Impacted Teeth Treatments

  • Causes
  • Impaction In The Following Order Of Frequency
  • Complications From Retained Impacted Teeth
  • Classification Of Impacted Mandibular Third Molar
  • Factors Complicating The Operative Procedure
  • Surgical Technique For Removal
  • Maxillary Impaction

IMPACTION

A tooth which fails to erupt in normal anatomical position either due to lack of space or due to obstruction from tooth, bone or soft tissue.


1. Causes :

1. LOCAL
» Irregularity in the position and pressure of an adjacent tooth.
» Density of the overlying or surrounding bone.
» Chronic inflammation with resultant fibrosis of the overlying mucosa.
» Lock of space due to under developed jaws. Unduly over retention of the deciduous teeth.
» Premature loss of deciduous teeth.
» Acquired disease such as necrosis due to infection.
» Inflammatory changes in the bone due to exanthematous diseases in children, like, Chicken pox, Parotitis.

2. SYSTEMIC

a. Prenatal
» Heredity
» Miscegenation
» Syphilis
» Tuberculosis
» Malnutrition

b. Post Natal
» Rickets
» Anemia
» Endocrine dysfunctions.
» Diseases of jaw and surrounding tissue

3. Rare Conditions
» Cleidocranial dysostosis
» Oxycephaly
» Progeria
» Achondroplasia
» Cleft palate


2. Impaction In The Following Order Of Frequency

» Mandibular third molars.
» Maxillary thirds molars.
» Maxillary cuspids.
» Mandibular bicuspids.
» Maxillary bicuspids.
» Upper central incisors.
» Upper lateral incisors.

3. Complications From Retained Impacted Teeth

Infection
» Pericoronal infections.
» Acute or chronic alveolar abscess.
» Chronic suppurative osteitis.
» Necrosis.
» Osteomyelitis.

Pain
» Pain may be reflected not only to the areas of distribution of the nerve but the associated areas too. Pain may be slight and localized.
» Severe and excruciating involving the entire upper and lower teeth.
» Intermittent, constant or periodical.

Fractures :
Frequency with which fractures of the mandible occur through areas occupied by the tooth, proves to be a factor.

4. Classification Of Impacted Mandibular Third Molar

A. Relation of the tooth to the ramus of the mandible and second molar.
CLASS I:
There is sufficient space between the ramus of the mandible and the distal of the second molar to accommodate the mesiodistal width of the third molar. Still it fails to erupt.
CLASS II:
Space between the ramus and distal of the second molar is less than the mesiodistal diameter.
CLASS III:
All or most of the third molar located within the ramus.


B. Relative depth of the third molar bone.
Position A: Highest portion of the tooth is on a level with or above the actual line.
Position B: Highest portion of the tooth is below the actual plane but above the cervical line of the second molar.
Position C: Highest portion of the tooth is below the cervical line of the second molar.

C. Relationship of the long Axis of the impacted third molar in relation to the long axis of the second molar
» Vertical
» Horizontal
» Inverted
» Mesioangular
» Distoangular
» Buccoversion
» Linguoversion

5. Factors Complicating the Operative Procedure

» Abnormal root curvature.
» Hypercementosis
» Proximity of mandibular canal.
» Extreme bone density especially in elderly patients.
» Follicular space filled with cementum or bone.
» Ankylosis.
» Small orbicular oris.
» Inability to open the mouth.
» Large and uncontrollable tongue.

6. Surgical Technique For Removal



» Radiographs should show the exact, full size not elongated or shortened form of the tooth. Also, number, size and curvature of the roots and proximity of crown to adjacent tooth or vital structures should be visible.
» Classify impaction.
» Determine the amount of overlying and surrounding bone.
» Carefully note the position of the roots and the inferior dental canal.
» Outline the extent of the soft tissue flaps to be used, keeping in mind the necessity for adequate exposure and maintenance of a good blood supply to the flap and the sequent support of soft tissue flap.
» Procedure or technique for removal:
A. Sectioning of the tooth.
B. Combination of the removal of surrounding bone and the sectioning technique.
C. Solely by removal of surrounding bone.
» Determine the surrounding and overlying osseous structure.
» Determine the best instrument.
» Determine the best direction for the removal of impacted tooth.

ADVANTAGE
1. Field of operation can be kept small.
2. Bone removal reduced to a considerable extent.
3. Operating time is shortened.
4. Problem is considerably reduced.
5. No damage to the adjacent teeth and bone.
6. Risk of jaw fracture is reduced.

DISADVANTAGE
1. Teeth with shallow groove do not split.
2. Teeth in elderly patient are difficult to split.
3. Sometimes it is impossible to split along the long axis of the tooth.
4. Direction control at times is difficult.

7. Maxillary Impaction

CLASSIFICATION
1. Relative depth of impacted maxillary third molar in bone.
CLASS I : Lowest portion of the crown of the impacted maxillary third molar is on a line with the occlusal plane of the second molar.
CLASS II : Lowest portion of the crown of the impacted maxillary third molar is between the occlusal plane of the second molar and the cervical line.
CLASS III : Lowest portion of the crown of the impacted maxillary third molar is above the cervical neck of the second molar.

2. Position of the long axis of impacted maxillary third molar in relation to the long axis of the second molar:
A. Vertical
B. Horizontal
C. Inverted
D. Mesioangular
E. Distoangular
F. Buccoversion
G. Lingoversion

3. Relationship with maxillary sinus
a. Sinus approximation—Thin portion of bone between impacted maxillary third molar and maxillary sinus.
b. No maxillary bone between maxillary sinus and impacted maxillary tooth.

FACTORS COMPLICATING THE OPERATIVE PROCEDURE
1. Present immediately within the vicinity of the roots of second molar.
2. Fusion with the roots of second molar.
3. Abnormal root curvature.
4. Proximity of the Zygomatic process.
5. Extreme bone density.
6. Difficult access to the operating site.

MAXILLARY CUSPIDS
CLASS I:
Impacted cuspids located in palate.
1. Horizontal
2. Vertical
3. Semi Vertical
CLASS II:
Impacted cuspids located in the labial or buccal surface of the maxilla
1. Horizontal
2. Vertical
3. Semi Vertical
CLASS III:
Impacted cuspids located in both the palatine and maxillary bones.
CLASS IV:
Impacted cuspids located in the alveolar process usually vertically between incision and first bicuspid.
CLASS V:
Impacted cuspids in edentulous mouth.

FACTORS COMPLICATING THE OPERATIVE PROCEDURE
1. Fear of damaging the adjacent tooth since crown and root are in close proximity with the teeth.
2. Possibility of infection or root being forced into maxillary sinus due to its close proximity.
3. Most of the cuspids have hypercementosed roots.
4. Marked curvature of the roots.

POST OPERATIVE TREATMENT
1. Sockets should be cleaned and check for any tooth remnants.
2. Periphery of the socket should be trimmed and then smoothened.
3. Sutures should be placed properly to appose the tissue and cover the socket.
4. In case of excessive bleeding. Check for the bleeding site and apply gel foam.
5. Alternate hot and cold packs should be applied.
6. Possibility of swelling is always present and so is ecchymosis.
7. If pain develops in the socket then so called dry socket treatment must begin immediately.
8. Basic vitamin tablets should be given.
9. Sutures to be removed seventh day post operatively.

POST OPERATIVE COMPLICATIONS
1. Exposure of inferior dental canal.
2. Parasthesia.
3. Acute trismus.
4. Disruption of blood supply.
5. Fracture of a large section of alveolar process.
6. Traumatization or dislodgement of adjacent teeth.
7. Injury to the lips or cheeks due to traumatization.
8. Opening into maxillary sinus or tooth forced into the pterygopalatine fossa.
9. Dry Socket.
10. Extensive exposure of adjacent tooth resulting in premature loss.