Professional Documents
Culture Documents
Impaction is cessation of eruption of a tooth caused by a physical barrier or ectopic positioning of a tooth.
Impaction per se is NOT an indication for removal, it is a clinical description of the position of the tooth
Due to the evolution the size of the human jaw is becoming smaller and since the third molar tooth is last to erupt there may not be room for it
to emerge in the oral cavity.
Pathological theory:
Third molar can be impacted in the jaw if it is involved in any pathological process which prevents its eruption into the oral cavity. Eg: involved in
dentigerous cyst.
Mendelian theory :
Here genetic variant plays a major role . If the individual genetically receives a small jaw from one of the parents and large teeth from other
parent , then impacted teeth can be seen because of lack of space.
Causes of impactions
Local causes
Obstruction for eruption due to non resorbing deciduous tooth
Lack of space in the dental arch due to discrepancy in tooth material and arch length
Ankylosis of the primary or the permanent tooth
Non absorbing alveolar bone
Ectopic position of the tooth
Dilaceration of the roots
Habits involving tongue,finger,thumb,cheek.
Systemic causes
Prenatal-:heredity
Postnatal: Rickets, malnutrition.
Endocrinal disorders of thyroid gland.
Hereditary linked disorders: Down syndrome, cleft palate .
OPG
IOPA
Occlusal radiograph
CT scan
General
Local
-Extraoral examination
-Intraoral examination
EXTRAORAL EXAMINATION
Regional lymph nodes: Enlarged , palpable and tender lymph nodes represents the spread of infection from the particular site
TMJ function: normal gliding movements of the TMJ allows adequate access.
Extensibility of lips and cheeks: the extensibility of the lips and the cheeks prevents any significant hematoma post-operatively
Mouth opening: assessing the mouth opening preoperatively is very important because inadequate mouth opening may lead to
inadequate access during surgery
Facial swelling: any facial swelling locally should be examined because it indicates the spread of infection to the fascial spaces
INTRAORAL EXAMINATION
Eruption status of impacted tooth should be examined in comparison to the occlusal table of the first and second molar
Resorption of second molar on the distal aspect should be examined
Presence of local infection- pericoronitis may necessitate administration of prophylactic antibiotics
Caries in third molar or adjacent teeth should be examined because otherwise it may lead to the fracture of the impacted tooth or
adjacent tooth while elevation.
Periodontal status of the impacted and the adjacent tooth should be checked.
Size of tongue should be examined because macroglossia may lead to inadequate access.
Assessment of teeth in particular
Occlusal relationship with the opposing tooth should be checked so as if necessary to plan its treatment at the same appointment.
CLASSIFICATION
BASED ON NATURE OF OVERLYING TISSUE IMPACTION
WINTER’S CLASSIFICATION(1926)
Based on long axis of 3rd molar in relation to 2nd molar
Mesioangular
Horizontal
Vertical
Distoangular
Buccoangular
Linguoangular
Inverted
Position A:
The highest position of the tooth is on a level with or above the occlusal line .
Position B:
Highest portion is below the occlusal plane but above the cervical line of the second molar.
Position C :
Highest portion of the tooth is below the cervical line of the second molar.
Difficulty Index for removal of impacted mandibular third molars - Pedersen 1988
CLASSIFICATION DIFFICULTY INDEX VALUE
ANGULATION
Mesioangular 1
Horizontal / transverse 2
Vertical 3
Distoangular 4
DEPTH
Level A 1
Level B 2
Level C 3
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
Horizontal 3
Distoangular 2
Mesioangular 1
Vertical 0
Height of the mandible
1-30 mm 0
31-34 mm 1
35-39 mm 2
1-59 degrees 0
60-69 1
70-79 2
80-89 3
90 + 4
Favourable curvature 1
Unfavourable curvature 2
complex 3
Follicles
normal 0
possibly enlarged -1
enlarged -2
Path of exit
space available 0
Usually the density of the root is the same throughout its length and this is not disturbed when the images of the tooth and inferior alveolar canal overlap.
When there is impingement of the canal on the tooth root, there is loss of density of the root the root appears darker .Howe and Poyton (1960) reported
that 93.1% of the teeth in true relationship to the canal showed this sign. Darkening of the root is attributed to the decreased amount of tooth substance
or loss of the cortical lining of the canal between the source of X-rays and the film (MacGregor, 1976).
Deflected roots
Deflected roots or roots hooked around the canal are seen as an abrupt deviation of the root, when it reaches the inferior alveolar canal . The root may be
deflected to the buccal or lingual side or to both sides so that it may completely surround the canal or it may be deflected to the mesial or distal aspect .
ARCHER’S (1975)
Mesioangular
Distoangular
Vertical
Horizontal
Buccoversion
Liguoversion
Inverted
PELL & GREGORY
Position A:
The highest position of the tooth is on a level with or above the occlusal line .
Position B:
Highest portion is below the occlusal plane but above the cervical line of the second molar.
Position C :
Highest portion of the tooth is below the cervical line of the second molar.
Vertical 63% +
Distoangular 25% +
Transverse <1% ++
Horizontal <1% ++
Inverted <1% ++
Difficulty factors
The mean distance from erupted mandibular third molar teeth to the inferior alveolar canal is 0.88 mm.
Marci H. Levine DMD, MD , Allison L. Goddard† and Thomas B. Dodson DMD, Journal of Oral and Maxillofacial Surgery Volume 65, Issue 3,
March 2007, Pages 470-474
Distance from superior border of the canal to the most apical aspect of the tooth
Inferior alveolar vein lies superior to the nerve and the artery appears to be solitary and lies on the lingual side of the nerve, slightly above the
horizontal position.
Radiographic proximity of the mandibular third molar to the inferior alveolar canal Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2005;100:545-9)
The Anatomic Structure of the InferiorAlveolar Neurovascular Bundle in theThird Molar RegionJ Oral Maxillofac Surg 67:2452-2454, 2009
The lingual nerve lies 0.5 mm lingual to the lingual cortex and 2mm apical to the alveolar crest in the third molar region.
Relationship of lingual nerve to mandibular third molar region. Journal of oral and maxillofacial surgery 53:1178-1181, 1995
Prophylactic odontectomy
Timing :
1 It can be done at the age of 6-9 yrs by enucleation before the beginning of mineralization or before the calcified cusp have united.
2 It is most commonly done at the age of 10-16 yrs by lateral trephination when only the crown is formed.
Best time to perform it is when the radiograph of the tooth shows the roots of the third molar to be half to two third formed.
Advantages:
If prophylactic odontectomy is done, generally all the four 3rd molars are removed.
CORONECTOMY
Damage to the inferior alveolar nerve when extracting lower third molars is often caused by the intimate relationship between the nerve and the
roots of the teeth. The technique of coronectomy, or intentional root retention, may minimize this problem.
Coronectomy appears to be a viable technique in those cases where removal of the whole tooth might put the inferior alveolar nerve at considerable
risk of damage. The technique appears to be associated with a low incidence of complications, but subsequent migration of the roots may be an issue
in the long term.
DENTAL FOLLICLE
4 Bone removal
6 Elevation + extraction
8 Control of bleeding
9 Closure (suturing)
10 Follow-up
scrubbing + painting of the skin and oral mucosa followed by draping of the patient
Chlorhexidine gluconate is used 7.5 % for skin and 0.2% for oral mucosa.
GENERAL ANAESTHESIA
GA is indicated when impacted tooth is situated deep in jaw bone ( red line > 9 mm )
INDICATION OF GA-
Lengthy procedure
Uncooperative patient
Flap design should be such that it provides adequate exposure of the operative site.
Base of the flap should be wide should be always wide so as to enable adequate blood supply to the flap.
The distal releasing incision should not be extended too far which can lead to herniation of the buccal pad of fat into the operating field.
Incision should be designed so that flap can be closed over the solid bone
Incision should not damage the vital structures like mental nerve, lingual nerve.
Triangular flap
Ward’s incision
Szmyd flap
Modified Szmyd
S shaped incision
Palpation of the external oblique ridge before the incision should be done .
The inferior limit of the incision should be upto the external oblique ridge to prevent excessive postoperative discomfort and edema due to
involvement of the buccinator muscle.
The mucoperiosteal flap for removal of the impacted tooth is required to be designed well for adequate access and for elimination of obstruction
in the pathway of removal .The incision for this mucoperiosteal flap will have an anterior limb and a posterior limb connected with or without an
intermediate limb.
Anterior releasing incision should begin from the vestibule upwards towards midway of the CEJ of the second molar at an angle. If third molar is
deep and surgery requires more removal of bone , this incision should be placed anterior to the second molar. The incision is then continued in
the gingival sulcus up to the distal aspect of the third molar. The distal releasing incision is started from the distal most point of the third molar
across external oblique ridge in to the buccal mucosa. This incision should not be taken on the lingual aspect of the ridge, as the lingual nerve can
be found at or above the crest of the alveolar ridge in approximately 17% of the population. The length of this mucoperiosteal flap and the
number of the teeth included will be determined by the amount of the exposure needed to gain the visibility of the region and experience of the
clinician. The sharp point of the periosteal elevator is used to carefully elevate a mucoperiosteal flap beginning at the point of incision behind the
second molar. The elevator is brought forward to elevate the periosteum around the second molar and down the releasing incision. The other
flatter end of the elevator is then used to elevate the periosteum posteriorly to the ascending ramus of the mandible.
The anterior releasing incision is started anterior to second molar from the vestibule and till the mesial Interdental papilla of the second molar.
The incision should follow the gingival sulcus of second molar and continue over the tuberosity area from the distal most point of the second
molar.
Important considerations
Requirement for a primary closure:
If the impacted tooth is partially erupted in the oral cavity and the primary closure of the wound after surgery is intended then a reverse bevel
incision on the free gingival margin should be given before raising of the mucoperiosteal flap.
The anterior part of the incision should be extended upto the external oblique ridge.
Elevation of the distolingual soft tissue should be done such that atleast 5 mm of bone covering the distal aspect of the crown of the tooth is visible
The raising of the mucoperiosteum should be done with utmost care so as to avoid the button holing of the mucosa due to sharp instrument which
otherwise may result in compromised blood supply and delayed healing.
BONE REMOVAL
Bone can be removed with handpiece and bur or with a chisel and a mallet.
IMPORTANT CONSIDERATIONS
It is not required in cases in which crown lies above or in front of amber line. No 8 round bur or no 703 straight fissure bur are frequently used
for this purpose. Copious saline irrigation should be done to avoid thermal injury. The buccal trough should always be made in the cancellous
bone which appears red in colour. The bone removal around the crown is done till cement-enamel junction to expose the crown beyond the
greatest width
Procedure:
First two vertical cuts are made . one of 5 mm at the distobuaccal aspect of the second molar and second of 4mm at the distobuccal aspect of
the impacted tooth. This is done to prevent the inadvertent fracture of the jaw while cutting in the anteroposterior direction because the grain
of the mandible runs in the same direction. Then a horizontal cut is made joining the two vertical cuts and a collar of bone surrounding the
impacted tooth is removed.
1 Reduced or eliminated bone removal resulting in less post op pain and swelling.
4 Danger of injury to the inferior alveolar nerve due to high leverage is lessened
IMPORTANT CONSIDERATIONS
ELEVATION + EXTRACTION
IMPORTANT CONSIDERATIONS
The tip of the elevator should be engaged in a purchase point in the bone or in the tooth.
Arc of the rotation of the tooth is the apical most point of the distal root in case of tooth with two roots.
Importance of buccal elevation: the buccal elevation can be try to elevate the tooth with multiple roots because it averages out the path of exit
of each root.
MESIOANGULAR IMPACTIONS
Distal half of the crown is section at the buccal groove till below the CEJ from buccal to ligual and extended into the furcation. A straight elevator
is placed in the cut and rotated to fracture the distal portion of the crown which is removed . Then a straight elevator is placed on the mesial
aspect of the third molar below the cervical area. A purchase point can be prepared into the crown at the mesiobuccal line angle with a small
round bur if the access to the elevator is not possible. Then a cryer or crane pick elevator can be used to elevate the tooth, engaging the
purchase point.
IMPORTANT CONSIDERATIONS
It accounts for approximately 40% of the total mandibular 3rd molar impactions.
In some cases the crown of the impacted tooth is situated below the convexity of the 2 nd molar which may cause inadvertent luxation the latter which
elevation.
VERTICAL IMPACTIONS
Sectioning in vertical impactions is similar to the mesioangular impactions or sectioning can be done along the long axis of the tooth, but in cases
where the purchase point is adequate and a single root exists it can be elevated with out sectioning of the tooth.
IMPORTANT CONSIDERATIONS
Buccal leverage can be used in case its too close to the 2nd molar or widely separated from it.
HORIZONTAL IMPACTIONS
For horizontal impactions the sectioning of the tooth is done at the CEJ thus separating the crown from the root. The cut is made upto the half to
threefourth of the tooth and it is completed by inserting the straight elevator in the cut and rotating it. The crown portion is then removed by
elevating from the mesial aspect and the root portion is then luxated in to the space created and removed.
IMPORTANT CONSIDERATIONS
DISTOANGULAR IMPACTIONS
Large amount of distal bone removal is required. The crown is sectioned from the root just above the cervical line after sufficient bone is
removed from the occlusal and buccal distal aspect. The entire crown is remove to improve the visibility and access to the roots. If the roots are
divergent they are further sectioned into two pieces and delivered individually .If the roots are convergent then the simple use of the straight
elevator is sufficient.
IMPORTANT CONSIDERATIONS
Most difficult mandibular impaction due its path of delivery into the ascending ramus.
Differentiating vertical impaction from distoangular impactions: in distoangular impactions the Interdental space between the second and the
third molar is less than as compared to between the first and the second molar but in vertical impactions there is no such significant difference
between the two Interdental spaces.
Buccoangular , linguoangular and inverted mandibular third molar impactions mostly requires both bone removal and tooth sectioning to
facilitate their removal.
Armamentariums are same as used for mandibular impactions except forceps and elevators.
Millers and Potts elevators are commonly used because of their curved blades.
Fracture of the maxillary tuberosity is most commonly associated with manipulation of the mesioangular impactions.
Displacement of the tooth in the infratemporal fossa occurs most frequently with the distoangular impactions.
Special procedures
The lingual split bone technique of Sir William Kelsey Fry.
It can be used for any type of mandibular third molar impaction but is most commonly used for horizontal and distoangular impactions. It should
not be used for buccoversion type of impactions.
Steps:
Vertical stop cut is made by facing the chisel bevel posteriorly distal to the second molar. With the chisel bevel downward, a horizontal cut is
made backward from the lower end of the vertical stop cut. The buccal bone plate is removed above the horizontal cut. The distolingual bone is
then fractured inward by placing the cut end of the chisel at 45 degree angle and parallel to the external oblique ridge. Bevel side of the chisel is
facing upwards. Finally small wedge of bone which then remaining distal to the tooth and between the buccal and the lingual cut is excised and
removed. A sharp straight elevator is then applied and minimum force is used to elevate the tooth. As the tooth moves upward and backwards,
the lingual plate gets fractured and facilitates the removal of the tooth. After the tooth is removed the lingual plate is grasped with the hemostat
and freed from the soft tissue and removed. Smoothening of the edges is done with a bone file and the wound is irrigated and sutured.
Any piece of bone , tooth, filling material should be removed from the socket by copious irrigation otherwise such particles will act as a nidus and
will result in to the infection of the wound.
If the impacted tooth is partially erupted in the oral cavity and the primary closure of the wound after surgery is intended then a reverse bevel
incision on the free gingival margin should be given before raising of the mucoperiosteal flap.
Primary closure of a wound should never be attempted when there is less than 5mm of attached gingiva buccally to the third molar.
Key suture.
This is placed immediately distal to the third molar. In this the needle is passed through the base of the distal papillae of the 2nd molar and is sutured
as far lingually as possible to prevent the loss of attachment of the gingiva on the distal aspect of the second molar.
This is done to tightly approximate the buccal and the lingual Interdental papilla in its preoperative position.
Precautions while using commercial mouth wash and H2O2 mouth rinses.:
Patients should always be advised to rinse the mouth thoroughly after using commercial mouthwashes because they may contain alcohol which can
irritate the wound post extraction.
Cold applications should be done only intermittently after extraction and only on the first day. Prolonged application of the cold may result in
rebound vasodilatation due to which bleeding may occur.
Cold provides a transient anesthesia of the applied part and minimizes the post op pain which may be due to extensive edema followed by tension of
the nerve endings.
Like cold , heat also should be applied only intermittently because prolonged application of the heat may also result in rebound vasoconstriction
which may then oppose its desired effect.
complications
Subcutaneous emphysema :
Two determining factors are always involved with subcutaneous emphysema. On the one hand, a compressed air procedure (air turbine handpiece,
air-water syringe), and on the other, a communication between the oral cavity and deeper tissue producing dissection . Air can penetrate through the
radicular apex affecting principally the submandibular and sublingual area . The facial muscle ie:- buccinators, connecting the maxilla and the
mandible, act as a guide for the air which follows the line of least resistance. The roots of the first, second and third lower molars communicate
directly with the sublingual and submandibular spaces. The sublingual space also provides a line of communication with the parapharyngeal,
pterygomandibular and retropharyngeal spaces. This last area forms the principal connection from the mouth to the mediastinum . Air may penetrate
the submandibular space which is delimited cranially by the mylohyoid muscle, laterocaudally by the superior fascia of the neck, and ventrocaudally
by the anterior ventral portion of the digastric muscle. Sekine et al recommend that any mucoperiosteal flap raised during a dental extraction should
be kept as small as possible and not extend towards the lingual area of the molar tooth. Caution should be exercised with periodontal pockets over 4
mm or when there is little adhered gingiva due to the increased susceptibility of producing emphysema. It is recommended to maintain the greatest
possible distance between the handpiece and the soft tissues and / or bone to prevent penetration of air, even in the absence of a mucoperiosteal
flap. Subcutaneous emphysema usually resorbs spontaneously without complications, and its treatment is symptomatic, as in the case of our patient .
Clinical improvement is noted after 2-3 days, with minimal crepitus after 7-10 days. Antibiotic prophylaxis is accepted, since the air introduced
through an intraoral location is likely to carry bacteria that can cause cellulitis or necrotizing fasciitis One point that may go unnoticed when
sectioning teeth with an air turbine dental handpiece, without raising a mucoperiosteal flap, and that may trigger emphysema, is the close insertion
of the handpiece into the tooth, we therefore recommend avoiding direct contact between the head of the handpiece and the tooth, as this may
cause air to penetrate directly into the tissues.
POSTOPERATIVE COMPLICATIONS
HEMORRHAGE:
Excessive bleeding is defined as bleeding beyond that expected from the extraction or continued bleeding beyond the postoperative window for clot
formation (6–12 hours). Excessive bleeding and hemorrhage have been reported to occur in the range of 1% to 6% of third molar surgery .
Preoperative assessment of intrinsic coagulation disorders and the use of anticoagulant and antiplatelet medications are essential. Of the
predisposing risk factors reported, the most important is the level of the impaction and its proximity to the neurovascular bundle .Excessive bleeding
has been reported to occur more frequently with the extraction of mandibular third molars versus their maxillary counterparts. Excessive bleeding is
more frequent, regardless of the type of impaction, for inexperienced surgeons .It is also more commonly reported in older patients, probably
because of vascular fragility and less effective coagulation mechanisms .It is reported that men are as much as 60% more likely to suffer from
excessive bleeding than women, possibly because of the higher incidence of contraceptive use in women and the positive effect of oral
contraceptives on coagulation .Identification of patients at risk is a critical first step in appraising the likelihood of bleeding complications after third
molar surgery. During the preoperative consultation, it is imperative that the surgeon inquire about any past surgeries and the occurrence of
associated bleeding complications. Any family history of bleeding abnormalities should be elicited. Excessive bleeding with loss of deciduous teeth
and, in women, a history of menorrhagia, can be suggestive of an underlying coagulopathy. Intraoperatively, careful soft tissue management and local
measures can control and prevent most bleeding problems. Hemorrhage that cannot be controlled with local measures are rare.
ALVEOLAR OSTEITIS:
Alveolar osteitis is one of the most common complications associated with third molar surgery . It is characterized by a severe throbbing pain that
usually begins 3 to 5 days postoperatively . By this time, most of the pain and swelling associated with surgical trauma should disappear, and residual
radiating pain to the ear is a common complaint in patients with alveolar osteitis. The causes of this painful condition, commonly known as ‘‘dry
socket,’’ are not completely known but are considered to be related to malformation or disruption of blood clots in a newly vacated third molar
socket . Although data support the rationale that alveolar osteitis can be caused independent of fibrinolysis, destruction of a formed thrombus by
invading oral bacteria is generally accepted as a more important etiologic factor. This conclusion is supported by data that indicate that the use of
antifibrinolytic agents decreases the incidence of alveolar osteitis and that saliva with a high bacterial count is associated with an increased incidence
.Overall rates of alveolar osteitis vary in the literature from 1% to 30% . The variability of reported percentages can be attributed largely to ambiguous
diagnostic criteria. Multiple authors have shown that factors such as age, sex, surgical experience, type of extraction, tobacco use, oral contraceptive
use, and use of irrigation intraoperatively affect the incidence of alveolar osteitis, but the mechanism of their effects is not clear. Mandibular third
molar surgery is more commonly associated with alveolar osteitis than maxillary third molar surgery . Incidence also increases with patient age.
Patients under the age of 20 are considered a low-risk population for this problem, which may be because the bone in these patients has more
elasticity, circulation, and greater healing capacity . Patients who take oral contraceptives and patients who are habitual tobacco users seem to be at
a greater risk for development of alveolar osteitis. The onset of alveolitis has been found to be higher in women than in men, possibly skewed by the
use of oral contraceptives. Surgical experience seems to be inversely related to the incidence of alveolar osteitis. Patients with preexisting
pericoronitis and patients with poor oral hygiene are at increased risk for development of osteitis, which suggests the role of bacteria in fibrinolysis
.Methods for reducing the incidence of alveolar osteitis have been recommended. Depending on the risk level of the patient, different courses of
action may be indicated. Some researchers have advocated the routine use of prophylactic agents for inexperienced surgeons . Various measures can
be taken to reduce the incidence of alveolar osteitis, including evacuation of the vacant socket via saline irrigation, the use of topical antibiotics, such
as tetracycline powder, within the socket ,placement of Gelfoam packing soaked in antibiotic media , and the perioperative use of chlorhexidine
rinses .
INFECTION :
Because of the large variety of indigenous oral flora, postoperative infection is of concern. Although the use of aseptic technique, hemostasis,
meticulous tissue management, and complete and thorough lavage of extraction sites can decrease the likelihood of postoperative infection, the
routine use of antibiotic therapy to prevent infection is still debated . The overall incidence of infection from third molar extraction has been
reported to be in the range of 3% to 5% . It has been suggested that the rates of postoperative infection are higher for mandibular bony
impactions than for any other type of extractions, reflective of the increased surgical trauma . Surgical experience also can influence the rate of
secondary infection . Systemic antibiotics have been of suggested value for infection prevention in patients with gingivitis, pericoronitis, or
general debilitating diseases, but their effectiveness in reducing postoperative infections overall remains controversial . The incidence of deep
fascial space infection is low . Management of these more severe infections depends on the severity. Treatment should include proper
assessment and management of the airway, adequate imaging, dependent drainage with culture and sensitivity testing, and appropriate use of
antibiotics.
REFERENCES
Daniel .M.Laskin ,Oral and maxillofacial surgery,vol2,AITBS publishers.
Fonseca,oral and maxillofacial surgery, anesthesia/dentoalveolar management/ office management, vol 1, Saunders.
Geoffrey L Howe, minor oral surgery, third edition, Varghese publishing house
Neelima Anil Malik, Textbook of oral and maxillofacial surgery, fifth edition, Jaypee publications.
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