DIAGNOSIS OF IMPACTION

-Dr. Asif
Wani
PG scholar
(Second year)
02/04/2023 1
CONTENTS:
• Introduction

• Etiology & theories of impaction

• Surgical anatomy

• Classification of impacted third molars

• Preoperative assessment of radiographs

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DEFINITION

Origin- Latin -- impactus

Cessation of eruption of teeth cause by physical barrier or ectopic eruption

American society of oral surgeons 1971-impacted tooth is defined as the tooth which has

already passed chronological age of eruption and failed to come to oral cavity inspite of normal

eruptive forces due to some mechanical obstruction.

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• According to WHO – An impacted tooth is any tooth that is prevented from reaching its normal
position in the mouth by tissue, bone or another tooth.

• According to ARCHER – A tooth which is completely or partially unerupted and is positioned against
another tooth, bone or soft tissue so that its further eruption is unlikely, described according to its
anatomic position.

• According to ANDERSON- An impacted tooth is a tooth which is prevented from completely

erupting into a normal functional position due to lack of space, obstruction by another tooth or an
abnormal eruption path

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CAUSES

• Lack of space- length of mandible, condylar growth, resorption of ant. ramus, A-P length of

alveolar process

• Tooth angulation

• Ectopic eruption

• Obstruction

• Late mineralization

02/04/2023 ANDREASEN,PETERSON AND LASKIN-1997 5

THEORIES
Orthodontic theory :
Jaws develop in downward and forward direction.
Growth of the jaw and movement of teeth occurs
in forward direction , so any thing that interfere
with such moment will cause an impaction (small
jaw-decreased space)
Phylogenic theory:
Nature tries to eliminate the disused organs
Due to changing nutritional habits of our
civilization have practically eliminated needs
for large powerful jaws, thus, over centuries
the mandible and maxilla decreased in size
leaving insufficient room for third molars.

Mendelian theory: Endocrinal theory Pathological theory:

Heredity is the most common cause.
The hereditary transmission of small
jaws and large teeth from parents to
siblings. This may be important
etiological factor in the occurrence
of impaction.
02/04/2023
Increase or decrease in Chronic infections affecting an
growth hormone secretion individual may bring the condensation
may affect the size of the of osseous tissue further preventing the
jaws. growth and development of the jaws
The Skeletal theory
Several studies have
demonstrated that when there is
inadequate bony length, there is
a higher proportion of impacted
teeth. 6
SURGICAL ANATOMY

Vestibule formed by buccinator

buccally, mylohyoid lingually

Along the ant. border of ramus,

tendinous insertion of temporalis

Facial vessels run in proximity with 1st

molar
Hence distal incision, laterally

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 By NORTJE et al.,1977
Type I: Bilaterally single high mandibular canals-single high
canals either touching or within 2 mm of the apices of 1 st and
2nd permanent molars.

Type II: Bilaterally single intermediate canals-single canals not

fulfilling the criteria for either high or low canals

Type III: Bilateral single low canals-single canals either touching

or within 2mm of the cortical plate of the lower border of the
mandible

Type IV: Variations including-asymmetry,duplications and

absence of mandibular canals

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 Relation of lingual nerve to medial aspect of mandible

The Relationship of the Lingual Nerve to the

Clinical and Anatomic Observations on the
Mandibular Third Molar Region: An Anatomic
Relationship of the Lingual /Verve to the
Study M. ANTHONY POGREL, MB, CHB, BDS,
Mandibular Third Molar Region JOHN E.
FDSRCS, FRCS,* ANDREW RENAUT, MB, BS,
KIESSELBACH, DDS,* AND JACK G.
BDS, FDSRCS, FRCSJ BRIAN SCHMIDT, DDS,*
CHAMBERLAIN, f=t-iDt
02/04/2023 AND AWNIE AMMAR, BS§ 9
CLASSIFICATION SYSTEMS
BASED ON NATURE OF OVER LYING TISSUE

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GEORGE WINTER’S

• Based on the relationship of the long axis of the impacted tooth in relation to the long axis of the 2nd molar

Mesioangular – Most common type(43%)

Vertical - 38%
Horizontal - 3%
Distoangular - 6%

Buccal version

Lingual version
Torsoversion

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02/04/2023 12
PELL & GREGORY’S CLASSIFICATION

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 COMBINED ADA & AAOMS CLASSIFICATION OF
PROCEDURAL TERMINOLOGY

• 07220-Soft tissue impaction

• 07230-Partial bony impaction
• 07240-Complete bony impaction
• 07241-Complete bony impaction with unusual surgical complications

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ACCORDING TO SUPERIO-INFERIOR POSITION OF 3RD MOLAR

Crown to crown

Crown to cervix

Crown to root

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G.R.OGDEN METHOD

Compare the distance between the roots of 2nd &

3rd molars with that of 1st & 2nd

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 KILLEY & KAY’S CLASSIFICATION

a) Based on angulation and position: Winter’s classification

b) Based on the state of eruption: Completely, partially and unerupted

c) Based on roots:1) Number of roots - Fused roots

- Two roots
- Multiple roots

2) Root pattern - Surgically favorable

- Surgically unfavorable

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• This study demonstrated that males (60.8%) were more likely to present with impacted mandibular third

molars than females (39.2%)

• The prevalence of third molar impactions was almost the same on both the left and right sides.

• This study also noted that mesioangular impactions were the most common type of impaction.

• The least common form of impactions was the transverse types (2%).

• The prevalence of impacted mandibular third molars for this study was high

Passi D, Singh G, Dutta S, Srivastava D, Chandra L, Mishra S, et al. Study of

pattern and prevalence of mandibular impacted third molar among Delhi-National
Capital Region population with newer proposed classification of mandibular
impacted third molar: A retrospective study. Natl J Maxillofac Surg 2019;10:59-
02/04/2023 67 18
PRE-SURGICAL ASSESSMENT
CLINICAL

• Patient complaint • Eruption status

• Patient age • Periodontal status

• Social history • Occlusal relationship

• Medical history • TMJ function
• Dental history • Mouth opening/trismus
• Extraoral examination
• Pathology
• Intraoral examination

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RADIOGRAPHS FOR ASSESSMENT

• Intra oral radiographs

• IOPA
• Occlusal
• Extraoral radiographs
• OPG
• Lateral cephalometric
• Digital imaging
• CT
• CBCT
Localization techniques:
-Buccal object rule (SLOB)
-CBCT
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INTERPRETATION

• Assessment of lower third molar

• Angulation
• The crown
• The roots
• Relationship of apices with inf alveolar canal
• Depth of tooth in alveolar bone
• Buccal / lingual obliquity

• Assessment of lower second molar

• Assessment of surrounding structures

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FACTORS FOR INTERPRETATION

1. Type of impaction
2. External oblique ridge
oblique & post . to third molars – good access
vertical & ant. to third molar – poor access
3. Position & depth (WAR lines)
4. Any pathology
-Dental caries in II and III molars
-Periodontal problems
-Fused roots of II and III molars
-Cysts, odontomes
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5. Assessing the buccal / lingual
obliquity
Lingual obliquity -difficult

6. Shape of the crown

Large square crown – difficult

7. Root pattern

8. Path of withdrawl

9. Texture of bone

10. Follicular size (More size- less

bone- easy removal)

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 PROXIMITY WITH INFERIOR CANAL

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HOWE AND POYTON’S

CHANGES IN THE ROOTS

Darkening of root
Dark and bifid root
Narrowing of root
Deflected root

Howe, G.L. and Poyton, H.G. (1960) Prevention of Damage to

02/04/2023
the Inferior Dental Nerve during the Extraction of Mandibular 25
Third Molars. British Dental Journal, 109, 355-363.
• CHANGES IN CANAL
Interruption of lines
Converging
Diverted

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WINTER’S WAR LINES

• White line: Indicates difference in occlusal levels of 7 and 8, inclination

• Amber line: Bone level

• Red line: Depth

(Differs in radiographs, when taken in angulation)

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02/04/2023 28
RED LINE

• For distoangular teeth, point of elevation on the buccal side

• Drawn from amber line which is a curved plane

• Change in angulation of radiograph

Kumar S, Reddy MP, Chandra L, Bhatnagar A. The "Red Line" Conundrum: A

02/04/2023 Concept Beyond Its Expiry Date?. J Maxillofac Oral Surg. 2014;13(4):612-614 29
DIFFICULTY INDICES

PEDERSON’S

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WHARFE BY McGREGOR
Horizontal 2
1.WINTERS CLASSIFICTION
Distoangular 3
Mesioangular 1
Vertical 0

2.HEIGHT OF MANDIBLE 1-30mm 0

31-34mm 1
35-39mm 2
3.ANGULATION OF SECOND MOLAR 1° - 50° 0
60° - 69° 1
70° -79° 2
80° - 89° 3
90°+ 4

4.ROOT SHAPE Complex 1

Favourable curvature 2
Unfavourable curvature 3

Normal 0
5.FOLLICLE Possibly enlarged 1
Enlarged 2
Space available 0
6.PATH OF EXIT
Distal cusp covered 1
Mesial cusp covered 2
02/04/2023 Both cusp covered 3 31
RISK ASSESSMENT

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THANK-YOU