Treatment and Complications of Impactions

By Suparn V Kelkar4th 1st

Roll no 27

Contents Treatment of Mandibular 3rd molar

impaction with complications Treatment of Maxillary 3rd molar

impaction with complications Treatment of Maxillary and Mandibular

Canine impactions ini. Class 1 position ii. Class 2 position iii. Class 3 position iv. Class 4 positionv. Class 5 position

Treatment of Mandibular 3rd Molars

HISTORY› Patients might be asymptomatic› when symptomatic- pain, swelling of the face, trismus› Symptoms of acute pulpitis or abscess› In denture wearers if denture no longer fits & at the same time

show the symptoms of pericoronitis.› General medical history & assessment of physical condition

EXAMINATION Clinical

Extra oral Intra oral

Radiographs

DECISION Diagnosis Treatment planning – type of anesthesia

- surgical procedure

Local Examination

EXTRA ORAL: • Signs of swelling & redness of the cheek• LN’s - enlargment & tenderness,• TMJ• Anesthesia or paraesthesia of lower lip,

INTRA ORAL:• Mouth opening & any evidence of trismus• State of eruption of tooth, signs of pericoronitis• Condition of 1st & 2nd molars• Space present b/w 2nd M & ascending ramus• Elasticity of oral tissues• Size of tongue

Investigations

Radiological Assesment by:a. IOPA

Bitewing

Occlusal Radiograph

Lateral Oblique Radiograph

Orthopantomograph (OPG)

CBCT( Cone Beam Computed Tomography)

Interpretation1. Assessing Access2. Assesing Position and Depth:o WAR LINESo White line, Amber Line, Red Line1. Asses Rootso Lengtho Fusion of rootso Curvature of rootso Width of rootso Roots of 2nd molar1. Asses Bone Texture2. Asses Relationship with Inferior

Alveolar Nerve

7 Radiological Signs (Howe and Poyton 1960)

1. Darkening of roots2. Deflected root3. Narrowing of the Roots4. Dark and Bifid roots5. Interruption of the white lines6. Diversion of Inferior Alveolar Canal7. Narrowing of the inferior alveolar

canal

Darkening of roots

Deflected root

Narrowing of the Roots

Dark and Bifid roots

Interruption of the white lines

Narrowing of the Inferior Alveolar Canal

WAR LINES (WINTERS LINES) White Line

Amber Line

Red Line

Assessment of Difficulty of removal

Wharf’s assessment

Pederson Scale

Surgical Removal

Factors affecting Type and Degree of impaction Amount of Soft tissue exposure Amount and technique of bone removal Odentectomy

SURGICAL INTRUMENTS

Step 1

Anesthesia LA : nerve block of the Inferior alveolar,

lingual, and long buccal nerve GA: indicated if tooth is situated deep

inside the jaw, when more than 2 impacted molars are to be removed

Step 2 Mucoperiosteal Flap Ideal Requirements: Adequate Exposure Base of flap Wide Expose entire site of operation No overextension of flap Incision should not damage vital

anatomic structures

MUCOPERIOSTEAL FLAP

Incision – 3 parts: Anterior, posterior & intermediate limb

Not to be extended too distally- Bleeding from buccal vessels & other arteries Postoperative trismus – temporalis muscle damage Herniation of buccal fat pad Damage to lingual nerve (lingual extention)

Step 3

Planned Ward’s IncisionAnterior release incision made including

the interdental papilla distal to 37. the incision extends downwards at 35 degree angle to the long axis of 36 extending 5 mm beyond the Mucogingival Junction taking care that the anterior limit of the incision does not cross the mesial line angle of 37 to avoid encountering facial artery

Crevicular incision or interdental bevel incision is done in relation to 38

Distal release incision is made from the distobuccal line angle of 38 buccolaterally to avoid encountering lingual nerve

Types of Flaps

L – shaped flap

(2nd molar para marginal Flap with vestibular extension)

Envelope flap(2nd molar

sulcus incision)

Bayonet – shaped flap (2nd molar sulcus incision

With vestibular extension)

Ward’s incision

ModifiedWard’s incision

Buccal extension flap

Triangular flap

Step 3

Buccal mucoperiosteal flap is raised staring the elevator frm the base of the falp at vestibular ( labial) mucosafor easy identification of the subperiosteal plane

Buccal mucoperiosteal flap is raisedincluding the interdental papilla

Complete elevation of the buccal mucopriosteal flap exposing the impacted 38

Step 4

Raising of the lingual mucoperiosteal flap

Complete exposure of the impacted 38 and surrounding bone

Step 5

Guttering of the mesial, buccal, and distal bone of 38 closest to the tooth ( Moore-Gillbe collar Technique)

Step 6

Initiation of dontectomy along long axis of the tooth midway at the bifurcation

Odontectomy performed uptill 2/3rd of the buccolingual width of the tooth using rotary instruments

Step 7

Completion of odontectomy using straight elevator

The working end of the elevator is engaged into created groove and rotated clockwise to complete odontectomy

Step 8

Removal of Distal segment of 38 Removal of mesial segment of 38

Step 9

Extraoral reorientation of the extracted tooth fragment and confirmtion of complete tooth removal

Step 10- Debridement of Wound & Closure

Thorough debridement of the socket by Periapical

curettage.

Smoothening of sharp bony margins by Bone file / burs.

Thorough irrigation of the socket Betadine solution +

Saline .

Initial wound closure is achieved by placing 1stsuture just

distal to 2ndmolar, sufficient number of sutures to get a

proper closure.

Bone Removal

Aim

1.      To expose the crown by removing the bone overlying it.2.      To remove the bone obstructing the pathway for

removal of the impacted tooth.

Types1. By consecutive sweeping action of bur (in layers).2. By chisel or osteotomy cut (in sections).

How much bone has to be removed?

1. Bone should be removed till we reach below the height of contour, where we can apply the elevator.

2. Extensive bone removal can be minimized by tooth sectioning

Moore & Gillbe’s Collar Technique

- Conventional tech of using bur.

- Rosehead round bur no.3 is used to create a gutter along the

buccal side & distal aspect of tooth.

A point of elevation is created with bur.

Amount of bone sacrificed is less.

Can be used in old patient.

Convenient for patient.

Split Bone / Lingual Split Technique Sir William Kelsey Fry(1933)

- Quick & clean tech - Reduces the size of blood clot by means of saucerization of socket. - Decreased risk of damage to the periodontium of the

second molar.

- Less risk of inferior alveolar nerve damage.

- Decreased risk of socket healing problems - Can use regional anaesthesia but endotracheal anaesthesia

is preferred one.

- Only suitable for young adults whose bone is elastic

- Inconvenience to patients due to chisel useage.

Incision Vertical stop cut

Split of Distolingual bone

Horizontal cut

Removal of distal & buccal bone

Removal of disto lingual bone

Elevation

Closure

Post Operative Instructions

Pressure pack – 1hr

Ice application

Soft diet –1st two days

1st dose of analgesic should be taken before the anesthetic

effect of LA wears off.

Avoid strenuous exercises for 1st 24 hrs.

Avoid gargling / spitting / smoking / drinking with straw.

Warm water saline gargling after 24 hrs + mouth wash

regularly thereafter.

Suture removal on 5th POD.

Complications

Intra Operative 1. During incision

a. Injury to facial arteryb. Injury to lingual nervec. Hemorrhage – careful history

2. During bone removal a. Damage to second molar b. Slipping of bur into soft tissue & causing injury c. Extra oral/ mucosal burns d. Fracture of the mandible when using chisel & mallet e. Subcutaneous emphysema

3. During elevation or tooth removala. Luxation of neighbouring tooth/

fractured restorationb. Soft tissue injury due to slipping of

elevatorc.  Injury to inferior alveolar neurovascular

bundled. Fracture of mandiblee. Forcing tooth root into submandibular

space or inferior alveolar nerve canal

f. Breakage of instrumentsg. TMJ Dislocation – careful history

Nerve Injuries 0.6-5% of all the third molar surgeries are involved with nerve

damages of which 0.2% are irreversible

IAN: immediate disturbance - 4-5% (1.3-7.8%) permanent disturbances - <1% (0-2.2%)

Lingual N: immediate - 0.2-22% permanent - 0-2%

96% IAN injuries show spontaneous recovery within 9 months, better than lingual nerve which is about 87%

Beyond 2yrs recovery is unlikely

Post-operative Complications Immediate

- Hemorrhage

- Pain

- Edema

- Drug reaction

Delayed

- Alveolitis

- Infection

- Trismus

Dry Socket 20% of extraction of mandibular 3rd molar 2% of routine extraction Moderate-severe pain develops generally on 3rd/4th day.(with no signs

of infection) Dull aching pain usually radiates to ear Empty socket Bad odor & taste Management

Gentle irrigation with warm saline followed by superficial suctioning.

Pack iodoform gauze socked with medications change every day for 3-6

days.

Intra-alveolar medicaments(controversial)

-with eugenol

-topical LA

-antifibrinolytic agents.

Analgesics.

Treatment of Maxillary 3rd Molar Impaction

Indications1. Pain2. Overeruption of the upper 3rd molar3. 3rd molar errupting towards cheek4. Exacerbation of pericoronitis of lower

3rd molar5. Complete Maxillary denture

Assessment

Clinical1. State of erruption2. Buccolingual displcement3. Impaction against 2nd molar4. Mouth opening5. Space around 3rd molar

Radiographical assessment1. Iopa 2. Lateral oblique3. Opg Interpretation: Position and

Morphology1. Vertical2. Distovertical3. Mesioangular4. Partially errupted

Complicating factors

1. Maxillary Sinus approximation2. 3rd molar within or above roots of 2nd

molar3. Fusion of roots with 2nd molar4. Abnormal root curvature5. Hypercementosis6. Extreme bone density: elderly patients7. Follicular space filled with bone8. Inability t open mouth widely

Armamentarium

Same as that of mandibular molars bt difference in choice of elevators and forceps

1. Upper molar forcep2. Miller and Potts elevator3. BP- no 12

Surgical Procedure

Step 1: Incision and Flap1. Incision beyond the tuberosity in the

hamular notch2. Mucous Membrane incised from the distal

most portion anteriorly3. Incision is continued buccally around the

neck of 2nd molar to the interproximal space os 1st molar and the towards mucobuca fold at 45 degree angle

4. Last incision using no 15 BP blade

Step 2:Elevation and Bone removal1. Overlying bone is not dense and can

be readily removed with a chisel2. Elevator is inserted at the height of

contour using buccal plate as fulcrum3. Extreme care must be taken not to

inadvertently drive tooth into maxillary sinus or Pterygomaxillary space

Step 3: Wound Toilet and Closure1. Debridement of socket and

smothening of bone margins before wound is closed

2. Sutures are placed

Complications

Intraoperative1. Fracture of tuberosity2. Dislodgement into maxillary sinus3. Dislodgement of tooth into maxillary

sinus4. Damage to adjacent 2nd molar

Postoperative1. Infection2. Dry Socket3. Oraantral fistula

Treatment of Impacted Maxillary and Mandibular Canines

Clinical Assessment1. Distinct bulge in palate or buccal

aspect of maxilla2. Deflection of lateral incisors in AP

plane

Radiographical Assessment1. IOPA2. Vertex

Occlusal film3. CBCT

Factors determining treatment

A. AgeB. Stage of tooth developmentC. Position of toothD. Evidence of root resorption of adjacent

permanent teeth

Treatment options

1. No treatment2. Surgical removal of unerupted canine3. Surgical exposure of crown with or

without orthodontic treatment4. Surgical repositioning5. Surgical transplantation

Indications for Surgeryi. No other methord possible to retain toothii. Tooth is located very far from occlusal

planeiii. Pt unwilling to undergo ortho treatmentiv. Resorption of adjacent toothv. Cystslike infection, cyst formationvi. Required space does not existvii. When repositioning is unfavorable

Contraindications for Surgery:i. When tooth can be repositioned

orthodontically ii. Medically compromised pts

Factors complicating surgery

1. Proximity to adjacent teeth2. Proximity to the antral and nasal

cavity3. Formation of oroantral fistulas leading

to acute sinusitis

Surgical Technique

Removal of Canine in Class 1 position (Maxillary)

1. Soft tissue flapNo 12 BP blade usedIncise tissuse around neck of teeth from

lingual side of central incisor

Mucoperiosteal flap raised from hard palte

Bone RemovalRemoved circumferentially 3mm around

the crown with burs

Elevation of toothPalatal bone is used as a fulcrum

Removal of tooth

Impacted Mandibular Canine removal

Wound Irrigation and Closure

Examination of extracted tooth

Flap is compressed onto the palatal bone with a gauze palatal packing placed for 4 hrs

Alternatively a compound stent may be used to prevent hematoma collection

Removal of Canine in Class 2 position

Labially placed impacted canine can be exposed by

1. Trapezoidal flap- 2 vertical limbs2. Semilunar flap- no vertical limb3. Triangular flap- one vertical limb

1. Mucoperiosteal flap2. Bone removed by chisel3. Labial cortical plate as fulcrum luxate

tooth4. Wound debridement and closure

Removal of impacted cuspid in class 3 position

A. Crown in palatal bone root on buccal side

1. Semilunar flap2. Circumferential bone removal3. Root is sectioned4. Palatal flap outlined and

mucoperiosteal flap reflected5. Blunt instrumentation used to elevate6. Wound closure

B. Maxillary cuspid lying in line of arch along alveolar crest

1. Trapezoidal flap2. Bone removal with chisel and mallet3. Buccal mucoperiosteal flap4. Removal of tooth in sections or toto5. Primary wound closure

ThankYou!!!!!