ByDr.Shouvik Chowdhury Post graduate Raja Rajeswari Dental College .ontents .ontents Definition of impaction Definition of impaction Classification of impacted teeth by their Classification of impacted teeth by their orientation orientation List the indications and contraindications for List the indications and contraindications for the removal of impacted teeth the removal of impacted teeth List the risks of intervention and non List the risks of intervention and non- - intervention with respect to impacted teeth intervention with respect to impacted teeth Radiographic analysis Radiographic analysis .hronology .hronology Tooth germ Tooth germ- -9 years 9 years Cusp mineralization Cusp mineralization- -2 2 years later years later 11 years 11 years- -tooth located in tooth located in anterior border of anterior border of ramus,occlusal suface ramus,occlusal suface facing anteiorly facing anteiorly Crown formation Crown formation- -14 years 14 years Root Root- -50% formed by 16 50% formed by 16 years years Root formation with open Root formation with open apex apex- -18 years 18 years 24 years 24 years- -95% of 3 95% of 3 rd rd molars completed eruption molars completed eruption 11 years 14 years 18 years 25 years %erminologies %erminologies impacted teeth impacted teeth unerupted teeth unerupted teeth Malposed teeth Malposed teeth Definition Definition --Origin Origin- - Latin Latin -- -- impactus impactus --Cessation of eruption of teeth cause by Cessation of eruption of teeth cause by physical barrier or ectopic eruption physical barrier or ectopic eruption --Definition Definition a completely / partially unerupted and is a completely / partially unerupted and is positioned against another tooth, bone / positioned against another tooth, bone / soft tissue, so that its further eruption is soft tissue, so that its further eruption is unlikely,described according to anatomic unlikely,described according to anatomic position.(Archer) position.(Archer) &nerupted tooth &nerupted tooth- -not having not having perforated oral mucosa perforated oral mucosa Malposed tooth Malposed tooth- -a tooth,erupted or a tooth,erupted or unerupted which is in abnormal unerupted which is in abnormal position in maxilla or mandible position in maxilla or mandible Causes of impaction of teeth Causes of impaction of teeth --Theories of impaction (Durbeck) Theories of impaction (Durbeck) The Phylogenic theory The Phylogenic theory The Mendelian theory The Mendelian theory The Endocrine theory The Endocrine theory The Pathological theory The Pathological theory The Orthodontic theory The Orthodontic theory The Skeletal theory The Skeletal theory Local causes Local causes -- Lack of space Lack of space -- Retained deciduous teeth Retained deciduous teeth -- Premature loss of deciduous teeth Premature loss of deciduous teeth -- Ectopic position of tooth bud Ectopic position of tooth bud -- Obstruction of eruption path Obstruction of eruption path -- Cyst tumor and supernumery teeth Cyst tumor and supernumery teeth -- Infection and trauma Infection and trauma -- Abnormality of jaw Abnormality of jaw -- Dilaceration : abnormal path of eruption of tooth Dilaceration : abnormal path of eruption of tooth due to traumatic forces during the eruption due to traumatic forces during the eruption period period $stemic causes $stemic causes -- Pre Pre--natal causes natal causes eredity eredity miscegenation miscegenation -- Post Post--natal causes natal causes Rickets, anemia, congenital syphilis, Rickets, anemia, congenital syphilis, tuberculosis, malnutrition tuberculosis, malnutrition -- Endocrine causes Endocrine causes ypothyroidism, hypoparathyroidism ypothyroidism, hypoparathyroidism -- Rare conditions Rare conditions Cleidocranial dysostosis, oxycephaly, Cleidocranial dysostosis, oxycephaly, progeria, achondroplasia, cleft palate progeria, achondroplasia, cleft palate mandibular third molars mandibular third molars maxillary third molars maxillary third molars maxillary cuspids maxillary cuspids mandibular bicuspids mandibular bicuspids mandibular cuspids mandibular cuspids maxillary bicuspids maxillary bicuspids maxillary central incisior maxillary central incisior maxillary lateral incisor maxillary lateral incisor supernumerary teeth mainly mesiodens supernumerary teeth mainly mesiodens Commonl impacted teeth ndications for removal ndications for removal prevention of pericoronitis prevention of pericoronitis Dental caries or prevention of dental caries Dental caries or prevention of dental caries Periodontal disease or its prevention Periodontal disease or its prevention Prevention of root resorption Prevention of root resorption Odontogenic cysts & tumours Odontogenic cysts & tumours -- dentigerous dentigerous cyst cyst Pain of unexplained origin Pain of unexplained origin autogenous transplantation to first molar autogenous transplantation to first molar socket socket ndications for removal ndications for removal racture of the jaw/tooth in the line of racture of the jaw/tooth in the line of fracture fracture Prosthetic problems e.g. under Prosthetic problems e.g. under prosthesis prosthesis Orthodontic relapse/facilitation of Orthodontic relapse/facilitation of orthodontic tooth movement orthodontic tooth movement Tooth interfering with orthognathic Tooth interfering with orthognathic and/or reconstructive surgery and/or reconstructive surgery Prophylactic removal Prophylactic removal - - Patients with Patients with medical or surgical conditions medical or surgical conditions requiring removal of third molar (e.g. requiring removal of third molar (e.g. organ transplants, alloplastic implants, organ transplants, alloplastic implants, chemotherapy, radiation therapy) chemotherapy, radiation therapy) Definition of peri.oronitis Definition of peri.oronitis is an infection of the is an infection of the soft tissue around the soft tissue around the crown of partially crown of partially impacted tooth and is impacted tooth and is caused by the normal caused by the normal oral flora. oral flora. Causes Causes 1. 1. If the patient experience a mild transient If the patient experience a mild transient decrease in host defense, pericoronitis decrease in host defense, pericoronitis may result. may result. 2. 2. pericoronitis may arise secondary to minor pericoronitis may arise secondary to minor trauma from maxillary third molar. The trauma from maxillary third molar. The soft tissue that covers the occlusal surface soft tissue that covers the occlusal surface of the partially erupted mandibular third of the partially erupted mandibular third molar known as the operculum can be molar known as the operculum can be traumatized and become swollen this can traumatized and become swollen this can be treated by removal of maxillary third be treated by removal of maxillary third molar. molar. 3. 3. entrapment of food under entrapment of food under operculum, in the pocket operculum, in the pocket under operculum and under operculum and impacted teeth ,this pocket impacted teeth ,this pocket can not be cleaned can not be cleaned ,bacteria invade it and ,bacteria invade it and pericoronitis begins. pericoronitis begins. 4. 4. streptococci and anaerobic streptococci and anaerobic bacteria (the usual bacteria bacteria (the usual bacteria inhabit the gingival sulcus) inhabit the gingival sulcus) cause pericronitis cause pericronitis .. hen third molar hen third molar is impacted or is impacted or partially impacted partially impacted ,the bacteria that ,the bacteria that cause dental caries cause dental caries can be exposed to can be exposed to the distal aspect of the distal aspect of the the 22nd molar, as nd molar, as well as to third well as to third molar molar B. B.Dental Caries Dental Caries Erupted teeth adjacent Erupted teeth adjacent to impacted teeth are to impacted teeth are predisposed to predisposed to periodontal disease. periodontal disease. As it decrease amount of As it decrease amount of bone on the distal aspect bone on the distal aspect of adjacent 2nd molar, of adjacent 2nd molar, with deep periodontal with deep periodontal pocket on the distal pocket on the distal aspect of the 2nd molar. aspect of the 2nd molar. C. C. Periodontal Disease Periodontal Disease Impacted teeth Impacted teeth cause sufficient cause sufficient pressure on the root pressure on the root of an adjacent tooth of an adjacent tooth to cause root to cause root resorption. resorption. D. D. Root Resorption Root Resorption . . Pain of unexplained Pain of unexplained origin: origin: Pain in the retro Pain in the retro molar region molar region with no obvious with no obvious reason. reason. . . Odontogenic cyst and Odontogenic cyst and Tumors Tumors The dental follicle The dental follicle may undergo cystic may undergo cystic degeneration and degeneration and become a become a dentigerous cyst or dentigerous cyst or keratocyst. keratocyst. Ameloblastoma Ameloblastoma may developed may developed from epithelium from epithelium within the dental within the dental follicle follicle . . racture of the jaw racture of the jaw impacted third impacted third molar occupies molar occupies space that is space that is usually filled with usually filled with bone, this weaken bone, this weaken the mandible and the mandible and render the render the mandible to mandible to fracture. fracture. . . acilitation of orthodontic acilitation of orthodontic treatment treatment to relief to relief crowding of crowding of mandibular mandibular anterior teeth. anterior teeth. . . impacted teeth under impacted teeth under dental prosthesis: dental prosthesis: Contraindications for removal Contraindications for removal Extremes of age Extremes of age Compromised medical status Compromised medical status Excessive risk of damage to adjacent Excessive risk of damage to adjacent structures structures hen there is a question about the future hen there is a question about the future status of the second molar status of the second molar &ncontrolled active pericoronal infection &ncontrolled active pericoronal infection Socioeconomic status Socioeconomic status fracture of atrophic mandible may occur fracture of atrophic mandible may occur #isk of ntervention: Minor transient #isk of ntervention: Minor transient Sensory nerve alteration Sensory nerve alteration Alveolitis Alveolitis Trismus Trismus Infection Infection emorrhage emorrhage Dentoalveolar fracture Dentoalveolar fracture Displacement of tooth Displacement of tooth #isk of ntervention: Minor Permanent #isk of ntervention: Minor Permanent Periodontal injury Periodontal injury Adjacent tooth injury Adjacent tooth injury TMJ injury TMJ injury #isk of ntervention: Major #isk of ntervention: Major Altered sensation Altered sensation Vital organ infection Vital organ infection racture of the mandible and racture of the mandible and maxillary tuberosity maxillary tuberosity injury injury #isk of Non #isk of Non- -intervention intervention Crowding of dentition based on growth Crowding of dentition based on growth prediction prediction Resorption of adjacent tooth and Resorption of adjacent tooth and periodontal status periodontal status Development of pathological condition Development of pathological condition such as caries, infection, cyst, tumor such as caries, infection, cyst, tumor ssessment of mandibular third molar ssessment of mandibular third molar impaction impaction Classification Classification BASED ON NATURE OF OVERLYING BASED ON NATURE OF OVERLYING TISSUE IMPACTION TISSUE IMPACTION SOT TISS&E IMPACTION SOT TISS&E IMPACTION ARD TISS&E IMPACTION ARD TISS&E IMPACTION inter's .lassifi.ation(1926) Based on long axis of 3 rd molar in relation to 2 nd molar Pell and Gregory classification (1933) Pell and Gregory classification (1933) According to the relation of the impacted tooth According to the relation of the impacted tooth to the ramus of the mandible & the 2 to the ramus of the mandible & the 2 nd nd molar molar Based on reIationship to occIusaI pIane of 2 nd moIar Acc to A. Garcia & co workers, Pell Acc to A. Garcia & co workers, Pell- - Gregory classification is not a reliable Gregory classification is not a reliable predictor of surgical difficulty in predictor of surgical difficulty in vertical impacted lower 3 vertical impacted lower 3 rd rd molars, molars, and classification of non and classification of non- -vertical vertical molars on Pell molars on Pell- -Gregory scales is Gregory scales is difficult. difficult. Br J Oral Maxillofac Surg 2000; Br J Oral Maxillofac Surg 2000; 83:585 83:585- -587 587 D .ode on pro.edures & D .ode on pro.edures & nomen.latures nomen.latures Describes the amount of soft and Describes the amount of soft and hard tissue over the coronal surface hard tissue over the coronal surface of an impacted tooth of an impacted tooth Soft tissue impactions Soft tissue impactions Complete bony impactions Complete bony impactions Partial bony impactions Partial bony impactions Combined Combined D & S D & S .lassifi.ation of .lassifi.ation of pro.edural pro.edural terminology terminology 22 22: removal of impacted tooth : removal of impacted tooth - - overlying soft tissue overlying soft tissue 23 23: removal of impacted tooth : removal of impacted tooth - - partially bony impacted partially bony impacted 24 24: removal of impacted tooth : removal of impacted tooth - - completely bony completely bony 241 241: removal impacted tooth : removal impacted tooth - - completely bony, with unusual surgical completely bony, with unusual surgical complications complications Difficulty ndex for removal of impacted Difficulty ndex for removal of impacted mand third molars mand third molars - - Pedersen 1988 Pedersen 1988 CLASSIFICATION CLASSIFICATION DIFFICULTY INDEX DIFFICULTY INDEX VALUE VALUE ANGULATION ANGULATION Mesioangular 1 Mesioangular 1 orizontal / transverse 2 orizontal / transverse 2 Vertical 3 Vertical 3 Distoangular 4 Distoangular 4 DEPTH DEPTH Level A 1 Level A 1 Level B 2 Level B 2 Level C 3 Level C 3 RAMUS RELATIONSHIP / SPACE AVAILABLE RAMUS RELATIONSHIP / SPACE AVAILABLE Class I 1 Class I 1 Class II 2 Class II 2 Class III 3 Class III 3 Difficult index Difficult index -- Very difficult : 7 to 10 Very difficult : 7 to 10 -- Moderately difficult : 5 to 7 Moderately difficult : 5 to 7 -- Minimally difficult : 3 to 4 Minimally difficult : 3 to 4 # assessment # assessment - - Macgregor 1985 Macgregor 1985 inters classification inters classification -- orizontal orizontal 33 -- Distoangular Distoangular 22 -- Mesioangular Mesioangular 11 -- Vertical Vertical 00 eight of the mandible eight of the mandible -- 11- -30 mm 30 mm 00 -- 31 31- -34 mm 34 mm 11 -- 35 35- -39 mm 39 mm 22 Angulation of 3rd molar Angulation of 3rd molar -- 11- -59 degrees 59 degrees 00 -- 60 60- -69 69 1 1 -- 70 70- -79 79 22 -- 80 80- -89 89 33 -- 90 + 90 + 44 # assessment # assessment Root shape and development Root shape and development -- favourable curvature favourable curvature 11 -- unfavourable curvature unfavourable curvature 22 -- complex complex 33 -- < 1/3 complete 2 < 1/3 complete 2 -- 1/3 to 2/3 complete 1 1/3 to 2/3 complete 1 -- > 2/3 complete 3 > 2/3 complete 3 ollicles ollicles -- normal normal 00 -- possibly enlarged possibly enlarged 11 -- enlarged enlarged 22 -- impaction relieved 3 impaction relieved 3 Path of exit Path of exit -- space available space available 00 -- distal cusps covered distal cusps covered 11 -- mesial cusp also covered mesial cusp also covered 22 -- both covered both covered 33 Maxillary third molar impaction Maxillary third molar impaction Clinical assessment Clinical assessment -- Eruption position of crown Eruption position of crown -- Presence of pericoronitis Presence of pericoronitis -- Periodontal status of 2 Periodontal status of 2 nd nd molar molar -- Soft tissue over tuberosity Soft tissue over tuberosity Radiological interpretation Radiological interpretation -- Crown Crown -- Root Root -- ollicle size ollicle size -- Periodontal ligament space Periodontal ligament space -- Antral position Antral position ssessment of impacted max third molar ssessment of impacted max third molar Classification Classification -- ARCHER'S (19 ARCHER'S (19 On anatomic basis similar to mand 3 On anatomic basis similar to mand 3 rd rd molar molar -- PELL & GREGORY PELL & GREGORY Based on relative depth in relation to 2 Based on relative depth in relation to 2 nd nd molar molar -- Based on relation of max 3 Based on relation of max 3 rd rd molar to max molar to max sinus floor sinus floor Sinus approximation Sinus approximation- - no bone / thin partition no bone / thin partition present present No sinus approximation No sinus approximation -- 2mm or more bone is 2mm or more bone is present present rcher's anatomic classification rcher's anatomic classification Pell & Gregor - relative depth in relation to 2 nd molar ctopic maxillary 3 ctopic maxillary 3 rd rd molar impaction molar impaction ANG&LATION OCC&RANCE DIIC<Y ANG&LATION OCC&RANCE DIIC<Y -- Vertical 63% + Vertical 63% + -- Distoangular 25% + Distoangular 25% + -- Mesioangular 12% Mesioangular 12% +++ +++ -- Transverse <1% ++ Transverse <1% ++ -- orizontal <1% ++ orizontal <1% ++ -- Inverted <1% ++ Inverted <1% ++ Difficulty factors Difficulty factors -- Most common Most common -- thin non fused root with thin non fused root with erractic curvature erractic curvature -- Sinus approximation Sinus approximation -- racture of tuberosity racture of tuberosity Difficult factors Maxillary canine impaction Maxillary canine impaction Clinical assessment Clinical assessment -- Presence of retained deciduous Presence of retained deciduous -- Presence of crowding in max arch Presence of crowding in max arch -- Palpate for the presence of bulge Palpate for the presence of bulge Radiological interpretation Radiological interpretation -- The crown The crown -- The root The root -- Surrounding structures Surrounding structures ssessment of maxillary canine impaction ssessment of maxillary canine impaction MAXILLARY CANINE MAXILLARY CANINE -- Labial position Labial position Crown in intimate relationship with incisors Crown in intimate relationship with incisors Crown well above apices of incisors Crown well above apices of incisors -- Palatal position Palatal position Crown near surface in close relation to roots of incisors Crown near surface in close relation to roots of incisors Crown deeply embedded in close relation to apices of incisors Crown deeply embedded in close relation to apices of incisors -- Intermediate position Intermediate position Crown between lateral incisor & 1 Crown between lateral incisor & 1 st st premolar root premolar root Crown above lat incisor & 1 Crown above lat incisor & 1 st st premolar with crown labially premolar with crown labially placed and root palatally placed or vice versa placed and root palatally placed or vice versa -- &nusual position &nusual position In nasal or antral wall In nasal or antral wall In infraorbital region In infraorbital region IELD & ACKERMAN (1935) Class I : PALATALLY PLACED Class I : PALATALLY PLACED MAXILLARY CANINE MAXILLARY CANINE a) horizontal a) horizontal b) vertical b) vertical c) semivertical c) semivertical Class II: LABIAL OR BUCCAL PLACED Class II: LABIAL OR BUCCAL PLACED MAX. CANINE MAX. CANINE a) horizontal a) horizontal b) vertical b) vertical c) semivertical c) semivertical Class III: INVOLVING BOTH BUCCAL Class III: INVOLVING BOTH BUCCAL AND PALATAL BONE AND PALATAL BONE Class IV: IMPACTED IN THE Class IV: IMPACTED IN THE ALVEOLAR PROCESS ALVEOLAR PROCESS BETWEEN THE INCISORS BETWEEN THE INCISORS AND FIRST PREMOLAR AND FIRST PREMOLAR CLASS V: IMPACTED IN EDENTULOUS CLASS V: IMPACTED IN EDENTULOUS MAXILLA MAXILLA CLA$$IFICATION FOR IMPACTED MANDIBULAR CLA$$IFICATION FOR IMPACTED MANDIBULAR CANINE CANINE LABIAL LABIAL : VERTICAL, OBLIQ&E , ORIZONTAL : VERTICAL, OBLIQ&E , ORIZONTAL ABBERANT ABBERANT : AT INERIOR BORDER : AT INERIOR BORDER ON TE OPPOSITE SIDE ON TE OPPOSITE SIDE #adiographic assessment of impacted tooth #adiographic assessment of impacted tooth Radiographic views Radiographic views -- intraoral periapical intraoral periapical -- occlusal occlusal -- orthopontamograph orthopontamograph -- lateral radiograph lateral radiograph -- Linear cross sectional Linear cross sectional tomography tomography A diagnostic A diagnostic technique for technique for determining the determining the buccolingual buccolingual relationship of relationship of impacted mandibular impacted mandibular third molar and third molar and inferior alveolar inferior alveolar neurovascular bundle neurovascular bundle #adiological assessment aids in #adiological assessment aids in determining determining Classification of impacted tooth Classification of impacted tooth Orientation of impacted tooth Orientation of impacted tooth Depth of the tooth Depth of the tooth Root shape Root shape Bone removal Bone removal -- or path of elevation or path of elevation -- or application of elevators or application of elevators Bone density Bone density Relationship to inferior alveolar canal Relationship to inferior alveolar canal Localization of impacted tooth Localization of impacted tooth #adiographic interpretation #adiographic interpretation Assessment of lower third molar Assessment of lower third molar -- Angulation Angulation -- The crown The crown -- The roots The roots -- Relationship of apices with inf alveolar canal Relationship of apices with inf alveolar canal -- Depth of tooth in alveolar bone Depth of tooth in alveolar bone -- Buccal / lingual obliquity Buccal / lingual obliquity Assessment of lower second molar Assessment of lower second molar Assessment of surrounding bone Assessment of surrounding bone inter's # lines inter's # lines ocalization of impacted teeth using ocalization of impacted teeth using radiographs radiographs Localization techniques Localization techniques -- Clark´s / buccal object / horizontal tube shift rule Clark´s / buccal object / horizontal tube shift rule (1909) (1909) -- Millers right angle rule Millers right angle rule -- Richard´s / vertical tube shift rule (1952) Richard´s / vertical tube shift rule (1952) -- Panorex split Panorex split- -mode panoramic tomograph mode panoramic tomograph ocalization of impacted third molar using ocalization of impacted third molar using radiographs radiographs Horizontal tube shift tech Horizontal tube shift tech -- or seperating superimposed objects with or seperating superimposed objects with vertical long axis vertical long axis -- or buccal / lingual localisation of impacted or buccal / lingual localisation of impacted third molar from roots of erupted teeth third molar from roots of erupted teeth vertical tube shift tech vertical tube shift tech -- or seperating horizontally oriented objects or seperating horizontally oriented objects -- or determining bucco or determining bucco- -lingual position of lingual position of third molar apices that super impose the third molar apices that super impose the mand canal mand canal Clark's horizontal tube shift Clark's horizontal tube shift Clark's horizontal tube shift tech Clark's horizontal tube shift tech Miller's right angle technique Miller's right angle technique Radiologi.al predi.tion of inferior Radiologi.al predi.tion of inferior alveolar nerve injury alveolar nerve injury According to J. P. Rood, B. A. A. Nooraldeen Shehab, According to J. P. Rood, B. A. A. Nooraldeen Shehab, -- Diversion of mandibular canal Diversion of mandibular canal- -changed direction changed direction -- Darkening of root Darkening of root- -decr.amnt of tooth substance or loss decr.amnt of tooth substance or loss of cortical lining of canal of cortical lining of canal -- Interruption of white lines Interruption of white lines- -dense canal wall structure dense canal wall structure -- Narrowing of roots Narrowing of roots- -greates diam.inv.by canal greates diam.inv.by canal -- Deflection of roots Deflection of roots- -deviation of root to b,l,m,d side deviation of root to b,l,m,d side -- Narrowing of mandibular canal Narrowing of mandibular canal- -cross the root of 3 cross the root of 3 rd rd mm -- Dark and bifid root Dark and bifid root- -canal cross the root apex,double canal cross the root apex,double periodontal membrane shadow of bifid apex. periodontal membrane shadow of bifid apex. Br Jr of Oral and Maxillofacial Surgery 1990; 28: 20 Br Jr of Oral and Maxillofacial Surgery 1990; 28: 20- -25 25 JJ Oral Oral Maxillofac Maxillofac Surg Surg 2003 2003; ; 61 61: : 417 417- - 421 421 JJ Oral Oral Maxillofac Maxillofac Surg Surg 2005 2005; ; 63 63: : 33- -77 #elationship with inf alv canal #elationship with inf alv canal Position of root to inferior alveolar canal Position of root to inferior alveolar canal ssessment of impaction ssessment of impaction Preoperative assessment Preoperative assessment -- Clinical assessment Clinical assessment General General Local Local ER&PTION STAT&S O IMPACTED TOOT ER&PTION STAT&S O IMPACTED TOOT RESORPTION O SECOND MOLAR RESORPTION O SECOND MOLAR PRESENCE O LOCAL INECTION PRESENCE O LOCAL INECTION- - PERICORONITIS PERICORONITIS ORTODONTIC CONSIDERATION ORTODONTIC CONSIDERATION CARIES IN OR RESORPTION O TIRD MOLAR OR ADJACENT CARIES IN OR RESORPTION O TIRD MOLAR OR ADJACENT TEET TEET PERIODONTAL STAT&S PERIODONTAL STAT&S ocal assessment ocal assessment -- Mouth opening Mouth opening -- Size of tongue Size of tongue -- Extensibility of lips and cheeks Extensibility of lips and cheeks -- Status of dentition Status of dentition -- Assessment of teeth in particular Assessment of teeth in particular ORIENTATION AND RELATIONSIP TO IDC ORIENTATION AND RELATIONSIP TO IDC OCCL&SAL RELATIONSIP OCCL&SAL RELATIONSIP REGIONAL LYMP NODES REGIONAL LYMP NODES TMJ &NCTION TMJ &NCTION If planned under GA, other impacted teeth should If planned under GA, other impacted teeth should also be also be considered for removal considered for removal $&#GC #MOV O MPCTD TOOT $&#GC #MOV O MPCTD TOOT ASEPSIS AND ISOLATION ASEPSIS AND ISOLATION LOCAL ANAESTESIA /SEDATION , LA/GA LOCAL ANAESTESIA /SEDATION , LA/GA INCISION AND LAP DESIGN INCISION AND LAP DESIGN RELECTION O M&COPERIOSTEAL LAP RELECTION O M&COPERIOSTEAL LAP BONE REMOVAL BONE REMOVAL SECTIONING (DIVISiON ) O TOOT SECTIONING (DIVISiON ) O TOOT ELEVATION ELEVATION EXTRACTION EXTRACTION DEBRIDEMENT AND SMOOTENING O BONE DEBRIDEMENT AND SMOOTENING O BONE CONTROL O BLEEDING CONTROL O BLEEDING CLOS&RE CLOS&RE -- S&T&RING S&T&RING MEDICATIONS MEDICATIONS -- ANTIBIOTICS, ANALGESICS ANTIBIOTICS, ANALGESICS OLLO &P OLLO &P sepsis and isolation sepsis and isolation Painting solution Painting solution povidine povidine --iodine 5% for skin, 1% for oral mucosa iodine 5% for skin, 1% for oral mucosa chx chx -- 7.5% for skin, 0.2%for rinsing oral mucosa 7.5% for skin, 0.2%for rinsing oral mucosa Drape the patient Drape the patient naesthesia naesthesia Mostly procedure performed under local anaesthesia Mostly procedure performed under local anaesthesia GA is indicated when impacted tooth situated deep in GA is indicated when impacted tooth situated deep in jaw bone ( red line > 5 mm ) jaw bone ( red line > 5 mm ) and more than two impacted tooth have to be and more than two impacted tooth have to be removed at one time removed at one time Indication of GA Indication of GA- - emotional inability emotional inability ear of pain & apprehension ear of pain & apprehension Medical condition req.alleviation of anxiet Medical condition req.alleviation of anxiet Lengthy procedure Lengthy procedure &nco op. patient &nco op. patient LA may not achieved desired effect LA may not achieved desired effect eneral anestheti. agents eneral anestheti. agents Premedication Premedication- - Pentobarbital(100 mg oral or 1 Pentobarbital(100 mg oral or 1- -2 ml 2 ml IV) IV) Diazepam(5 Diazepam(5- -15 mg.oral,3 15 mg.oral,3- -20 mg.IV) 20 mg.IV) Sedative & hypnotic Sedative & hypnotic agents(methohexital(0.5 agents(methohexital(0.5- -1.5mg/kg 1.5mg/kg body wt) body wt) Surgi.al anatomy Surgi.al anatomy Situation of 3 Situation of 3 rd rd molar in molar in respect to ant.boder of respect to ant.boder of ramus ramus Lingual position Lingual position Incisions and nerves and Incisions and nerves and vessels vessels Retromolar triangle & fossa Retromolar triangle & fossa Incisions & facial vessels Incisions & facial vessels Lingual nerve Lingual nerve Lingual sockets(root Lingual sockets(root fenestration) fenestration) Spaces Spaces- -sublingual and sublingual and submandibilar space submandibilar space lap design lap design Adequate exposure of the operative site Adequate exposure of the operative site Base of the flap should be wide Base of the flap should be wide ull thickness mucoperiosteal flap should be elevated ull thickness mucoperiosteal flap should be elevated lap should not be extended too far distally lap should not be extended too far distally injure the vessel injure the vessel trismus trismus herniate the buccal pad of fat into the operating herniate the buccal pad of fat into the operating field field Incision should be designed so that flap can be closed Incision should be designed so that flap can be closed over solid bone over solid bone Incision should not damage the vital st. Incision should not damage the vital st. Different types incision and flap design Different types incision and flap design Short envelope Short envelope Long envelope Long envelope L shaped incision(L shaped flap) L shaped incision(L shaped flap) Bayonet shaped incision Bayonet shaped incision Triangular flap Triangular flap ward´s incision ward´s incision Modified ard´s incision Modified ard´s incision Groove and Moore(1970) Groove and Moore(1970) Comma shaped incision Comma shaped incision S shaped incision S shaped incision Szmyd flap Szmyd flap Modified szmyd Modified szmyd Berwick´s tongue flap Berwick´s tongue flap Guralnik horizontal incision Guralnik horizontal incision Donlon trinta Donlon trinta motamedi motamedi nvelope flap nvelope flap Adv Adv- - Visibility Visibility Easy to suture Easy to suture Less post op.pain Less post op.pain Osseous defect can b Osseous defect can b covered covered Adequate blood supply Adequate blood supply to wound margin to wound margin Disadv: Disadv: Cuts insertion of Cuts insertion of temporalis tendon temporalis tendon %riangular flap %riangular flap Bayonet flap Bayonet flap Distal Distal Intermediate Intermediate gingival gingival rooves & moore(1970) rooves & moore(1970) Didn´t involve gingival margin Didn´t involve gingival margin- - decrease pocketing decrease pocketing Involve margin Involve margin olffe etal(1978) compared effects olffe etal(1978) compared effects of removing a wedge of soft tissue of removing a wedge of soft tissue distal to m2 with primary closure distal to m2 with primary closure ormer ormer- -allow dainage allow dainage Later Later- -prevents ingress of infection prevents ingress of infection Sir %eren.e ward's in.ision Sir %eren.e ward's in.ision Ant Ant- -distobuccal corner of distobuccal corner of crown of m2ends along crown of m2ends along mesiobuccal cusp of teeth mesiobuccal cusp of teeth Any epithelium present in Any epithelium present in gingival crevice must be gingival crevice must be excised with reverse bevel excised with reverse bevel incision with no.12 blade incision with no.12 blade Primary closure should not Primary closure should not be attempted unless a be attempted unless a band of buccal attached band of buccal attached mucoperiosteum of 5 mucoperiosteum of 5 mm.is present mm.is present Better results Better results- -allow for allow for secondary intention secondary intention Barwi.k's tongue flap(1966) Barwi.k's tongue flap(1966) Szmyd in.isions(1971) Szmyd in.isions(1971) Szmyd incision Modified szmyd .omma shaped in.ision .omma shaped in.ision Adv: Adv: No part of wound lies No part of wound lies o resultant bone o resultant bone defect defect No approach to No approach to temporalis muscle temporalis muscle tendon tendon No distal extension No distal extension Ind: Ind: Total soft tissue Total soft tissue impaction impaction Partially impacted 3 Partially impacted 3 rd rd molar molar Criteria for su..ess of in.ision Criteria for su..ess of in.ision Surgical access Surgical access ealing both in terms of lack of ealing both in terms of lack of discomfort,pd health discomfort,pd health Schow(1974) extending the flap Schow(1974) extending the flap beyond EOR incr.chances of dry beyond EOR incr.chances of dry socket socket Referen.es Referen.es Oral and maxillofacial surgery:Archer Oral and maxillofacial surgery:Archer Impacted teeth:Alling Impacted teeth:Alling Oral & maxillofacial surgery:Neelima Oral & maxillofacial surgery:Neelima Malik Malik Journals Journals Internet sources Internet sources