Professional Documents
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I mpacted Teet h
Pamela L. Alberto, DMD*
KEYWORDS
Impacted central incisor Impacted canine Impacted second molar Impacted premolar
Surgical exposure Orthodontic treatment
KEY POINTS
The management of impacted permanent teeth requires a team effort with input from the orthodon-
tist, general dentist, and surgeon to develop a satisfactory treatment plan.
It is important to evaluate the 3-dimensional position of the impacted tooth to the roots of the adja-
cent teeth to determine the proper treatment plan.
A full orthodontic evaluation is required before any surgical intervention.
The oral and maxillofacial surgeon must decide whether an open or closed exposure procedure
should be performed and provide optimal condition for the orthodontist to apply the correct forces
for alignment.
Bonding position on the impacted tooth depends on the intended direction on traction forces to be
applied. The orthodontist should determine this position.
The management of impacted teeth other than maxillary premolar and 0.09% for mandibular ca-
third molars is one of the most challenging and nines.2 Although the overall incidence of impacted
complicated types of dento-alveolar surgery. teeth, excluding third molars, is rare, it is important
Proper diagnosis and treatment planning requires that every oral and maxillofacial surgeon under-
interdisciplinary care by an orthodontist, general stands all treatment options and their manage-
dentist, and oral and maxillofacial surgeon but ment. The appropriate surgical procedure and
the orthodontist is responsible for the overall suc- orthodontic treatment plan will result in a stable,
cess of the treatment plan.1 predictable, and aesthetic result.
The most common impacted teeth aside from Surgical exposure of these impacted teeth is
the third molar are maxillary canines, maxillary accomplished using various approaches. We
second molar, mandibular second premolars, discuss surgical techniques used to expose the
and mandibular second molar (Fig. 1). There are impacted canine, central incisor, premolar, and
systemic and local factors that contribute to the second molar.
impaction of these permanent teeth. The contrib-
uting factors include arch length discrepancy, IMPACTED MAXILLARY CANINE
space deficiencies, ankylosed primary teeth, pa- Etiology
thology, trauma, and some systemic and genetic
Calcification of the maxillary canine starts at 4 to
factors.2 Although the incidence of impacted teeth
5 months and erupts into the oral cavity in 11 to
oralmaxsurgery.theclinics.com
Department of Oral & Maxillofacial Surgery, Rutgers School of Dental Medicine, Newark, NJ, USA
* 171 Woodport Road, Sparta, NJ 07871.
E-mail address: alberto@sdm.rutgers.edu
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Surgical Exposure of Impacted Teeth 563
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564 Alberto
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Surgical Exposure of Impacted Teeth 565
Etiology
Eruption failure is caused by supernumerary teeth,
Fig. 8. Brackets ligated to arch wire. odontomas, ectopic position of the tooth bud,
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566 Alberto
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Surgical Exposure of Impacted Teeth 567
Premolar impactions are usually due to local fac- The impaction of the second molar is a rare
tors. Mesial drift of teeth is due to premature loss complication in tooth eruption occurring approxi-
of the primary tooth, pathology, ectopic position mately 0.03% to as high as 3%, depending on
of the tooth bud, and ankyloses of the primary the study. It occurs unilaterally more commonly
tooth. Cleidocranial dysplasia, osteopetrosis, than bilaterally and slightly more in men than
Down’s syndrome, hypothyroidism and hypopitu- women (Fig. 14). It is more common in the
itarism can also cause premolar impactions.29 mandible than maxilla.3
The management of impacted second molar has
always been a challenge for the orthodontist and
oral and maxillofacial surgeon. The impacted
second molar usually goes unnoticed until the or-
thodontic treatment is complete and the roots
are fully formed. Proper alignment of the
second molar into the dental arch is required to
complete orthodontic therapy.
ETIOLOGY
There are multiple etiologies for impacted
second molar. When the deciduous
second molar is lost, the first permanent molar
must move forward to accommodate the eruption
of the second molar. If this does not occur, the
Fig. 13. Impacted maxillary and mandibular premolar. eruption of the second molar is compromised.
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568 Alberto
Fig. 14. Bilateral impacted mandibular second and Fig. 16. Impacted maxillary and mandibular
third molars. second molar due to ortho bands.
This can lead to tipping. If the developing third Observation is not an option. Impacted second
molar infringes on the space required for the molars must be treated because they can cause
second molar to erupt, mesial tipping occurs decay and periodontal disease with bone loss.33
(Fig. 15). Ill-fitting first molar bands are an iatro- The following treatment options can be used to
genic cause of the mesial impacted treat the impacted second molar.
second molar (Fig. 16).
Nonextraction treatment has become increas- 1. Surgical extraction of the impacted
ingly common due to the possibility of unpleasing second molar.
facial aesthetics outcomes. Desnoes32 has shown 2. Surgical exposure and uprighting the
that this has also contributed to complications in second molar.
the eruption of second molar. 3. Transplantation of the third molar into the
impacted second molar site.
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Surgical Exposure of Impacted Teeth 569
material is used to bond the second molar to the 1. Ecchymosis of the upper lip or lower lip and
first molar. This is not required with maxillary chin
impacted second molar. Luxation of the maxillary 2. Infection
impacted second molar will stimulate eruption. In 3. Paresthesia
Fig. 15, the second molar is exposed and luxated. 4. Damage to adjacent structures
Within 6 months, the tooth erupted. After eruption, 5. Noneruption
the third molar was removed (Fig. 17). 6. Loss of soft tissue flap/dehiscence
In most cases, an orthodontic appliance needs 7. Lack of attached gingiva
to be placed to upright the second molar. Going 8. Devitalization of the pulp
and Rayes-Lois34 reports of a technique in which 9. Pain
the second molar is bracketed with a band con- 10. Early loss of the orthodontic bracket
taining a buccal tube. Then a heavy-gauge nickel 11. External resorption
titanium arch wire is threaded through the tube 12. Loss of tooth
and the arch wire is ligated to the 2 premolars
and canine. The arch wire will then help to upright
the second molar.34 Other appliance can be used SUMMARY
instead. For example, segmental springs and The exposure of impacted teeth can be chal-
nickel titanium coil springs have been successful lenging but rewarding. The decision to surgically
in uprighting the second molar.35,36 TADs have correct these impacted teeth is usually made by
been developed that can be placed in the alveolar the orthodontist. Treatment planning these cases
bone and used as an anchorage device. A 2-week should be multidisciplinary with the oral and maxil-
healing period is necessary before elastics are lofacial surgeon making the final decision on the
placed. Orthodontic forces of 50 g to 250 g can surgical treatment plan. The risk-to-benefit ratio
be placed on the TAD. This method is especially usually favors the preservation of the impacted
useful when trying to upright lingually tipped lower tooth. In general, the recommendation is surgical
second molar and buccally tipped upper exposure of the impacted tooth with orthodontic
second molar.12 In addition, brass wire can be alignment into the arch. It is also recommended
used as a separator when placed below and above to upright the second molar with the removal of
the contact point between the first molar and the impacted third molar. Close follow-up by the
impacted second molar. The wire can be tightened orthodontist and surgeon is important to the suc-
incrementally to upright the second molar. This cess of these procedures. Preserving these teeth
technique is used infrequently, because it causes is an important orthodontic standard of care, so
pain, swelling, and future periodontal problems. it is imperative that our treatment is based on an
appropriate diagnosis made with adequate radio-
graphic localization and consultation with an
RISK FACTORS AND COMPLICATIONS orthodontist.
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