1. Management of Impacted Teeth Part II
Dr. Rahaf Al-Habbab BDS. MsD. DABOMS
Diplomat of the American Boards of OMFS
Consultant of Oral and Maxillofacial Surgery
Head of Orthognathic Unit
Saudi Boards Residents Director
Hospital Education and Residency Director
2013

2. Management of Impacted Teeth Part I
Impacted Teeth vs. Unerupted Teeth
Indications of Impacted Teeth Removal
Management of Pericoronitis
Contraindications for Removal of Impacted Teeth

3. Management of Impacted Teeth Part II
Classification System of Impacted Teeth
Modification of Classification Systems for Maxillary Impacted Teeth
Surgical Procedure
Perioperative Patient Management

4. Classification System of Impacted Teeth
The difficulty of extraction should be determined prior to the surgery
The primary factor determining the difficulty of the removal is ACCESSIBILITY
ACCESSIBILITY is determined by adjacent teeth, or other structures impairing access or delivery pathway
Panoramic radiograph shows the most accurate picture and is the radiograph of choice

5. Classification System of Impacted Teeth
Angulation
Relationship to Anterior Border of Ramus
Relationship to Occlusal Plane

6. Angulation Most commonly used classification system
Determined by the angulation of the impacted tooth with respect to the long access of the adjacent second molar.
Angulation of the third molar determines the pathway for removal
Provides initial evaluation of the difficulty of extractions, but not sufficient by itself to define difficulty for molar removal fully

7. Angulation Mesioangular:
Generally acknowledged as the least difficult impaction,
particularly when only partially impacted.
Most common type of impaction, making up approximately 43% of all impactions

8. Angulation Horizontal:
Long access of the third molar is perpendicular to the second molar
More difficult to remove than mesioangular
Less frequently seen, count for 3% of all mandibular impactions
Occlusal films to determine bucco-lingual position

9. Angulation
Vertical:
Long axis of the impacted tooth is parallel to the long axis of the second molar
Second most common impaction to occur, count for 38% of all impaction
Third in difficulty of removal

10. Angulation Distoangular: Most difficult tooth to remove
Long axis of the third molar is distally or posteriorly angled away from the second molar
Uncommon, counting for 6% of all impacted third molars

11. Relationship to Anterior Border of Ramus
Based on the amount of third molar covered by the mandibular ramus bone
Known as the Pell and Gregory Classification 1, 2, and 3
Surgeon have to examine the relationship between the tooth and the anterior part of the ramus.

12. Pell and Gregory Classification
Class 1 Relationship:
The mesiodistal diameter of the crown is completely anterior to the anterior border of the ramus
If the tooth is vertical and the root is incompletely formed, it has a great chance to erupt.

13. Pell and Gregory Classification
The tooth is positioned posteriorly so that one half is covered by the ramus
The tooth can not erupt completely free because of bone distally overlying the crown

14. Pell and Gregory Classification
Tooth is located completely within the mandibular ramus
Provides the least accessibility and therefore presents the greatest difficulty

15. Relationship to Occlusal Plane
The Depth of the impacted tooth compared with the height of the adjacent second molar
Determines the difficulty of impaction removal
Known as the Pell and Gregory A, B, and C classification

16. Pell and Gregory Classification
Class A:
The occlusal surface of the impacted tooth is at the same or nearly the same level as the occlusal plane of the second molar.

17. Pell and Gregory Classification
Class B:
Impacted tooth occlusal surface between the occlusal plane and the cervical line of the second molar

18. Pell and Gregory Classification
Class C:
The occlusal surface of the impacted tooth is below the cervical line of the second molar

19. Summery
All these three classifications are used to determine the difficulty of extraction.
Example;
Mesioangular impaction with a class 1 ramus and class A depth is usually straight forward to remove

20. Root Morphology Considerations
As it is an important factor in determining the degree of difficulty in the extraction of an erupted tooth, it is as important in Impacted teeth
Considerations
Root length
1/3-2/3 root formed, with blunt roots
Longer might have some abnormal morphology
Shorter will rotate

21. Considerations Root fusion: Fused, conical roots vs.
widely separated roots
Root Curvature:
Severely curved or dilacerated roots
Straight or slightly curved

22. Considerations
Careful examination of the apical area of impacted teeth on the radiographs (small, abnormal, sharply hooked roots)
The direction of the root curvature (distally curved tip vs. straight or mesially curved)
Total width of the roots mesiodistally should be compared with the width of the tooth at the cervical line (more difficult, more bone removal, or sectioning)
Periodontal ligament space (wider vs. narrow) especially in patients over 40.

23. Size of Follicular Sac
Young patients tend to have larger follicles
In narrow or non-existent space, the surgeon must create space around the crown
Density of Surrounding Bone
Radiographs are not reliable
Best determined by the age of the patient
(less than 18, older than 35)

24. Contact with Mandibular Second Molar
If space exist, easier extraction will take place
Distoangular or Horizontal impaction, usually in a direct contact with the second molar, carefull extraction should take place.

25. Relationship to IAN
Third molar roots are usually superimposed on the IAC on radiographs
The canal is usually on the buccal aspect of the tooth
If in close relationship, injury to the nerve can occur resulting in paresthesia or anesthesia
Usually lasts few days, weeks, or months, and rarely permanent depending on the degree of injury
Cone-beam computerized tomographic scans for preoperative assessment of the root and canal relationship

26. Nature of Overlying Tissue
Classification system used to determine the more
straightforward extraction from the more difficult one:
Soft tissue
Partial bony
Full bony

27. Soft Tissue Impaction
The height of the contour of the tooth is above the level of the alveolar bone
The superficial portion of the tooth is covered only by soft tissue
To remove it, the surgeon should reflect a soft tissue flap to obtain access to the tooth
The easiest of the three types

28. Partial Bony Impaction
The superficial portion of the tooth is covered by soft tissue
At least a portion of the height of the contour of the tooth is below the level of the surrounding alveolar bone
To remove it, the surgeon must reflect a soft tissue flap, and remove the bone above the height of the contour
Tooth sectioning might also be needed
More difficult that the first type

29. Complete Bony Impaction
Tooth is completely encased in bone
When reflecting the soft tissue flap, the tooth will not be visible
To remove the tooth, extensive amount of bone should be removed
The tooth almost always requires sectioning
The most difficult type of extraction

30. Modification of Classification Systems for Maxillary Impacted Teeth
The same as the mandibular classification, with several distinctions and additions
The same angulation in mandibular third molar extraction cause opposite degree of difficulty for maxillary third molar extraction

31. Modification of Classification Systems for Maxillary Impacted Teeth
Angulations:
Vertical Impaction (63%)
Distoangular Impaction (25%)
Mesioangular Impaction (12%)
Rarely, other positions are
encountered (transverse, inverted,
horizontal), accounting for less
than 1%

32. Maxillary Impacted Teeth
Mesioangular impaction is the most difficult impaction, because the bone that requires removal or expansion is on the posterior aspect of the tooth, which is much thicker than in vertical or distoangular
Buccopalatal direction is also important
Palatal impaction requires more bone removal with possible injury to the nerves and vessels of the palatine foramina.
Radiographic and clinical examination by digital palpation of the tuberusity area

33. Maxillary Impacted Teeth
Most common factor that causes difficulty is a thin, nonfused roots with erratic curvature
PDL space
Follicular space
Bone density (age)
Relationship to the adjacent tooth
Adjacent large restorations
Type of impaction

34. Maxillary Impacted Teeth
Additional factors doesn’t exist for the mandibular third molar:
Maxillary sinus proximity (sinusitis, oroantral fistula)
Maxillary tuberosity
Factors increasing the risk of tuberosiy fracture:
Nonelastic bone (older patients)
Multirooted tooth with large bulbous roots (older patients)
Large and greatly pneumatized maxillary sinuses
Use of excessive force

35. Other Impacted Teeth Impacted maxillary Canine
If decided to be removed or exposed
Determine tooth position
(labial, palatal, or midway)
Exposure:
Flap is created
Tooth exposure
Luxation and Debridement
Gold chain placement
Flap repositioning allowing
maximum coverage

36. Position is still needed to be determined
Other Impacted Teeth
Impacted mandibular premolars
Supernumerary teeth
Position is still needed to be determined
Mesiodens:
Midline supernumerary tooth,
most commonly in the palate
Approached from the palatal
direction to be removed

37. Surgical Procedure
Five basic steps are followed in almost any impaction:
Adequate Exposure
Sufficient bone removal
Tooth sectioning
Tooth delivery by appropriate elevators
Bone filing, wound irrigation, flap reapproximation and suturing

38. Surgical Procedure
Bone removal should be enough to expose the impacted tooth, but not too much prolonging the healing time
Tooth sectioning should be done to avoid excessive bone removal, not prolonging the procedure so much

39. Surgical Procedure 1- Adequate Exposure
Reflecting adequate flaps for accessibility:
Adequate mucoperiosteal flap
Adequate dimension to allow the placement and stabilization of retractors and instruments for bone removal
Envelope Flap:
Preferred technique
Quicker to close
better to heal
Three-cornered Flap:
Envelop flap with releasing incision
Allows greater access to apical region

40. Envelope Flap
Extends from the mesial papilla of the mandibular first molar around the neck of the teeth
To the distobuccal line angle of the second molar, and then
Posteriorly and laterally up the anterior border of the mandibular ramus.

41. The incision should not extend posteriorly in a straight line.. Why?
Flap reflected laterally exposing the external oblique ridge, using periosteal elevator (minimally)
Stabilize retractor on bone

42. Releasing Incision
If the tooth is deeply embedded in bone and requires more bone removal
Releasing incision extending from the mesial aspect of the second molar
Flap must have a broad base with a smooth edge
Incision should be closed on bone and not on a defect
Should avoid vital structures
Only a single releasing incision should be used

43. 2- Removal of Overlying Bone
Amount of bone varies according to the depth of the tooth, morphology of the roots, and the angulation of the tooth
Avoid lingual bone removal
Large round bur (No.8) is desirable (end-cutting bur)
Fissure burs (lateral cutting)

44. Removal of Overlying Bone
The bone of the occlusal aspect is first removed
Followed by the buccal and distal aspect down to the cervical line of the impacted tooth
Remove bone between tooth and cortical bone (ditching)
Create purchase points and pathway for delivery

45. Removal of Overlying Bone
For maxillary teeth:
If bone removal is needed, it is removed primarily on the buccal aspect of the tooth , down to the cervical line to expose the entire clinical crown.
Usually accomplished using a periosteal elevator, rather than a bur.
Additional bone removal from the mesial aspect of the tooth should be done to allow purchase point

46. 3- Sectioning The Tooth
Allow portion of the tooth to be removed through the opening created
The direction of dividing the tooth, depends primarily on the angulation of the tooth
Sectioning is performed using a bur, ¾ of the way toward the lingual aspect
Straight elevator is then used to split the tooth through the slot created.

47. Mesioangular Mandibular Impaction
The least difficult impaction to remove
After sufficient bone removal, the distal half of the crown is sectioned off
Starting at the buccal groove to just below the cervical line at the distal aspect
The portion is removed, and the reminder of the tooth is then removed using a dental elevator
Purchase point can be created in the tooth using a bur

48. If the roots are divergent, further sectioning might be required.
Horizontal Impaction
The next least difficult impaction to remove
Sufficient bone is removed down to the cervical line to expose the superior aspect of the distal root and the majority of the buccal surface of the crown
Tooth is sectioned by dividing the crown of the tooth at the cervical line
Crown is removed, and the roots are displaced into the space, using a cryer elevator.
If the roots are divergent, further sectioning might be required.

49. Vertical Impaction One of the most difficult impactions to remove
Bone removal and sectioning procedure is similar to the mesioangular tooth
Occlusal, buccal, and distal bone is removed
The distal half of the crown is sectioned and removed
The tooth is then elevated from a mesial approach
Because it is difficult to obtain access around the second molar, requires substantial amount of bone removal buccally and distally

50. Distoangular Impaction
The most difficult tooth to remove
Sufficient bone should be removed from the occlusal, buccal, and distal aspect of the crown
The crown is sectioned from the roots just above the cervical line
If the roots are fused, elevate the tooth into the space using a cryer or a straight elevator
If the roots are divergent, they will be sectioned into two pieces and individually delivered
Difficulty of this impaction is related to the substantial amount of bone removal needed distally, and because of the distal direction of the tooth elevation

51. 4- Delivery of the Sectioned Tooth with Elevator
Following adequate bone removal, and tooth exposure, the tooth is delivered from the alveolar process with dental elevator
The most commonly used elevators are the
Straight elevator
Cayer elevator (paired)
Crane elevator

52. 4- Delivery of the Sectioned Tooth with Elevator
The difference between the removal
of impacted mandibular third molar and
other teeth in the mouth:
No luxation of the tooth
Bone removal instead of expansion
Tooth is sectioned and pathway is created
Excessive forces should be avoided
Tuberosity should be supported during maxillary third molar extraction

53. 5- Preparing For Wound Closure
Smooth bone margins using a bone file
Vigorous irrigation allowing proper debridement of the wound (normal Saline)
Remove any remnant of the dental follicle
Final irrigation and inspection
Control bleeding points if exist
Application of antibiotics to the socket
Primary closure starting with the Initial suture (on the posterior aspect of the second molar)
Releasing incision and passive maxillary flap

54. Perioperative Patient Management
Anxiety control
Long acting local anesthetics
Analgesics
Parenteral (IV) steroids administration (Dexamethasone)
Ice pack use
Antibiotics (pericoronitis, abscess)