management impacted teeth pt 1 Flashcards
Impacted tooth
A tooth that fails to erupt into the dental arch within a specific
time frame
etiologies of impacted teeth
- Inadequate arch length
- Prolonged deciduous tooth retention
- Malposition of Impacted tooth (most common)
- Malposition of adjacent tooth/teeth
- Excessive bone and/or soft tissue
- Associated pathology
Impacted Teeth Order of Frequency
- Mandibular third molars
- Maxillary third molars
- Maxillary canines
- Mandibular premolars
- Mandibular canines
- Maxillary incisors
- Supernumeraries
Classification of Impacted Teeth (Third Molars) categories
- Degree of impaction (Depth in Bone)
- Position of tooth (Long axis of tooth in Bone)
- Pell and Gregory
Degree of Impaction - Depth in Bone classes
- Erupted-normal levels of surrounding bone
- Soft tissue impaction (7220- Procedure Code)
- Partial bone impaction (7230- Procedure Code)
- Complete bone impaction (7240- Procedure Code)
soft tissue impacted, clinical dx
partial bone impacted
complete bone impacted
Classification of Impacted Teeth (Third Molars)
Position of Tooth (long axis of the tooth in bone
- Vertical – Most common in the maxilla
- Mesioangular – Most common in the mandible
- Horizontal
- Distoangular
- Inverted
- Buccal/Palatal or Lingual
orientation
veritcal
mesioangular
horizontal
distoangular
Order of Frequency with reference to Position of Tooth
(long axis of the tooth in bone)
Mandibular Third Molar Impactions
- Mesioangular MOST COMMON
- Distoangular
- Horizontal
- Buccal/Lingual
- Inverted
Order of Frequency with reference to Position of Tooth
(long axis of the tooth in bone)
Maxillary Third Molar Impactions
- Vertical MOST COMMON
- Distoangular
- Mesioangular
- Disto-horizontal
- Mesio-horizontal
- Buccal/Palata
Pell and Gregory Classifications
- Class 1,2 or 3 – Relation of the Mandibular third molar to the anterior border of the ramus.
- Class A, B, or C – Depth of the impaction of maxillary or
mandibular 3rd molar in bone relative to the adjacent tooth
(Maxillary or Mandibular 2nd Molar
Helpful in predicting surgical difficulty
Pell and Gregory - Class 1
Class 1 : Sufficient amount of space between the anterior border of ramus and the distal of the second molar for the accommodation of the entire crown (mesio-distal diameter) of the third molar
Pell and Gregory - Class 2
Pell and Gregory - Class 2
Class 2 - Space between the anterior border of ramus and the distal of
the second molar less than the mesio-distal diameter of the crown of the third molar
Pell and Gregory - Class 3
Class 3 - All of the third molar is within the ramus
Pell and Gregory - Class A (Maxilla)
- The occlusal plane of the impacted tooth is at the same level as
the adjacent tooth
Pell and Gregory - Class A Mandible
- The occlusal plane of the impacted tooth is at the same level as
the adjacent tooth
Pell and Gregory - Class B (Maxilla)
- The occlusal plane of the impacted tooth is between the occlusal
plane and the cervical line of the adjacent tooth
Pell and Gregory - Class B (Mandible)
- The occlusal plane of the impacted tooth is between the occlusal
plane and the cervical line of the adjacent tooth
Pell and Gregory - Class C (Maxilla)
- The occlusal plane of the impacted tooth is apical to the cervical
line of the adjacent tooth
Pell and Gregory - Class C (Mandible)
- The occlusal plane of the impacted tooth is apical to the cervical
line of the adjacent tooth.
Management of Impacted Teeth
General Principles
* All impactions are potentially?
* Prudent care requires?
* In certain selected cases what can be appropriate
* Pathologic conditions are more common with ?
- All impactions are potentially pathologic – PREVENTION.
- Prudent care requires removal, exposure, or repositioning.
- In certain selected cases, long term monitoring with necessary
patient education is appropriate. - Pathologic conditions are more common with increasing age.
General Principles
* Surgery is more difficult and associated with more complications
with?
* Surgery is more difficult if what is present?
* Surgery in younger patients (<25 years old) associated with?
* Third Molar Surgery performed ideally when roots are?
- Surgery is more difficult and associated with more complications
with increased age (oral and systemic compromises) - Surgery is more difficult if symptoms present (Acute pain and
infection) - Surgery in younger patients (<25 years old) associated with better
healing and less morbidity. - Third Molar Surgery performed ideally when roots are 1/2 to
2/3rds formed
Indications For Removal of Impacted Teeth
* Facilitate the management of or limit progression of?
* caries?
* pulp?
* infection?
* Preventive or prophylactic?
* Ectopic?
Indications For Removal of Impacted Teeth
* Facilitate the management of or limit progression of periodontal
disease
* Non-restorable caries
* Non-treatable pulpal lesions
* Acute or chronic infection (e.g., cellulitis, abscess, pericoronitis)
* Preventive or prophylactic removal
* Ectopic position
Indications For Removal of Impacted Teeth
* Internal or external?
* prothesis?
* ortho?
- Internal or external resorption of tooth of adjacent teeth
- Facilitate prosthetic rehabilitation
- Facilitate orthodontic movement and promote dental stability
- Orthodontic abnormalities (e.g., arch length/tooth size
discrepancies, malposed/impacted second molars
Indications For Removal of Impacted Teeth
* Pathology?
* Tooth interfering with?
* Prophylactic removal?
- Pathology associated with tooth follicle (e.g., cysts, tumors)
- Tooth interfering with orthognathic, reconstructive surgery,
trauma or tumor surgery - Prophylactic removal in patients with certain medical or surgical conditions or treatments (e.g. organ transplant, alloplastic implants, chemotherapy, radiation therapy)
chronic recurrent pericoronitis
indication for removal
damage to adj teeth
remove
resorb adjacent root
fuck dat hoe
Contraindications to the Removal of Impacted Teeth
* age?
* Medical conditions?
* Surgical morbidity?
* Good outcome with?
- Extremes in age (e.g. 80 yr old patient with full bony impaction)
- Medical condition (e.g. poor surgical candidate like patient on I.V Bisphosphonates, Head and Neck irradiation, significantly compromised cardiac status)
- Surgical morbidity(e.g., neurosensory disturbance, fracture,
injury to adjacent teeth or structures,etc.) - Good outcome with orthodontic eruption
Evaluation of Impacted Teeth
The evaluation of the impacted tooth and diagnosis of associated problems are based on:
* History
* Clinical examination
* Radiography
Evaluation of Impacted Teeth
History
- Teeth with or without history of pain and swelling of overlying mucosa.
- Inflammation around the crown of the tooth that make more acute symptoms (Pericoronitis).
- Mouth opening
- Airway Exam
- TMJ Exam
Pericoronitis - Diagnosis
\
- lnfection of the soft tissue (operculum) around the crown of a
partially impacted tooth - Caused by normal oral flora
- Compromised host defenses
- Trauma (occlusal)
- Food entrapment
Pericoronitis Treatment
- Removal of offending tooth
- Removal of opposing tooth
- Irrigation/debridement
- Removal of operculum
- Incision and drainage of infection
- Antibiotic therapy
Impacted teeth
Clinical Examination
- Identify caries and periodontal diseases (pain might be fromadjacent carious tooth, this would influence the proposed treatment planning)
- Vitality test of all teeth in doubt.
- Examination for sign of infection (swelling, discharge, trismus and enlarged lymph nodes)
- Facial asymmetry and jaw bone expansion.
Status of tooth in question based on clinical evaluation
- Erupted but non-functional (no opposing, tilted, carious)
- Partially erupted (covered partially with soft tissue)
- Partially erupted with sign of recurrent infection
- Truly impacted (bony or soft tissue)
- Association with pathological lesio
Radiographic Assessments
Radiographic Assessment
* Periapical radiograph
* Orthopantomogram (OPG) – Standard of care
* Cone Beam C.T.Scan
Impacted teeth
Radiographic Examination
* To identify the impacted tooth and?
* To identify the position of? relative to?
* To disclose the degree and orientation of ?
* To examine the configuration of?
* To examine the existence of?
- To identify the impacted tooth and the density of the surrounding
bone. - To identify the position of the impacted tooth in the jaw and its
relation to adjacent teeth and other vital structures (Maxillary
Sinus, Inferior Alveolar Canal) - To disclose the degree and orientation of impaction.
- To examine the configuration of the roots (curvature, numbers,
hypercemntosis, bulbous, fused or diverged) - To examine the existence of pathological development around the impacted tooth
Radiographic predictors of nerve injury
– Darkening of root
– Deflection of root
– Narrowing of root
– Interruption of the white line of the canal
– Diversion of the canal
– Narrowing of the canal
how can CBCT be used
can trace the root, positioning of teeth/supernumeraries
canal deviation
narrowing of canal
PA radiolucency
root narrowing
darkening of root
root curve
interruption of canal wall
