Presentation is loading. Please wait.

Presentation is loading. Please wait.

Management of Impacted Teeth Part I

Similar presentations

Presentation on theme: "Management of Impacted Teeth Part I"— Presentation transcript:

1 Management of Impacted Teeth Part I
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 What is the Difference between Impacted and Unerupted Teeth?

3 Impacted Teeth Teeth that fails to erupt into the dental arch
within the expected time, because of: An adjacent teeth Dense overlying bone Excessive soft tissue Genetic abnormality prevents eruption Retained for the patient’s lifetime unless surgically removed or exposed because of resorption of overlying tissue.

4 Include impacted teeth and teeth that are in the process of erupting
Unerupted Teeth Include impacted teeth and teeth that are in the process of erupting

5 Most Common Cause of Impaction
Inadequate dental arch length and space, where the total length of the alveolar dental arch is smaller than the total length of the dental arch Most common impacted teeth are: Maxillary and mandibular third molars (last to erupt) Maxillary canines (crowding of other teeth) Mandibular premolars, most commonly 2ed PM (after molars and canine)

6 General Rule All impacted teeth should be removed before complications arise unless removal is contraindicated or will cause more serious problems Extraction should take place as soon as the dentist determines that the tooth is impacted Dentist should not recommend to leave impacted teeth in place until they cause difficulty Removal becomes more difficult with advanced age

7 Causes of Third Molar Impaction
Average age of third molar eruption completion is age 20, it may continue in some patients until age of 25. Normal development of lower third molar begins in a horizontal angulation (as the tooth develop and the jaw grow)→ mesioangular angulation → vertical angulation

8 Causes of Third Molar Impaction
Failure of rotation from mesioangular to vertical direction is the most common cause of third molar impaction Lack of mesiodistal dimension of the arch length to the teeth anterior to the ramus

9 Advantages of Early Removal
Early removal reduces the postoperative morbidity and allows for the best healing: Young patients tolerate the procedure better and recover more quickly Better periodontal healing because of better more complete regeneration of periodontal tissue Better nerve recovery Less dense bone and incomplete root formation

10 Ideal Impacted Third Molar Removal Time
When the roots are one third formed and before it is two third formed Between the age of 17-20

11 Indications of Impacted Teeth Removal
Prevention of Periodontal Disease Prevention of Dental Caries Prevention of Pericoronitis Prevention of Root Resorption Impacted Teeth Under a Dental Prosthesis Prevention of Odontogenic Cysts and Tumors Treatment of Pain of Unexpected Origin Prevention of Jaw Fracture Facilitation of Orthodontic Treatment Optimal Periodontal Healing

12 Prevention of Periodontal Disease

13 Prevention of Dental Caries

14 Prevention of Pericoronitis
Pericoronitis: Infection of the soft tissue (operculum) around the crown of a partially impacted tooth and its usually caused by normal oral flora

15 Trauma → swelling→ more trauma→ more swelling
Pericoronitis causes If the host defenses are compromised (e.g., during minor illness, such as influenza or upper respiratory infection, or immune-compromising drugs) Minor trauma from maxillary third molar Trauma → swelling→ more trauma→ more swelling Food entrapment under the operculum Streptococci and a large variety of anaerobic bacteria causes pericoronitis (present normally in the gingiva)

16 Treatment Depending on the severity of the infection: Mild infection:
Mechanical debridement of the large periodontal pocket under the operculum, using Hydrogen Peroxide, chlorhexidine, iodophors, and normal saline. Hydrogen Peroxide: Mechanically removes bacteria with its foaming action Release oxygen into the usually anaerobic environment reducing their number

17 Treatment Chlorhexidine or Iodophors: Reduce the bacterial count of the pocket Normal Saline: If delivered under pressure it can reduce the bacterial number, and flush away food debris

18 Treatment Slightly more severe infection:
Large amount of local soft tissue swelling, being traumatized by the maxillary third molar. Management: Local irrigation Dentist should consider immediately extracting the maxillary third molar

19 Management More sever infection:
Patient with swelling, pain, and mild facial swelling Mild trismus ?? Low grade fever Management: Local irrigation under pressure Extraction of opposing tooth Administration of Antibiotics (Penicillin, clindamycin in case of allergy)

20 Management Severe infection:
Involve facial spaces of the mandibular ramus and the lateral neck Trismus (less than 20mm) Temperature (greater than 101.2°F) Pain and malaise Management: Refer the patient to OMFS Patient hospital admission I.V antibiotics and fluids administration Careful monitoring

21 General Rules Patient who develops one episode of pericoronits, is more likely to have another episode, unless the offending tooth is removed The mandibular third molar should not be removed UNTIL the signs and symptoms of pericoronitis have completely resolved If removed during active infection phase (The incident of postoperative complications increase): Dry socket postoperative infection Bleeding Slower healing

22 Prevention Removal of the third molar before they penetrate the soft tissue into the oral cavity Operculectomy painful usually ineffective recurs The distal gingival pocket remains deep

23 Prevention of Root Resorption

24 Root Resorption??

25 Impacted Teeth Under a Dental Prosthesis
Slow alveolar bone resorption usually follow extraction, resulting in closer tooth to the bone Overlying soft tissue ulceration Initiation of odontogenic infection Alteration of the alveolar ridge with extraction after bridge construction Avoid removing it late at an older age (poor health, atrophic mandible)

26 Prevention of Odontogenic Cysts and Tumors
Dental follicle → Cystic Degeneration→ Dentigerous Cyst or Keratocyst Epithelium within Dental Follicle → Odontogenic Tumors (Ameloblastoma)

27 Treatment of Pain of Unexpected Origin
Unexplained Pain at retromolar region Exclude myofascial pain dysfunction syndrome and other facial pain disorders Resolution of the pain sometimes result from the wisdom tooth removal

28 Prevention of Jaw Fracture

29 Facilitation of Orthodontic Treatment
Allows premolars retraction Retromolar implants placement

30 Optimal Periodontal Healing
Two most important factors: Extent of preoperative infrabony defect on the distal aspect of the second molar. Patients age

31 Contraindications for Removal of Impacted Teeth

32 Contraindications for Removal of Impacted Teeth
When the risks are greater than the potential benefits, the procedure should be Deferred Contraindications primarily involve the patient’s physical status

33 Contraindications for Removal of Impacted Teeth
Extremes of Age Compromised Medical Status Probable Excessive Damage to Adjacent Structures

34 Extreme of Age Young Age:
Third molar tooth bud can be radiographically visualized by age 6 It is not possible to predict accurately if the forming third molar will be impacted Removal should be deferred until an accurate diagnosis of impaction can be made

35 Most common contraindication of impaction removal
Extreme of Age Old Age Most common contraindication of impaction removal As patient age: Bone becomes highly calcified, therefore, less flexible and less likely to bend under extraction force More possible postoperative complications and sequelae Absence of periodontal disease, caries, or cystic degeneration at that age (over 35), makes it unlikely to develop at that age But should be followed every 1-2 years

36 Compromised Medical Status
Usually go hand in hand with advanced age If the cardiovascular or respiratory function or host defenses for combating infection are seriously compromised or the patient has a serious acquired or congenital coagulopathy The surgeon should consider leaving the tooth UNLESS symptomatic Should consider working with the patient’s physician for proper planning

37 Probable Excessive Damage to Adjacent Structures
Nerve, teeth, previously constructed bridge. Have to look at the age of the patient too, and Reason should be weighed against potential future complications

38 Case Older patient with a sever periodontal defect on the distal aspect of the second molar, but its removal will surely result in the loss of the second molar What should you do?

39 Summary Patients with one or more pathologic symptoms or problems should have their impacted teeth removed Most problems result from partially erupted teeth and less commonly with complete bony impaction Less clear is what should be done with impacted teeth before they cause symptoms or problems How to make a decision?

40 Factors to be considered
Available space in the arch into which the tooth will erupt. The status of the impacted tooth and the age of the patient Mesioangular third molar in 17 years old? By the age of 18 the dentist should be able to predict whether there will be adequate room for the third molar to erupt

41 Reference: Contemporary Oral and Maxillofacial Surgery, 5th Edition James R. Hupp, Edward Ellis III, Myron R. Tucker Chapter 9, Principles of Management of Impacted Teeth

42 March, 2, 2013: Clinical Cases (Quiz) March, 9, 2013: Quiz (written)

Download ppt "Management of Impacted Teeth Part I"

Similar presentations

Ads by Google