with
a rotary and levering motion.
Vertically impactedPETERSON‘S PRINCIPLES OF ORAL AND MAXILLOFACIAL SURGERYSecond Edition
Mandibular 3rd molar removal!
Impaction of teeth other than 3rd molar
Impaction of teeth other than 3rd molar
Max. canine Premolars 2nd molar
Systemic
• Hypothyroidism, Febrile disease , Down syndrome
Local
• Malposed tooth germ, arch-length def, superneumerary, clef lips +palate, prolonged decisous retention
Hereditary
• Cleidocranial dysplasia
Etiology
• Labially : Arch-length deficiency• Palatally : Extra space owing to
excessive growth, agenesis, peg shape lateral incisor
canine
• Ectopic eruption
1st molar
•Arch -length deficiency
2nd molar
Clinical problem : malocclusion, loss of arch length, migration/ loss of adjacent tooth, periodontal disease, root resorption (internal & external) of impacted tooth, dentigerous csyt & pericoronitis.
Management for impacted tooth other than 3rd molar
Exposure Uprighthing
transplantation Removal
a) Exposure (with/ without ortho band)
• Allow natural eruption of impacted teeth • Most appropriate technique • Most common : bonded orthodontic bracket to
1. Conserve exposure of the tooth2. Remove only enough soft tissue + bone to place
bracket3. Avoid exposure of CEJ
PETERSON‘S PRINCIPLES OF ORAL AND MAXILLOFACIAL SURGERYSecond Edition
Labially impacted canine exposed important part of this surgical procedure using an apically repositioned flap
Palatally impacted canines
Maxillary Palatal cuspid Maxillary Labially cuspid
• Full thickness palatal cuspid•Conservative exposure of the tooth•Bonding of a bracket to its palatal surface
• A position in the arch must be established by preliminary orthodontic treatment prior to cuspid exposure
If the tooth near the free edge of the flap :1. Soft tissue may be removed to
leave the crown expose2. Wound packed gently during initial
healing period
•Preservation of attached mucosa adjacent to the cervical line of the tooth
If the tooth deeply impacted :1. Replace the tissue flap2. Bringing a wire attached to the
bonded bracket through the soft tissue near the crest of the ridge
b) Uprighting
• Commonly for impacted MOLARS
• Remove 3rd molar for 2nd molar to erupt normally
• Normal time for uprighting molar teeth : 2/3 of the root has formed
• If root fully formed poor prognosis
• If 3rd molar : Remove bone to ensure occlusal force, antibiotic
Molar uprighting is frequently needed to treat a malocclusion bad bite that occurs years after the extraction of the lower first molar tooth
Third molar in path of second molar eruption
c) Transplantation• For adult : undergo conventional
ortho movement of canine / premolar
• how?1. Expose the impacted tooth2. Move into position + stabilize with
ortho app.3. Endo treatment : calcium hydroxide
paste (antimicrobial effect & bone-regeneration stimulant) 6-8 weeks after surgical procedure
4. Conventional root canal filing at 1 year following surgery
• Extraction possible : transalveolar transplantation (max. canines)
PETERSON‘S PRINCIPLES OF ORAL AND MAXILLOFACIAL SURGERYSecond Edition
iv. Removal• Last choice! : canines / premolar / molar• Surgical + Radiographic assessment• Conservation of bone through conservative
exposure + removal with sectioning
Impacted canines
• Approach from surface of maxilla which they are closely related
Labially impacted canines
• Frequently removed with an elevator technique
Palatal impacted canines
• Removal of crown by sectioning the root (longitudinal sectioning)
• Large palatal flap : palatal splint
• May be removed likely like caninesImpacted Maxillary bicuspid
• General approach from labial surface• Careful!!! Preserve mental nerve
Impacted Mandibular bicuspid
• Identify the tooth through a lingual exposure• a labial flap - raised & a small hole placed in
the labial surface of the bone allow the bicuspid to be pushed through to the lingual
Lingually position
* Molar tooth similar to 3rd molar!
Indication for removal of impacted tooth
Pericoronitis Prevention
or Treatment
Prevention of Dental Disease
Orthodontic Consideratio
n
Prevention of
Odontogenic Cysts and Tumors
Teeth under Dental
ProsthesesPrevention of Jaw Fracture
Management of
Unexplained Pain
Root Resorption of adjacnet teeth
i. Pericoronitis Prevention or Treatment
The most cases for removal of impacted tooth! Usually mandibular – partially erupt Microbes : Peptostreptococcus, Fusobacterium, and Bacteroides
(Porphyromonas)
Initial treatment :i.Débridement
ii. Disinfection with irrigation solution (hydrogen peroxide or chlorhexidine)
iii. surgical management – extract opposing max 3rd
molar.iv. Severe cases with systemic effect – antibiotic
• Recurrent – Removal of involved tooth
ii. Prevention of Dental Disease
• Caries! – At mand 3rd molar / adjacent tooth(mostly at cervical line)
• unable to clean effectively & inaccessible to the restorative dentist advanced periodontal disease : Extract!
iii. Orthodontic Considerations•Controversional•Anterior incisor crowding associated with deficient arch length rather than presence of impacted teeth.
Crowding of Mandibular Incisors
•facilitate treatment and allow predictable outcomes.
Obstruction of Orthodontic Treatment
•For mand. Ostoetomies - delaying removal : the thickness & quality of lingual bone at the proximal aspect of the distal segment where fixation screws are usually applied.•If removed – sufficient time for the extraction site to fill with mature bone.
Interference with Orthognathic Surgery
iv. Prevention of OdontogenicCysts and Tumors
Follicular sac (formation of the crown) cystic degeneration dentigerous cyst --> odontogenic tumor (rare)
Reason for removal of asymptomatic teeth because pathology occurs, it may pose a serious health threat!
v. Root Resorption of Adjacent Teeth
Misaligned erupting teeth may resorb the roots of adjacent teeth just like succedaneous teeth resorb the roots of primary teeth during normal eruption.
Most cases - adjacent tooth recalcified (deposition of a cementum over the resorbed area) & formation of 2o dentin.
If severe resorption & the mandibular 3o molar displaces significantly into the roots of the second molar REMOVE.
vi. Teeth under Dental Prostheses
Removable tissueborne prosthesis – is constructed on a ridge where an impacted tooth is covered by only soft tissue or 1 or 2 mm of bone overlying bone resorbed, mucosa perforate & the area become painful and inflamed. So ----> Extract!
In older patients with tooth- or implant-borne fixed prostheses asymptomatic deeply impacted teeth can be safely left in place.
vii. Prevention of Jaw Fracture
Patients engage in contact sports (football, rugby, martial arts) & noncontact sports (basketball) remove to prevent jaw fracture
An impacted third molar - resistance to fracture in mandible common site for fracture
increased complications in the treatment of the fracture.
viii. Management ofUnexplained Pain
Jaw pain in the area of an impacted third molar but clinical or radiographic signs of pathology.
the surgeon must make sure that all other sources of pain are ruled out before suggesting surgical removal of the third molar.
Patient must be informed that removal of the third molar may not relieve the pain completely
Contraindication for removal of impacted tooth
Extremes of Age
• Healing • Greater bony defect
postoperatively• Difficult - more
densely calcified bone (less flexible & likely fracture)
• Tolerated less easily and the recuperation period grows longer.
• If no complication - extraction
Surgical Damage to adjacent Structures
• Removal may compromise adjacent nerves, teeth & other vital structures (sinus), making it
• If benefits than complication, don’t extract
Compromised Medical Status
• In older : pulmonary disease
• younger people : congenital coagulopathies asthma &epilepsy.