By

Dr.Shouvik Chowdhury
Post graduate
Raja Rajeswari Dental
College
 contents
 Definition of impaction
 Classification of impacted teeth by their
orientation
 List the indications and contraindications for
the removal of impacted teeth
 List the risks of intervention and non-
intervention with respect to impacted teeth
 Radiographic analysis
 chronology
 Tooth germ-9 years
 Cusp mineralization-2
years later
 11 years-tooth located in
anterior border of
ramus,occlusal suface
facing anteiorly 11 years 14 years
 Crown formation-14 years
 Root-50% formed by 16
years
 Root formation with open
apex-18 years
 24 years-95% of 3rd molars
completed eruption
18 years 25 years
 Terminologies

 impacted teeth
 unerupted teeth
 Malposed teeth
 Definition

– Origin- Latin -- impactus

– Cessation of eruption of teeth cause by
physical barrier or ectopic eruption
– Definition
a completely / partially unerupted and is
positioned against another tooth, bone /
soft tissue, so that its further eruption is
unlikely,described according to anatomic
position.(Archer)
 Unerupted tooth-not having
perforated oral mucosa
 Malposed tooth-a tooth,erupted or
unerupted which is in abnormal
position in maxilla or mandible
 Causes of impaction of teeth

– Theories of impaction (Durbeck)

 The Phylogenic theory
 The Mendelian theory
 The Endocrine theory
 The Pathological theory
 The Orthodontic theory
 The Skeletal theory
 Local causes

– Lack of space
– Retained deciduous teeth
– Premature loss of deciduous teeth
– Ectopic position of tooth bud
– Obstruction of eruption path
– Cyst tumor and supernumery teeth
– Infection and trauma
– Abnormality of jaw
– Dilaceration : abnormal path of eruption of tooth
due to traumatic forces during the eruption period
 Systemic causes

– Pre-natal causes
 Heredity
 miscegenation

– Post-natal causes
 Rickets, anemia, congenital syphilis,

tuberculosis, malnutrition
– Endocrine causes
 Hypothyroidism, hypoparathyroidism

– Rare conditions
 Cleidocranial dysostosis, oxycephaly,

progeria, achondroplasia, cleft palate

Commonly impacted teeth

 mandibular third molars

 maxillary third molars
 maxillary cuspids
 mandibular bicuspids
 mandibular cuspids
 maxillary bicuspids
 maxillary central incisior
 maxillary lateral incisor
 supernumerary teeth mainly mesiodens
 Indications for removal

 prevention of pericoronitis

 Dental caries or prevention of dental caries

 Periodontal disease or its prevention
 Prevention of root resorption
 Odontogenic cysts & tumours – dentigerous cyst
 Pain of unexplained origin
 autogenous transplantation to first molar socket
 Indications for removal
 Fracture of the jaw/tooth in the line of
fracture
 Prosthetic problems e.g. under prosthesis
 Orthodontic relapse/facilitation of
orthodontic tooth movement
 Tooth interfering with orthognathic and/or
reconstructive surgery
 Prophylactic removal - Patients with
medical or surgical conditions requiring
removal of third molar (e.g. organ
transplants, alloplastic implants,
chemotherapy, radiation therapy)
 Definition of pericoronitis
 is an infection of the
soft tissue around the
crown of partially
impacted tooth and is
caused by the normal
oral flora.
 Causes
1. If the patient experience a mild transient
decrease in host defense, pericoronitis
may result.
2. pericoronitis may arise secondary to minor
trauma from maxillary third molar. The
soft tissue that covers the occlusal surface
of the partially erupted mandibular third
molar known as the operculum can be
traumatized and become swollen this can
be treated by removal of maxillary third
molar.
3. entrapment of food under
operculum, in the pocket
under operculum and
impacted teeth ,this pocket
can not be cleaned ,bacteria
invade it and pericoronitis
begins.
4. streptococci and anaerobic
bacteria (the usual bacteria
inhabit the gingival sulcus)
cause pericronitis .
 B.Dental Caries
 When third molar
is impacted or
partially
impacted ,the
bacteria that cause
dental caries can
be exposed to the
distal aspect of the
2nd molar, as well
as to third molar
C. Periodontal Disease
 Erupted teeth adjacent
to impacted teeth are
predisposed to
periodontal disease.
 As it decrease amount of
bone on the distal aspect
of adjacent 2nd molar,
with deep periodontal
pocket on the distal
aspect of the 2nd molar.
 D. Root Resorption
 Impacted teeth
cause sufficient
pressure on the root
of an adjacent tooth
to cause root
resorption.
 E. Pain of unexplained
origin:

 Painin the retro

molar region
with no obvious
reason.
 F. Odontogenic cyst and
Tumors
 The dental follicle
may undergo cystic
degeneration and
become a
dentigerous cyst or
keratocyst.
 Ameloblastoma
may developed from
epithelium within
the dental follicle
 G. Fracture of the jaw
 impacted third
molar occupies
space that is
usually filled with
bone, this weaken
the mandible and
render the
mandible to
fracture.
 H. impacted teeth under
dental prosthesis:

I. Facilitation of orthodontic
treatment
 torelief
crowding of
mandibular
anterior teeth.
 Contraindications for removal

 Extremes of age
 Compromised medical status
 Excessive risk of damage to adjacent structures
 When there is a question about the future status of
the second molar
 Uncontrolled active pericoronal infection
 Socioeconomic status
 fracture of atrophic mandible may occur
Risk of Intervention: Minor transient

 Sensory nerve alteration

 Alveolitis
 Trismus
 Infection
 Hemorrhage
 Dentoalveolar fracture
 Displacement of tooth
 Risk of Intervention: Minor Permanent

 Periodontal injury
 Adjacent tooth injury
 TMJ injury
 Risk of Intervention: Major

 Altered sensation
 Vital organ infection
 Fracture of the mandible and
maxillary tuberosity
 injury
 Risk of Non-intervention

 Crowding of dentition based on growth

prediction
 Resorption of adjacent tooth and
periodontal status
 Development of pathological condition
such as caries, infection, cyst, tumor
 Assessment of mandibular third molar
impaction
 Classification

BASED ON NATURE OF OVERLYING

TISSUE IMPACTION

SOFT TISSUE IMPACTION

HARD TISSUE IMPACTION
 Winter’s classification(1926)
Based on long axis of 3rd molar in relation to 2nd molar
 Pell and Gregory classification (1933)

According to the relation of the impacted tooth

to the ramus of the mandible & the 2nd molar
Based on relationship to occlusal plane of 2nd molar
 Acc to A. Garcia & co workers, Pell-
Gregory classification is not a reliable
predictor of surgical difficulty in vertical
impacted lower 3rd molars, and
classification of non-vertical molars on
Pell-Gregory scales is difficult.

Br J Oral Maxillofac Surg 2000; 83:585-

587
 ADA code on procedures &
nomenclatures
Describes the amount of soft and
hard tissue over the coronal surface
of an impacted tooth
Soft tissue impactions

Complete bony impactions

Partial bony impactions

 Combined ADA & AAOMS
classification of procedural
terminology
 07220: removal of impacted tooth -
overlying soft tissue
 07230: removal of impacted tooth -
partially bony impacted
 07240: removal of impacted tooth -
completely bony
 07241: removal impacted tooth -
completely bony, with unusual surgical
complications
Difficulty Index for removal of impacted mand
third molars - Pedersen 1988
CLASSIFICATION DIFFICULTY INDEX
VALUE
 ANGULATION
 Mesioangular 1
 Horizontal / transverse 2
 Vertical 3
 Distoangular 4
 DEPTH
 Level A 1
 Level B 2
 Level C 3
 RAMUS RELATIONSHIP / SPACE AVAILABLE
 Class I 1
 Class II 2
 Class III 3
 Difficulty index

– Very difficult : 7 to 10
– Moderately difficult : 5 to 7
– Minimally difficult : 3 to 4
 WHARFE assessment - Macgregor 1985

 Winters classification
– Horizontal 3
– Distoangular 2
– Mesioangular 1
– Vertical 0
 Height of the mandible
– 1-30 mm 0
– 31-34 mm 1
– 35-39 mm 2
 Angulation of 3rd molar
– 1-59 degrees 0
– 60-69 1
– 70-79 2
– 80-89 3
– 90 + 4
 WHARFE assessment

 Root shape and development

– favourable curvature 1
– unfavourable curvature 2
– complex 3
– < 1/3 complete 2
– 1/3 to 2/3 complete 1
– > 2/3 complete 3
 Follicles
– normal 0
– possibly enlarged 1
– enlarged 2
– impaction relieved 3
 Path of exit
– space available 0
– distal cusps covered 1
– mesial cusp also covered 2
– both covered 3
 Maxillary third molar impaction

 Clinical assessment
– Eruption position of crown
– Presence of pericoronitis
– Periodontal status of 2nd molar
– Soft tissue over tuberosity
 Radiological interpretation
– Crown
– Root
– Follicle size
– Periodontal ligament space
– Antral position
 Assessment of impacted max third molar

 Classification
– ARCHER’S (1975)
 On anatomic basis similar to mand 3rd molar

– PELL & GREGORY

 Based on relative depth in relation to 2 nd molar

– Based on relation of max 3rd molar to max

sinus floor
 Sinus approximation- no bone / thin partition
present
 No sinus approximation – 2mm or more bone is
present
Archer’s anatomic classification
Pell & Gregory – relative depth in relation to
2nd molar
Ectopic maxillary 3rd molar impaction
 Difficulty factors

ANGULATION OCCURANCE DIFFICULTY

– Vertical 63% +
– Distoangular 25% +
– Mesioangular 12% +++
– Transverse <1% ++
– Horizontal <1% ++
– Inverted <1% ++

 Difficulty factors
– Most common – thin non fused root with
erractic curvature
– Sinus approximation
– Fracture of tuberosity
 Maxillary canine impaction

 Clinical assessment
– Presence of retained deciduous
– Presence of crowding in max arch
– Palpate for the presence of bulge

 Radiological interpretation
– The crown
– The root
– Surrounding structures
Assessment of maxillary canine impaction

 FIELD & ACKERMAN (1935)

MAXILLARY CANINE
– Labial position
 Crown in intimate relationship with incisors
 Crown well above apices of incisors
– Palatal position
 Crown near surface in close relation to roots of incisors
 Crown deeply embedded in close relation to apices of incisors
– Intermediate position
 Crown between lateral incisor & 1st premolar root
 Crown above lat incisor & 1st premolar with crown labially
placed and root palatally placed or vice versa
– Unusual position
 In nasal or antral wall
 In infraorbital region
 Class I : PALATALLY PLACED
MAXILLARY CANINE
a) horizontal
b) vertical
c) semivertical

 Class II: LABIAL OR BUCCAL PLACED

MAX. CANINE
a) horizontal
b) vertical
c) semivertical

 Class III: INVOLVING BOTH BUCCAL

AND PALATAL BONE

 Class IV: IMPACTED IN THE

ALVEOLAR PROCESS
BETWEEN THE INCISORS AND
FIRST PREMOLAR

 CLASS V: IMPACTED IN EDENTULOUS

MAXILLA
 CLASSIFICATION FOR IMPACTED MANDIBULAR
CANINE

LABIAL : VERTICAL, OBLIQUE , HORIZONTAL

ABBERANT : AT INFERIOR BORDER

ON THE OPPOSITE SIDE
Radiographic assessment of impacted tooth

 Radiographic views
– intraoral periapical
– occlusal
– orthopontamograph
– lateral radiograph
– Linear cross sectional
tomography
 A diagnostic
technique for
determining the
buccolingual
relationship of
impacted mandibular
third molar and
inferior alveolar
neurovascular bundle
 Radiological assessment aids in
determining

 Classification of impacted tooth

 Orientation of impacted tooth
 Depth of the tooth
 Root shape
 Bone removal
– For path of elevation
– For application of elevators
 Bone density
 Relationship to inferior alveolar canal
 Localization of impacted tooth
 Radiographic interpretation

 Assessment of lower third molar

– Angulation
– The crown
– The roots
– Relationship of apices with inf alveolar canal
– Depth of tooth in alveolar bone
– Buccal / lingual obliquity

 Assessment of lower second molar

 Assessment of surrounding bone
Winter’s WAR lines
 Localization of impacted teeth using
radiographs

 Localization techniques

– Clark’s / buccal object / horizontal tube shift rule

(1909)
– Millers right angle rule
– Richard’s / vertical tube shift rule (1952)
– Panorex split-mode panoramic tomograph
Localization of impacted third molar using
radiographs

 Horizontal tube shift tech

– For seperating superimposed objects with
vertical long axis
– For buccal / lingual localisation of impacted
third molar from roots of erupted teeth

 vertical tube shift tech

– For seperating horizontally oriented objects
– For determining bucco-lingual position of third
molar apices that super impose the mand
canal
Clark’s horizontal tube shift
Clark’s horizontal tube shift tech
Miller’s right angle technique
 Radiological prediction of inferior
alveolar nerve injury
 According to J. P. Rood, B. A. A. Nooraldeen Shehab,
– Diversion of mandibular canal-changed direction
– Darkening of root-decr.amnt of tooth substance or loss
of cortical lining of canal
– Interruption of white lines-dense canal wall structure
– Narrowing of roots-greates diam.inv.by canal
– Deflection of roots-deviation of root to b,l,m,d side
– Narrowing of mandibular canal-cross the root of 3rd m
– Dark and bifid root-canal cross the root apex,double
periodontal membrane shadow of bifid apex.

Br Jr of Oral and Maxillofacial Surgery 1990; 28: 20-25

J Oral Maxillofac Surg 2003; 61: 417- 421
J Oral Maxillofac Surg 2005; 63: 3-7
Relationship with inf alv canal
Position of root to inferior alveolar canal
 Assessment of impaction

 Preoperative assessment
– Clinical assessment
 General
 Local
 ERUPTION STATUS OF IMPACTED TOOTH
 RESORPTION OF SECOND MOLAR
 PRESENCE OF LOCAL INFECTION- PERICORONITIS
 ORTHODONTIC CONSIDERATION
 CARIES IN OR RESORPTION OF THIRD MOLAR OR ADJACENT
TEETH
 PERIODONTAL STATUS
 Local assessment

– Mouth opening
– Size of tongue
– Extensibility of lips and cheeks
– Status of dentition
– Assessment of teeth in particular
 ORIENTATION AND RELATIONSHIP TO IDC
 OCCLUSAL RELATIONSHIP
 REGIONAL LYMPH NODES
 TMJ FUNCTION
 If planned under GA, other impacted teeth should also be
considered for removal
 SURGICAL REMOVAL OF IMPACTED TOOTH

 ASEPSIS AND ISOLATION

 LOCAL ANAESTHESIA /SEDATION , LA/GA
 INCISION AND FLAP DESIGN
 REFLECTION OF MUCOPERIOSTEAL FLAP
 BONE REMOVAL
 SECTIONING (DIVISiON ) OF TOOTH
 ELEVATION
 EXTRACTION
 DEBRIDEMENT AND SMOOTHENING OF BONE
 CONTROL OF BLEEDING
 CLOSURE – SUTURING
 MEDICATIONS – ANTIBIOTICS, ANALGESICS
 FOLLOW UP
 Asepsis and isolation

 Painting solution
povidine –iodine 5% for skin, 1% for oral mucosa
chx – 7.5% for skin, 0.2%for rinsing oral mucosa

 Drape the patient

 Anaesthesia
 Mostly procedure performed under local anaesthesia

 GA is indicated when impacted tooth situated deep in

jaw bone ( red line > 5 mm )
and more than two impacted tooth have to be
removed at one time
Indication of GA-
emotional inability
Fear of pain & apprehension
Medical condition req.alleviation of anxiet
Lengthy procedure
Unco op. patient
LA may not achieved desired effect
 General anesthetic agents
 Premedication-

 Pentobarbital(100 mg oral or 1-2 ml

IV)
 Diazepam(5-15 mg.oral,3-20 mg.IV)

 Sedative & hypnotic

agents(methohexital(0.5-1.5mg/kg
body wt)
 Surgical anatomy
 Situation of 3rd molar in
respect to ant.boder of
ramus
 Lingual position
 Incisions and nerves and
vessels
 Retromolar triangle & fossa
 Incisions & facial vessels
 Lingual nerve
 Lingual sockets(root
fenestration)
 Spaces-sublingual and
submandibilar space
 Flap design

 Adequate exposure of the operative site

 Base of the flap should be wide
 Full thickness mucoperiosteal flap should be elevated
 Flap should not be extended too far distally
injure the vessel
trismus
herniate the buccal pad of fat into the operating
field
 Incision should be designed so that flap can be closed
over solid bone
 Incision should not damage the vital st.
 Different types incision and flap design

 Short envelope
 Long envelope
 L shaped incision(L shaped flap)
 Bayonet shaped incision
 Triangular flap
 ward’s incision
 Modified Ward’s incision
 Groove and Moore(1970)
 Comma shaped incision
 S shaped incision
 Szmyd flap
 Modified szmyd
 Berwick’s tongue flap
 Guralnik horizontal incision
 Donlon trinta
 motamedi
 Envelope flap
 Adv-
 Visibility
 Easy to suture
 Less post op.pain
 Osseous defect can b
covered
 Adequate blood supply
to wound margin
 Disadv:
 Cuts insertion of
temporalis tendon
Triangular flap
 Bayonet flap
 Distal

 Intermediate

 gingival
 Grooves & moore(1970)
 Didn’t involve gingival margin-
decrease pocketing
 Involve margin

 Wolffe etal(1978) compared effects

of removing a wedge of soft tissue
distal to m2 with primary closure
 Former-allow dainage

 Later-prevents ingress of infection

 Sir Terence ward’s incision
 Ant-distobuccal corner of
crown of m2ends along
mesiobuccal cusp of teeth
 Any epithelium present in
gingival crevice must be
excised with reverse bevel
incision with no.12 blade
 Primary closure should not
be attempted unless a
band of buccal attached
mucoperiosteum of 5
mm.is present
 Better results-allow for
secondary intention
Barwick’s tongue flap(1966)
 Szmyd incisions(1971)

Szmyd incision Modified szmyd

 comma shaped incision
 Adv:
 No part of wound lies
o resultant bone
defect
 No approach to
temporalis muscle
tendon
 No distal extension
 Ind:
 Total soft tissue
impaction
 Partially impacted 3rd
molar
 Criteria for success of incision
 Surgicalaccess
 Healing both in terms of lack of
discomfort,pd health
 Schow(1974) extending the flap
beyond EOR incr.chances of dry
socket
 References
 Oral and maxillofacial surgery:Archer
 Impacted teeth:Alling

 Oral & maxillofacial surgery:Neelima

Malik
 Journals

 Internet sources