IMPACTION

BY
T.SUBBA RAJU
IIND YEAR
POST GRADUATE
DEFINITION
 Impaction is any tooth that is prevented
from reaching its normal position in mouth
by tissue or bone or another tooth.
- WHO

 A tooth that is completely or partially

unerupted and is positioned against another
tooth / bone / soft tissue, so that its further
eruption is unlikely, described according to
its anatomical position.
- ARCHER’s
THEORIES OF IMPACTION

i) Nature & Nurture theory – John Hunter

1771
ii) Mendelian theory.
iii) Anthropological theory. – Begg & Kesling
1971
iv) Endocrine theory.
v) Orthodontic theory.
vi) Growth studies. – Bjork, Richardson &
Broadbent.
ETIOLOGY
BERGER’S CLASSIFICATION
I. Systemic causes:
a) Prenatal.
b) Postnatal.
c) Skeletal disturbances.

II. Local causes:

a) Irregularity in position.
b) Increased density of bone.
c) Increased density of mucosa.
d) Jaw size discrepancy.
 e) Premature loss of retained deciduous teeth.
f) Infection in bone or systemic causes.
ETIOLOGY

III. OTHER CAUSES

a) Dilaceration
b) Any obstruction- retained, odontome, cyst ,tumor
ORDER OF FREQUENCY :
Archer
 Mandibular third molars
 Maxillary third molars
 Maxillary canines
 Mandibular premolar
 Mandibular canines
 Maxillary premolar
 Maxillary central incisors
 Maxillary lateral incisors
 Supernumerary teeth
MANDIBULAR 3RD MOLAR
CLASSIFICATION OF IMPACTED MANDIBULAR 3rd MOLAR

GEORGE WINTER’S CLASSIFICATION

1.MESIOANGULAR 11.DISTOANGULAR 111.VERTICAL
1V. HORIZONTAL V. BUCCOVERSION VI. LINGUOVERSION
VIII. INVERTED
 WINTER’S SUB-CLASSES :-

Angle between the longitudinal axis of 3rd molar and occlusal plane.

ANGLE TOOTH

- ve or 0o Inverted

0o to 30o Horizontal

31o to 60o Mesio-angular

61o to 90o Vertical

>90o Disto-angular
PELL AND GREGORY’S CLASSIFICATION (1933)

I) Skeletal anatomic space between posterior aspect of 2nd

molar and anterior border of ramus of mandible

CLASS I CLASS II

CLASS III
II) Relative depth of 3rd molar in bone –

POSITION - A POSITION - B

POSITION - C
COMBINED ADA AND AAOMS CLASSIFICATION : - Alling

Based on the operation performed to remove impacted teeth.

I) D7220 – (Soft tissue impaction)

II) D7230 - (Partially bony impaction)
III) D7240 – (Complete bony impaction)
IV) D7241 – (Complete bony impaction with surgical difficulties )

OMFSCNA FEB 2007

PETER TETSCH & WILFRIED WAGNER’S
CLASSIFICATION
i) Vertical retention
ii) Horizontal retention
◦ a) Sagittal – Mesio-angular, Disto-angular
◦ b) Transverse – Buccoversion, Linguoversion.
iii) Inclined retention
 THIRD MOLAR CLASSIFICATION ON OPG:-

LINE –I : Line of the Occlusal plane

LINE-II : Class A,B,C as per the PELL & GREGORY classification
LINE-III : Class- I, II, III as per the PELL & GREGORY
classification
LINE-IV: Winter’s classification sub - classes
 RADIOGRAPHS NEEDED:
Orthopantomographs
PRE-OPERATIVE ASSESSMENT


 Intra oral periapical view.
 Occlusal view.
 Special technique.
 Cone shift or tube shift.
 WINTER’S LINES (WAR lines)
RADIOLOGICAL ASSESMENT IOPA & OPG

I. White line.
II. Amber line.
III. Red line
RADIOLOGICAL ASSESMENT IOPA & OPG
WINTER’S LINES
 ANDERSON’S DIFFICULTY SCORE INDEX :-
CRITERIA SCORE
 PELL & GREGORY
Class I 1
Class II 2
Class III 3
Position A 1
Position B 2
Position C 3
 WINTER
Mesio-angular 1
Horizontal 2
Vertical 3
Disto-angular 4
INTERPRETATION :

 Relatively Easy – 3 to 5

 Moderate – 6 to 8

 Difficult – 8 to 10.
WHARFE’S ASSESSMENT

CATEGORY SCORE
1. Winter’s classification
Horizontal 2
Disto-angular 2
Mesio-angular 1
Vertical 0
2. Height of mandible
1 – 30mm 0
31 – 34mm 1
35 – 39mm 2
3. Angulation of 3rd molar.
1o to 50o 0
60o to 69o 1
70o to 79o 2
80o to 89o 3
90o + 4
 4. Root shape
a) < 1/3rd complete 2
WHARFE’S ASSESSMENT
b) 1/3rd to 2/3rd complete 1
c) > 2/3rd complete
i) Complex 3
ii) UnFavourable curvature 2
iii) Favourable curvature 1
5. Follicles
Normal 0
Possibly enlarged -1
Enlarged -2
Impaction relieved -3

6. Path of exit
Space available 0
Distal cusps 1
Mesial cusps covered 2
Both the covered 3

Total 33
 ROOT PATTERN
 Converging roots – easy to remove.
RADIOLOGICAL ASSESMENT IOPA& OPG

 Divergent roots – difficult to remove.

 Bulkier roots or dilacerated roots – difficult to remove.
 Tooth 1/3rd to 2/3rd development – easier to remove than
fully formed root.
 Limited root formation – difficult to remove as the follicle
keeps rolling.
 Roots with mesio-distal diameter that is greater than at
the cervical line must be sectioned longitudinally
TEXTURE OF INVESTING BONE :
 Bone tends to become sclerosis and less elastic as age
advances.
 Bone is elastic and cancellous in younger.
 Dense and sclerosed in aged.
 If the trabecular spaces of bone are large and bone
structure is fine, then it seem to be elastic.
 If the trabecular spaces are small and the bone shadow is
dense, then the bone is sclerotic and brittle.
 INDICATIONS FOR
IMPACTED TOOTH REMOVAL
 Recurrent Pericoronitis – most commonest indication
 Dental caries
 Food impaction
 TMJ disorders
 Preventive dentistry
 Nonspecific pain
 Foci of infection
 Trauma
 Orthodontic consideration
 Prior to Orthognathic surgeries.
 Prosthetic consideration
 Pathology.
 Prophylactic removal.
CONTRAINDICATIONS FOR TOOTH REMOVAL

Extremes of age.
Compromised medical status.
Probable extensive damage to adjacent structures

SURGICAL STEPS

1. Aseptic environment
2. Regional anesthesia
3. Access.
4. Incisions
5. Elevation of soft tissue
6. Retraction of soft tissue
7. Operations on osseous tissue
8. Sectioning
9. Removal of tooth
10. Surgical closure
METHOD OF REMOVAL
I. Conventional method –
a) Forceps technique – Wedge, lever and
fulcrum, wheel and axle.
b) Elevator technique
c) Combination of both.
II. Open method / Transalveolar extraction –
a) Odontectomy – by removal of bone
b) Odontotomy.- by division of tooth.
PRINCIPLES OF INCISIONS

1. Incision is made with sharp blade .B.P blade No.15, handle

No.3 or No. 4
2. Continuous in one stroke & deep to bone
3. Incision is made at right angle to the epithelial surface
4. Care for vital structures
5. Full thickness mucoperiosteal flap
6. Base flap must be broad
7. Length of flap should not exceed base
8. Line of closure should rest on sound bone & not on deep
surface.
9. Either include or exclude the papilla
10. Avoid sharp corners in the flap.
 L – SHAPED FLAP OR 2ND MOLAR PARA-
MARGINAL FLAP WITH VESTIBULAR
EXTENSION
INCISION AND FLAP ELEVATION

 Advantage : prevent the formation of periodontal pocket.

 Modifications –
 Shift the distal incision away from the distobuccal aspect of
2nd molar
 Shifting the junction of both limbs from the distobuccal region of 2nd molar to
midpoint of distal region or even to shift lingually
 BAYONET – SHAPED FLAP
ADVANTAGE :
INCISION AND FLAP ELEVATION

- Good blood supply to the flap due to broad base.

- It can be comfortably used for partially erupted tooth
 ENVELOPE FLAP
INDICATIONS:
-For mesioangular impacted teeth, superficial impactions.
INCISION AND FLAP ELEVATION

-For distoangular teeth, length of the incision is 3/4th inch.

Schow (1970) – identified that any incision or flap extended

beyond the external oblique ridge will have high chances of
dry socket formation.
 MODIFIED ENVELOPE FLAP:
- The deeper the tooth, the more anteriorly the sulcular incision
given.
- Indicated for better visibility and lingually inclined 3rd molar
INCISION AND FLAP ELEVATION

LINGUAL FLAP :

- Used with the lingual approach.

- The incision starts on ascending ramus aiming at the disto-buccal
corner of 2nd molar follows the distal surface of 2nd molar as a
sulcular incision and then continues lingually to the first molar.

- A sulcular incision is also made along the buccal aspect of 2nd

molar.

- Disadvantage:- Lingual nerve injury.

 TERENCE WARD’S INCISION :-
- Used for superficial impactions.
- The vertical anterior releasing incision is
INCISION AND FLAP ELEVATION

placed at the gingival related to the disto-

buccal line angle of 2nd molar 1/3rd the
way into papilla.
- Followed by gingival crevicular incision.
- Followed by the posterior distal incision
of 3/4th inch or 2cms, angulated from the
middle of the distal surface of 2nd molar
laterally towards the external oblique
ridge.
 MODIFIED TERENCE WARD’S INCISION :-
Indications:
- Used for deep impactions.
- The vertical releasing incision starts at the mesio-buccal line
angle about 1/3rd the way into papilla of 2nd molar .
- Followed by gingival crevicular incision.
INCISION AND FLAP ELEVATION

Caution:
- Followed by distal limb of 3/4th inch extending laterally towards
the external oblique ridge to:
a) To avoid injury to the Lingual nerve.
b) To avoid injury to the nutrient vessels.
c) To avoid the damage to temporalis muscle thereby prevention
of trismus
d) To avoid the buccal pad fat to be encountered
e) Distal incision should not be extended too posteriorly
so as to prevent the damage to lingual and facial artery.
INCISION AND FLAP ELEVATION

TERENCE WARD’S INCISION & MODIFIED WARD’S INCISION

 Depends on:
BONE AND TOOTH REMOVAL

 Shape of the tooth.

 Position of tooth.
 Shape of surrounding bone.
 Age of the patient.
A) MOORE AND GILBE COLLAR TECHNIQUE
B) CHISEL TECHNIQUE
 CRITERIA CHISEL AND MALLET BUR
1. Technique Difficult Easy
2. Patient’s acceptance Not well tolerated Tolerated well
under local anesthesia. Under local anesthesia
3. Chance of fracture of bone Relatively high Less possibility.
4. Healing of bone Good Delayed due to over heating
and inefficient cooling
5. Postoperative edema Less More
6. Dry socket Incidence is less Very high
7. Postoperative infection Less More
8. Advantage/ Disadvantage Difficult to remove Relatively easy to remove
deeply buried impactions; deeply buried impactions;
impacted in edentulous impactions in edentulous
jaws and in elderly patients. jaws and in elderly patients.
REMOVAL OF HORIZONTAL IMPACTION
 REMOVAL OF
DISTOANGULAR IMPACTION
 REMOVAL OF
MESIOANGULAR IMPACTION
 ADVANTAGES OF THE TOOTH- DIVISION TECHNIQUE –

Decrease damage to adjacent teeth.

Decrease bone removal results in decrease postoperative

swelling and pain

Decreased fracture of mandible.

Danger of lingual nerve injury and inferior alveolar nerve

injury is decreased because of leverage forcing apex of
the tooth down into the canal.
-Indicated unerupted 3rd molar in the age group 9 to 16 years.
- Modified S- shaped incision is made from retromolar fossa across the
external oblique ridge. It then curves down along the reflection of the
mucous membrane above the vestibule, extending upto the 1st molar
anteriorly.
- Such an incision leaves behind 5mm cuff of attached mucosa at the
distobuccal region of 2nd molar.
- The buccal cortical plate is trephined over the 3rd molar crypt.
 LINGUAL SPLIT BONE TECHNIQUE
Sir William Kelsey Fry 1933

-Introduced by Kelsey Fry and popularized by Terence Ward.

- Indicated in the removal of impacted molars that are placed lingually
Advantages :-
 Faster tooth removal
 Less risk of inferior alveolar nerve damage.
 Lessened risk of damage to the periodontium of the 2nd molar.
 Lessened risk of socket healing problems.
Disadvantages :-
 Risk of damage to lingual nerve.
 Increased risk of post-operative infection and greater danger of spread.
 Patient’s discomfort due to use of chisel and mallet for lingual bone
removal or fracture of the jaw.
IMPACTED MAXILLARY 3RD
MOLAR
CLASSIFICATION OF IMPACTED
MAXILLARY 3RD MOLAR – by Archer
(1975)

VERTICAL DISTOANGULAR MESIOANGULAR

CLASS – A CLASS – B CLASS - C

Relationship of the impacted maxillary
3rd molar to the maxillary sinus :-
a) Sinus approximation (SA) - No bone or thin
partition of bone between the impacted
3rd molar and the maxillary sinus.
b) No Sinus approximation (NSA) - 2mm or
more of bone between maxillary 3rd molar
and the maxillary sinus.
INCISION & FLAP ELEVATION
IMPACTED MAXILLARY CANINE
Etiology :-

Space loss.
Ectopic eruption of the tooth germ.
Delayed resorption of primary canine.
Hereditary cause.
 Cleft lip and cleft palate deformity
 CLASSIFICATION OF IMPACTED CANINE – by Field
IMPACTED MANDIBULAR CANINE & Ackerman (1935)

I. Maxillary canines :
1. Labial position :
a. Crown in intimate relationship with the incisors
b. Crown well above the apices of incisors

2. Palatal position :
a. Crown in intimate relationship with the incisors
b. Crown deeply embeded above the apices of incisors

3. Intermediate position :
a. crown between lateral incisor and first premolar roots
b. crown above these teeth with crown labially placed and root
palatally placed or vice versa

4. Unusual position :
a. In nasal or antral wall
b. In infra-orbital rim
IMPACTED MANDIBULAR CANINE

II. Mandibular canines :

1. Labial position : a.Vertical

b. Oblique
c. Horizontal

2. Unusual position :
a. At inferior border
b. In mental protruberance
c. Migrated to
opposite side
 CLASSIFICATION BY PELL & GREGORY :-

CLASS –I : Impacted cuspids located in palate

a) Horizontal.
b) Vertical.
IMPACTED CANINE

c) Semi-vertical.

CLASS-II:- Impacted cuspids located in labial or buccal suface of

maxilla.
a) Horizontal.
b) Vertical.
c) Semi-vertical.

CLASS-III:- Impacted cuspids located in both the palate and buccal

side.
a) Crown in palate and root in buccal side.
b) Crown in buccal and root in palate.
CLASS-IV:- Impacted cuspids located in alveolar process usually
vertically between the incisors and 1st bicuspids.

CLASS- V:- Impacted cuspids located in an edentulous maxilla.

CLASS- VI:- When the impacted canines are positioned abnormally

like maxillary antral wall or infraorbital position
IMPACTED MAXILLARYCANINE
IMPACTED MANDIBULAR CANINE
IMPACTED MANDIBULAR PREMOLAR
COMPLICATIONS DURING SURGERY

Dental complications.
Soft tissue complications.
Bone complications.
Nerve complications.
Instrument breakage
 DENTAL COMPLICATIONS
i)Extraction of wrong tooth.
ii) Fracture of crown of teeth
- Gross caries.
- Excessive force.
- Endodontically treated teeth.
iii) Damage to the root of teeth
- Abnormal root morphology.
- Unmonitored bone removal.
iv) Displacement of tooth or tooth fragment
- Lingually – sublingual or submandibular space.
- Posteriorly – Lateral pharyngeal space.
- Inferiorly – Inferior alveolar canal.
- Into maxillary sinus.
v) Swallowing or aspiration of teeth
SOFT TISSUE COMPLICATIONS
i) Trauma or flap tear
ii) Hemorrhage:
a) Primary
b) Secondary
c) Teritiary
iii) Prolapse of buccal pad of fat.
iv) Surgical emphysema.
v) Trismus
BONE COMPLICATIONS
i) Hemorrhage.
ii) Fracture of alveolar process mandible or
maxilla.
iii) TMJ dislocation.
iv) Oro antral fistula
v) Post operative infections
vi) Alveolar osteitis
vii) Bone necrosis.
NERVE AND VESSEL COMPLICATIONS
i) Inferior alveolar nerve damage.
ii) Lingual nerve damage.
iii) Mylohyoid nerve damage.
iv) Facial artery.
v) Internal maxillary artery.
vi) Greater palatine artery.
REFERENCES
TEXT BOOKS
 KILLEY & KAY’S OUTLINE OF ORAL SURGERY – VOLUME I
 TEXTBOOK OF ORAL & MAXILLOFACIAL SURGERY – DANIEL LASKIN VOLUME II.
 ORAL & MAXILLOFACIAL SURGERY- VOLUME 1 –W.HARRY ARCHER
 COMPLICATIONS OF ORAL & MAXILLOFACIAL SURGERY – KABAN & PERROTT.
 SURGERY FOR IMPACTED TEETH – ALLING & ALLING
 MINOR ORAL SURGERY – GEOFFREY L. HOWE
 IMPACTED TEETH – KILLEY & KAY.
 PRINCIPLES OF OMFS – VOLUME – I – PETERSON
 CONTEMPORARY ORAL AND MAXILLOFACIAL SURGERY – LARRY.J.PETERSON.
 TEXT BOOK OF OMFS – B.SRINIVASAN.
 TEXT BOOK OF OMFS – S.M.BALAJI
 TEXT BOOK OF OMFS – NEELIMA. ANIL. MALIK.
JOURNALS
 BRITISH JOURNAL OF ORAL & MAXILLOFACIAL SURGERY
 INTERNATIONAL JOURNAL OR ORAL & MAXILLOFACIAL SURGEONS
 ORAL & MAXILLOFACIAL SURGERY CLINICS OF NORTH AMERICA, MAY 2003.
 ORAL & MAXILLOFACIAL SURGERY CLINICS OF NORTH AMERICA, FEB 2007.N
 ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ENDODONTOLOGY
 JOURNAL OF ORAL & MAXILLOFACIAL SURGERY