IMPACTION

IMPACTION

IMPACTION

Surgical & Orthodontic Considerations of Exposing Impacted Teeth

Anne-Marie Hoa Nguyen, DDS, MS Houston, Texas
2006 Vietnamese American Medical-Dental Association National Convention

Tooth Impaction

Third Molars Most common Maxillary Cuspids Maxillary Central Incisors Mandibular/Maxillary second premolar

Tooth Impaction
Complications External resorption Infection Cyst Formation Loss of arch length Resorption of the roots of adjacent teeth Periodontal defects

Tooth Impaction
Complications

Root resorption Tooth transposition

Pre-Operative Orthodontics
Provide adequate anchorage Create sufficient space

Pre-Surgical Preparation Localization

Inspection Palpation Radiography Periapical Occlusal Panoramic

Pre-Surgical Preparation
Determine the location Radiographs at different angles Buccal Object Rule [S.L.O.B.]

Radiography
Parallax: the apparent displacement of an image, relative to the image of a reference object, caused by an actual change in the angulation of the X-ray beam. Reference Object: root of adjacent tooth

Surgical Exposure
Armamentarium

Surgical Exposure
Techniques

Local anesthetic agents

1:50K Epi for hemostasis

Blades [15C, 12] & periosteal elevator Surgical Round Bur [Size 4, 6] Periodontal curettes Bonding brackets or gold chain Bonding materials Sutures [4.0 Plain Gut] Camera

Excisional Uncovering Apically Positioned Flap Closed-Eruption Technique

Surgical Exposure
CRITERIA

Canine Impaction

Facio-Lingual Position
Intra-alveolar NEVER used excisional uncovering nor APF

Vertical Position Relative to the CEJ If below any of the 3 If above NEVER excisional Amount of keratinized gingiva Mesiodistal position

Surgical Exposure
Techniques

Surgical Exposure
Techniques

Curette follicular sac Hemostasis controlled

NEED

Surgicel [Johnson & Johnson] Gel Foam [Upjohn Co.] Acid-etch Bracket or gold chain

to remove all bone off up to the CEJ! ENAMEL DOES NOT RESORB BONE.

Surgical Exposure
Techniques

Canine Impaction
Most common in maxillary arch 2% of orthodontic patients Palatal > Labial [ 2 : 1] Female > Male [3x] Cause: Retained primary tooth, Diversion of tooth bud, idiopathic

Canine Impaction
Width: 7.5 to 8 mm 1 to 1.5 mm wider than the first premolars

Canine Impaction

Canine Impaction Transposition

Advantages of delaying extraction 1o canine * Space preservation * Maintaining ridge width * One surgical procedure

C C A A B B

Canine Impaction

Canine Impaction

Canine Impaction

Canine Impaction

Canine Impaction

Canine Impaction

Bracket attached to tooth Closed flap technique Gold chain to archwire for stabilization and attachment Immediate activation

Canine Impaction
*
Primary Canine

Canine Impaction

Oops Factor!!!

Bilateral Canine Impaction

Bilateral Canine Impaction

Bilateral Canine Impaction

Bilateral Canine Impaction

Palatal View

Occlusal XR

Bilateral Canine Impaction

Bilateral Canine Impaction

(R) PAR

R Buccal

R Buccal View after surgical exposure with gold chain attachment

(L) PAR

L Buccal

Bilateral Canine Impaction

*Closed eruption technique *Traction wire tunnelled through extraction socket

Bilateral Canine Impaction

L Palatal View after surgical exposure with gold chain attachment

Bilateral Canine Impaction

Bilateral Canine Impaction

25 y.o. Hispanic Male, referred by a local orthodontist, for an exposure of Upper Right and Left Canine. NOTE multiple external root resorption to the anterior teeth. WARN patient BEFORE SURGERY!

Bilateral Canine Impaction

Bilateral Canine Impaction

Mandibular Canine Impaction

Impaction : Rare, 0.05% to 0.4% Causes: Ectopic position, Lack of space, Obstruction of the eruption pathway, defects in the follicle.

Mandibular Canine Impaction

Orthodontic Repositioning
Space availability Tooth axis

Mandibular Canine Impaction

Orthodontic Repositioning

* *
*

Mandibular Canine Impaction

Orthodontic Repositioning

Mandibular Canine Impaction

Orthodontic Repositioning

Mandibular Canine Impaction

Orthodontic Repositioning

Central Incisors Impaction

Central Incisors Impaction

2nd most common in maxillary Cause: Mesiodens

Central Incisors Impaction

OCR before Surgery

PAR after extraction

Premolar Impaction
Etiology

Premolar Impaction
Maxillary 2nd Premolar impaction: 0.1% to 0.3% Mandibular Premolar impaction: 0.2% to 0.3% Last tooth to erupt

Space loss Ectopic position Obstacles in the eruption path

Ankylosed primary molars Supernumerary teeth (Odontomas)

Premolar Impaction
Pre-Operative Orthodontics

Upper 2nd Premolar Impaction

Determine to Extract primary 2nd molar Delayed Ortho space maintainer Wait for all permanent teeth eruption Provide adequate space

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Upper 2nd Premolar Impaction

Upper Premolars Impaction

Impacted Left 2nd Premolar

Impacted Right 1st & 2nd Premolars

Upper Premolars Impaction

Lower 1st Premolar Impaction

Buccal View

Lingual View

Lower 1st Premolar Impaction

Lower 2nd Premolar Impaction

Clarks Rule : SLOB

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Lower 2nd Premolar Impaction

Lower 2nd Premolar Impaction

38 y.o. Asian female, referred by an orthodontist, for: Extraction of Upper Left 1st premolar #12 Surgical Extraction of Lower Right 2nd premolar #29

Lower 2nd Premolar Impaction

Lower 2nd Premolar Impaction

18 mm Root Length

Based solely on Panoramic radiograph, referring doctor cited reasons for Ext: Severe External Root Resorption Weak tooth Replace with a single endosseous implant after Ortho

Molar Impaction

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Molar Impaction
Physical

Molar Impaction
Pre-Operative Orthodontics Evaluate 3rd molars Place ortho appliances on all teeth Refer for surgical exposure

obstacle in the eruption path Ectopic eruption path

Molar Impaction
??? Wisdom Teeth Extraction ???? Insufficient space Ext. Disadvantages Trauma & Postop Discomfort Flap Management

2nd Molar Impaction

2nd Molar Impaction

Upper Molars Impaction

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Upper Molars Impaction

Potential Problems
Immobile Resist movement
Insufficient bone removal Inappropriate orthodontic mechanics Ankylosed tooth

Potential Problems
Loss of attached gingiva Tissue Overgrowth Pigeon Hole --- damage to the crown or adjacent roots, inadequate bone removal, poor isolation

Potential Problems
Tissue Overgrowth

Potential Problems
Closed

Conclusion
Early

Eruption Technique

Debonding of Brackets Mucogingival Defects

detection and treatment Proper diagnosis and treatment Periodic follow up

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Thank you for your attention!

Comments !!!! Questions?????

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