‫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.
 ‫كلية طب الفم واألسنان‬
Oral Surgery OSA401

SURGICAL MANAGEMENT OF
IMPACTED TEETH

Dr. Raafat Riad

Prof. Of Oral And Maxillofacial
Surgery, MIU university.
Military Medical Academy
 ‫كلية طب الفم واألسنان‬
Oral surgery OSA401

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.
DEFINITIONS
 What is an impacted tooth?
It is that tooth whose normal eruption is partially
or wholly obstructed by adjacent teeth or bone.
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.
DEFINITIONS

• Un-erupted tooth
– A tooth which is still unerupted because its proposed date of
eruption has not yet been attained
– Normal phenomenon
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
DEFINITIONS
• Submerged tooth
– A deciduous tooth that refused to shed

– Appears in an infra-occlusion
 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)
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)
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
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
PRENATAL(HERIDATRY)
POSTNATAL(AFFECT GN. DEV.):

Rickets Anemia Tuberculosis

Congenital syphilis Malnutrion Achondroplasia

Cledocrainal
Endocrinal dysfunction
dysostosis &Gardner's
syndrome
(hypopituitarism and
hypothyroidism)
 WHY SHOULD WE
REMOVE AN
IMPACTED TEETH?
(INDICATION)
1-Prevention of pericoronal infection (Pericoronitis)
2- Prevention of dental caries in both mesial aspect of
the third molar and distal aspect of the second
molar.
3-Prevention of periodontal diseases due to food accumulation

4- Prevention of root resorption of 2nd molar .

 5- Prevention of orthodontic problems caused by
continuous pressure of the impacted tooth that causing
crowding of anterior teeth.
6- Prevention of formation of odontogenic pathologies
like Cysts or tumors.
 7- Prevention of fracture mandible in case of large
impacted tooth that causes weakening of the mandible
8- Prevention of pain and ulceration of mucosa under removable
prosthesis because of bone resorption over residual impactions.
9- To facilitate some Orthognathic surgery like
sagittal split osteotomy
 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.
 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
Patient assessment
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

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)
RADIOGRAPHIC EVALUATION

Techniques
 Intraoral radiographs
 Periapical radiograph
 Occlusal radiograph
RADIOGRAPHIC EVALUATION

Techniques

 Extraoral radiographs
 Panoramic radiograph-
 Lateral oblique
RADIOGRAPHIC EVALUATION

Techniques

 Advanced radiographic
techniques-
 CT Scan
CBCT
 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
 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

FREQUENCY OF IMPACTION
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.
Clinical (preoperatively)
complications of
impacted teeth

36
 1- INFECTION

 Pericoronal (pericoronitis): most common

 Periapical: not common

 Osteomyelitis: rare

37
What is a pericronitis?
It is an inflammation of the soft tissue that surrounds
the crown of the partially erupted tooth.
* PeriapicalInfection
Impacted tooth causes pressure on the adjacent tooth
and lead to food stagnation resulting in caries and
Periapical infection

39
* Osteomyelitis
 

Pericoronal or periapical infection with lack of

antibiotic and low body resistance may progress to
Osteomyelitis

40
 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
 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.
 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.
 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
 TREATMENT OF ACUTE PERICORONITIS

How to treat acute pericronitis??

Conservative method.
 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.
 CHRONIC PERICORONITIS

Dull pain.
Mild discomfort.
Unpleasant taste.
 TREATMENT:

How to treat chronic pericronitis??

1- Operculectomy.
2- Odontectomy.
 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
1- Operculectomy:
It is the surgical removal of the soft tissue flap that covers the partially
erupted tooth.
 OPERCULECTOMY
Anesthesia
Ring block anesthesia
Or
Nerve block anesthesia

Gripping the operculum

Suture material
Allis forceps
 OPERCULECTOMY

Indications for removal

• Chronic / subacute pericoronitis

• Less than 1/3 of the crown covered by operculum
• Its removal expose the crown
 OPERCULECTOMY

Removal of operculum
• Surgical using blade no. 12 blade
• Using electrocautery blades
 ZnO/Eugenol cotton pellet is applied between
the distal surface of the tooth and the adherent
soft tissue.
Antibiotics are prescribed if necessary.

OPERCULECTOMY
OPERCULECTOMY
 Odontectomy: Removal of the offending tooth is recommended.
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
 3- ORTHODONTIC PROBLEMS

 Some orthodontists claim the impaction is the

reason of crowding of anterior teeth
 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

5- WEAKNESS OF THE JAW
Liable to fracture with trauma,
deeply impacted 8 causes
interruption of bone continuity

60
6- CYST & TUMORS FORMATION
Tooth Follicle lead to the formation of
Dentigerous cyst, and Ameloblastoma

61
1-What is the preoperative complications of the
impaction?
2-What are radiographic views for impaction?
CLASSIFICATION OF IMPACTED
TEETH
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.
 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.
 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.
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.
 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.
 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
 CLASSIFICATION OF THE MD. THIRD
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.
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.
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
 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.
 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
 CLASSIFICATION OF THE MD. THIRD
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)
 Vertical impaction: the long axis of the third molar is parallel to that of
the second molar.

(WINTER'S CLASSIFICATION)
  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."

(WINTER'S CLASSIFICATION)
 Mesio-angular impaction.

(WINTER'S CLASSIFICATION)
 Distoangular impaction

(WINTER'S CLASSIFICATION)
  inverted impaction

(WINTER'S CLASSIFICATION)
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

81
- 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

82
  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

(WINTER'S CLASSIFICATION)
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.
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.
 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 )
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
 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)
PATIENT PREPARATION

 Remove calculus .
 Informed the patient about oral care .
 Mouth wash to reduce the bacterial count .
 Prescription of antibiotics and corticosteroid .