Management of Impacted Teeth Flashcards
Impacted tooth
A tooth that fails to erupt into the dental arch within a specific
time frame
Impacted tooth
Etiology
(6)
- Inadequate arch length
- Prolonged deciduous tooth retention
- Malposition of Impacted tooth
- 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)
(3)
- Degree of impaction
(Depth in Bone) - Position of tooth
(Long axis of tooth in Bone) - Pell and Gregory
Classification of Impacted Teeth (Third Molars)
Degree of Impaction - Depth in Bone
(4)
- Erupted-normal levels of surrounding bone
- Soft tissue impaction
- Partial bone impaction
- Complete bone impaction
Classification of Impacted Teeth (Third Molars)
Position of Tooth (long axis of the tooth in bone)
(6)
- Vertical
- Mesioangular
- Horizontal
- Distoangular
- Inverted
- Buccal/Palatal or Lingual
– Most common in the maxilla
– Most common in the mandible
- Vertical
- Mesioangular
Pell and Gregory Classification
(3)
- Less commonly used
- Class 1,2 or 3 –
- Class A, B, or C –
- 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)
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.
Class I - Situated anterior to the anterior border of the ramus and there is
adequate room to erupt
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
Class 2 - Crown ½ covered by the anterior border of the ramus
Pell and Gregory - Class 3
Class 3 - All of the third molar is within the ramus
Class 3- Crown fully covered by the anterior border of 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.
- All impactions are potentially
pathologic – PREVENTION.
- Prudent care requires (3)
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.
- 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 — formed.
1/2 to
2/3rds
Indications For Removal of Impacted Teeth
(13)
- 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
- 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 - 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)
Contraindications to the Removal of Impacted Teeth
(4)
- 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:
(3)
- History
- Clinical examination
- Radiography
Evaluation of Impacted Teeth
History
(5)
- 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
(5)
- 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
(6)
- Removal of offending tooth
- Removal of opposing tooth
- Irrigation/debridement
- Removal of operculum
- Incision and drainage of infection
- Antibiotic therapy
Impacted teeth
Clinical Examination
(4)
- Identify caries and periodontal diseases (pain might be from
adjacent 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
(5)
- 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 lesions
Radiographic Assessment
(3)
- Periapical radiograph
- Orthopantomogram (OPG) – Standard of care
- Cone Beam C.T.Scan
mpacted teeth
Radiographic Examination
(5)
- 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 teeth
Inferior Alveolar Nerve
* Radiographic predictors of nerve injury
(6)
– 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
Radiographic signs of increased risk of inferior alveolar
nerve injury
(7)
1.Deviation of the canal
2.Narrowing of the canal
3.Periapical radiolucent area
4.Narrowing of root
5.Darkening of roots
6. Curving of root
7. Interruption of the white
line of the canal (Loss of
lamina dura of canal )
Position of an Impacted Tooth
The examination was requested to evaluate right maxillary bicuspid area for root
resorption.
CBCT can identify
(3)
- Number, location, relative position
- Cystic degeneration,
- Effect on adjacent teeth, nerve, sinus floor
