1. Discuss classification of impacted mandibular molars.
Describe your method of removal of an impacted mandibular 3
rd
molar in horizontal position
Definition Classification- George Winters Classification Gregery Winters Classification Petersons Winter s Classification Method Indications for removal Pre-operative assessment- History Clinical Exam Radiographic Exam Assessment of difficulty of removal procedure
Definition Tooth that has failed to erupt completely or partially to its correct position in the dental arch and its eruption potential has been lost. A completely/partially unerupted tooth positioned against a physical such as another tooth, bone/soft tissue, so that its further eruption is unlikely even beyond its normal chronological age of eruption. 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.
Classification Aim: Describe general position of impacted tooth estimation of difficulty in removal.
3. Pell + Georgys classification (A33) Based on the space available distal to 3 rd molar
Class I Class II Class III Space between ramus & distal side of 2 nd molar is more than mesiodistal diameter of crown of impacted 3 rd molar Space is less than mesiodistal diameter of crown of impacted 3 rd
molar All or most of the 3 rd molar is in ramus Position A Position B Position C Highest portion of impacted tooth is an level with or above occlusal plane of 2 nd molar Below occlusal plane above cervical line of 2 nd molar Below cervical line of 2 nd molar
Position of tooth in relation to long axis of second molar 1. Mesioangular 2. Horizontal 3. Vertical 4. Distoangular 5. Lingual defective 6. Buccal 7. Inverted 8. Transverse
4. Kays Classification 1. Based on angulation and position - Mesioangular - Distoangular - Vertical - Horizontal 2. Based on state of eruption - Fully erupted - Partially erupted - Embedded 3. Based on number of roots - Fused roots - 2 roots - Multiple roots 4. Based on root pattern Favourable Unfavourable- curved at different angles
Indications a. According to Peterson - Prevention of periodontal diseases - Prevention of dental caries - Prevention of treating pericohonitis - Prevention of Root resorption - Prevention of odontogenic cysts of tumors - Impacted teeth under a dental prosthesis
Pain in retromolar region of MPDS TMJ disorders should be ruled out - Facilitation of orthodontic treatment - Prevention of fracture of jaw
5. Mandibular angle fractures is more frequent in patients with impacted lower third molar + fracture of condyle is higher in patients without it - Crown on 2 nd molar - Orthognathic surgery
Contraindications- local- if there is adequate space if 3 rd molar is used as abutment if deeply placed Tooth in tumour Asymptomatic tooth Acute infections Recently irradiated jaw Systemic-relative
Uncontrolled diabetes Uncontrolled hypetension Cardiac diseases Liver diseases Steroid therapy Blood dyocrasias Anticoagulant therapy Toxic goiter Fever of unexplained origin Pregnancy 1 st and 3 rd semester Chemotherapy Absolute-Leukemia Haemophilia Recent M I Nephritis
Preoperative Assesment- History-Medical+ Dental history must be recorded Clinical exam-Facial form-Tapered-access better Compact-access origin
Presence of swelling Intraoral - Small mouth or mandibular retrusion-makes tough removal - If external oblique ridge is posterior to tooth, access is good, if ridge is odogentic the tooth or anterior to it access is If external oblique ridge is lower and posterior to tooth- buccal bone will be relatively - Soft tissue over wisdom tooth Check for Fibrosis Indentation by upper buccal tooth Active inflammation - Position of upper 3 rd molar on periocoronal flap of lower 3 rd molar - Larger tongue size- more difficult removal Radiographic Assessment - For orthodontic treatment - Rule out pathologic changes - Eruption prediction - For treatment plan in surgical - Proximity of vital structures Intraoral Radiographic- IOPA Bite Sing Occlusal view Indication- Tooth in alveolus Adequate mouth opening Tube shift Relationship with inferior alveolar canal Extraoral OPG Lat. Oblique view of mandible Indication- Trismus Tooth in abevant position Associated pathology Relationship with inferior alveolar canal Assessment- Angulation, Depth, Space available anatomical relation Crown size + shape Roots, configuration length development, curvature, size and root position of adjacent tooth Bone texture + density- Depth of impacted tooth Nature of covering tissue Follicular size Accessibility WHARFES Assessment Winters classification Height of mandible Horizontal-2 1-300 Mesioangular-1 31-341 Vertical-0 35-392 Distoangular-2 A.Angle of 2 nd molar (degrees) 1-59-0 60-69-1 70-79-2 80-89-3 90+-4 R-Root shape and development A. Less than 1/3 rd complete-2 B. 1/3-2/3 complete-1 C. More than 2/3 Complete-3 Unfavourable Curve-2 Favourable curve-1 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 Total-33 War lines - White line - Red line-if>5mm- extraction difficult every additional mm makes removal 3 times more difficult If > 5mm-better removal under general anaesthesia. Bone deficiency index Classification Buccal relationship Mesioangular 1 Horizontal /Transverse 2 Vertical 3 Distangular 4 Depth Level A-1 Level B-2 Level C-3 Ramus relationship Class I- 1 Class II-2 Class III-3 Difficulty index Very difficult- 1-10 Moderatly difficult- 5-7 Minimally difficult- 3-4 Surgical Removal a. Isolation of surgical site- Scrubbing on skin Citrinide+povidone+iodine or Citrinide+absolute alcohol Citrinide+absolute alcohol+chlorhexidine
- Cleaning solution- Normal saline alcohol - Painting solution- a. Povidine-Iodine 5%-skin 1% oral mucosa b. Chlorhexidine gluconate- 1.5% for skin 0.2% for rinsing oral cavity Drape the patient - Local anesthesia- IANB, lingual nerve block + long buccaline block - Flap design+ Reflection-Ideal requirements for a flap for 3 molar removal
1. Flap must be a full thickness mucoperiosteal flap 2. Provide visibility access 3. Brad base for adequate blood supply 4. After bone + tooth removal, margins of flap are repositioned, they should rest on sound bone.
1. Short envelope flap- shallow or superficial impactions Distal- incision Crevicular-incision 2. Long envelope flap- deeper impactions extend up to mesiobuccal line angle of 1 st molar 2 nd premolar- but this flap gives inadequate accessibility. a. Triangular flap- distal part crevicular part vertical part Envelope flap with anterior vertical relieving incision is 3 cornered flap A. Wards incision distal incision is similar to envelop flow ii. Anterior relieving incision is started at disto buccal line angle or point on gingiva corresponding to distobuccal cusp tip of 2 nd molar taken downwards and anterior till it coincides with buccal groove of the tooth. iii. Crevicular incision connects both the above
B. Modified Wards incision of deeply impacted anterior incision- started from distobuccal corner of crown of lower 1 st molar (instead of 2 nd molar) C. L-shaped vertical relieving incision is given 45 angle to the long axis 2 nd molar and runs straight anteriorly and downwards without having smooth curvature as in wards incision. Raise a mucoperiosteal flap with a periosteal elevator in contact with bone on buccal side, place the periosteal elevator on lingual side of tooth after reflecting on that side to avoid damage to lingual nerve- 5mm of bone distal to third molar should be visible D. Bone removal i. To expose maximum height of contour of crown that lies on buccal side at junction of cervical of middle 3 rd of crown ii. To facilitate path of removal iii. To create a fulcrum for elevator
For use of bur For use of mallet Old patient brittle sclerotic bone Growing elastic bone External or internal oblique ridges or both are far forward relation to tooth External oblique ridge in slightly below the level of bone internal oblique ridge is slightly behind tooth Where sectioning of the tooth Under GA If surgery is under LA If tooth sectioning not required
Chisel technique through buccal approach Vertical extent of anterior cut-7mm , so 5mm chisel taken Chisel is rotated 90 corner of blade is engaged in lower end of anterior cut of horizontal cut joining the vertical cut Bone removal using a burr Remove bone on occlusal surface Round burr used to create gutter on buccal and distal aspect. Distolingual spur of bone is removed on mesial aspect. Point to engage elevator is made. Cortical buccal bone is removed and its called ditching. Removal of tooth- by an elevator Sectioning- by osteoteme or straight fissure burr or both Indications-If crown of impacted tooth is obstructed by 2 nd molar - Unfavourable root pattern - To protect anatomic structures nerve, vessels, adjacent tooth from injury Advantages- Operating field minimized Reduced bone removal edema reduced Reduced weakening of jaw Reduced damage to important anatrimical re structures The burr should section m of the occlusal surface of the tooth from buccal side, to avoid injury to lingual nerve. Horizontal impaction-after sufficient bone is removed down to cervical line to explore superior aspect of distal root and buccal surface of down. Crown is sectioned from roots of tooth delivered. Roots are delievered together or independently by elevator with rotational , purchase point made to engage the elevator, mesial root of tooth is then removed Debridement of wound closure Irrigate with saline and inspect, Mosquito haemostat used to remove remnants of dental follule. control bleeding and sutures are placed -3.0 silk or vicryl can be used. Post operative care - Ice pack extra orally - Instructions same as for non surgical extraction - Instructions regarding mouth opening good oral hygene trisumus and swelling
Complications (can be included if need be) Intraoperative Due to LA haematona infection nerve damage Due to incision- bleeding due to damage of facial artery, retromolar vessels Damage to lingual nerve Damage to soft tissue Complications during bone cutting abrasions (burn) - injury to adjacent tooth - Damage to mandibular canal - injury to lingual nerve - necrosis of bone - injection Complications due to elevation of tooth - Adjacent tooth injury - Adjacent tooth luxation 16. Fracture of jaw Injury to inferior dental canal Displacement of tooth into lingual pauch Immediate post operative Pain Swelling Prolonged anaesthesia Bleeding Delayed- Trismus Delayed Healing Dry socket
SHORT ESSAY 1. Inferior Alveolar Nerve Block (IANB) Other name: Mandibular block
Areas anaesthetized Mandibular teeth to midline Body of mandible, inferior portion of ramus Buccal mucoperiosteum, nucous membrane anterior to mandibular 1 st molar (mental nerve) Anterior 2/3 rd of tongue and floor of oral cavity (lingual nerve) Lingual soft tissues and periosteum (lingual nerve)
Indications
Contraindications Infection or acute inflammation Patients who might bit lip or tongue Very young child Mentally or physically challenged patient
Advantages Wide area of anaesthetized for quadrant dentistry
Disadvantages Wide area of anaesthetized not needed for localized procedures 15-20% rate of inadequate anaesthesia Intraoral landmarks not consistent 10-15%- positive aspirations Lingual and lower lip anaesthesia dangerous for patients in whom its contraindicated Possible anaesthesia possible where bifid inferior alveolar nerve and bifid mandibular canals.
Technique 1. 25 gauge long needle inserted in mucous membrane on medial side of rames at intersection of 2 lines 1 horizontal height of injection 1 vertical representing anteroposterior plane of injection
2. Landmarks i. Mucobuccal fold ii. Anterior border of mandible iii. Coronoid notch iv. Internal and external oblique ridge v. Retromolar triangle vi. Buccal sucking pod vii. Pterygomandibular raphe, ligament and space occlusal plane of mandibular posterior teeth
3. Orientation of needle bevel at roughly 90 to the nerve through mucosa, a thin plate of buccinator muscle, loose connective tissue and buccal pad of fat.
Procedures Position of operator for right handed operator Right I ANB 8 O clock position facing patients Left I ANB - 10 O clock positions facing patients Patient supine or semisupine, mouth opened wide body of mandible is parallel to floor Approximating structures when needle is in position Superior to: Inferior alveolar nerve + blood vessels Insertion of internal pterygoid nerve Mylohyoid vessels + nerve Anterior to deep part of parotid gland Medial to inner ramus Lateral to: Lingual nerve, Internal pterygoid, Sphenomandibular ligament
Left thumb palpates mucobuccal fold is moved posteriorly till contact is made with external oblique ridge in the greatest depth of ramus i.e coronoid notch in line with mandibular sulcus. Palpating finger moved lingually across retromolar triangle and into internal oblique ridge and buccal sucking pad. Holding ramus between thumb and index finger, Needle is inserted from opposite side of mouth parallel to occlusal plane of mandibular teeth. At a level bisecting the finger penetrating tissues of pterygoid temporal depression entering pterygoid mandibular space. Needle must be inverted half the width of ramus thats hold between index finger and thumb and then withdrawn about 5mm -1-1.8 ml of LA injected over 1 1/2 -2 min after aspiration. Needle is withdrawn and when half of its inserted depth is withdrawn remainder of LA is deposited to anasthetized lingual nerve (0.1 ml) withdraw syringe slowly and make needle safe wait for 3-5 min before starting therapy.
Symptoms of Anesthesia Subjective Jingling and membranes of areas supplied by inferior alveolar nerve Objective Instrumentation does not elicit pain
Failures Depositing too inferiorly or anteriorly follow protocol If bidifid inferior alveolar nerve- incomplete anesthesia so, deposit la lower to normal landmark as a 2 nd mandibular foramen is generally present there if central or lateral incisors are supplied by mylohyoid nerve, they dont get anaesthetized so infiltrate supraperiostatly or give PDL injection
SHORT ANSWERS Bupivacaine Bupivacaine HCl Amide: Metabolised in liver by conjugation with glucoranic acid, end products Potency: 4 times, that of Lidocaine, Mepivacaine, Prilocaine Toxicity- less than 4 times that of lidocaine + mepivacaine Onset of action: 6-10 min Effective dental concentration: 0.5% Anaesthetic half life: 2.7 hours Maximum recommended dose: 2 mg/kg (upto 825 mg with epinephrine 1: 2,00,000 + 175 mg without vasoconstrictor) Total doses repeated upto once every 3 hrs not to exceed 400 mg in 24 hrs Uses: For postoperative pain: in lengthy dental procedures Contraindications: not in children or physically + mentally challenged patients due to risk of self mutilation