impaction assessment

Management of Impacted Management of Impacted Lower Third Molar TeethLower Third Molar Teeth

Diagnosis & Assessment

BYBY

Associate Prof. Hamed OrafiAssociate Prof. Hamed Orafi

BDS, MDS, FICD,AAOMFSBDS, MDS, FICD,AAOMFS

Dr Hamed Orafi

A Third Molar Tooth That Cannot Or Will A Third Molar Tooth That Cannot Or Will

Not Erupt Into Its Normal Functional Not Erupt Into Its Normal Functional

Position.Position.

There Is Potentially Risk Of Development There Is Potentially Risk Of Development

Of Irreversible Hard And Soft Tissue Of Irreversible Hard And Soft Tissue

Pathological Condition In Un Treated Pathological Condition In Un Treated

Cases.Cases.

DefinitionDefinition

Dr Hamed Orafi

DefinitionDefinition

Dr Hamed Orafi

Indications for RemovalIndications for Removal

Dr Hamed Orafi

Indications For RemovalIndications For Removal Caries Leading to Pulpal ExposureCaries Leading to Pulpal Exposure

Dr Hamed Orafi

Indications For RemovalIndications For Removal Periapical PathologyPeriapical Pathology

Dr Hamed Orafi

Indications For RemovalIndications For Removal Periodontal DiseasePeriodontal Disease

Dr Hamed Orafi

IndicationsIndications ForFor RemovalRemoval Fractured ToothFractured Tooth

Dr Hamed Orafi

IndicationsIndications ForFor RemovalRemoval Previous History Of Infection Previous History Of Infection

Including Pericoronitis/Abscess Including Pericoronitis/Abscess Development And OsteomyelitisDevelopment And Osteomyelitis

Dr Hamed Orafi

IndicationsIndications ForFor RemovalRemoval ResorptionResorption of Adjacent Teeth of Adjacent Teeth

Dr Hamed Orafi

IndicationsIndications ForFor RemovalRemoval Disease Of Follicle Including Disease Of Follicle Including

Cyst / TumorCyst / Tumor

Dr Hamed Orafi

IndicationsIndications ForFor RemovalRemoval Tooth In Line Of Bony FractureTooth In Line Of Bony Fracture

Dr Hamed Orafi

IndicationsIndications ForFor RemovalRemoval Malpositioned , Non-functional or Malpositioned , Non-functional or Unrestorable Tooth Susceptible To Unrestorable Tooth Susceptible To

DiseaseDisease

Dr Hamed Orafi

Indications For RemovalIndications For Removal Facilitation of Fracture Treatment or Facilitation of Fracture Treatment or

Orthognathic SurgeryOrthognathic Surgery..

Dr Hamed Orafi

Indications of RemovalIndications of Removal

Others.Others. Facilitation Of Restorative Treatment Facilitation Of Restorative Treatment

Including Prostheses.Including Prostheses. Obscure Facial Pain.Obscure Facial Pain. Prophylactic Removal In Presence Of Specific Prophylactic Removal In Presence Of Specific

Medical And Surgical Conditions (e.g. Medical And Surgical Conditions (e.g. Bacterial Endocarditis).Bacterial Endocarditis).

Orthodontic Abnormalities Including Arch Orthodontic Abnormalities Including Arch Length/Tooth Discrepancies And AnkylosisLength/Tooth Discrepancies And Ankylosis..

Dr Hamed Orafi

Aims of TreatmentAims of Treatment

Dr Hamed Orafi

To Produce Positive To Produce Positive

Health Gain And / Or Health Gain And / Or

Benefit In The Form Of:Benefit In The Form Of: Pain Relief.Pain Relief.

Treatment Of Acute And Treatment Of Acute And

Chronic Infection.Chronic Infection.

Prophylaxis Of Infection.Prophylaxis Of Infection.


Dr Hamed Orafi

Improvement In Restorative Rehabilitation.Improvement In Restorative Rehabilitation.

Improvement In The Potential For Successful Improvement In The Potential For Successful

Trauma Surgery Including The Healing Of Trauma Surgery Including The Healing Of

Bony Fractures.Bony Fractures.

Improvement In The Potential For Improvement In The Potential For

Orthodontic Treatment.Orthodontic Treatment.


Dr Hamed Orafi


Reduce Potential For Complications Reduce Potential For Complications

Resulting From Radiotherapy Or Resulting From Radiotherapy Or

Transplantation Surgery.Transplantation Surgery.

Improve Potential For Orthognathic Improve Potential For Orthognathic

Surgery Including Osteosynthesis.Surgery Including Osteosynthesis.

Dr Hamed Orafi

Factors Affecting the Factors Affecting the Management Management

General FactorsGeneral Factors

Factors Related To The Oral Cavity Factors Related To The Oral Cavity

Impacted Tooth Structure And MorphologyImpacted Tooth Structure And Morphology

Dr Hamed Orafi

General FactorsGeneral Factors

Age Of The Patient.Age Of The Patient.

Previous Medical History.Previous Medical History.

History Of Allergy.History Of Allergy.

Presence Of Any Underlying Disease.Presence Of Any Underlying Disease.

History Of Drug Therapy , e.g. Aspirin.History Of Drug Therapy , e.g. Aspirin.

Patient Cooperation And Compliance Patient Cooperation And Compliance

Dr Hamed Orafi

Local FactorsLocal FactorsRelated To Oral CavityRelated To Oral Cavity

Access Size Of Mouth Opening And Size Of Access Size Of Mouth Opening And Size Of The Tongue.The Tongue.

Oral Hygiene.Oral Hygiene. Condition Of The Soft Tissue And External Condition Of The Soft Tissue And External

Oblique Ridge.Oblique Ridge. Presence Or Absence Of Acute Or Chronic Presence Or Absence Of Acute Or Chronic

Infection.Infection. Status Of Adjacent Teeth ( e.g. Periodontal Status Of Adjacent Teeth ( e.g. Periodontal

Disease Or Presence Of Restoration Or Disease Or Presence Of Restoration Or Function As Bridge Abutment).Function As Bridge Abutment).

Dr Hamed Orafi

Associated Fracture Of Maxilla / Mandible.Associated Fracture Of Maxilla / Mandible. Previous Radiotherapy.Previous Radiotherapy. Bone Density.Bone Density. Bulk Of Mandible Presence Or Absence Of Other Bulk Of Mandible Presence Or Absence Of Other

Local Bone Or Soft Tissue Disease (e.g. Paget's Local Bone Or Soft Tissue Disease (e.g. Paget's Disease , Vascular Malformations , Post-radiation Disease , Vascular Malformations , Post-radiation Vascular Sclerosis).Vascular Sclerosis).

Presence Or Absence Of Associated Disease (e.g. Presence Or Absence Of Associated Disease (e.g. Cysts / Neoplasia).Cysts / Neoplasia).

Local FactorsLocal FactorsRelated To Oral CavityRelated To Oral Cavity

Dr Hamed Orafi

Presence Or Absence Of Associated Presence Or Absence Of Associated Disease Disease

(e.g. Cysts Or Neoplasia).(e.g. Cysts Or Neoplasia).

Dr Hamed Orafi

Presence Or Absence Of Other Local Presence Or Absence Of Other Local Bone Or Soft Tissue Disease Bone Or Soft Tissue Disease (e.g. Vascular Malformations)(e.g. Vascular Malformations)

Dr Hamed Orafi

Presence Or Absence Of Acute Or Presence Or Absence Of Acute Or Chronic Infection.Chronic Infection.

Dr Hamed Orafi

Bulk Of Mandible.Bulk Of Mandible.

Dr Hamed Orafi

Associated Fracture Of Mandible.Associated Fracture Of Mandible.

Dr Hamed Orafi

Status Of Adjacent Teeth ( Presence Of Status Of Adjacent Teeth ( Presence Of Restoration , Function As Bridge Restoration , Function As Bridge

Abutment).Abutment).

Dr Hamed Orafi

Tooth Structure And MorphologyTooth Structure And Morphology

Local Anatomy (Neighboring Structure) e.g. Local Anatomy (Neighboring Structure) e.g.

Inferior Alveolar Never, Inferior Alveolar Never,

Root Morphology.Root Morphology.

Associated Ankylosis.Associated Ankylosis.

Anatomical Position.Anatomical Position.

Dr Hamed Orafi

Anatomy Of Adjacent Important Anatomy Of Adjacent Important Structure Structure e.g.e.g. Inferior Alveolar Inferior Alveolar

Nerve .Nerve .

Dr Hamed Orafi

Relation To The Inferior Dental Canal

Dr Hamed Orafi

Associated Ankylosis.Associated Ankylosis.

Dr Hamed Orafi

Root Morphology.Root Morphology.

Dr Hamed Orafi

Anatomical PositionAnatomical Position Classification Of Impacted Classification Of Impacted

Mandibular Third MolarMandibular Third Molar::

Pell And Gregory Classification.Pell And Gregory Classification.George B. WinterGeorge B. Winter’’s Classification.s Classification.

Dr Hamed Orafi

Pell And Gregory ClassificationPell And Gregory Classification

In Relation Of In Relation Of The Tooth To The Tooth To The Ramus Of The Ramus Of The Mandible The Mandible And The Second And The Second Molar:Molar: Class I.Class I. Class II.Class II. Class III.Class III.

Relative Depth Relative Depth

Of The Third Of The Third

Molar In Bone:Molar In Bone:

Position A.Position A.

Position B.Position B.

Position C.Position C.

Dr Hamed Orafi

Class IClass I

The Available Space , At The Level Of The The Available Space , At The Level Of The Retro Molar Triangle Is Sufficient To Retro Molar Triangle Is Sufficient To Accommodate The Mesiodistal Diameter Of Accommodate The Mesiodistal Diameter Of The Crown Of The Third Molar.The Crown Of The Third Molar.

The Third Molar Will Erupt As Far As The The Third Molar Will Erupt As Far As The Occlusal Plane.Occlusal Plane.Dr Hamed Orafi

Class IIClass II

The Space Between The Ramus And The Distal The Space Between The Ramus And The Distal Side Of The Second Molar Is Less Than The Side Of The Second Molar Is Less Than The Mesiodistal Diameter Of The Crown Of The Third Mesiodistal Diameter Of The Crown Of The Third Molar Molar

The Tooth Will Not Be Able To EruptThe Tooth Will Not Be Able To EruptDr Hamed Orafi

Class IIIClass III

All Or Most Of The Third Molar Is Located Within All Or Most Of The Third Molar Is Located Within The Ramus ,The Crest Of The Ramus Places The Ramus ,The Crest Of The Ramus Places Against The Distal Aspect Of The Second MolarAgainst The Distal Aspect Of The Second Molar

No Space For Eruption Of The Third MolarNo Space For Eruption Of The Third Molar

Dr Hamed Orafi

Position APosition A

The Highest Portion Of The Tooth Is On The Highest Portion Of The Tooth Is On A Level With Or Above The Occlusal LineA Level With Or Above The Occlusal Line

Dr Hamed Orafi

Position BPosition B

The Highist Portion Of The Tooth Is The Highist Portion Of The Tooth Is Below The Occlusal Plane But Above Below The Occlusal Plane But Above The Cervical Line Of Second MolarThe Cervical Line Of Second Molar

Dr Hamed Orafi

Position CPosition C

The Highest Portion Of The Tooth Is Below The Highest Portion Of The Tooth Is Below The Cervical Line Of The Second MolarThe Cervical Line Of The Second Molar

Dr Hamed Orafi

George B. WinterGeorge B. Winter’’s Classifications Classification

According To The Position Of The Long According To The Position Of The Long Axis Of The Impacted Third Molar In Axis Of The Impacted Third Molar In Relation To The Long Axis Of The Second Relation To The Long Axis Of The Second Molar Into:Molar Into:

MesioangularMesioangular DistoangularDistoangular VerticalVertical HorizontalHorizontal

They May Also Occur Simultaneously In They May Also Occur Simultaneously In Buccal VersionBuccal Version Lingual VersionLingual Version

Dr Hamed Orafi

MesioangularMesioangular

The Long Access The Long Access Of The Tooth Of The Tooth Converges Converges Towards The Towards The Long Axis Of The Long Axis Of The Second Molar.Second Molar.

Dr Hamed Orafi


Dr Hamed Orafi

VerticalVertical Vertical The Vertical The

Long Access Of Long Access Of The Impacted The Impacted Tooth Is Parallel Tooth Is Parallel To The Long To The Long Axis Of Second Axis Of Second Molar Tooth.Molar Tooth.

Dr Hamed Orafi

VerticalVertical

Dr Hamed Orafi

DistoangularDistoangular The Long The Long

Access Of The Access Of The Impacted Tooth Impacted Tooth Diverges From Diverges From The Long Axis The Long Axis Of The Second Of The Second Molar.Molar.

Dr Hamed Orafi

DistoangularDistoangular

Dr Hamed Orafi

HorizontalHorizontal The Long The Long

Access Of The Access Of The Impacted Tooth Impacted Tooth Is Is Perpendicular Perpendicular On The Long On The Long Axis Of The Axis Of The Second MolarSecond Molar

Dr Hamed Orafi

Winter ClassificationWinter Classification

To Diagnose Local Factors Causing Difficulty To Diagnose Local Factors Causing Difficulty During Removal Of Impacted Mandibular During Removal Of Impacted Mandibular

Third MolarThird Molar

--Amount Of Bone Removal .Amount Of Bone Removal .

- Application Of Force For Extraction.- Application Of Force For Extraction.

Dr Hamed Orafi

George Winter Determined Three Imaginary George Winter Determined Three Imaginary Lines On The Standard Dental RadiographLines On The Standard Dental Radiograph

White Line.White Line. A Line Drawn Along The Occlusal Surface Of The A Line Drawn Along The Occlusal Surface Of The

Erupted Mandibular Molars And Extended Posteriorly Erupted Mandibular Molars And Extended Posteriorly Over The Third Molar Region.Over The Third Molar Region.

Amber Line.Amber Line. A Line Drawn From Bone Lying Distally To The Third A Line Drawn From Bone Lying Distally To The Third

Molar To The Crest Of The Interdental Septum Molar To The Crest Of The Interdental Septum Between The First And Second Mandibular Molars.Between The First And Second Mandibular Molars.

Red Line.Red Line. Line Used To Measure The Depth At Which The Line Used To Measure The Depth At Which The

Impacted Tooth Lies Within The Mandible, It Is Impacted Tooth Lies Within The Mandible, It Is Perpendicular Dropped From The Amber Line To An Perpendicular Dropped From The Amber Line To An Imaginary Point Of Application of An Elevator. Imaginary Point Of Application of An Elevator.

Dr Hamed Orafi

The Roots Of This Tooth Have The Roots Of This Tooth Have Conflicting Lines Of WithdrawalConflicting Lines Of Withdrawal..

WW = = WWhite Line.hite Line. AA = = AAmber Line.mber Line. RR = = RRed Line.ed Line. XX = = XX Application Application

Point Of The Point Of The Elevator.Elevator.

W

A

R

X

Dr Hamed Orafi


Green Area :Denotes The Amount Of Bone Removal .

P: Denotes Application Of Force.Dr Hamed Orafi


Dr Hamed Orafi

Vertical Vertical

Dr Hamed Orafi

VerticalVertical

Dr Hamed Orafi

DistoangularDistoangular

Dr Hamed Orafi

HorizontalHorizontal

Dr Hamed Orafi

Results Of George Winter Results Of George Winter HypothesisHypothesis

Clinical Experience Revealed That Any Clinical Experience Revealed That Any

Increase Of The Length Of The Increase Of The Length Of The RRed Line ed Line

By By One mmOne mm. The Extraction Becomes . The Extraction Becomes

About About Three TimesThree Times More Difficult. More Difficult.

Any Tooth With A Any Tooth With A RRed Line ed Line 5mm.5mm. Or Or MoreMore

In Length Is Better Removed Under General In Length Is Better Removed Under General

Anaesthesia.Anaesthesia.Dr Hamed Orafi

If If RRed Line Is ed Line Is 9mm.9mm. Or Or MoreMore In Length, In Length, The Inferior Surface Of The Crown Of The The Inferior Surface Of The Crown Of The Impacted Third Molar May Be With Or Impacted Third Molar May Be With Or Even Below The Apex Of The Second Molar Even Below The Apex Of The Second Molar Tooth.Tooth.

It Is Better To Remove The Second Molar It Is Better To Remove The Second Molar With A Denuded Root At The Time The With A Denuded Root At The Time The Third Molar Is Extracted.Third Molar Is Extracted.

Results Of George Winter Results Of George Winter HypothesisHypothesis

Dr Hamed Orafi

Selection Of Radiographic Selection Of Radiographic ExaminationExamination

Periapical Radiograph.Periapical Radiograph.

Paralleling Technique.Paralleling Technique.

Bisecting-angle Technique.Bisecting-angle Technique.

Bite wing TechniqueBite wing Technique

Occlusal Radiograph.Occlusal Radiograph.

Panoramic Radiograph. (Ortho-pantomo-graph).Panoramic Radiograph. (Ortho-pantomo-graph).

Computerized Tomography Scan.Computerized Tomography Scan.

Dr Hamed Orafi

Periapical FilmPeriapical Film( Paralleling Technique( Paralleling Technique((

Image FieldImage Field Film PlacementFilm PlacementDr Hamed Orafi

Periapical FilmPeriapical Film( Paralleling Technique( Paralleling Technique((

Dr Hamed Orafi

Periapical FilmPeriapical Film( Paralleling Technique With Distal ( Paralleling Technique With Distal

ProjectionProjection((


Periapical FilmPeriapical Film( Paralleling Technique With Distal ( Paralleling Technique With Distal

Projection)Projection)

Dr Hamed Orafi

Periapical FilmPeriapical Film( Bissecting Technique)( Bissecting Technique)


Periapical FilmPeriapical Film( Bissecting Technique( Bissecting Technique((

Dr Hamed Orafi

Periapical FilmPeriapical Film( Bite-wing Technique( Bite-wing Technique((

Image FieldImage FieldLoop Around The Film Loop Around The Film For Patinet To Bite OnFor Patinet To Bite On

Dr Hamed Orafi


Film PlacementFilm Placement Projection Of Central Projection Of Central RayRay

Dr Hamed Orafi


Projection Of Central RayProjection Of Central Ray

Dr Hamed Orafi

Occlusal Radiograph Reviews The Occlusal Radiograph Reviews The Buccolingual Position Of At Least The Buccolingual Position Of At Least The Crown Of The Impacted Mandibular Crown Of The Impacted Mandibular

Third MolarThird Molar

Dr Hamed Orafi

Occlusl Film Local Anatomy Occlusl Film Local Anatomy Localization TechniqueLocalization Technique

A.A. Radiograph With The Tube In A Normal Position.Radiograph With The Tube In A Normal Position.

B.B. Shift The Tube Distally, The Third Molar Image Shift The Tube Distally, The Third Molar Image

Move Mesially i.e Tooth In The Buccal Side.Move Mesially i.e Tooth In The Buccal Side.

C.C. Occlusal View Proves Buccal Position Of The Crown.Occlusal View Proves Buccal Position Of The Crown.Dr Hamed Orafi

Panoramic RadiographPanoramic Radiograph Idea:Idea:

Two Adjacent Disks Two Adjacent Disks Rotating At The Rotating At The Same Speed In Same Speed In Opposite DirectionOpposite Direction

AdvantageAdvantage Broad Anatomic Broad Anatomic

ImagingImaging Low Radiation DoseLow Radiation Dose Convenient Ease And Convenient Ease And

SpeedSpeed Can Be Done In Can Be Done In

Closed MouthClosed MouthDr Hamed Orafi

Panoramic RadiographPanoramic Radiograph

Disadvantage.Disadvantage. Magnification And Geometric Distortion.Magnification And Geometric Distortion. Overlapped Image Of Teeth.Overlapped Image Of Teeth. Can Not Resolve Fine Anatomic Details.Can Not Resolve Fine Anatomic Details.

Dr Hamed Orafi

C.T scanC.T scan

Dr Hamed Orafi

Thank You

impaction assessment

Health & Medicine