1

Guide : Dr. Keerthi. RBy : Dr. Shreedevi. B

Oral & Maxillofacial Surgery

2

Contents

Introduction Definition Causes Indications and contraindications Classification Clinical examination Assessment Surgical procedure Post operative care Complications

3

Introduction

Origin- Latin -- Impactus"IMPINGO", "IN" and Pingo or strike.

Heironymous cardus -Dens sensus et sapientia et intellectus.

Dens sapientia Dens serotinus – lateness Allen - wisdom tooth (1685)

4

Impaction -Definitions

Impacted Tooth : A tooth which is completely or partially unerupted and is positioned against another tooth, bone or soft tissue so that its further eruption is unlikely, described according to its anatomic position.

American society of oral surgeons 1971

Andreason:

Is defined as a cessation of the tooth eruption caused by a clinical or radiographically detectable physical barrier in the path or by an ectopic position of tooth.

5

Archer: “A tooth which is completely or partially un erupted and is positioned against another tooth , bone, or soft tissue so that its further eruption is unlikely, described according to its anatomic position”

Lytle (1979):

“ A tooth that has failed to erupt into the oral cavity to its functional level of occlusion, beyond the time usually expected for that tooth to erupt and is prevented by adjacent hard or soft tissue including overlying teeth or dense soft tissue”

6

Peterson:

“A tooth is considered to be impacted when it has failed to fully erupt in the oral cavity within its expected developmental time period and can no longer do so.”

WHO:

“ Impaction is any tooth that is prevented from reaching its normal position in the mouth by tissue or bone or another tooth”

7

Theories of impaction-Durbeck

Phylogenic theory Mendelein theory Orthodontic theory Pathological theory Endocrine theory

8

Phylogenic theoryPhylogenic theory:: Nature tries to eliminate the disused Nature tries to eliminate the disused

organs i.e., use makes the organ develop better, disuse organs i.e., use makes the organ develop better, disuse

causes slow regression of organ.causes slow regression of organ.

[More-functional masticatory force – better the [More-functional masticatory force – better the

development of the jaw]development of the jaw]

Changing nutritional habits of modern civilized man in Changing nutritional habits of modern civilized man in

last 2000 years have practically eliminated needs for last 2000 years have practically eliminated needs for

large powerful jaws, thus, over centuries the mandible large powerful jaws, thus, over centuries the mandible

and maxilla decreased in size leaving insufficient room and maxilla decreased in size leaving insufficient room

for third molars. for third molars.

9

Orthodontic theoryOrthodontic theory:: Jaws develop in downward and Jaws develop in downward and

forward direction. Growth of the jaw and movement of forward direction. Growth of the jaw and movement of

teeth occurs in forward direction. Any thing that teeth occurs in forward direction. Any thing that

interfere with such movement will cause an impaction interfere with such movement will cause an impaction

(small jaw-decreased space).(small jaw-decreased space).

A dense bone decreases the movement of the teeth in A dense bone decreases the movement of the teeth in

forward direction. forward direction.

Causes for increased density of boneCauses for increased density of bone

a) Acute infection, b) Local inflammation of PDL a) Acute infection, b) Local inflammation of PDL

c) Malocclusion, d) trauma, e) Early loss of primary c) Malocclusion, d) trauma, e) Early loss of primary

teeth – arrested growth of the jaw.teeth – arrested growth of the jaw.

10

Mendelian theoryMendelian theory:: Heredity is most common Heredity is most common cause. The hereditary transmission of small cause. The hereditary transmission of small jaws and large teeth from parents to siblings. jaws and large teeth from parents to siblings. This may be important etiological factor in the This may be important etiological factor in the occurrence of impaction. occurrence of impaction.

Pathological theoryPathological theory:: Chronic infections Chronic infections affecting an individual may bring the affecting an individual may bring the condensation of osseous tissue further condensation of osseous tissue further preventing the growth and development of the preventing the growth and development of the jaws. jaws.

Endocrinal theoryEndocrinal theory:: Increase or decrease in Increase or decrease in growth hormone secretion may affect the size growth hormone secretion may affect the size of the jawsof the jaws

11

Causes -BergerLocal causes A. Obstruction of the eruption Compact bone Dense soft tissue Premature loss /Retained deciduous

tooth Scar tissue Gingival fibromatosis Cyst formation, Odontogenic tumor Ankylosis

12

Change in angulations of the tooth Chronic inflammation Reduced jaw growth Irregularities of adjacent tooth Arch length tooth material discrepancy Ectopic position of tooth bud

13

Systemic causes

Prenatal causes: Heredity

Post natal causes Rickets Anemia Congenital syphilis Tuberculosis Malnutrition Endocrinal causes- thyroid, parathyroid

14

Rare conditions: * Cleidocranial dysostosis

* Oxycephaly

* Osteopetrosis

* Progeria

15

Indications

Pain Infection - Pericoronitis, Abscess Pathological resorption of 2nd , 3rd

molar Jaw going for irradiation Mobility of 2nd molar Unrestorable caries

16

Facilitate orthodontic treatment Tooth in fracture line Retained tooth in edentulous jaw Periodontal diseases Prior to orthognathic surgery Radiological evidence of pathology…

………cyst, tumor

17

Prophylactic removal Prosthodontic reasons Autogenous transplantation Previous attempted extraction To prevent jaw fracture Recurrent trauma

18

Mandibular Fracture

Weak areas : angle, condyle & parasymphysis region.

Frequency of occurrence of mand. angle # is higher in pts, with impacted lower third molars & that of condylar # is higher in pts, without it.

(Lida & colleagues,2004)

Mechanism: occupy osseous space decreasing cross-sectional area of bone.

Absence of unerupted 3rd molars is significantly associated with higher incidence of condylar #. Combination of symphysis & condyle # seen in cases without impacted lower third molars.

(Zhu et al , 2005)

19

MANDIBULAR SAGITTAL SPLIT OSTEOTOMIES

Prior to orthognathic surgery : Patients with bony vertical

impactions and those who are scheduled for rigid fixation without

maxillomandibular fixation.

1 year prior to the planned orthognathic surgery.

Simultaneous with orthognathic surgery : Teeth where in intra-

operative removal is facilitated by the planned osteotomies and the

surgical flap design does not compromise the vascular supply to

adjacent dentoalveolar structures may be extracted

intraoperatively.

Following orthognathic surgery : rarely planned following SSRO

20

Additional considerations

Data suggests that asymptomatic patients with a pocket depth around third molars greater than 5mm, have significantly increased levels of inflammatory mediators vs patients with pocket depths less than 5mm.

White, R; et al. JOMS 60:1241-1245, 2002

21

Presence of periodontal disease is significantly associated with pre-term birth.

– Data from 1,020 obstetric patients– Results more significant if perio disease around

third molars Moss, K; et al. JOMS 64:652-658, 2006

Patients with visible third molars are more likely to have progression of periodontal disease than patients without third molars

Blakey, G; et al. JOMS 64:189-193, 2006

22

ContraindicationsLocal contraindications: Adequate space Abutment tooth Deeply placed tooth Acute infections Recently irradiated jaw

23

Systemic contraindications-relative

Uncontrolled diabetes Uncontrolled hypertension Cardiac diseases Liver diseases Steroid therapy Blood dyscrasias

24

Fever of unexplained origin Congestive cardiac failure Renal failure Pregnancy-1 & 3

25

Absolute contraindications

Acute pericoronitis

Acute necrotising ulcerative gingivitis

Haemangioma

Thyrotoxicosis

26

“A strong indication for removal of impacted third molar should be complemented with a strong contraindication to its retention”

– Mercier P, Precious D, Risk and benefits of removal of impacted third molars, IJOMS 21:17, 1992.

27

Order of Frequency of Impacted Teeth

• Maxillary 3rd Molar

• Mandibular 3rd Molar

• Maxillary cuspids

• Mandibular bicuspids

• Mandibular cuspids

• Maxillary bicuspids

• Maxillary central incisors

• Maxillary lateral incisors

According to Archer

28

Sequelae Infection Eruption cyst… Periodontal Orthodontic Ankylosis Proximal caries Pain

29

RISK OF CYST & TUMOR DEVELOPMENT:– Most common age : 20- 25 years.

– Incidence of cyst formation-2.31% (Guven et al,2000)

– Incidence of dentigerous cyst- 1.6% (Keith,1973)

– Incidence of ameloblastoma – 0.14- 2% (Shear,1978)

– Risk of surgical morbidity increases with age

30

Mandibular Angle Fractures (3.8 times more) (-Monty Reitzik ,J Oral Maxillofac Surg 1995:53:649) Trismus

Eye – blindness, Iritis, Dimness of vision

Ear –ringing sound, otitis

Damage to adjacent tooth

31

Development of Mandibular 3rd Molar

9 yrs. – tooth germ visible

11 yrs. – cusp mineralization completed - located with in ant. border of ramus facing

anteriorly at the level of occlusion plane

14 yrs. – crown formation complete

16 yrs. – 50% roots formation completed - body of mandible grows at the expense of ant. border of ramus

- position changes to approx. root level of 2nd molar

- angulation becomes more horizontal

18 yrs. – root formation complete with wide apex

24 yrs. – 95% of 3rd molars have already erupted

32

Mandibular third molar impaction classification

Aim :Describe general position of impacted

tooth.Estimation of difficulty in removal.

33

Mandibular third molar Mandibular third molar impaction classificationimpaction classification

Winters classification [1926]Winters classification [1926]

1. Mesio angular 1. Mesio angular 2. Horizontal 2. Horizontal 3. Vertical 3. Vertical 4. Disto angular 4. Disto angular 5. Lingo angular 5. Lingo angular 6. Buccoangular 6. Buccoangular 7. Inverted 7. Inverted These may also These may also occur simultaneously in-occur simultaneously in- a. Buccal a. Buccal version b. version b. Lingual version Lingual version c. Torsoversion c. Torsoversion

34

WINTERS WINTERS CLASSIFICATIONCLASSIFICATION

35

Modified winter’s classification

Vertical impaction +/_ 10° Mesio & disto angular +/_ 11-70° Horizontal > +/_ 70-100° Other types –Buccolingual

mesioinverted, distoinverted

36

Archer (1975) & Kruger (1984)

Angulation :Mesio angular Horizontal VerticalDisto angularLingo angularBuccoangular Inverted

37

Based on the nature of overlying tissue - [Peterson]

Soft tissue impaction Partial bony impaction

Bony impaction

38

Pell And Gregory Classification [1933]

1.Based on the space available distal to 2nd molar

39

2.Relative depth of third molar in bone

POSITION B

POSITION C

POSITION A

40

3.Position of the tooth in relation to long axis of second molar

1. Mesio angular 2. Horizontal

3. Vertical

4. Disto angular

5. Lingual deflection

6. Buccal deflection 7. Inverted

8. Torsion

41

4. Complications

Abnormal root curvature Hypercementosis Proximity to mandibular canal Bone density Adipose tissue Lack of accessibility Inflexibility of muscles of mouth

42

AAOMS & ADA CLASSIFICATION

07220 - soft tissue impaction.07230 - partial bony impaction.07240 - complete bony impaction07241 - complete bony impaction with unusual complications.

43

Killey & Kay's classification-

A. Angulation and position -Vertical - Mesioangular - Distoangular - Horizontal - Transverse - Buccoangular, lingoangular

- Inverted

- Aberrant position

44

B. State of eruption- - Erupted - Partially erupted - Unerupted – soft tissue impaction - Complete bony impaction

C. Number of roots-

Unfavorable impaction- Mesial curvature of roots - Multiple roots

Favorable impaction- Fused roots - Distal curvature of roots

45

Assessment

Preoperative assessment:

- Clinical assessment

- Radiological assessment

- Psycological assessment

46

Clinical assessment General assessment * Age * Systemic condition Intraoral examination * Medical risk * Mouth opening * General examination * Tongue size * Drug history * Status of dentition * Anesthesia history * Extensibility of lips Extraoral examination * Swelling * Presence of Sinus * Lymphnode * Trismus

47

Assessment of impacted teeth

Status of eruption Periodontal status External/internal oblique ridge Relationship with adjacent teeth Soft tissue covering Occlusal relationship

48

Radiographic assessment-Indications

For orthodontic treatment plan. Rule out pathologic changes Eruption predilection For treatment plan in surgical

removal Identify proximity of vital structures.

49

Intra oral radiographs

IOPA Bite wing Occlusal view

Indications : Tooth in alveolus Adequate mouth opening Relationship with inferior alv canal

50

Extra oral radiographs OPG Lateral cephalometrics Lateral oblique view of mandible Special techniques: CT scans ( Dodson 2005) MRI

Indications: Trismus Tooth in aberrant position Associated pathology Relationship with inf alv canal

51

Radiological assessment

Angulation, Depth , Space available Crown size Roots - Configuration , Length ,

development, Curvature, size Bone texture & density Nature of covering tissue Follicular size Accessibility Inferior alveolar vascular bundle

52

Factors that make surgery less difficult

Mesio angular position Class I molar relation Class A depth Roots 1/3-2/3 formed Fused conical roots Wide periodontal ligament Large follicle Young age Sep from 2 nd molar, inferior alveolar canal Soft tissue impaction

53

Factors that make surgery more difficult

Disto angular position Class III molar relation Class C depth Long thin roots Divergent curved roots Narrow periodontal ligament Thin follicle Elder age Contact with 2nd molar, inferior alveolar canal Bony impaction

54

Position of the molarMesioangular 1Horizontal 2Vertical 3Distoangular 4Relative depthClass A 1Class B 2Class C 3Relation with ramus and space available Class 1 1Class 2 2Class 3 3

Assessment of difficulty PEDERSON SCALE

Difficulty score Total

Easy 3–4

Moderate 5–6

Difficult 7–10

55

Criteria of modified parent scale

Easy I - Extraction requiring forceps only Easy II - Extraction requiring osteotomy Difficult III - Extraction requiring osteotomy

and coronal section Difficult IV - Complex extraction (root

section)

(Marcio –Deniz ,The British asso of oral maxillofac surg 2005)

56

WHARFE ASSESSMENT- Mac Greger

Winters classification Horizontal 2 Mesioangular 1 Vertical 0 Distoangular 2

Height of mandible. (mm)

1-30 0 31-34 1 35-39 2

57

Angle of the second molar. (degrees)

1-59 0 60-69 1 70-79 2 80-89 3 90+ 4

Root shape and development.

a. Less than1/3complete - 2

b. 1/3-2/3 complete - 1

c. More than 2/3 Complex - 3

Unfavourable curve - 2

Favourable curve - 1

58

59

Follicle

Normal 0 Possible enlarged (-1)

Enlarged (-2)

Impaction relieved (-3)

Exit path.

Space - 0

Distal cusp covered- 1

Mesial cusp covered- 2

All covered - 3

60

Winter’s assessment-WAR lines

61

Winter’s WAR lines

62

Relationship of Root to Canal

– Related but not involving the canal

– Separated– Adjacent– Superimposed

Related to changes in the roots

– Darkening of root– Dark and bifid root– Narrowing of root– Deflected root

Related with changes in the canal

– Interruption of lines– Converging canal– Diverted canal

63

Relationship of Inferior Alveolar Nerve to the Roots of Third Molar

Roods Radiographic Criteria:

Darkening of root Deflection of root Narrowing of canal Dark & Bifid

apex

64

Related with changes in canal

Loss of lines Converging canals Diverted canals

Rood & Shebab criteria (Rood JP ,Shihab BA - British J OMFS 1998:28:20)

65

Radiological prediction of inferior alveolar nerve injury

According to J. P. Rood, B. A. A. Nooraldeen Shehab,– Diversion of mandibular canal– Darkening of root– Interruption of white lines– Narrowing of roots– Deflection of roots– Narrowing of mandibular canal– Dark and bifid root

Br Jr of Oral and Maxillofacial Surgery 1990; 28: 20-25

J Oral Maxillofac Surg 2003; 61: 417- 421 J Oral Maxillofac Surg 2005; 63: 3-7

66

RELATION SHIP TO LINGUAL NERVE

(Antony Pogrel ,J oral maxillofac Surg 1995:53:1178)

67

Surgical procedure

John tomes-1848-extn of 2nd molar-

Impaction Steele-1895- Grinding of distal surface of

2nd molarNOVITSKY-1890-1st to raise the flap and

remove boneEdmund kells-1918-tooth sectioning.Winter-1926-chisel (ossisector)

68

Treatment plan

9 to 10 years –prophylactic removal - Enucleation (Henry &Morant 1936) - Germectomy (Ricketts 1972)

 10 to13 years- create adequate space for eruption by proximal striping of primary tooth

Just before crown is fully formed –Henry -> 1/3 root formed

2/3 of root is developed (NIH Health consensus development conference)

69

Instrumentation Mouth mirror Probe No 15 blade on a Bard Parker handle. Mosquito artery forcep Howarth’s nasal raspirator Retractors Chisel Mallet Bur: No 8 rose head, straight fissure Elevators Bone file Needle holder Tissue forceps Scissors

70

71

SURGICAL PROCEDURE

Asepsis and isolation Anesthesia Incision and flap design Reflection of mucoperiosteal flap Bone removal Tooth sectioning Elevation & Extraction Debridement Closure Postoperative care

72

Choice of anesthesia

Apprehension level

The patient’s acceptance of the procedure

The length and technical difficulty of the

procedure

Physical status of the patient

73

Indications of GA/sedation

Fear of pain during the procedure Emotionally unstable patient Anticipated lengthy procedures Removal of all four impacted molars in one sitting Uncooperative patients Allergy to LA Tooth in aberrant position

74

Advantages of LA

Less expensive Less bleeding Less complications Patient will be conscious Medically compromised patients Simple, short time procedures

75

Incision and Muco periosteal Flap

Principles of flap Accessibility Vascularity Base wider than apex Rest on sound bone Full thickness flap Should not extend too far distally

76

MUCOPERIOSTEAL FLAP

– Incision – 3 parts: Anterior, Posterior & Intermediate limb

Not to be extended too distally-– Bleeding from buccal vessels & other

arteries.– Postoperative trismus – temporalis muscle

damage.– Herniation of buccal fat pad.– Damage to lingual nerve (lingual extension).

77

Factors Governing Planning of Incision

– Surgical access– Healing of sutured wound – dry socket – Periodontal health of II molar – distal

pocket– Suture line must rest on normal bone– Partly visible crown: de-epitheliazation

78

L-shaped incisionss

79

Bayonet-shaped incision

80

Envelope incision

81

Ward’s incision

82

FLAP DESIGN

ENVELOPE FLAP

THREE CORNERED FLAP

83

MODIFIED FLAP DESIGN

SZMYD DESIGN

TRIANGULAR DESIGN

84

MOORE’S FLAP

85

Vestibular Tongue shaped Flap

Berwick in 1986 designed a vestibular tongue shaped flap.

Extended into the buccal shelf of the mandible.

86

Comma incision

87

88

Paragingival single flap, distal end incision

Prof Kapadia`s cunicular incision

89

Flap reflection

Instruments: Howarth nasal raspirator

Le cluse elevator

Hopkin & molt periosteal elevator

Aim- Exposure of tooth & Bone

90

Flap retraction

Howarth nasal raspirator Thimble Austin retractor Ward killner retractor Dyson’s Malleable copper retractor Mac gregor periosteal elevator Fickling periosteal elevator Read periosteal elevator

91

Criteria Buccal Approach

Lingual Approach

Access Easy Difficult

Instruments Chisel or Bur Only chisel

Procedure Tedious Easy

Operating time Time consuming Less

Technique Easy Difficult

Bone removal Thick buccal plate Thin lingual plate

Post op pain Less More

Post op edema More Less

Dry socket High Less

Bruising of face Possible Absent

92

Bone RemovalAim:

1. To expose the crown by removing the bone overlying it.

2. To remove the bone obstructing the pathway for removal of the impacted tooth.

Types:

1. By consecutive sweeping action of bur (in layers).2. By chisel or osteotomy cut (in sections).

How much bone has to be removed?

1. Bone should be removed till we reach below the height of contour, where we can apply the elevator.

2. Extensive bone removal can be minimized by tooth sectioning.

93

Indications for use of chisel

Young patients with elastic boneTooth which dose not require sectioning,

performed under G AExternal oblique ridge should be below the

level of bone enclosing tooth. Internal oblique ridge should be behind the

tooth.

94

Methods of bone removal

With Bur:

1.Buccal guttering technique 2.Postage stamp technique 3.Collar technique (Moore & Gillbe) 4.Lateral trepanation technique [Bowdler Henry]

With Chisel:

1.Window technique 2.Shaving technique 3.Lingual split technique 4.Distal lingual split technique

95

Chisel vs BurSl.No Criteria. Chisel&Mallet Bur

1. Technique Difficult Easy.

2. Control over bone cutting Uncontrolled Controlled.

3. Patient acceptance. Not tolerated in L.A.

Well tolerated in L.A.

4. Healing of bone. Good Delayed Healing

5. Postoperative edema Less More.

6. Dry socket. Less. More.

7. Postoperative Infection. Less. More.

Sl.No Criteria. Chisel&Mallet Bur

1. Technique Difficult Easy.

2. Control over bone cutting Uncontrolled Controlled.

3. Patient acceptance. Not tolerated in L.A.

Well tolerated in L.A.

4. Healing of bone. Good Delayed Healing

5. Postoperative edema Less More.

6. Dry socket. Less. More.

7. Postoperative Infection. Less. More.

Sl.NoSl.NoSl.No Criteria.Criteria.Criteria. Chisel&MalletChisel&MalletChisel&Mallet BurBurBur

1.1.1. TechniqueTechniqueTechnique DifficultDifficultDifficult Easy.Easy.Easy.

2.2.2. Control over bone cuttingControl over bone cuttingControl over bone cutting UncontrolledUncontrolledUncontrolled Controlled.Controlled.Controlled.

3.3.3. Patient acceptance.Patient acceptance.Patient acceptance. Not tolerated in L.A. Not tolerated in L.A. Not tolerated in L.A.

Well tolerated in L.A.Well tolerated in L.A.Well tolerated in L.A.

4.4.4. Healing of bone.Healing of bone.Healing of bone. GoodGoodGood Delayed HealingDelayed HealingDelayed Healing

5.5.5. Postoperative edemaPostoperative edemaPostoperative edema LessLessLess More.More.More.

6.6.6. Dry socket.Dry socket.Dry socket. Less.Less.Less. More.More.More.

7.7.7. Postoperative Infection.Postoperative Infection.Postoperative Infection. Less.Less.Less. More.More.More.

96

Bone Removal TechniquesMoore & Gillbe’s Collar Technique

Conventional tech of using bur. Rosehead round bur no.3 is used to create a gutter

along the buccal side & distal aspect of tooth. A point of elevation is created with bur. Amount of bone sacrificed is less. Can be used in old patient. Convenient for patient.

97

Split Bone / Lingual Split Technique Sir William Kelsey Fry(1933)

- Quick & clean technique.- Reduces the size of blood clot by means of saucerization of socket.- Decreased risk of damage to the periodontium of the second molar.- Less risk of inferior alveolar nerve damage.- Decreased risk of socket healing problems.- Can use regional anesthesia but endotracheal anesthesia is preferred one. - Only suitable for young adults whose bone is elastic.- Inconvenience to patients due to chisel usage.

98

Vertical stop cut

Distal cut

Elevation

Horizontal cut

Removal of distal & buccal bone

Removal of tooth

Incision

Closure

99

Modified Lingual Split Technique for Modified Lingual Split Technique for Removal of Mandibular Third Molar Removal of Mandibular Third Molar

(Dr. Davis 1979)(Dr. Davis 1979)

Distal cutVertical stop cutIncision

100

ClosureTooth elevation

101

Kamanishi modification: Do not raise the lingual flap Advance to the lingual side under the bone only

to the extent which is necessary.

Lewis modification: Flap was made lingual to second molar instead

of third. Vertical lingual step cut just distal to second

molar. Lingual plate was hinged like an osteoplastic

flap. It is considered as combination of both lingual

and buccal approach

102

- Employed to remove any partially formed unerupted 3rd molar

that has not breached the overlying hard & soft tissues.

- Age 9-18 yrs

- GA/LA with sedation.

- Excellent PDL healing on distal surface of 2nd molar.

- Bone healing is excellent as there is no loss of alveolar bone

around 2nd molar.

- Disadvantage – increased buccal swelling

Lateral Trepanation Technique Bowdler Henry

103

Lateral Trepanation Technique Bowdler Henry

104

Chisel technique –Buccal approach

Elevation of mucoperiosteal flap Vertical limiting cut -5-6mm Oblique cut -45 deg Removal of triangular plate of bone Point of application of elevator Distolingual bone fractured parallel to

internal oblique ridge

105

106

Tooth Division“ Rationale of tooth sectioning is to create a space into which

impacted tooth can be displaced & then removed.”

Tooth is sectioned in various ways depending on the type & degree of

impaction.

Mesioangular Impaction

Horizontal Impaction

107

Vertical Impaction

Disto Angular Impaction

108

Debridement of Wound & Closure

Thorough debridement of the socket by Periapical curettage.

Smoothening of sharp bony margins by Bone file / burs.

Thorough irrigation of the socket Betadine solution + Saline .

Initial wound closure is achieved by placing 1stsuture just

distal to 2ndmolar, sufficient number of sutures to get a

proper closure.

109

Wound closure……

Principle: Use as few sutures as possible. Suture should penetrate the lingual flap close to

and behind the third molar and the buccal flap further distally.

Should not be excessively tight. Suture distal to second molar - importance. Determination of suture requirment is done in

half closed mouth position.

110

Post Operative Instructions

Pressure pack – 1hr

Ice application

Soft diet –1st two days

1st dose of analgesic should be taken before the anesthetic effect

of LA wears off.

Avoid strenuous exercises for 1st 24 hrs.

Avoid gargling / spitting / smoking / drinking with straw.

Warm water saline gargling after 24 hrs + mouth wash regularly

thereafter.

Suture removal on 7th POD.

111

Complications

Intra Operative 1. During incision

a. Injury to facial arteryb. Injury to lingual nervec. Hemorrhage – careful history

2. During bone removal a. Damage to second molar b. Slipping of bur into soft tissue & causing injury c. Extra oral/ mucosal burns d. Fracture of the mandible when using chisel & mallet e. Subcutaneous emphysema

3. During elevation or tooth removala. Luxation of neighbouring tooth/ fractured restorationb. Soft tissue injury due to slipping of elevatorc.  Injury to inferior alveolar neurovascular bundled. Fracture of mandiblee. Forcing tooth root into submandibular space or inferior

alveolar nerve canalf. Breakage of instrumentsg. TMJ Dislocation – careful history

112

Nerve Injuries

0.6-5% of all the third molar surgeries are involved with nerve damages of which 0.2% are irreversible

IAN: Immediate disturbance - 4-5% (1.3-7.8%) Permanent disturbances - <1% (0-2.2%)

Lingual N: Immediate - 0.2-22% Permanent - 0-2%

96% IAN injuries show spontaneous recovery within 9 months, better than lingual nerve which is about 87%.

Beyond 2yrs recovery is unlikely.

113

Treatment Flowchart for IAN Injury

114

Treatment Flowchart for Lingual Nerve Injury

115

Post operative-

Hemorrhage Pain Trismus Swelling Hematoma Sorethroat Pyrexia Surgical emphysema Wound dehiscence Paresthesia Alveolar ostitis Periodontal defect of the adjacent tooth

116

Dry socket

Coined by Crawford(1896) Alveolitis sicca dolorosa Empty socket Focal osteomyelitis Painful socket Postoperative osteitis Sloughing socket Alveolalgia Necrotic socket Fibrinolytic alveolitis Delayed extraction Alveolitic osteitis Fibrinolytic osteitis Sclerosing osteomyelitis Alveolar osteitis Localized acute alveolar osteomyelitis Post extraction osteomyelitic syndrome

117

Dry socket-Definition

Shafer-a focal osteomyelitis in which the blood clot has disintegrated or been lost, with the production of a foul odour and severe pain, but no suppuration

MacGregor 1968- classically occurs after forceps extraction and the diagnosis is made by excluding the other causes of pain.

118

Dry socket-Definition

Post operative pain in and around the alveolus which increases in severity at some moment between 2-3 days after a dental extraction accompanied by partial or total disintegration of the intra alveolar clot accompanied with a foul smell.

119

Aetiology

Alling and kerr-gross amount of peridontal membrane adherent to teeth after extraction appeared to predispose development of dry socket.

Lysis of formed clot Trauma Reduced blood supply- Diabetes, vasoconstrictors Generalised debilitation Dense bone Smoking

120

Local factors

Birn’s theory of fibrinolysis

Fibrinolytic activity of alveolar bone than the bacteria.

Nitzin’s theory

Trauma reduced resistance to infection

Bacterial theory

121

Clinical features

Pain

-Dull aching pain

-2-3 days after extraction Empty socket

-Sensitive, gray Foul smell Bad taste

122

Treatment

Mechanical debridement Zinc oxide eugenol Curettage Tetracycline Topical metronidazole Benzocaine Formula as given by Alling- Eugenol--- 46% Balsam of peru— 46% Chlorobutanol 4% Benzocaine 4 %

123

Adv: • Less tissue damage• Good illumination • Clear magnified visualization of operative field• More conservative surgery with precision dissection.

Disadv:• Costly • Needs specific equipments • Good hand-eye coordination and training required

Use of Endoscopic Approach for Ectopic Use of Endoscopic Approach for Ectopic Mandibular 3rd MolarMandibular 3rd Molar

(BJOMS 2003; Oct. 41: 340-42)

124

Use of Erbium (Er):YAG laser [by M.Abu-Use of Erbium (Er):YAG laser [by M.Abu-Serriah A.Ayoub : Serriah A.Ayoub : BjomsBjoms 2004; 42: 203-208] 2004; 42: 203-208]

Adv:Adv: Less stressful Less stressful Less unpleasant Less unpleasant No vibrations & soundNo vibrations & sound Sharp clean cut through the bone & toothSharp clean cut through the bone & tooth Can be used in anxious patientsCan be used in anxious patientsDis adv:Dis adv: It is more technique sensitive.It is more technique sensitive. more chances of Trismus.more chances of Trismus. Time consumingTime consuming Costly Costly

125

Conclusion Impacted teeth are a medical deformity with variable

presentations, brought about by the dietary changes of modern civilization, or genetic predisposition.

Our recent ancestors did not experience this problem or the problem of the underdeveloped jaw and resulting Class II or class III malocclusion to the extent present in modern society.

Oral & Maxillofacial surgeons should be aware of the devastation that impacted teeth can cause to the jaws and overall health of an individual and hence should undertake a rational treatment approach after performing a clear clinical and radiographic assessment of the patient’s mouth & reviewing the pathological ramifications resulting from impacted teeth.

126

References

Harry Archer – Oral & Maxillofacial Surg. Vol I

Geoffrey Howe – Minor Oral Surg.

Kelley & Kay – The Impacted Wisdom tooth.

Pederson- Oral surgery

Peterson – Contemporary Oral & Maxillofacial Surg.

Dental Clinics of North America

Textbook & colour atlas of tooth impaction- Andreasen.

Impacted teeth- Alling & Alling.

Textbook of oral & maxillofacial surgery-Srinivasan.

Textbook of oral & maxillofacial surgery-Nilima Malik

127

Journals

JOMS 1995; 53:1178-1181. JOMS 2006; 64:94-99 JOMS 2005; 63:1443-1446 OOO 2001; 92:377-83 OOO 2006; 102:448-52 OOO 2006; 102:300-6 JOMS 2006; 64:1371-1376 OOO 2006; 102:154-8 JOMS 2005; 63:3-7