Management of Impacted Wisdom I

Management of impacted third molars
The doctor started the lecture by asking the students if they have ever
seen a third molar extraction before and the reason of that extraction
then he said >>> unfortunately wisdom teeth in the past were not a big
issue like now because the food nature and the eating habits in our
fathers and grand fathers life were different, and there jaws were
slightly bigger 0_o !! so there was enough space for the wisdom teeth to
erupt,, but now we are running into molars because of the inadequate
space as a result we have different kinds of angulations of the wisdom
teeth
??What do we mean by impacted tooth *

Impacted tooth is the tooth which failed to fully erupt in the oral cavity
within its development time period,, be attention to the word FULLY
erupt not PARTIALY
We have some commonly impacted teeth,, we will talk mainly about the
wisdom teeth but there are also other teeth which can be impacted too
like upper and lower canines > mainly upper canines, lateral incisors are
not impacted they are missing but if we want to talk about impaction we
will talk about central incisors because of supernumerary tooth and other
reasons
I referred to last year lec and the doctor mentioned in that lec
:that the most commonly impacted teeth are
Wisdom teeth (1
Maxillary canines (2
Mandibular premolars (3
The reason that makes these teeth the most commonly impacted ones
because they are the last teeth to erupt,, the teeth which erupt earlier
will find space, and those which erupt later may not find space
then Dr. Mansor said that he needs more than 2 lectures to cover this
topic and he wants to give us a complete lecture about pericoronitis which
is a very important cause of impaction
The follicle stars to appear in the bone at the age of 10 years, at 11 years
we start having a cusp mineralization and the tooth is located in the
ramus anteriorly at the occlusal plane,, at 14 years the crown of third
1
molar is fully formed,, at 16 years 50% of the root is formed,, the rest
50% of the root will be formed between 16 to 18 years old where we have
an adequate mandibular growth so there will be tooth which is up righting
and usually it will be at the level of the roots of the 2 nd molar,, so its a
process which stars from 9 years until 18 years ,, during this sequence a
lot of orthodontics when they think that the wisdom tooth is erupting
with angulations, they recommend its removal around the age of 16, 17 or
even 15 years old before the root is fully formed to avoid the possible
numbness of the lower lip because of the inferior dental nerve injury
:Classifications of impaction *
we have winter's classification which described by Goerge winter in 1926
>>> it describes the angulation according to the long axes of the 8 in a
relation to the long axes of the 7 which is up right,,, so the 8 will be
either mesially inclined, distally inclined or horizontally inclined and when
..we say its vertical, it means its parallel to the 7
Here are some illustrating pictures I've got from last year lecture
Vertical impaction
Meso-angular impaction
Horizontal impaction
Disto-angular impaction
There is another one like buccoangular, and linguoangular, (so its

transverse) when we say buccoangular we mean the cusp is towards the
buccal plate and linguo angular the cusp is toward the lingual plate,
transverse is opposite to vertical inverted. So mostly what we see is
mesioangular, distoangular, vertical, horizontal; these are the most
.common ones we see
So as we said the classification is according to two systems: the system
thats according to the level of the 7 tooth (second molar)
Whats OP? Occlusal plane
So now we have two classifications, one is the angle and the other one is
.the depth
position A is either the same (you have to refer to the slides for this)
level or above the occlusal plane - meaning its the same level as the 7 th
but in this thing its not impacted, if the molar is mesioangular so half of
it is impacted but the distobuccal and distolingual cusps are higher than
the occlusal plane of the 7th
,Position B is between the occlusal plane and the cervical line
Position C is bellow the cervical line or CEJ
4
Now the same classification compared to the ramus they dont want us to
say A,B,C so we dont get confused, they named it 1,2,3
Crown is anterior to the ramus = 1
Half of the crown is within the ramus = 2
All crown is in the ramus = 3
So A, B, C our reference is to the occlusal plane and 1,2,3 is our
.reference to the ramus
Now if I had a radiograph for a patient with wisdom tooth if he is
symptom free, if I gave it to 60 dentists, 20 would say leave it, 20 would
.say remove it, 20 would say its your choice
?So when do we choose to remove it
Personally if the tooth is showing angulation I would like to remove it. So
there might not be lower anterior crowding. Some orthodontists would
say remove it, some would say dont; thats because they are from
.different schools
Prevention and treatment of pericoronitis around the mandibular third
molar (very important and the doctor will leave a special lecture for it
:later)
The picture in the slide shows second molar and third molar which is
vertically partially erupted because it has a tissue called operculum
.covering the distal aspect of the tooth
Food accumulates underneath this gum (operculum) inflammatory
process pericoronitis can lead for admission of patient to the
.hospital
:Acute pericoronitis
-Pus
-Limited mouth opening (can t open >3 mm).
We admit the patient for treatment which includes IV fluid, *
antibiotics..etc
We have also chronic and recurrent pericoronitis (the doctor will *
explain them all on a separate lecture dont worry)
5
Indications for removal:

1- Pericoronitis
?Should we extract on acute, chronic or recurrent phase
We have more than one opinion or answer; some people say yes for
recurrent pericoronitis and extract but for acute theyll give it sometime,
if its the first episode, theyll wait but if it happened again and again
.theyll extract
2- For the treatment of caries:
Its a triangle for food accumulation and caries for 8 or distal or root
caries for 7. A lot of patients come with irreversible pulpitis from the 2 nd
molar with severe pain, they are referred for 3 rd molar extraction but
after extraction, the pain stayed; this is a wrong judgment so we have to
.do pulpectomy and then extract the tooth
The doctor showed a picture of resorption of 2nd molar from pressure of
the 3rd molar (refer to slides)
3- Periodontal diseases:
Showed a picture of 1st, 2nd and 3rd molar which is impacted and
surrounded by a follicle, and this follicle has bone inside so once we
remove the 3rd molar, all the distal root of 2 nd molar is exposed and
unsupported, so what shall we do? Remove the 7?
No, we remove the 8 but we tell the patient that he might have
sensitivity for few weeks until complete soft tissue healing, then after 34 months there will be bone formation in that area, and the tooth will not
.have a periodontal problem
.Doctor showed more pics of root resorption of 2nd molar due to 3rd molar
4- Odontogenic cyst lesions:
The most common cystic lesion associated with the 3 rd molar is
dentigerous cyst, which is a cystic lesion associated with unerupted teeth
.or part of a tumor as a pathology
The doctor showed a pic; its a panoramic radiograph showing right side of
posterior teeth, the abnormality is a remaining root and impacted possibly
3rd molar, we dont know if its the 3 rd, associated with a large multilocular
radiolucency extending from the distal aspect of the tooth up to the
ascending ramus resorbing the whole ramus reaching the condylar neck, it
could be ameloblastoma, OKC, etc
6
Again this is for ex. An easier case if you can see, Now if I want to talk
about this case: this is an ortho pantomgram of a dentate patient showing
both upper & lower jaws with a fully dentate teeth showing clearly all the
dentition, part of the ramus (not clear) & the other part of the ramus is
superimposed on the vertebrae, the abnormality I can see here,
1) On the left side there is a mesioangular impaction.
2) Now how deep is it?? It's between B & C {if you say it's B, I will
consider it right bcz the distal cusp here is approximately at the
level of the cervical line}.
3) It's not in the ramus so it's position 1.
Now on the other side this is a different story these are teeth no. 4, 5,
6, 7 and this is the 8 it's in the ramus not only the crown but even the
root, also it's approximately between B & C & it's inverted or
(horizontal),, associated with a large radiolucency extending from the
mesial aspect of the 5 >> down to the lower border>> up to the ascending
ramus >> encircling the impacted wisdom tooth >> & back the whole way.
Why do I call this cyst,, What's cyst?? It's a pathological cavity within
the bone which is usually filled with liquid, semi liquid or even gaseous
material & mainly associated with epithelial lining. Cystic lesion is usually a
sloooooooooooow process which takes a long period to develop & usually is
covered by routine radiograph without symptoms. 90% of cystic lesions
are symptoms free unless they became infected then they will cause some
problems.
What does that mean?? Allah sob7anaho wa ta3ala created us with

defense mechanisms in our body (As WBCs & lymph nodes in
infection) there is also defense mechanisms from the bone,, since it's
a slow lesion, the body starts trying to prevent the extensions of this
lesion so there will be radiopaque line (white line) which is a defense
from the body so the cyst will be localized & it's usually capsulated
Another cystic lesion,, now if you want to remove this, what would you
worn your patient about??
1) Fracture.
2) Paresthesia of the lower lip (bcz of the presence of the inferior
dental nerve).
Sometimes we remove the wisdom tooth for the sake of prostho in
case it's slightly piercing.
7
Also extraction of teeth depends on orthodontic opinions.
This radiograph is showing lower anterior crowding and there is a need

for extraction because of the crowding.
# Socio economic factor:
Social: For ex. A patient wants to go to study in Canada and his 3 rd
molars are symptom free of any problem but potential problems
may arise after 1, 2, or 10 years no one knows,, so there will be a
kind of agreement between you and the patient to get rid of them
so he can go and study without any problem,,, so this is a kind of
social factor.
# Treatment of unexplained facial pain:This is becoming more real problem,, the patient comes with a typical
facial pain (each day the pain will be in a place different than the previous
day) I will not remove wisdom tooth for a typical facial pain unless
the patient will accept, so facial pain is something that we should give it
adequate time.
Now this tooth what's its classification??
It's horizontally impacted
Position 1 (bcz it's anterior to the ramus)
# Contraindications for removal of teeth:
Extreme of age unless it's indicated.
Local or systemic factors (temporary usually):Even if I have medical problem, I can adjust it then remove unless
it's elective & there is no need for removal.

Excessive damage to adjacent structures:If for ex. It's deeply impacted or if I know that if I remove it I
will cause paralysis to the lip then leave it.
The End
Done By: Aula, Nadine, Mira & Rahaf

Management of Impacted Wisdom I

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Management of Impacted Wisdom I

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Management of impacted third molars

??What do we mean by impacted tooth *

There is another one like buccoangular, and linguoangular, (so its

Indications for removal:

What does that mean?? Allah sob7anaho wa ta3ala created us with

Also extraction of teeth depends on orthodontic opinions.

This radiograph is showing lower anterior crowding and there is a need

it's elective & there is no need for removal.

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