Impaction 1

‫كلية طب الفم واألسنان‬
‫رؤية الكلية‬
‫تتطلع الكلية أن تكون في مصاف المؤسسات التعليمية المعترف بها إقليميا ً وعالميا ً من خالل برامج تعليمية متطورة‬
.‫وأبحاث تطبيقية مبتكرة وتنمية مجتمعية مستدامة‬
The Faculty aspires to be a recognized educational institution, regionally and internationally, by

providing advanced educational programs, innovative applied research, and sustainable community
development.
‫رسالة الكلية‬
‫ ذو كفاء ة معرفي ة وتطبيقي ة م ن خالل برام ج تعليمي ة‬،‫إعداد ط بيب أس نان ملتزم بالقي م االنس انية واألخالق المهني ة‬
‫ كم ا تلتزم الكلي ة بإعداد بحوث تطبيقي ة‬.‫متطورة تتواف ق م ع االحتياجات الفعلي ة لس وق العم ل المحل ي والعالمي‬
.‫متوافقة مع االستراتيجيات القومية وكذلك تقديم خدمة مجتمعية مستدامة وفقا ً لمعايير الجودة العالمية‬
The mission is to prepare knowledgeable and well-trained dentists committed to human values and
professional ethics, by developing advanced educational programs that correspond to the actual needs
of the local and global labor market. The Faculty is also committed to preparing applied research in
line with national strategies, as well as providing sustainable community service following
international quality standards.
Oral Surgery OSA401
SURGICAL MANAGEMENT OF
IMPACTED TEETH
Dr. Raafat Riad

Prof. Of Oral And Maxillofacial
Surgery, MIU university.
Military Medical Academy
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Student learning outcomes (SLOS)
1- Identify definition and different causes of

impaction.
2- List different indications & contraindications of
impaction.
3- Describe different classifications of impaction.
4- Assess the degree of difficulty of impactions.
5- Surgical Management of impaction.
6- Post operative complications.
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DEFINITIONS
 What is an impacted tooth?
It is that tooth whose normal eruption is partially
or wholly obstructed by adjacent teeth or bone.
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DEFINITIONS
 What is an embedded tooth?

It is the tooth who failed to erupt although it has
enough space, and there is no barrier preventing its
eruption but it lacks the eruptive force.
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DEFINITIONS
• Un-erupted tooth
– A tooth which is still unerupted because its proposed date of
eruption has not yet been attained
– Normal phenomenon
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DEFINITIONS
• Malposed tooth
– A tooth which appears in an abnormal position in the arch
– Impacted teeth are malposed teeth BUT not all malposed
teeth are impacted
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DEFINITIONS
• Submerged tooth
– A deciduous tooth that refused to shed
– Appears in an infra-occlusion
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ANKYLOSIS:
Fusion of 2 hard tissues on the expense of the

intervening soft tissue e.g.
 Between bone & cementum on the expense of the

periodontal ligament (ankylosed teeth)
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ANKYLOSIS
Fusion of 2 hard tissues on the expense of the

intervening soft tissue e.g.
 Between the condyle & the glenoid fossa on the

expense of the articulating space (TMJ ankyloses)
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CAUSES OF IMPACTED TEETH

• Theoretical
 .Role of
civilization and
refined foods
 .Orthodontic cause
 .Endocrine (increase
or decrease growth
hormone)
 .Pathological
 .Heridatry
Local • Clinical Systemic

causes of causes of
Impaction impaction
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LOCAL CAUSES OF IMPACTION

1) Lack of space due to underdeveloped jaw arch length in relation to teeth
size.
2) Over density of the overlying bone due to
longstanding chronic inflammation.
3) Premature loss or over-retained primary teeth
Ectopic position of the tooth bud.
4) Abnormal path of eruption of the tooth due to
traumatic forces.
6) Cleft alveolar ridge.
7) Odontogenic cysts or tumors.
8) Supernumerary teeth.
SYSTEMIC CAUSES Oral Surgery OSA401
PRENATAL(HERIDATRY)
POSTNATAL(AFFECT GN. DEV.):
Rickets Anemia Tuberculosis
Congenital syphilis Malnutrion Achondroplasia
Cledocrainal
Endocrinal dysfunction
dysostosis &Gardner's
syndrome
(hypopituitarism and
hypothyroidism)
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WHY SHOULD WE
REMOVE AN
IMPACTED TEETH?
(INDICATION)
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1-Prevention of pericoronal infection (Pericoronitis)

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2- Prevention of dental caries in both mesial aspect of

the third molar and distal aspect of the second
molar.
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3-Prevention of periodontal diseases due to food accumulation
4- Prevention of root resorption of 2nd molar .

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5- Prevention of orthodontic problems caused by

continuous pressure of the impacted tooth that causing
crowding of anterior teeth.
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6- Prevention of formation of odontogenic pathologies

like Cysts or tumors.
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7- Prevention of fracture mandible in case of large

impacted tooth that causes weakening of the mandible
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8- Prevention of pain and ulceration of mucosa under removable

prosthesis because of bone resorption over residual impactions.
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9- To facilitate some Orthognathic surgery like

sagittal split osteotomy
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CONTRAINDICATIONS FOR REMOVAL OF

IMPACTED THIRD MOLARS :
1) Advanced age as the bone will become very dense and possibility
of jaw fracture became very frequent.
2) In medically compromised patients with asymptomatic

impactions but if it is symptomatic it should be removed.
3) Partially impacted asymptomatic teeth that can be used as

abutment in construction of fixed prosthesis.
4) When surgical damage to adjacent important structures is

highly expected.
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Management of impacted third molars
Non-
Intervention
Intervention
RISKS RISKS
Minor complications:
Crowding of
Alveolitis
dentition Benefits
Parethesia
Resorption of Avoidance of risk BENEFITS
Trismus
adjacent tooth Preservation of Fractures
Decreased morbidity in
and periodontal younger patients
functional teeth Hemorhage
status Preservation of
Therapeutic control
Major complications:
Development of residual ridge Dysesthesia
infection cyst and bactermia
tumor
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Patient assessment
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CLINICAL ASSESMENT
1. The patient should be examined clinically for:
Eruption status of the third molar and its classification which gives
an idea about the difficulty encountered during its removal
2. Caries on both 2nd and 3rd molars that need restoration, some times
badly decayed 2nd molars is to be removed and 3rd molar left to erupt
and used as abutment for fixed prothesis or replanted in 2nd molar
socket
3. Presence of infection that to be treated before surgery

(Pericronities )
4. Periodontal condition of adjacent teeth
5. Presence of a swelling, trismus and pain

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RADIOGRAPHIC ASSESSMENT
1- Intraoral periapical or occlusal radiographs

2- Extra oral orthopantogram, lateral oblique view or cone
beam CT are used to see the root morphology which
determine the degree of difficulty of surgical removal of the
impacted teeth
3- Size of follicular sack ( the larger the less bone the easier
removal )
4- Density of surrounding bone(decrease age less dense bone)
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RADIOGRAPHIC EVALUATION
TECHNIQUES
 Intraoral radiographs
 Periapical radiograph
 Occlusal radiograph
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TECHNIQUES
 Extraoral radiographs
 Panoramic radiograph-
 Lateral oblique
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TECHNIQUES
 Advanced radiographic
techniques-
 CT Scan
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IMPORTANCE OF RADIOGRAPH
 Reveal the root pattern
 Relation to important neighbouring structures
 The maxillary sinus
 Tuberosity of the maxilla
 Inferior dental and mental nerves
 Proper planning of the operation
 Preparing the proper instruments required to perform the surgery
 Least amount of trauma to the tissues
 Shorter operating time
 Prevents postoperative complications:
 Necrosis and sloughing of tissues
 Minimizes pain
 Promotes healing
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Shift sketch Technique (SLOB)
 To determine whether the canine is labial or palatal but the occlusal

method is the most accurate
 Using 2 periapical films
Shift the tube horizontally or vertically:
a. If tooth moves in the same direction of the tube lingual side
b. If tooth moves in the opposite direction of the tube labial side

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FREQUENCY OF IMPACTION
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FREQUENCY OF IMPACTION
 1. Mandibular third molars.

 2. Maxillary third molars.
 3. Maxillary canines.
 4. Mandibular canines.
 5. Mandibular second premolars.
 6. Maxillary second premolars.
 7. Maxillary central and lateral incisors, and other
teeth have been found to be impacted on very rare
occasions.
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Clinical (preoperatively)
complications of
impacted teeth
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1- INFECTION
 Pericoronal (pericoronitis): most common
 Periapical: not common

 Osteomyelitis: rare
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What is a pericronitis?
It is an inflammation of the soft tissue that surrounds
the crown of the partially erupted tooth.
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* PeriapicalInfection
Impacted tooth causes pressure on the adjacent tooth
and lead to food stagnation resulting in caries and
Periapical infection
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* Osteomyelitis

Pericoronal or periapical infection with lack of

antibiotic and low body resistance may progress to
Osteomyelitis
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PERICORONITIS
What are the types of pericronitis??

a- Acute
b- Chronic
 N.B. There must be a communication between the tooth and the oral
cavity. This communication may be obscured by edema. A periodontal
probe may be used to ascertain such communication
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ACUTE PERICORONITIS:
What is the etiology of acute pericronitis??
a- Bacterial growth.
 Moisture, darkness, and food debris under the
operculum are an ideal incubator for the
lodgment and flourish of the microorganisms as
oral flora (str viridans, fusiform bacilli, spirillum
b- Trauma.
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ACUTE PERICORONITIS:
What is the etiology of pericronitis??
a- Bacterial growth.
b- Trauma.
The cusps of the opposing teeth cause traumatic
irritation of the operculum. The opposing cusps do not
only initiate the attack but also helps in intensifying and
prolonging it.
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SIGNS AND SYMPTOMS:
 Severe throbbing intermittent pain which is exacerbated by

mastication, and radiates to adjacent areas.
 Trismus.
 Extra-oral swelling.
 Difficulty in swallowing.
 Severely inflamed edematous red painful operculum
 pus + Feted odor
 Indentation related to the cusps of opposing tooth
 Submandibular lymphadenitis
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TREATMENT OF ACUTE PERICORONITIS
How to treat acute pericronitis??

Conservative method.
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CONSERVATIVE METHOD:
Gentle irrigation under the operculum by H2O2.
Warm saline mouth wash.
Antibiotic therapy.
Supportive treatment, rest in bed, and analgesics to
control pain.
Selective grinding of the impinging cusp.
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CHRONIC PERICORONITIS
Dull pain.
Mild discomfort.
Unpleasant taste.
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TREATMENT:
How to treat chronic pericronitis??

1- Operculectomy.
2- Odontectomy.
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SURGICAL METHOD:
 Operculectomy: surgical excision of the operculum if the tooth is of

normal position and has enough space to erupt
 Odontectomy: Removal of the offending tooth is recommended after

treatment of the acute pericoronitis, if the tooth is mal-posed or has no
enough space to erupt
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1- Operculectomy:
It is the surgical removal of the soft tissue flap that covers the partially
erupted tooth.
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OPERCULECTOMY
ANESTHESIA
RING BLOCK ANESTHESIA
OR
NERVE BLOCK
ANESTHESIA
GRIPPING THE
OPERCULUM
SUTURE MATERIAL
ALLIS FORCEPS
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OPERCULECTOMY
Indications for removal
• Chronic / subacute pericoronitis

• Less than 1/3 of the crown covered by operculum
• Its removal expose the crown
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OPERCULECTOMY
Removal of operculum
• Surgical using blade no. 12 blade
• Using electrocautery blades
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ZnO/Eugenol cotton pellet is applied between

the distal surface of the tooth and the adherent
soft tissue.
Antibiotics are prescribed if necessary.
OPERCULECTOMY
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OPERCULECTOMY
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 Odontectomy: Removal of the offending tooth is recommended.

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2- PAIN & OTHER NEUROLOGIC SYMPTOMS
Causes
Infection
Pressure of the impacted tooth on adjacent tooth, overlying

bone, surrounding soft tissue, nerve
Other neurologic symptoms as Diplopia, tinnitus, weakness of
facial & masticatory muscles, excitability, insomnia, headache
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3- ORTHODONTIC PROBLEMS
 Some orthodontists claim the impaction is the

reason of crowding of anterior teeth
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4- AFFECTION ON ADJACENT TEETH
 Periodontal disease
 Resorption
 Caries at the distal
surface of the 2nd molar
All these conditions may lead to periapical infection

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5- WEAKNESS OF THE JAW

Liable to fracture with trauma,
deeply impacted 8 causes
interruption of bone continuity
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6- CYST & TUMORS FORMATION

Tooth Follicle lead to the formation of
Dentigerous cyst, and Ameloblastoma
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1-What is the preoperative complications of the

impaction?
2-What are radiographic views for impaction?
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CLASSIFICATION OF IMPACTED
TEETH
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CLASSIFICATION OF IMPACTED TEETH
This is done to help the dentist in:

- Evaluation of the extent of the required surgical procedure.
- planning of this procedure.
o Classifications are looked at from various angles, in order

to give more or less a three dimensional picture.
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CLASSIFICATION OF THE MD. THIRD

MOLAR
Relationship of the tooth to the anterior border of the ramus:

It shows the anteroposterior relationship of the tooth to the arch and the
amount of resistance offered by the bone of the ascending ramus that
may influence tooth removal.
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RELATIONSHIP OF THE TOOTH TO THE ANTERIOR BORDER OF THE RAMUS:
 Class I: the space between the anterior part of the ascending ramus and
the distal surface of the second molar is sufficient to accommodate the
mesiodistal diameter of the crown of the third molar.
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RELATIONSHIP OF THE TOOTH TO THE

ANTERIOR BORDER OF THE RAMUS:
 Class II: the space between the anterior part of the ascending ramus
and the distal surface of the second molar is less than the mesiodistal
diameter of the crown of the third molar. Hence, part of this tooth is
located within the ramus.
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RELATIONSHIP OF THE TOOTH TO THE
ANTERIOR BORDER OF THE RAMUS:
 Class III: All the third molar is located within

the ascending ramus of the mandible.
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ACCORDING TO THE RELATION OF THE TOOTH TO
THE ASCENDING RAMUS OF THE MANDIBLE AND
TO THE DISTAL SURFACE OF THE SECOND MOLAR
 Class I:
The space between the anterior part of the ascending ramus and the
distal surface of the second molar is sufficient to accommodate the
mesiodistal diameter of the crown of the third molar
 Class II:
The space between the anterior part of the ascending ramus and the
distal surface of the second molar is less than the mesiodistal
diameter of the crown of the third molar. Hence, part of this tooth is
located within the ramus
 Class III:
All the third molar is located within the ascending ramus of the
mandible
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MOLAR
 Relative depth of the third molar in

bone;
This shows the supero-inferior relationship of
the tooth in relation to the occlusal plane of the lower 7.
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RELATIVE DEPTH OF THE THIRD MOLAR IN BONE;
 Position (A): The highest portion of the tooth

is on level with or above the occlusal plane of the mandibular second
molar.
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RELATIVE DEPTH OF THE THIRD MOLAR

IN BONE;
 Position (B): The highest portion is below the

occlusal plane of the second molar but above its cervical margin
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RELATIVE DEPTH OF THE THIRD MOLAR IN BONE;
 Position (C): The highest portion of the tooth is below the cervical
margin of the second molar. This is relatively a very deep impaction.
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ACCORDING TO THE RELATIVE DEPTH OF

THE 3RD MOLAR IN BONE
 Position A
The occlusal surface of the third molar is flush with
the second molar
 Position B
The occlusal surface of the third molar is located
between the occlusal plane and the cervical line of
the second molar
 Position C
The third molar presents with its occlusal surface
below the cervical line of the second molar
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MOLAR
A. The position of the long axis of the impacted tooth in relation to

the long axis of the second molar (Winter's classification)
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 Vertical impaction: the long axis of the third molar is parallel to that of
the second molar.
(WINTER'S CLASSIFICATION)
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 Horizontal: the long axis of the third molar is at right angles to that of the
second molar. "Between these two extreme positions comes another two
classes."
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 Mesio-angular impaction.
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 Distoangular impaction
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 inverted impaction
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B) Bucco-lingual Relationship ( Best by occlusal films)

- Lingual Version
long axis in a lingual direction (Most impacted 3rd molars are in lingual
version)
A tooth in lingo- version can be vertical, mesioangular, distoangular
By using periapical film, the portion of the tooth nearest to the film more
sharply defined & more radio-opaque
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- Buccal Version
The long axis of the 3rd molar is pointed buccally.
(vertical, mesioangular, distoangular)

- Transverse
This is a very unusual relationship with the tooth
lying in a transverse direction in buccal or lingual
version
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 All the previous four classes can come in:

a. Lingual deflection.
b. Buccal deflection.
Transverse
This is a very unusual relationship with the tooth lying in a transverse
direction in buccal or lingual version
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FACTORS IMPORTANT IN PLANNING SURGICAL REMOVAL
(ASSESSMENT OF DIFFICULTY)
1-Application depth.
2-Angulation .
3-Crown size and condition.
4-Distance across roots is larger than width of(Crown-Root) junction .
5-Root surface area .
6-Root no and morphology .
7-Follicular width.
8-Periodontal state .
9-Restorative condition of adjacent 7.
10-Proximity to inf. Alv. canal (Rood’s radiograph predictors)
11-Atrophic mandible . 12-Density of bone .
13-Contact with lower 7. 14-Nature of overlying tissue.
15-Position and root pattern of the second molar.
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IMPACTED LOWER THIRD MOLAR IS DIFFICULT

WHEN;
1-Distoangular impaction . 2- Class 3 impaction .

3-Position C impaction . 4- Long thin root .
5-Narrow period.lig.Space 6- Divergent curved root
7-thin tooth follicle space 8-Dense calcified bone
9- Close contact root to I.C. 10-Close contact to 7.
11-complete bony impaction .
12- other complicating factors; small mouth opening ,enlarged
tongue ,obese pt. ,old age , uncooperative pt , excessive
bleeding during surgery.
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INDICES OF DIFFICULT IN REMOVING 0F WISDOME

TOOTH
 1-Pell and Gregory.

 2-Pederson scale .
 3-Parent scale.(depend on surgical maneuver's.)
simple extraction –ostectomy - ostectomy plus coronal
section – complex ( root section )
 4-Winter lines (WAR lines )
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Assessment of position and depth to evaluate difficulty of extraction WAR lines
White line
White line is drawn along the occlusal surfaces of the erupted Mandibular molars and extended over the
third molar region posteriorly
Amber line
Amber line is drawn from the surface of the bone on the distal aspect of the third molar to the crest of
the interdental septum between the first and second Mandibular molars
Red line
Red line is an imaginary line drawn perpendicular from the amber line to an imaginary point of
application of the elevator
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Assessment of relationship with inferior alveolar nerve
Seven radiological signs had been suggested by Howe and Poyton
1. Darkening of the root
2. Deflected 3. Narrowing of the root

4. Dark and bifid root
5. Interruption of the white line(s)
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PATIENT PREPARATION
 Remove calculus .
 Informed the patient about oral care .
 Mouth wash to reduce the bacterial count .
 Prescription of antibiotics and corticosteroid .
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UPPER THIRD MOLAR TOOTH.
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UPPER THIRD MOLAR TOOTH.
1. According to the relationship of the upper third molar tooth to

the maxillary sinus.
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CLASSIFICATION OF IMPACTED UPPER
THIRD MOLAR TOOTH (CONT.)
Class I: Sinus approximation.
Where no bone or very thin bone exists between the tooth and the floor the
maxillary sinus.
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Class II: No Sinus approximation.
Where 2 mm or more bone exists between the tooth and the floor the
maxillary sinus.
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UPPER THIRD MOLAR TOOTH (CONT.)
2. According to the relative depth of the tooth inside the bone.

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Position A: The lowest point of the impacted upper wisdom tooth is in the
same level of the occlusal plane of the upper second molar.
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UPPER THIRD MOLAR TOOTH
(CONT.)
Position B: The lowest point of the impacted upper wisdom tooth is

between the occlusal plane of the upper second molar and its cervical
margin.
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(CONT.)
Position C: The lowest point of the impacted upper wisdom tooth is above
the cervical margin of the upper second molar (the crown is not seen
intraorally).
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According to the relative depth of the 3rd molar in
bone
 Position A
The occlusal surface of the third molar is flush with the
second molar
 Position B
The occlusal surface of the third molar is located between
the occlusal plane and the cervical line of the second
molar
 Position C
The third molar presents with its occlusal surface above
the cervical line of the second molar
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(CONT.)
3. According to the relation of the long axis of the impacted upper wisdom
tooth to the long axis of the upper second molar.
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(CONT.)
Vertical impaction:
Long axis of the impacted wisdom tooth is parallel of the long axis of
the upper second molar tooth.
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CLASSIFICATION OF IMPACTED UPPER THIRD

MOLAR TOOTH (CONT.)
Horizontal impaction:
Long axis of the impacted wisdom tooth is perpendicular to the long axis of
the upper second molar tooth.
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(CONT.)
Mesioangular impaction:
Long axis of the impacted wisdom tooth is in a mesial direction to the long
axis of the upper second molar tooth.
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(CONT.)
Distoangular impaction:
Long axis of the impacted wisdom tooth is in a distal direction to the long
axis of the upper second molar tooth.
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UPPER THIRD MOLAR TOOTH (CONT.)
Inverted impaction:
The occlusal surface of the impacted wisdom tooth faces the floor of the
maxillary sinus.
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According to the position of the long axis of
the impacted tooth in relation to the long axis
of the second molar (Winter’s classification)
• Vertical:
The long axis of the third molar is parallel to that of the second molar
• Horizontal:
The long axis of the third molar is at right angles to that of the second molar
"Between these two extreme positions comes another two classes"
• Mesio-angular impaction
• Distoangular impaction
N.B. All the previous four classes can come in:

Lingual deflection
Buccal deflection
• Inverted Impaction
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CLASSIFICATION OF IMPACTED MAXILLARY CANINES:
 Class I: Palatally impacted canines:

these could be in:
a. Vertical ,
b. Horizontal, or
c. Semi vertical position.
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Class I: Palatally impacted canines:

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Class I: Palatally impacted canines:

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CLASSIFICATION OF IMPACTED MAXILLARY CANINES:
 Class II: Labially impacted canines which

could also be in:
a. Vertical ,
b. Horizontal or
c. Semi vertical position.
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Class II: Labially impacted canines

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 Class III:
transversely impacted canines lying labio-palatally and located both in
the palatal and labial surfaces.
CLASSIFICATION OF IMPACTED MAXILLARY

CANINES:
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transversely impacted canines

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 Class IV: Impacted canines that are present in the alveolar

process, usually vertical between the 2 and 4
MAXILLARY CANINES
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 Class V: Impacted canines that are present in an edentulous maxilla

and may assume any of the previous three classes
MAXILLARY CANINES
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SURGICAL REMOVAL OF IMPACTED

TEETH
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SURGICAL REMOVAL OF
IMPACTED TEETH
1. Clinical Evaluation
2. Radiograhic Evaluation
3. Access to the field
4. Reduction of Resistance
 Bone removal
 Tooth Division
5. Removal of tooth structure
6. Debridement of the surgical field
7. Closure
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A) MUCOPERIOSTEAL PYRAMIDAL FLAP
Distal Incision
• 1.5 cm distal to 7 from a point just medial to EOR to
avoid injury to long buccal artery & nerve),to a
midpoint on the distal surface of 7
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Gingival Incision
Around the gingival tissues of 7
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Oblique Incision
From interdental papilla between 6 7 at 45 degree to the
mucobuccal fold
122
Oral Surgery OSA401
Modification 1
Pyramidal flap without gingival incision (2incision lines)
- Distal Incision: the same

- Gingival Incision: none
- Oblique Incision: distal to 7
123
Oral Surgery OSA401
 Modification 2
Gingival (envelop flap)
 Eliminating the use of semivertical incision
 Indicated in the impactions of high position
Oral Surgery OSA401
SURGICAL REMOVAL OF IMPACTED TEETH
4. Reduction of the Resistance:

a. Bone Removal (guttering)
 Exposure of the impaction.
 Reduction of resistance.
 Making a fulcrum for application of the elevator.
Oral Surgery OSA401

4. Reduction of the Resistance:
a. Bone Removal (guttering)
 Exposure of the impaction.
 Reduction of resistance.
 Making a fulcrum for application of the elevator.,which depends on:

Root curvature
 Distal root curvature: Mesial point
 Mesial root curvature: Distal point
 Straight roots: Buccal point

Oral Surgery OSA401
TEETH
b. Tooth Division
Oral Surgery OSA401
 Decapitation:
- Division of the crown of the tooth at the
cervical margin level.
- It is indicated in horizontal mandibular.
- Division should start by the use of surgical
fissure burs and is completed by bibeveled chisels.
-The space created by the bur between the crown
and roots of the tooth is utilized to deliver the
crown of the tooth first then the roots.
Oral Surgery OSA401
TEETH
Oral Surgery OSA401
 Division of the interlocked cusp only (decuspation):

This is done with some mesio-angular impactions using the same
principles. Removing the interlocked segment of the tooth usually
located under the distal surface of the second molar.

Oral Surgery OSA401
TEETH
Oral Surgery OSA401
 Longitudinal (vertical) tooth division:

-It is indicated when the impacted tooth has widely divergent straight
roots, also when one of the roots is straight and the other is curved.
-Division also starts using surgical burs then completed by bibevel
chisel
Oral Surgery OSA401
TEETH
Oral Surgery OSA401
SURGICAL REMOVAL OF
IMPACTED TEETH
 5. Tooth Delivery
After tooth division, each segment is delivered on its own, using
suitable force by suitable elevator.
Oral Surgery OSA401
TOTAL DELIVERY BY APPLICATION OF FORCE
USING ELEVATORS
 Mesial application of force:
 Straight elevators are used
 Indicated in cases of impacted teeth with distal
curvature of the roots
 Pott's elevators are used in impacted maxillary third
molars as the blade of the elevator engages all the
mesial surface of the tooth and hinges on its palatal
surface
Oral Surgery OSA401
 Buccal application of force:

 Cryer’s elevators / buccal applicator elevators are used to engage the
bifurcation of the roots of the impacted teeth using the buccal cortical plate as a
fulcrum
 This is applied only when the impacted tooth has straight roots that are not
widely divergent
Oral Surgery OSA401
 6. wound debridement:
- Any remnants of the residual tooth sac should be removed.
Oral Surgery OSA401
 Removing of any loose fragments or

pathological tissues from the socket using
bone curettes
 Trimming of sharp bony edges
 Smoothening of the edges by bone file
 Irrigation of the surgical field to remove any

fine debris
Oral Surgery OSA401
 7. Closure of the Wound:
 A Sufficient number of sutures are put to hold

the flap into place.
 Suture material
 Types of sutures
 Key suture
Oral Surgery OSA401
SURGICAL REMOVAL OF
IMPACTED TEETH
 8. Post-operative Care:
A. Pressure pack is kept on the wound for one hour.
B- Cold packs on the outside, 20 minutes/hour,
five times/per day, on operation day only, in order
to reduce swelling.
C. Proper antibiotic therapy for the next 5 days
D- Mild antiseptic mouth wash .
E- Fluid and soft diet.
F- Suture removal after five days.
‫‪147‬‬
Oral Surgery OSA401
summary end
Definition and causes of impaction.

Indications and contraindication.
Classification .
Frequency .
Complications .
Surgical management.
Postoperative care

Impaction 1

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‫كلية طب الفم واألسنان‬

The Faculty aspires to be a recognized educational institution, regionally and internationally, by

Dr. Raafat Riad

Student learning outcomes (SLOS)

1- Identify definition and different causes of

 What is an embedded tooth?

Fusion of 2 hard tissues on the expense of the

 Between bone & cementum on the expense of the

Fusion of 2 hard tissues on the expense of the

 Between the condyle & the glenoid fossa on the

CAUSES OF IMPACTED TEETH

Local • Clinical Systemic

LOCAL CAUSES OF IMPACTION

Rickets Anemia Tuberculosis

Congenital syphilis Malnutrion Achondroplasia

1-Prevention of pericoronal infection (Pericoronitis)

2- Prevention of dental caries in both mesial aspect of

3-Prevention of periodontal diseases due to food accumulation

4- Prevention of root resorption of 2nd molar .

5- Prevention of orthodontic problems caused by

6- Prevention of formation of odontogenic pathologies

7- Prevention of fracture mandible in case of large

8- Prevention of pain and ulceration of mucosa under removable

9- To facilitate some Orthognathic surgery like

CONTRAINDICATIONS FOR REMOVAL OF

2) In medically compromised patients with asymptomatic

3) Partially impacted asymptomatic teeth that can be used as

4) When surgical damage to adjacent important structures is

Management of impacted third molars

3. Presence of infection that to be treated before surgery

4. Periodontal condition of adjacent teeth

5. Presence of a swelling, trismus and pain

1- Intraoral periapical or occlusal radiographs

CBCT Oral Surgery OSA401

Shift sketch Technique (SLOB)

 To determine whether the canine is labial or palatal but the occlusal

 Using 2 periapical films

Shift the tube horizontally or vertically:

a. If tooth moves in the same direction of the tube lingual side

b. If tooth moves in the opposite direction of the tube labial side

 1. Mandibular third molars.

 Pericoronal (pericoronitis): most common

 Periapical: not common

Pericoronal or periapical infection with lack of

What are the types of pericronitis??

SIGNS AND SYMPTOMS:

 Severe throbbing intermittent pain which is exacerbated by

TREATMENT OF ACUTE PERICORONITIS

How to treat acute pericronitis??

How to treat chronic pericronitis??

 Operculectomy: surgical excision of the operculum if the tooth is of

 Odontectomy: Removal of the offending tooth is recommended after

Indications for removal

• Chronic / subacute pericoronitis

ZnO/Eugenol cotton pellet is applied between

 Odontectomy: Removal of the offending tooth is recommended.

2- PAIN & OTHER NEUROLOGIC SYMPTOMS

Pressure of the impacted tooth on adjacent tooth, overlying

 Some orthodontists claim the impaction is the

4- AFFECTION ON ADJACENT TEETH

All these conditions may lead to periapical infection

5- WEAKNESS OF THE JAW