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Impacted Teeth

Impacted Teeth

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Published by Fon Wijidtra Dent

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Published by: Fon Wijidtra Dent on May 30, 2010
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Paul ThaiManagement of Impacted Teeth1
Management of ImpactedTeeth
Oct 2, 2006
Removal of impacted teeth is one of the mostcommonly performed surgical procedures bythe OMFS.
Requires extensive training, skill andexperience to perform in atraumatic fashion
Impacted teeth
Mandibular third molar most commonlyimpacted tooth
98% of impacted teeth are mandibular third molars
Maxillary canines 1.3%
Mandibular premolars and other teeth make upthe remainder 
Classification of impacted thirdmolars
Classified by position or direction ocrown of impacted tooth
 –Mesioangular, distoangular, vertical, or horizontal –Pell and Gregory classification
Classifies impaction based on the tooth’srelationship to the anterior ramus and occlusalplane
Pell and Gregory Classification
 –Relationship of tooth to anterior border of ramus
1, 2, 3
 –Relationship of tooth to occlusal plane
A, B, C
Paul ThaiManagement of Impacted Teeth2
Pell and Gregory
•Class 2 impaction
Pell and Gregory
Indications for removal of thirdmolars
Prevention or presence of periodontaldiseasePrevention or presence of dental cariesPrevention or presence of soft tissueinfection (pericoronitis or abcess)Prevention or presence of odontogenic cystsand tumorsFacilitation of orthodontic treatmentImpacted teeth under a dental prosthesis(relative indication)Preparation for head and neck radiation (for oral/head and neck cancer)
Additional considerations
Data suggests that asymptomaticpatients with a pocket depth aroundthird molars greater than 5mm, havesignificantly increased levels of inflammatory mediators vs patients withpocket depths less than 5mm
 –White, R; et al. JOMS 60:1241-1245, 2002
Additional considerations
Presence of periodontal disease issignificantly associated with pre-termbirth
 –Data from 1,020 obstetric patients –Results more significant if perio diseasearound third molars
Moss, K; et al. JOMS 64:652-658, 2006
Additional considerations
Patients with visible third molars aremore likely to have progression of periodontal disease than patientswithout third molars
 –Blakey, G; et al. JOMS 64:189-193, 2006
Paul ThaiManagement of Impacted Teeth3
Additional considerations
Indications for Elective Therapeutic Third Molar Removal: The Evidence is In
Assael, LJOMS 63:1691-1692, 2005Editorial
Assael, LJOMS 2005
Conclusions from recent evidence-basedresearch1.All third molars should be considered foremoval in young adults in order tomitigate the risks of systemic inflammationand local progression of emergingperiodontal disease2.Patients who elect to retain their thirdmolars need to be monitored for theprogression of periodontal disease3.Patients with retained third molars shouldbe informed of research regarding 
Preoperative Considerations
Determining Surgical Difficulty
Position of toothMesioangular impaction (45%) of all impactedmandibular 3
molars and least difficult to remove.Vertical impaction (40%) and horizontal impaction(10%) are intermediate difficulty.Distoangular (5%) is the most difficult to extract.Age of patientDensity of bonePosition of tooth in relation to other anatomic structureseg: IAN, Maxillary sinusCooperation of patientSurgeon experience
Technique of Surgery
Mucoperiosteal flap to gain adequate accessto underlying bone and tooth.
Envelope flap with or without releasing incision.Buccal artery sometimes encountered during releasing incision.Posterior extension should extend lateral and up the anteriorborder of the mandible. If extend straight posterior, will enterthe sublingual space and likely damage the lingual nerve.Releasing incision rarely necessary in maxillary third molar.
Technique of Surgery
Remove bone around impacted tooth
 –Air-driven or electric hand piece with round or fissure burs –Chisel –For mandibular teeth, bone on the occlusal,buccal and distal aspects of impacted tooth isremoved down to the cervical line. Advisable notto remove bone on lingual aspect due tolikelihood of damage to lingual nerve.

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