Differences in surgery regarding age

DIFFERENCES IN SURGERY REGARDING AGE

16-25 y/o > 30 y/o

Periodontal Healing Bone Epithelial attachments

goodbone growth possiblereadily established

limitedbone resorption likelypoor; positions apically

Surgical difficulty Bone Periodontal ligament Follicle Teeth

easypliable, little removedwide, supplelargenormal, little sectioning

tough!!!rigid, much removal requiredabsent, rigid or ankylosedsmall or absentbrittle, much sectioning

Patient health usually excellent systemic disease common

Surgical morbidity little with fast recovery great with slow recover

Complication Surgical Anesthetic

fewfew

many, often seriousgreater, potentially serious

Lecture 2

Objective is to familiarize and help understand Classification of third molar Assess degree of difficulty while

performing the procedure

Predicting Difficulty Accessibility (Risk evaluation factors)

Radiographic evaluation Location of the IAN Third molar position-Angulation Bone mass density

Clinical evaluation Age Obesity Large tongue Dilacerated roots Strong gag reflex Complaining patient Surgical access space Interincisal opening

Ideal time for extraction of Impacted teeth Average age: 20years Ideal time for extraction

When the roots are 1/3 formed and before they reach 2/3 formation

Early removal Low morbidity Tolerate procedure better Quick recovery

Classification Winter 1926 Based on the position of their long axis in

relation to the long axis of the second molars Angulation and Position

Vertical Mesioangular Horizontal Distoangular Buccoangular Lingoangular Inverted Unusual

Angulation- Mesioangular

When the third molar is titled towards the second molar in a mesial direction

Most common 43% of impacted teeth

Angulation- Vertical

Long axis of the third molar runs parallel to the second molar

Second largest frequency-38%

Angulation- Horizontal

Long axis of the third molar perpendicular to the second molar

More difficult to remove 3% of all mandibular impactions

Angulation- Distoangular

Long axis of the third molar is distally or posteriorly angled away from the second molar

Most difficult-(runs into the ramus of the mandible)

Comprehensive classification Based on Pell and Gregory and includes

a portion of George B. Winter’s classification is most comprehensive: A. Relation of the tooth to the ramus of the

mandible and the second molar (class I,II,III) B. Relative Depth of the third molar in bone

(Position A, B,C) C. The position of the long axis of the

impacted Mandibular third molar in relation to the long axis of the second molar (from Winter’s classification)

Relation of the tooth to the ramus of the mandible and the second molar

Class I : There is sufficient space between the ramus and the distal side of the second molar for accommodation of mesiodistal diameter of the crown of the third molar

Class II

The space between the ramus and distal side of the second molar is less than the mesiodistal diameter of crown of the second molar

Class III

Class III : All or most of the third molar is located within the ramus

Relative Depth of the third molar in Bone

Position A: The highest portion of the tooth is on a level with or above the occlusal line

Relative Depth of the third molar in Bone

Position B: The highest portion of the tooth is below the occlusal plane, but above the cervical line of the second molar

Relative Depth of the third molar in Bone

Position C: The highest portion of the tooth is below the cervical line of the second molar

Mesioangular Class I ramus Position A

Horizontal Impaction- Class II Position B

Vertical Impaction-Class II Position C

Difficulty index

Other difficulty factors Root Morphology

Length Conical or fused roots Divergent Curvature

Direction Number Width Periodontal ligament space

Size of the follicular sac

Wide- (almost cystic) Extraction is easier Less bone removal Younger patients

No Space Difficult extraction More bone removal Older patients

Density of Bone Age determining factor 17-25years favorable for extraction

Less dense More pliable, Expands easily Easy to cut with a dental bur

>35years unfavorable for extraction More dense Decreased flexibility, does not expand Difficult to cut with a dental bur

Other factors of difficulty

Relationship with IA nerve Close proximity

with the roots Damage Parasthesia or

anesthesia of the lower lip and chin on the affected side

Other factors of difficulty

Contact with Mandibular second molar

Cautious with Horizontal and distoangular extraction

Safe application of elevators

Check for large restorations, crowns, endodontic treatment on second molars

Nature of Overlying Tissue

Soft tissue impacted Height of the contour of the tooth is

above the level of the alveolar bone and the superficial part of the tooth is covered with soft tissue

Nature of Overlying Tissue

Partial bony impacted Superficial portion of the tooth is

covered by soft tissue but at least a portion of the height of contour of tooth is below the level of the alveolar bone.

Nature of Overlying Tissue

Full bony impacted Completely encased in the bone.

Pell and Gregory class A, B, C

Erupted-Soft tissue impacted

Partial Bony

Full Bony

Why is Buccal position easy

Accessibility-Good Accessibility-Better

instrumentation Overlying Bone Lower surgical morbidity

Why is Palatal impaction difficult ?

Accessibility-Poor Accessibility-Poor instrumentation More bone removal High surgical morbidity

Difficulty factors specific to Impacted Maxillary 3rd Molars Maxillary Sinus

Roots are in intimate contact Tooth may form the posterior wall of sinus

Sinusitis Oroantral communication

Maxillary tuberosity fracture Dense, non elastic bone Large maxillary sinus Divergent roots Mesioangular impactions Excessive force

Impacted Maxillary Cuspids

Positioning in the alveolar process Labial Palatal Middle

Impacted Maxillary Cuspids –

Degree of Difficulty Based on determination of position

Labial (easy) Palatal (difficult)/Middle (difficult)

Potential damage to adjacent teeth Potential Periodontal deficits due to bone

removal

Impacted Maxillary Cuspids

Treatment Options Wait and watch Surgical extraction Surgical exposure with Orthodontic

movement in Arch

Factors that make impaction more difficult

Factors that make impaction surgery less difficult

Thank you!!

Have a Great weekend!