MAXILLARY IMPACTIONSPresented by: Guided by: Dr.Rince Mohammed Dr. S MohanMDS 1st year Professor and HOD

Department of OMFS Govt. Dental college, Kottayam

CONTENTS Impacted tooth-defn Order of frequency Maxillary third molar impactions

Classification Indications,Contraindications for removal Radiographic Examinations Degree of difficulty steps for removing impacted teeth Complications

Maxillary canine impaction Etiology Classification Sequelae Localization Management

IMPACTED TOOTH Impaction is the cessation of the eruption of a

tooth caused by a clinically or radiographycally detectable physical barrier in the eruption path or by an ectopic position of the tooth. Andreasen et al (1997)

Archer (1975) defines impacted tooth as one which is completely or partially unerupted and is positioned against another tooth or bone or soft tissue so that its further eruption is unlikely

ORDER OF FREQUENCY 1. Mandibular 3rd molars 2. Maxillary 3rd molars. 3. Maxillary cuspids. 4. Mandibular bicuspids. 5. Mandibular cuspids. 6. Maxillary bicuspids. 7. Maxillary central incisors. 8. Maxillary lateral incisors.

MAXILLARY THIRD MOLAR IMPACTIONS

CLASSIFICATION1. Based on state of eruption

Fully erupted Partially erupted Unerupted

Within the bone Immediatey beneath the soft tisses

2. Based on Angulation

Vertical – 63 %

Mesioangular - 25 %

Distoangular- 12%

Laterally displaced with the crown facing the cheek,horizontal,inverted,and transverse positions - <1%

Aberrant position associated with pathologial condition such as cyst.

3. Based on the depth: (Pell and Gregory)

Position A - highest point of 2nd molar and highest point of impacted 3rd molar is in line.

Position B - highest point of 3rd molar is in between plane of occlusion and cervical line.

Position C - highest point of 3rd molar is below cervical line.

4.Based on relationship of the impacted max 3rd molar to the maxillary sinus

Sinus Approximation (S.A) no bone or a thin partition of bone between the impacted tooth and the maxillary sinus.

No Sinus Approximation (N.S.A) 2 mm or more bone present

5. Based on nature of roots Fused Multiple

Indications for removal

Extensive caries Recrrent pericoronitis Malplaced tooth which causes the patient to

adopt a convenience bite to avoid cheek biting. Tooth involved in pathogical process like cyst, Buccaly erupting tooth which causes impinging

on the coronoid process. Interference with placement of prosthesis.

Local Contraindications for removal

Symptomless tooth completely embedded in bone

Tooth positioned high in alveolus-Risk of displacing tooth into max antrum

Deeply impacted tooth – removal may cause damage to adjacent structures.

Radiographic Examinations

IOPA OPG Occlusal Lateral view PNS C.T Scan CBCT

Degree of difficulty

Angulation - opposite to mandibular 3rdmolar.DA < V < MA. In MA impactions,bone in distal region is more and dense with less accessability.

Buccoangular position:more buccal more easy,less bone removal needed.

Type of overlying tissue - Easier if soft tissue covering only.

Sinus poximity – Chance of oro antral communiation.

Poximity to tuberosity – chance of fracture.

Other factors

Tooth with thin,curved,hypercementosed roots difficult.

Tooth with wider periodontal space,follicular space – easier

Difficult access Presence of large restoration on second molar. Bone density

STEPS FOR REMOVING IMPACTED TEETH

1. Adequate exposure of the area-flap2. Bone removal.3. Sectioning of tooth.4. Tooth delivery.5. Cleaning ,debridement and closure of

wound.

Triangular flap- releasing incision from the mesial aspect of 2nd molar-more access

Envelope flap - starts from the mesial aspect of 1st molar

FLAP DESIGN

Envelope Flap Incision and Reflection

Triangular Flap Incision and Reflection

Palatal diagonal flap - Dr. Lee Darichuk (2005)

• Gives excellent unrestricted access to the maxillary tuberosity region.The Laster (Surgical Science, Toronto, Ont.) and the Minnesota (Hu-Friedy, Chicago),cheek retractors both provide good access to the tuberosity region and prevents displacement of tooth

Removal of overlying bone

The aim of bone removal is to visualize most of the crown of the tooth and establish access for extraction instruments.

Restricted to occlusal and buccal aspect of tooth down to cervical line with bur or chisel.

Purchase point is made on the mesial aspect of the tooth above the height of countour.This can be accomplished using chiesel with hand pressure as maxillary bone is thin.

Tooth sectioning and delivery

Sectioning should be avoided and considered only as a last resort as small fragments can be displaced into the sinus or infratemporal fossa.

Delivery of the tooth is achieved by using small strt elevator like 301 elevator with a distobuccal force.

Further elevation and delivery by angled elevators, such as the Potts or Miller elevators.

The practitioner should be careful with the forces directed superiorly or posteriorly because of the presence of the maxillary sinus and tuberosity

The tooth is delivered with straight elevators applied on the mesiobuccal with rotational and lever types of motions.The tooth is always delivered in a distobuccal and occlusal direction

Farish and Bouloux (2007) advice the use of Minnesota retractor or periosteal elevator to be placed distal to 3rd molar so that it wil not be displaced under the flap and into the infratemporal fossa.

Should not apply excessive pressure anteriorly to avoid damage to the root of the 2nd molar.

As force is applied to displace the tooth posteriorly, the surgeon should have a finger on the tuberosity (especially in MA impcn) to detect tuberosity fracture.

Debridement and closure

Upon completion, thorough examination of the socket followed by irrigation of the area beneath the flap is advised so as to flush any and all debris.

Suturing is not essential for max 3rd molars as gravity and surrounding soft tissues favour wound closure.

COMPLICATIONS

Displacement into maxillary sinus• If entire tooth is displaced it should be

removed as early as possible to prevent infection.

• According to Pogrel (1990) initial attempt should be with a suction at the opening, if It fails irrigate with saline again use suction.if again fails place the patient on antibiotics and nasal decongestants and plan caldwell Luc approach.

Dislodged into soft tissues

Usually to buccal soft tissues and infratemporal fossa.

The tooth should be removed as early as possible to avoid infection.

Put an incision and try to retrieve with a hemostat or allis forceps.if it is not possible wait till fibrosis occurs and tooth become stable.and place the patient under antibiotic coverage.

Damage to adjacent 2nd molar-during bone removal and elevation.

Fracture of maxillary tuberosity – If the operator anticipates such a fracture, avoiding reflection of the periosteum will preserve the blood supply and will provide the best chance of survival postoperatively.

If the overlying tissue has been reflected and a fracture is noted, removal of the fractured segment is advocated to prevent infection.

Oro antral fistula – Rare complication once detected should be repaired as soon as possible.

Prolapse of buccal fat pad –because of wrong incision. Management by pushing the prolapsed fat back into the cheek and giving a suture.

MAXILLARY CANINE IMPACTION Permanent max canine is considered

impacted when its eruption is retarded in relation to the normal eruption sequence

Incidence 1-3 % of general population,Twice in women than men,5 times more in caucasians than asian.85% palatally and 15% labially.

Etiology

Deleyed resorption of deciduous teeth,trauma to its bud,disturbances in eruption sequence,arch length descrepancy ,rotation of tooth bud,premature root closure,endocrine disturbances ,vit D deficiency,cleft lip and cleft palate.

Guidance theory: Distal aspect of lateral incisor root act as a guide to allow the canine to erupt into position.

Genetic theory : impacted canines are usually seen associated with other anomalies of tooth and these are genetically related.

CLASSIFICATION OF IMPACTED MAXILLARY CANINES

By Archer (1975) Class I : palatally placed maxillary canine

Horizontal Vertical Semi-vertical

Class II : Labially placed maxillary canine Horizontal Vertical Semi-vertical

Class III : Involving both buccal and palatal bone

Class IV : Impacted in the alveolar process between the incisors and the first premolar

Class V : Impacted in the edentulous maxilla

Based on the location:-

1. Labially or palatally placed.2. Intermediate position

i. Crown between lateral incisor and premolar.

ii. Crown above root tip with labial or palatal orientation of lateral incisor or premolar.

3. Aberrant position: Impacted maxillary canine lie in maxillary sinus or nasal cavity.

SEQUELAE OF CANINE IMPACTION Resorption of adjacent teeth-incisors-most

common Poclination of lat incisor - due to pressure

from erupting cuspid Cyst – dentigerous cyst or

adenoameloblastoma Loss of vitality of incisors

Impacted canine causing resorption of lateral

incisor

RetainedDeciduous canine and

resorbed lateral incisor.

LOCALIZATION OF IMPACTED CANINE Inspection – over retained primary canine, Lack of canine

prominence in the buccal sulcus, inclined lat incisor, swelling in either labial or palatal side of arch.non vital or mobile lat incisors.

Palpation – palpable protuberance of the area designates

the position of the tooth quite accurately.

Radiography

Accurate methods – CAT,CBCT ,3D imaging Plane radiographs – OPG, Occlusal

radiography, Anteroposterior and lateral radiographic views

For localisation using conventional radiographs 2 pinciples are used

Parallax technique or cone shift Degree of magnification - objects away from film

wil be more magnified for a given focal spot film distance.buccal more magnified

Parallax technique or cone shift (Clark)

Parallax in horizontal plane - taking 2 peri apical radiographs at 2 diff horizontal angle and with same vertical angle.Due to parallax lingual object moves in the same direction of tube shift and buccal opposite.(SLOB rule )

Parallax in vertical plane –different vertical angulation bt same horizontal

Occlusal view - shows buccal or palatal displacement

OPG – shows vertical and mesiodistal relationship

Lateral skull view – vertical height and antero posterior position of the canine

MANAGEMENT Depends on age of the patient, stage of root

formation, presence of pathology, condition of adjacent teeth, position of tooth, patient’s willingness to undergo orthodontic treatment, physical health etc.

Extraction of deciduos canine – for palatally impacted canines of age group 10 -13. it may erupt if local space conditions are favorable.

Surgical exposure of the tooth –if sufficient space for eruption available and root formation is not complete.

Surgical exposure and orthodontically assisted eruption -for favorably impacted canine and pt who is willing for ortho treatment.

Surgical removal of the impacted tooth - tooth in unfavorable position and which are likely to create problem.

Surgical removal with orthodontic space closure

Surgical removal with prosthetic replacement

No treatment – completely formed canine without any pathology and well above the apices of adjacent teeth esp in an elderly individual can be left alone.regular check up needed.

Surgical repositioning or auto transplantation impacted canine with a favorable root pattern can be tried to be transplanted into the socket of deciduous canine or 1st premolar.

SURGICAL REMOVAL OF PLATALLY IMPACTED MAX CANINE

Flap design – bilateral palatal flap-

The incision for creation of the flap begins at the first or second ipsilateral premolar and, after continuing along the cervical lines of the teeth, ends at the first premolar on the contralateral side

Radiograph showing an impacted maxillary canine with palatal

localization

Clinical photograph of the area of impaction

Palatal incision along the cervical lines of the teeth.

After reflection of the flap

Bone removal and delivery

Bone is removed around the tooth with a chisel or a round bur or both taking care not to damage the roots of adjacent teeth.

once sufficient bone is removed a groove is made on the mesial side.

Introduce elevater into the groove and luxate tooth.

Upper anterior or premolar forceps is used to remove the tooth.

Removal of bone using a round bur, to expose the crown of an impacted tooth

If the tooth is resistant to elevation do tooth sectioning.

A groove is created on the cervical line of the tooth using a fissure bur and, after placing the elevator blade in the groove created, the instrument is rotated until the crown is separated from the root .

The crown is then removed, and, after using the round bur to create a purchase point on the root it is elevated.

The bone edges are smoothed, and the area is thoroughly irrigated,The flap is repositioned and sutured with interrupted sutures

Sectioning of an impacted tooth at the cervical line and separation of the crown from the root

Placement of the straight elevator in the groove created to separate the crown from the root and

removal ofthe crown

Removal of root from its position in the bone using an angled elevator

The flap is repositioned in its initial position and

pressure isapplied to the area with

the index finger for a few seconds

The two segments of tooth after removal

Surgical field after suturing

Complications

Damage to adjacent teeth Hematoma under palatal flap may cause

infection Necrosis of palatal flap Perforation of the floor of the maxillary sinus

or nose

SURGICAL REMOVAL OF LABIALY IMPACTED MAX CANINE

Flap design – trapezoidal or semilunar incision is created and the mucoperiosteum is then reflected.

The bone covering the tooth is removed using a round bur, with a steady stream of saline solution, until the entire crown of the tooth and part of the root are exposed

A groove is then created at the cervical line using a fissure bur, in order to separate the crown from the root.

Trapezoidal incision Reflection of the mucoperiosteal flap

A round bur is used to remove the bone covering

the crown of the tooth

Complete exposure of the crown of the toothand part of the root

Sectioning of the crown–root at the cervical line

of the tooth, using a fissure bur

Tooth after sectioning

Separation is achieved using a straight elevator, which is placed in the groove. Upon rotation, the instrument separates the tooth into two segments.

The crown is removed first and the root is then luxated, after creating a purchase point on the surface of the root.

After smoothing the bone, the area is thoroughly irrigated with saline solution, and the wound is sutured.

Removal of the crown of the impacted tooth

using a straight elevatorRoot of the tooth after removal of the crown

Purchase point created on the root for

placementof the elevator blade

Luxation of the root using a curved elevator

Final step of root extractionRemoval of follicle using

a hemostat and periapical

curette

The two segments of tooth after removal Surgical field after

removal of the tooth

Smoothing of the bone edges of the wound

usinga bone file

Surgical field after suturing

CONCLUSION An impacted tooth that fails to attain a

functional position can cause infection, cysts, tumours, unrestorable caries, periodontal disease, pericoronitis.

In such situation surgical removal is indicted.the surgeon should consider patient’s overall health status and potential risk of complications prior to surgery.

The atraumatic removal of the impacted teeth is the most commonly performed surgical procedure in oral & maxillofacial surgery.

REFERENCES A Practical Guide to the Management of

Impacted Teeth – by Dr K George Varghese A synopsis of minor oral surgery –G Dimitroulis Oral Surgery -Fragiskos D. Fragiskos (Ed.) Contemporary Oral and Maxillofacial Surgery,4th

Ed by peterson Illustrated Manual of Oral and Maxillofacial

Surgery -Geeti Vajdi Mitra Text Book Of Oral And Maxillofacial Surgery -

Neelima Anil Malik

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