Impacted teeth - learn everything about it (classification - complications - indications of removal - contraindications for removal - operative and post operative complications - and more about it) موضوع باوربوينت عن الاسنان المنحصرة : تتعلم فيها كل ما يتعلق عنها: (الاعراض والاختلاطات - دواعي الازالة - موانع الازالة - اختلاطات المعالجة واختلاطات بعد المعالجة - والمزيد..) Prepared by: Dr.Basma Elbeshlawy

3. Items
- Definition of Impacted Tooth
- Causes
- Classification
- Frequency
- Indications for removal of Impacted Tooth
“ Complication that may result from impacted tooth “
* Prophylactic removal of impacted tooth .
- Contraindications for removal of Impacted Tooth
- Diagnosis
- Surgical Technique for removal of impacted tooth .
- Operative complications.
- Post operative complications
- References.

4. Definition :-
To “Impact” mean “to contact and Pressure”
Impacted tooth is that tooth that fails
to erupt into its normal functioning position
in the dental arch within the expected time.
The term Unerupted includes both
impacted teeth and teeth that are in the
process of eruption.

5. Causes of impaction
• Systemic causes
• Local causes

6. Systemic Causes
1- Prenatal causes – hereditary
a hereditary syndrome of cleidocranial dysistosis termed primary
Retention.
2- Postnatal causes Rickets
Anemia
Tuberculosis
Congenital syphilis
Malnutrition
Endocrinal deficiency (hypothyrodism, hypopituitarism).
Febrile disease,
Down syndrome ,
Gorlin syndrome.

7. Local Factors
1- Lack of space in dental arch due to
Small size dental arch with disproportion between teeth and jaw size
Macrodontia
2- Over retained deciduous teeth
3- Premature loss of deciduous teeth
4- High density of overlying and surrounding bone
5- Long standing chronic inflammation soft tissue fibrosis
6- Incorrect alignment and abnormality of teeth
7- Direct or indirect effect of cysts or neoplasm.
8- Cleft palate or lip
9- Ectopic position of tooth bud

8. Classification system
of impacted teeth
This is done to help dentist in evaluation of the extent
of the surgical procedure and in the planning of this
procedure.

9. A - Relation of the tooth to the ascending
ramus of the mandible and to the distal
surface of the 2nd molar (Pell
&Gregory):
– This show the anterioposterior relationship of the
tooth to the arch and the amount of resistance
offered by the bone of the ascending ramus that
may influence the tooth removal
1-Classification of
impacted mandibular third
molar:

10. Class1
• The space between
the anterior part of the
ascending ramus and
the distal surface of
the 2nd molar is
sufficient to
accommodate the
mesiodistal diameter
of the crown of the
third molar.

11. Class2
• The space between
the anterior part of the
ascending ramus and
distal surface of the
2nd molar is less than
the mesiodistal
diameter of the crown
of the third molar (part
of the tooth located
within the ramus)

12. Class3
• All the third molar is
located within the
ascending ramus of
the mandible.

13. - This show the superior
inferior relationship of the tooth
in relation to the occlusal plan.
(Pell & Gregory)
• Position A:
The highest portion of the tooth is on level
with or above the occlusal plane.
• Position B:
The highest portion is below the occlusal
plane but above the cervical margin of the
2nd molar.
• Position C:
The highest point of the tooth is below the
cervical margins of the 2nd molar.
(deep impaction)
B - Relative depth of the third molar in
bone:

14. 1-Vertical: the long axis of the third molar
is parallel to that of the 2nd molar.
2-Horizontal: the long axis of the third
molar is at right angle to that of the
2nd molar .
3-Mesioangular impaction.
4-Destoangular impaction:
all the previous four classes can come in:
a - lingual deflection.
b - buccal deflection.
5-Inverted impaction .
C - The position of the long axis of the impacted
tooth in relation to the long axis of the 2nd molar
(winter's classification):

15. Classification of impaction
of mandibular third molars,
according to
Archer (1975) and Kruger (1984).
1 Mesioangular, 2 Distoangular,
3 Vertical, 4 Horizontal,
5 Buccoangular,6 Linguoangular,
7 inverted.
Classification of impacted
mandibular third molars according
to
Pell and Gregory (1933):
according to
a The depth of impaction
b their position
according to the distance between
the 2nd and the anterior border of
raums of the mandible

16. Soft tissue impaction
in which crown of tooth is
covered by soft tissue only and
can be removed without bone
removal
Partial bony impaction
in which part of tooth, usually
posterior aspect, is covered with
bone and requires either bone
removal or tooth sectioning for
extraction .
Complete bony impaction
in which tooth is completely
covered with bone and requires
extensive removal of bone for
extraction.
Another
classification
of impaction

17. 2 -Classification of
impacted maxillary
third molar:according to
Archer (maxillary 1975), depending on the depth of impaction
compared to the adjacent second molar
Class A:
The occlusal surface of the impacted tooth is
at approximately the same level as the
occlusal surface of the 2nd molar (Fig.a).
Class B:
The occlusal surface of the impacted tooth is
at the middle of the crown of the adjacent 2nd
molar (Fig.b).
Class C:
The occlusal surface of the crown of the
impacted tooth is below the cervical line of
the adjacent molar or even deeper,
or even above its roots (Figs.c–e).

18. According to Archer (1975).
1Mesioangular,
2 distoangular,
3 vertical,
4 horizontal,
5 buccoangular,
6 linguoangular,
7 inverted
According to the relationship of tooth to maxillary sinus
a-Sinus approximation :
(s.a) where no bone or very thin bone exist
between the impacted teeth and floor of sinus.
b-No sinus approximation :
(n.s.a) where 2 mm or more of bone exist
between the floor of sinus and impacted teeth

19. • Class1:
Palatally impacted cuspids ,these could be in vertical, horizontal,
semivertical position.
• Class2:
Labialy impacted cuspide which could be in vertical, horizontal,
semivertical.
• Class3:
Impacted cuspid located both in the palatal and labial surfaces.
• Class4:
Impacted cuspid in the alveolar process
• Class5:
Impacted cuspid that are present in an edentulous maxilla.
3-Classification of
impacted maxillary
cuspids:

20. frequency of impaction
1. mandibular 3rd molar
2. maxillary 3rd molar
3. maxillary cuspid
4. mandibular cuspid
5. Mandibular premolar
6. maxillary premolars
7. maxillary central and lateral incisors
( wisdom teeth are very common to be impacted as they
are the last molar to emerge. They are normally
emerge between 17 -21 years of age )

21.  Complications of impacted tooth.
 Operative complications.
 Postoperative complications.

22. Complication of impacted
teeth
(indication for removal):
the presence of impacted teeth in the jaw can create
a variety of problems, so it should be removed as
soon as diagnosis is made:

23. Pain
Pain may originate from
• caries
• Periodontal disease
• Pericoronitis
• Root resorption
• Pressure on nerve
(neuroalagic pain)

24. • When third molar is
impacted or partially
impacted ,the bacteria
that cause dental
caries can be
exposed to the distal
aspect of the 2nd
molar, as well as to
third molar
Dental Caries

25. • Erupted teeth adjacent to
impacted teeth are
predisposed to periodontal
disease.
• As it decrease amount of
bone on the distal aspect of
adjacent 2nd molar, with
deep periodontal pocket on
the distal aspect of the 2nd
molar.
Periodontal Disease

26. Pericoronitis
• when a tooth is partially
impacted with a large
amount of soft tissue over
the axial and occlusal
surfaces, the patient
frequently has one or
more episodes of
pericoronitis.

27. Definition
• Is an infection of the soft
tissue around the crown of
partially impacted tooth and
is caused by the normal
oral flora.

28. Causes
Decrease in host defense.
Minor trauma from maxillary 3rd molar.
“The soft tissue that covers the occlusal surface of the
partially erupted mandibular 3rd known as the
operculum can be traumatized and become swollen
this can be treated by removal of maxillary 3rd molar.”
Entrapment of food under operculum ,this pocket can not be
cleaned ,bacteria invade it and pericoronitis begins.
Streptococci and anaerobic bacteria (the usual bacteria
inhabit the gingival sulcus) cause pericronitis.

29. • pericronitis can present as a very mild infection or as
a sever infection that requires hospitalization of the
patient .
A. In its mildest form:-
- Percronitis is present as a localized swelling and
soreness.
- Mild irrigation and curettage by dentist and home
irrigation by pt is sufficient.
B. In sever infection with local tissue swelling:
that is traumatized by maxillary 3rd molar,
the dentist should consider the maxillary 3rd molar
and local irrigation .
Treatment and Management

30. • For the patient who have in addition to local swelling and
pain, mild facial swelling ,mild trismus secondary to
inflammation extending into muscle of mastication ,and a
low grade fever, the dentist should consider
administration of antibiotics along with irrigation and
extraction, (penicillin is the antibiotic of
choice).
• The mandibular third molar shouldn't be removed
until sign and symptoms of pericronitis have been
completely resolved
• The incidence of post operative complication as dry
socket and post operative infection ,increases if
tooth is removed during time of active infection.

31. • Impacted teeth cause
sufficient pressure on
the root of an adjacent
tooth to cause root
resorption.
Root Resorption

32. Orthodontic problems
crowding of mandibular anterior teeth.
Malocclusion (maxillary canine)
Prosthetic problems
Dentulous patient under bridge
Edentulous patient under denture
Mucosal ulceration
so it’s very important to have preprosthetic radiograph

33. Odontogenic cyst and Tumors
• The dental follicle
may undergo cystic
degeneration and
become a dentigerios
cyst or keratocyst.
• Ameloblastoma may
developed from
epithelium within the
dental follicle

34. Fracture of the jaw
Impacted third molar
occupies space that is
usually filled with bone, this
weaken the mandible and
render the mandible to
fracture.

35. Prophylactic removal of
impacted tooth
• If the impacted tooth is asymptomatic there are two
opinions either remove it as a prophylactic line of
treatment or do not remove it and follow up the case
periodically by x-ray for any cystic formation
• Several reasons are given for the early removal of
asymptomatic or pathology free impacted teeth especially
wisdom teeth almost all of which are not based on reliable
evidence.
 They have no useful role in the mouth
 They may increase risk of pathological changes and symptoms.
 If they are removed only when pathological changes occur patient may be
older and the risk of serious complications after surgery may be greater.
• But prophylactic removal should only be carried out if
there is good evidence of patient benefit

36. Contraindication for
removal of impacted
teeth:

37. 1. Extreme of age:
- As the bone become highly calcified, less flexible,
less likely to bend under force of tooth extraction
the result ,bone more surgically removed to
displace tooth from its socket and less post
operative sequels
2. Compromised medical status:
e.g. cardiovascular patient
3. Probable excessive damage to adjacent
structure:
e.g. teeth, nerves or previously
constructed bridges

39. History:
Symptomatic individuals with an impacted tooth may report
1- Pain and tenderness of the gums (gingiva)
2- Unpleasant taste when biting down on or near the area
3- A visible gap where a tooth did not emerge
4- Bad breath
5- Redness
6- Swelling of the gums around the impacted tooth
7- Swollen lymph nodes (occasionally)
8- Difficulty opening the mouth (occasionally)
9- Headache or jaw ache.
Physical exam:
Examination of the teeth by the dentist may show
1-Enlargement of the tissue where a tooth has not emerged or has emerged only
partially.
2-The impacted tooth may be pressing on adjacent teeth.
3-The gums around the area may show signs of infection (such as redness, drainage,
and tenderness).
4-As gums swell over impacted wisdom teeth and then drain and tighten, it may seem to
the individual that the tooth came in and then went back out again.

40.  Radiological assessment of impacted teeth should
cover:
– Type, orientation of impaction & the access to the tooth
– Crown size & condition
– Root number & morphology
– Alveolar bone level including depth & density
– Follicular width
– Periodontal status, adjacent tooth
– Relationship or proximity of upper tooth to the nasal cavity or
maxillary antrum
– Relationship or proximity of lower tooth to the inter dental
canal, mental foramen & lower border of the mandible
Radiography:
Dental x-rays confirm the presence of a tooth (or teeth)
that has not emerged.

41. Standard radiographic techs used to localize the
unerupted teeth, these include:
 Periapical films The tube shift method
 Occlusal films
 Panoramic view
 CT

42. The tube shift method
• Uses two periapical radiographs, shifting
the tube horizontally between exposures.
• If the unerupted teeth moves in the same
direction in which the tube is shifted, its
located on the lingual or palatal side
• A facial or buccally located tooth moves in
the opposite direction to the tube shift.

43. The periapical &occlusal
method
• Uses the periapical radiograph taken with
standard technique and an occlusal
radiograph to give different views of the
impacted tooth.
• Panoramic film can be used to assess
maxillary canine position

45. 45
More accurate 3-D views of impacted teeth
 Provides more accurate 3-D views of
impacted molars, impacted cuspids, and other
supernumerary anomalies
 Visualize impaction within the alveolar bone,
location relative to adjacent teeth, and
proximity to vital structures
 More accurate information can result in less
invasive surgery/decreased surgical time

47. Surgical removal of
impacted teeth:

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

49. 1- Proper radiographic and clinical evaluation of the
condition.
2- Classification of impaction to help in planning the
surgical procedure
3- Selection of the time for surgical procedure:
If the impacted tooth is to be removed, the most suitable
time to do so is when the patient is young, that for these reasons:-
*Avoid the aforementioned complications and undesirable
situations that could get worse with time.
* Younger patients generally deal with the overall surgical
procedure and stress well,
* Present fewer complications
* Faster postsurgical wound healing compared to older patient
* Easier bone removal
Preparation for the surgery

50. 4- The condition should be explained to patient in a simple
easy way directing his attention to possible complication
that may arise from leaving tooth in position
5- Surgical removal can be made under local anesthesia
as well as general anesthesia the choice of the
anesthetic technique depends on:
a- general condition of the patient and his ability psychologically and
physically take the procedure. in very apprehensive patient, general
anesthesia is preferred.
b- position of impaction and extent of surgical procedure
c- patient co-operation
d- number of impaction that will be removed

51. The surgical procedure is divided
into following stages:
1. Incision and reflection of the mucoperiosteal flap
2. Removal of bone to expose the impacted tooth
3. Tooth delivary
4. Care of the postsurgical socket and suturing of the wound
The main factors for a successful outcome to the surgical procedure
are as follows:
􀁏 Correct flap design, which must be based on the
clinical and radiographic examination (position of
tooth, relationship of roots to anatomic structures,
root morphology).
􀁏 Ensuring the pathway for removal of the impacted
tooth, with as little bone removal as possible. This is
achieved when the tooth is sectioned and removed
in segments, which causes the least trauma possible

52. A- Elevation of an adequate
mucoperosteal flap to expose the
field of surgery:
Pyramidal flap used in all third molar
impaction, the anterior incision of
the flap could extend from the distal
aspect to 2nd molar running at 45
degree angel and extend to the
mucobucal fold.
In deep impaction ,a bigger flap is
advisable. the anterior incision could
start from the mesial aspect of 2nd
molar
1- gaining access to impacted tooth:

53. Incision and types of flap for impacted
mandibular 3rd molar
Types of flaps A- Triangular flap
Incision for the creation of a triangular flap, which is indicated in certain cases
of extraction of impacted mandibular 3rd molar

54. When impaction is deep (vertical releasing incision is distal to the first
molar).

55. B-Horizontal flap
These types of flaps used in case of impaction is relatively superficial

56. Incision and reflection of the flap for
impacted maxillary 3rd molar

57. Incision and reflection of the flap for
impacted maxillary canine
Palatal approachLabial approach

58. 2-Bone removal:
This is done for :-
A- Exposure of impaction
B- Reduction of resistance
C- Making a point for application of the elevator

59. 3- Tooth delivery
1- Total delivery by application of force using elevators:
a- Mesial application of force :straight elevators and pot's elevators.
b- Buccal application of force :winter elevator
2- Delivery of the tooth after tooth division :
Division is indicated to reduce resistance ,create a space or remove
interlocked cusps of the tooth
a- Decapitation:-
Division of the crown of the tooth at cervical margin level .
- indicated in horizontal mandibular and maxillary third molar impaction and
pallataly impacted maxillary cuspid
b- Longitudinal tooth division:
- indicated when the impacted tooth has a widely divergent straight roots,
or when one root is straight and the other is curved
c- Division of the interlocking cusp:
- this is done with mesioangular impaction ,removal of the inter locking
segment of the tooth usually located under the distal surface of 2nd
molar

60. Extraction of Impacted 3rd Molar in Horizontal
Position

62. Extraction of Impacted 3rd Molar in
mesioangular position

65. Extraction of Impacted 3rd Molar in
distoangular position

66. Extraction of Impacted maxillary 3rd
Molar

67. Extraction of Impacted
maxillary canine
Labial approach

68. Extraction of Impacted
maxillary canine
Palatal approach

69. 4-Preparation for wound closure:
- After removal of the tooth from it's socket the
wound is gently irrigated with sterile normal
saline solution and inspected for:
a- any remnant of the residual tooth sac is removed
b- remnant of tooth structure or fragments of bone
debris is gently removed
c- small fragments of the detached bone
d- sharp edges of interseptal or alveolar bone is
trimmed and smoothed
- Then final irrigation and wound now is ready for
closure.

70. 5-closure of the wound:
• Well designed and properly reflected flap fall back easily
into place. using half circle a traumatic needle and 000
black silk suture to hold flap into place
post operative care:
1. A pressure pack is held in place for 1hour
2. Proper antibiotic therapy
3. Patient return back for check up after two days
4. Suture removal after 5 days

71. POST OPERATIVE INSTRUCTIONS
ON THE DAY OF TREATMENT
Do not rinse your mouth for at least 24 hours.
Avoid hot fluids, alcohol, hard or chewy foods.
Choose cool drinks and soft foods.
Avoid vigorous exercise.
Smokers should avoid smoking.
If the wound start to bleed, apply a small compress.
This can be made by placing cotton wool on the bleeding point and bite firmly on it .
• If you cannot stop the bleeding yourself please seek professional advice.
Any pain or soreness can be relieved by taking the prescribed medication.
such as paracetamol (Panadol) 2 tablets every 4 hours as required.
Do not take more than the recommended number per day.
STARTING 24 HOURS LATER
Gently rinse the wound with hot saltwater mouth rinses for a few days.
This should be carried out three times a day after each meal.

72. Complications associated with
surgical removal of impacted
tooth:

73. 1- laceration of the soft tissue flap:
a-improper incision
b-improper elevation of the flap and improper retraction this
leads to delayed healing and sever discomfort
2- Affection of the alveolar bone
3- Fracture of the jaw:
- in angle of mandible ,improper use of elevator with
uncontrolled force
4- Fracture of tuberosity:
- due to improper use of force

74. 5-Comlications related to injury of adjacent structure:
a-Injury to inferior alveolar canal:
- occurs in deeply seated vertical impaction, the nerve pass between
roots of impacted tooth .permanent numbness and heamorraghe
b-Damage to nasal floor:
- during surgical removal of impacted maxillary cuspid, profuse bleeding from
nasal mucosa
c- Involvement of maxillary sinus:
- during removal of impacted maxillary third molar. oro anntral fistula
results
d- Pushing of impacted tooth into maxillary sinus
e- Pushing of impacted maxillary molar into ptrygopalatine
fossa:
- uncontrolled mesial application of force in deep impaction
f- Pushing impacted mandibular third molar into sub -
mandibular space:
- uncontrolled buccal application of force and fracture of the lingual plate
g-Aspiration or swallowing of impacted tooth:
- with general anesthesia

75. post operative complications:
1. pain.
2. infection
3. hemorrhage
4. Nerve injury (lingual or inferior alveolar nerve)
5. Trismus , limitation of jaw movement
6. osteomylitis
7. pain at TMJ
8. pain on swallowing due to edema of pharynx and
hematoma formation.

76. references
 Peterson΄s principles of oral and Maxillofacial surgery
 Master Dentistry
 Pub Med central Journal.
 Fragiskos D. fragiskos (ed.)
 Net pages :
www.Dentalcare.com
www.ada.org
www.dentistry.com