Professional Documents
Culture Documents
AND COMPLICATIONS
INTRODUCTION
CAUSES OF IMPACTION
CLASSIFICATION
ASSESSMENT
-MAXILLARY CANINE
-OTHER TEETH
COMPLICATIONS
CONCLUSION
REFERENCES
Impacted tooth is 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.
Malposed tooth is tooth, unerupted / erupted which is in an abnormal position in the
maxilla/mandible
Unerupted tooth is a tooth not having perforated the oral mucosa.
Classification
Impacted, mandibular 3rd Molar
I. Winter (1926) – 1st to device classification
1. Vertical – 38%
2. Mesioangular – 43%
3. Horizontal – 3%
4. Distoangular – 6%
5. Buccoangular
6. Linguoangular
7. Inverted
8. Unusual
II. Pell & Gregory
a) Relation of the tooth to ramus of mandible & 2nd molar
Class I: - Sufficient amount of space for accommodation of mesiodistal diameter of the
crown of the 3rd molar
Class II: - The space between the ramus and distal side of 2nd molar that is less than
mesiodistal diameter of the 3rd molar.
Class III: - All/most of the 3rd molars is located within the ramus.
b) Relative depth of the third molar in the bone
Position A: - The highest portion of the tooth is on a level with/above occlusal line.
Position B: - The highest portion of the tooth is below occlusal plane, but above the
cervical line of the 2nd molar.
Position C: - The highest portion of the tooth below the cervical line of the 2nd molar
teeth in relation to the long axis of impacted 2nd molar
B. The position of the long axis of the impacted maxillary 3rd molar in relation to the long
axis of the 2nd molar.
1. Vertical
2. Horizontal
3. Mesioangular
4. Distoangular
5. Inverted
6. Buccoangular
7. Linguoangular
They may occur simultaneously in
a. Buccalversion
b. Lingual version
c. Torsi version
Maxillary canine
Archer classifies maxillary impacted cuspid s as followes:
Class 1: Impacted cuspids located in the palate.
1. Horizontal.
2. Vertical
3. Semi vertical
Class2: Impacted cuspids located in the labial or buccal surface of maxilla.
1. Horizontal.
2. Vertical
3. Semi vertical
Class 3: Impacted cuspids located in the both palatal process and labial /buccal maxillary
bone; e.g., the crown is on the palate and root is on the labial surface of maxilla.
Class 4: impacted cuspids located in the alveolar process, usually vertically between the
incisor and first bicuspid
Class 5: Impacted cuspids located in the edentulous maxilla.
A. Root morphology
The number of factors considered.
a) Length of the root - Optimal time is when the roots ⅓ to ⅔ formed. When this is the
case, the ends of the roots are blunt and almost never fracture. If the full length of root
develops, the possibility of abnormal root morphology and the fractures of the root tip
during extraction increases. If the root development is insufficient less than ⅓ of the tooth,
it is difficult to remove, because it tends to roll in its crypt like a ball in a socket, which
prevents easy elevation.
b) Single/conical, separate/distinct roots are noted.
c) Curvature of roots - the surgeon should examine the tooth apex area carefully to assess
the presence of the small, abnormal and sharply hooked roots that probably fracture if the
surgeon does not give them special consideration. The direction of root curvature also
examined.
d) Total width of the roots in mesiodistal direction should be compared with the width of
the tooth at the cervical line.
e) Assess the periodontal ligament space. More the width the periodontal ligament space is
the easier the tooth is to remove.
Localizing the mandibular canal in relation to lower 3rd molar impaction is valuable in
planning surgical technique to avoid trauma to nerve.
G. Lingual Nerve
The studies by Kisselbach and Chamberlain demonstrated that the lingual nerve may be
located some time slighter superior to the crest of bony ridge medial to the mandibular 3rd
molar region and only ½mm toward midline in the lingual soft tissue. At this position
lingual nerve is at risk during flap reflection. Usual location is superior and inferior to
mylohyoid muscle. The nerve may be in various locations from crest of alveolar process
to positions below mylohyoid muscle. More than one branch of the nerve may be present,
and the position of the lingual nerve, relative to the mandibular 3rd molar may vary
depending on the intersection of the body of the mandible and the ramus. The lingual nerve
is relatively more superior and more directly associated with the soft tissue immediately
adjacent to the mandible and hence greater chance of damage during surgery, in the class
III and II relationships than in the class I .
L. Wharfs assessment
The six factors chosen for scoring are
A) Winters classification
B) Height of the mandible
C) Angulation of the molar
D) Root shape
E) Follicle
F) Path of exit of the tooth during removal.
The scoring by this system helps the beginners to anticipate problems and to avoid
difficult impactions. Unfortunately disadvantage of this method is that it is relate d only to
radiological features alone, the details of the surgical procedures are not considered. The
total scoring is directly related corresponding difficulties in removing that impacted teeth.
Scoring details for Wharf assessment.
NOMBER RADIOGRAPHIC CATEGORY SCORE
CHARECTERISTICS
1. WINTERS Horizontal 2
CLASSIFICATION Distoangular 2
Mesioangular 1
Vertical 0
2. HEIGHT OF THE 1-30mm 0
MANDIBLE 31-34mm 1
35-39mm 2
3. ANGULATION OF 1˚-50˚ 0
THE THIRD 60˚-69˚ 1
MOLAR 70˚-79˚ 2
80˚-89˚ 3
90˚+ 4
I. OBSERVATION
II. EXPOSURE
III. TRANSPLANTATION
IV. REMOVAL OF IMPACTED TOOTH
Observation
If the impacted mandibular 3rd molar is encased in bone with no perceptible to follicle,
as may be seen in an older individual and if it has no history, signs of associated
pathology, long-term observation is appropriate.
Most impacted teeth retain an erupting potential and annual/biannual evaluation would be
needed if no indications for direct surgical management arise.
Exposure
- Is considered if there is
Probability that it may erupt into useful occlusion
But obstructed by follicle, sclerotic bone, hypertrophic soft tissue, odontoma etc.
If the 2nd molar is absent, exposure of a third molar that is blocked from eruption may be
considered.
Removal
The primary reasons to remove impacted teeth are to correct associated pathology and to
intercept reasonably expected pathological process.
Indication for therapeutic removal of 3rd molar
1. Pericoronitis
2. Periodontitis
3. Caries
4.Pathologic resorption
5. Cyst formation
6. Neoplasm
7. Pain
8. Retention in an “edentulous” ridge
9. Crowding of dentition
10. Involvement in a fracture
1.Henry during 1st half of 20th century developed a technique of removal of 3rd molar at
bell stage of growth following morphodifferentiation, by enucleation/aspiration.
Preparative analysis used to differentiate 2nd and 3rd molar tooth bud. Small incision
placed to remove the uncalcified tooth using curettes/suction devices. There are few side
effects and vascular/ neural complication.
2. Fister and Gross 1980 - To approach the tooth, an incision is made along the alveolar
crest from the anterior surface of the ramus to just behind the second molar. The
enveloped flap is raised and the bone over the tooth is removed with a bur. The ensuing
opening must be large enough to accommodate the width at the crown and allow easy
removal of the tooth whether the tooth is in any position; the remaining soft part of the
tooth germ generally furnishes enough space for displacement. So that tooth can be
removed without sectioning. Purchase point/distal bone removal done according to
demand of situations. After the tooth has been extracted, the remainder of the dental
follicle must be carefully removed, since the epithelilium has potential for continued
growth and may form a cyst/tumor.
The incisions
Incisions permit the elevation and retraction of surgical soft tissue flaps to give access to
The surgical site without endangering adjacent structure in normal positions.
The incisions may be considered in following sequences from posterior to anterior.
Posterior to the 2nd molar the usual incision takes advantage at the lateral flare of the
ramus and is angled from lateral to medial as it passes forward, terminating at the
distobuccal aspect of 2nd molar (ensure avoid cutting of lingual nerve). If incision were
given directly posterior to 2nd molar, in most cases it would be a medial side of ramus of
mandible on soft tissue not on the bone may open in to pterigomandibular space and may
encounter branches of lingual nerve. The inferior portion of the incision may terminate in
any location, depending on the indication of regional anatomy and surgeon’s preference,
from the distobuccal area of 2nd molar to bicuspid area.
Occasionally, there may be no anterior component to incision, anterior to distoboccual
angle of 2nd molar, however usually the incision passes anteriorly from distobuccal aspect
of 2nd molar and may terminate at the gingival papilla between 1st and 2nd molar.
There are two options for incision that pass in the vicinity of papillae - the incisions may
include the papillae/ it may pass in the buccogingival crevice adjacent to the teeth but
below the papillae.
A periosteal elevating instrument is placed in contact with the posterior surface of the
second molar and soft tissue elevated from the 2nd molar with a downward, apically
directed movement of the instrument into the gingival crevice. This elevation does not
extend medially past the distolingual curve of 2nd molar and the tip of instrument is kept
in firm contact with 2nd molar.
The second maneuver is a movement with the soft tissue-elevating instrument horizontally
across either the crest of the osseous ridge of the retromolar triangle/the crown of impacted
teeth. If it protrudes out towards lingual side, small sweeping motions anteriorly and
posteriorly, to raise retromolar tissue in a single block with a liver type movement. For
this purpose mucosal elevating instrument/curette are used. The tip should be in contact
with the bone/erupted teeth.
Surgical Closure
1. Wedge removal -In a study done in UK states 19% surgeons done wedge removal.
This step involves the removal of a triangular wedge of soft tissue immediately posterior to
the 2nd molar to provide surgical drainage. It is expected to repair by secondary intention,
producing granulation tissue for epithelialization and gingival attachment posterior to the
2nd molar. Indications for the procedure is when we have to give post operative dressing,
which will provide access that will be comfortable for the patient as the dressing are
changed.
When there is excessive tissue prevent beveling of incision to get edge-to-edge closure,
and also to get tight sealing the gingival tissue against 2nd molar.
2. Debridement
a. Smoothen the osseous surgical margins with a bur, irrigate with sterile saline/with hand
file.
b. Debridement of alveolus performed by generous lavage of saline and suctioning. It
removes debris generated by the cutting by bur.
c. When there is no residual cyst/other pathological lesions debridement by curettage is not
indicated. Curettage of surgical site may damage the residual periodontal ligament
attached to the alveolar wall. The major portion of the cellular response to vitalize
coagulum arises from the residual, undamaged, periodontal ligament.
d. If the follicle appears to be pathological, hyper tropic/inflammatory, it should be
removed with care to avoid straining of the lingual nerve.
e. If a cyst is being removed concurrently with the 3rd molar surgery, the cystic lining is
removed with a curette, but the remaining alveolar wall not involved in the cyst formation
are not curettaged.
According to Ailling if we do deft, delicate, accurate removal of the tooth with a minimum
manipulation of tissue, he suggests no drug to be placed in addition to the normally
occurring coagulum.
These objectives may be achieved by Suturing the flaps into position/depending on the
surgeons preference, by repositioning the flap and placing no sutures but relying the
maturation of the coagulum between the flap and osseous bed to stabilize the flap.
A survey of 100 surgeons reported.61% used only one suture posterior to 2nd molar .39%
used two-suture posterior to 2nd molar.2 surgeons rarely used. Alling states that it is better
to place 2/more suture to firmly stabilize the flap.
Intraoral Dressings
It is most important in preserving the coagulum during critical 1st hour of repair. It is
advisable to use folded gauze moistened with saline/water to prevent adherence to oral
mucous membrane and to prevent dislodgement of clot from surgical site. It is better to
retain the gauze to remain place for at least 1to 2 hours.
Incisions
Incisions for exposing the site of impacted teeth maxillary 3rd molar should be full
thickness
The usual incision, which is described from posterior to anterior, is routinely placed over
the mid portion of the tuberosity/slightly buccal to intersect the distobuccal aspect of 2nd
molar. It passes anteriorly in to gingival crest. According to Surgeons preference
extension to 1st molar mesiobuccal surface and oblique extension /releasing incision
placed. The mucoperiosteal tissue covering the crown of impacted tooth is loosened and
reflected. Parallel portion of mucoperiosteal tissue reflected.
Using appropriate elevator, using buccal plate used as fulcrum, the tooth is elevated
buccally and distally from the alveolus.
Maxillary 3rd molar may also displaced by cyst/ tumor. In such case ideal surgical plan
would be to enucleate the lesion and to remove associated teeth.
1. Hemorrhage
The PSA artery may be positioned on the lateral surface of the tuberosity. In this case it
may be lacerated by LA injection/during elevation of mucoperiosteal flap. If it is due LA
injection intact overlying tissue may balloon and stop hemorrhage by pressure against
artery. If bleeding occurs during elevation of periosteum/flap it is initially stopped by
pressure from metal instrument followed by either crushing of contagious bone to small
vessel or by electrodessication by cautery. Hemorrhage may be fro injury to pteriogoid
plexus of veins by needle tip. No specific immediate treatment necessary.
2. Ecchymosis
The raising of Intraoral flaps may produce a normal postoperative ecchymosis, creating
subcutaneous discolorations in the facial tissue. Usually it is seen in buccal facial space,
between elderly patients ecchymosis may dissect to distant sites.
3. Trismus
May occur due to inflammation, infection and hemorrhage may secondarily affect
masticatory space and produce trismus.
Localizations
It may be in one of 4 locations
1. It may pass through sinus membrane and may be in the sinus.
2. It may be between the sinus membrane and osseous wall of the sinus.
3. It may be lodged under the mucoperiosteum lateral to the alveolar process.
4. It may pass posteriorly in the infratemporal space
• Tube shift x-ray method, often with periapical films used for exact location.
• The positioned x-ray films are taken with patient’s head in an up right position, forward in
the prone position and posteriorely in the supine position.
Spontaneous removal
* If a non-infect root is in the sinus of a patient who is historically and clinically free of
sinus inflammations there is no need to remove the root. The antral cilia should be given
opportunity to carry the root to the ostium of the antrum. If this occurs, with in 10
days/less time root will be expelled through the nose. Patients may recover the root by
sneezing/blowing the nose.
* If the root remains in the antrum, the patient should be monitored to determine whether it
would cause an inflammatory response. If the retained root is a psychological problem to
patient/if doctor considers it is better to remove prophylactically the root should be
removed. Roots that remained in the maxillary sinus for months/years are usually bound
to the normal sinus membrane by make fibrotic tissues.
Surgical Removal
An empty alveolus should never enlarged to recover a root/tooth from maxillary sinus
since it may end up in Oroantral tissue. Recovery of root may be accomplished by one of
the two approaches.
1. Opening made in the posterior lateral wall of the sinus, in the lower aspect of zygomatic
process of maxilla.
2. Through an opening in the canine fossa of anterior surface of maxilla.
If the sinus is acutely inflamed it may be necessary to make nasal-antral drainage window
following the removal of a root/tooth.
Post operatively excess soft tissue posterior to 2nd molar interferes with oral hygiene and
affects gingival attachment
Excessive tissue removed with a pyramid- shaped tissue mass with the base against the
2nd molar (the incision line should be divergent the mucosa. The buccal incision beveled
more than the lingual one because the mucosa covering soft tissue is more abundant and
there is no concern or encountering of highly placed lingual nerve.
Tooth segment displaced through very thin cortex of submandibular fossa may remain in
submandibular gland.
3 options
1. Indefinite observation and treatment as indicated if on inflammatory process should
occur.
2. Delay of removal for 3/4 weeks to await stabilizing fibrosis and then removal of
segment.
3. Immediate/early removal.
Surgical Procedure
Incision from the retro molar triangle to cuspid region with a lingual gingival crevice
incision done. The mucoperiosteum is elevated to the mylohyoid muscle. Scalpel used to
excise myelohyoid muscle fibers from bicuspid to 3rd molar region about 4mm from
margin of mandible. An assistant/surgeon provide superior support of submandibular
tissues, and the surgeon slowly separates the lobules of the submandibular gland with a
mosquito hemostat until the root is located and removed. Mylohyoid muscle incision is
closed with chromic gut suture and medial mucosal flap is closed in usual manner.
Hemorrhage
Hemorrhage following removal of mandibular impacted teeth may arise from inferior
alveolar vessels. Blood loss may be rapid patient may go for hypotension.
Preoperative radiographs used to observe
1. Proximity of the tooth to inferior alveolar canal.
2. Tributaries from inferior alveolar vessel.
3. Radiolucencies produced by AV aneurisms.
If inferior alveolar vessel is cut prompt hemorrhage ensues. If it is incompletely cut
intermittent copious hemorrhage occurs.
1.Cleansing the alveolus, suctioning, usually controls hemorrhage. Pack oxidized cellulose,
microfibirillar collagen haemostatic material into the site.
2. Crush bone into the bleeding site using sharp curette, but it may damage inferior
alveolar nerve.
3.Seperately neurovascular bundle with sharp curette, free the arteries and use
Electrocautery.
Prevention of Complication
* Attention to the basic principles of surgery, including proper preparation of patient,
evaluation, asepsis, hamostasis, use of controlled force, thorogh debridement and
meticulous management of bone and soft tissues, will reduce the severity of side effects
and the number of complications.
* To reduce complications current literature advocates removal of 3rd molar at an early
age by experienced surgeon, the unpleasant side effects and complication rates are
dramatically reduced
* The prophylactic use of antibiotic are advised unless there is a systematic condition
present that indicates their use. They may be used locally to prevent dry socket.
* Many studies suggest that the use of glucocorticosteroid in management of postoperative
pan, swelling trismus decreases pain, swelling and trismus.
* The literatures also suggest the use of long acting L.A. and NSAID s in the management
of postoperative pain.
* Efficacy of most of the opoids in the management of postoperative pain was poor.
periosteum should be carefully reflected from the bone and the fragments should be
removed with the tooth.
Predisposing factors
1. Injudicious force during removal of deeply impacted tooth
2. Patients with osteoporosis and other disorder of bone.
3. Mandible weakened by cysts or tumors.
4. Severely atrophic mandible
5. Infection involving bone surrounding the tooth. The patients with above conditions are
more likely to experience fracture of mandible.
• When a fracture occurred, the tooth should be removed carefully so that injury to inferior
alveolar nerve minimized. The fracture is than reduced and managed in the standard
fashion usually with intraosseous wiring or bone plating technique.
4.Root fracture
5. Oro antral communication.
Postoperative Complication
1. Post operative Hemorrhage
Hemorrhage most of the time is due to local rather than systemic factor
Thorough History taken prior to impaction surgery.
(i) Patients taking NSAIDs on chronic basis may affect platelet function prolong the BT
(ii) Patients taking anticoagulants.
(iii) Coagulopathy disorders.
When the bleeding is local an aggressive approach is usually indicated. Vital signs should
be obtained and recorded. IV infusion started. Infuse Normal Saline /Ringers lactate if
indicated. Pressure must be used.
Status, local haemostatics, crushing the bone over bleeding site are used whenever
indicated.
2.Myelspherulosis
1969 - Meclotchin and associates reported it as a fungal disease.1980 - Dunlap and Barker
described two cases. Later Lynch reported six cases.
Most cases have occurred following surgery in which the surgical site was dressed with a
tetracycline-containing petrolatum-based ointment. Spherules noted microscopically were
erythrocytes altered by the petrolatum and the brownish black color was due to
decomposition of the heamoglobin. Most lesions are assymptomatic and present as a
swelling with an associated radiolucency on x-rays, however patient may present with
pain/purulent drainage. Treatment consists of thorough curettage and irrigation of area.
4. Epulis Granulomatosum
Exuberant - reactive form of tissue, which totally fills the socket within, severed days. It
indicates a foreign body, usually bony sequestrum within the socket. The patient should be
anesthetized, the socket curetted and irrigated of all debris.
5. Infections
* The surgeon must be prepared to distinguish between the pain, swelling and trismus
associated with surgical trauma and those associated with infection.
* Pain due to surgery peaks in 24 hours and then tapers. If pain increases after 3 or more
days following surgery, infection/localized osteitis considered.
* Dry socket is not usually associated with increase in trismus.
* Trismus occurs in 24 hours if associated with surgical trauma, however it begins on the
3rd/4th day following surgery, on infection must be considered.
* Swelling that increases after the 2nd/3rd day following surgery is most commonly as a
result of infection. The swelling is firm rather than soft, it is extremely tender to palpation
and the overlying skin is warm and erythematous. General systemic sign such as increase
in body temperature, chills and malaise must be considered.
* Infections after 3rd molar surgery usually limited to site, infections may involve the
buccal and temporal spaces and some times submassetric and pterigomandibular spaces
may be involved.
Management
1.Use of antibiotics.
2.Surgical drainage.
3.Supportive management.
6.Osteomyelitis
* Uncommon may occur after removal of 3rd molar.
* Chronic swelling, dull pain and trismus are clinical findings.
* Lip anesthesia may be seen.
• Radiographs reveal osteolytic process
Management
* Surgery involves debridement of necrotic bone or soft tissue from the region and
decortications of buccal cortical plate. The primary blood supply in 3rd molar region is
from lingual soft tissue and the removal of the dense buccal cortex allows for frequent
irrigation of the infected bone.
* Parenteral antibiotics are given for a period up to 6 weeks.
* Control of risk factors such as DiabetesMellitis should be done.
* Fluid administration., Application of moist heat, rest. Analgesic and antipyretic.
Risk Factors
* Horizontal mandibular impaction is at higher risk than vertical and lingual impactions.
* Lingual nerve is at higher risk in approximately 10% of humans; in some the nerve
normally courses at a "high" level relative to the internal oblique ridge.
* Intra bony nerve and root proximity is as obvious risk factors.
• Burs used blindly beneath posterior and lingual flap may be associated with nerve injury.
* Smoking and other tobacco habits, poor oral hygiene with foreign body entrapment
adjacent to exposed nerve/over packing of a socket may complicate benign nerve injury.
* Dry socket may interfere with the down growth of regenerating axons and contribute to
neuroma formations.
* Patient’s general metabolic states and psychiatric status.
2. Compression injuries
1. It occurs usually to Lingual and infraorbital nerve from instrument retraction on tissue
flaps. Less than 80mm Hg pressure – interferes with micro vascular perfusion and induce
epineural edema, tingling parasthesia and reversible class I injury.
400mm Hg compressive forces cause micro vascular rupture, local demylination and gap
dislocation on the nodes of Ranvier.
ii) Displaced bone fragments and root/crown fragments lodged against nerve may exert
such effects - Epineural and intraneural edema - loss of large mylinated fiber coat.
iii) Patient with compressive lesions report early sporadic pain, later more constant
burning, radiating and throbbing pain. If there are signs of progression to class III
neuroma microsurgical internal decompression may be required.
3. Puncturing Injuries
Direct injury to nerve may occur due to elevator, burs/needles/indirectly from displaced
and sharp roots/bone spicules.
When patients sustain nerve injury, if they report an intense, burning sensation that
radiates distally through nerve distribution. Usually class I reversible injury occurs. But if
there is true intrafasicular puncture it may result in more severe class III, IV and VI
injuries. Careful monitoring of symptom and reflex recovery is needed. It ever after 3
months spontaneous or triggered pain is present surgical decompression, neuroma
resection and repair indicated.
4. Laceration Injuries
A nerve laceration may result from more severe crushing, penetration by larger
instruments, direct incisions and tears. Class V injuries may result due to formation of
amputation neuroma which will likely to interfere with normal lingual nerve recovery.
• Early exploration and microsurgical reanastamosis within 3 months produce excellent
results.
• Nerve tear result when traction exceeds the nerves elastic limit, usually seen in cases
where dilacerated roots has "hooked" the inferior alveolar nerve.
• Lingual nerve is especially vulnerable to tear lacerations when the nerve is localized at
higher-level
• Overzealous curettage and cyst enucleation may result in avulsive class V laceration.
• Incomplete laceration may result in lateral exophytic neuromas. Patients with such injuries
and neuromas typically have background aching pain and triggered sharp pain in response
to percussion of the retro molar mucosa. Such patients may need aggressive transcortical
exposure, excision of neuroma and reanastomosis correction.
Anesthesia Dolorosa –
Pain/annoying sensation felt in an area of subjective numbness.
Hyperpathia-
* It is a delayed, surging and spreading pain, brought on by moderate mechanical pressure.
* Often seen in association with class III and IV injuries.
* It is partially/temporarily blocked by blocking the nerve proximal to the injury.
* Inferior alveolar hyperpathia occurs when we compress on mental foramen.
* Lingual nerve hyperpathia may result in compression medial to internal oblique ridge.
Allodynia-
It is a quick, intermittent pain, response to low intensity stimuli that are not normally
painful.
Regional anesthesia blocks of both the trigger point and trunk quickly and completely
eliminate Allodynia and Hyperalgesia.
Non-surgical treatment
1. Physical therapy - encouraged engaging in regular work and play to increase vascular
perfusion with heat and movement. TENS used, nerve recovery zones should be touched
with recognizable object.
2. Medical treatments
• Sedative narcotics
• NSAIDS
• Topical capsaicin
• Anticonvalascents
• Antidepressants
iii) Behavioral therapy
It focuses on anxiety reduction, depression control and reversal of negative conditioned
behavior. Counseling should be done. A program of physical exercise and play should be
mandatory.
iv) Surgical Treatment
* Reparative surgery
* External land internal decompression
* Neuroma resection
• Direct/graft nerve reanastomosis.
Dry socket
Shafer and associates defines it as
Focal osteomyelitis in which the blood clot disintegrated or been lost, with the production
of foul odor and severe pain, but no suppuration.
Thoma explains it as
It is a condition in which the blood clot disintegrates. At 1st clot has dirt gray appearance,
and then it falls leaving a bony socket bare of granulation tissue. Suppuration absent, a foul
odor present, severe neurological pain persists for day. Symptoms starts from 2nd /3rd
days lasts for 10 to 40 days. Bare bone is extremely sensitive to touch. The socket may
not always open. It may contain necrotic granulation tissue/the orifice may be covered by
a flap of tissue so that detection is difficult. It occurs in spite of the most careful aseptic
procedure and regardless of the ability and judgment of the surgeon.
Incidence
Overall incidence of dry socket is 1% to 3.2%
AAOMFS - mean incidence of dry socket in mandibular 3rd molar area is 6.35%
More incidence of dry socket in the case of removal of mandibular 3rd molar by 9 studies
is 26.7%
Thus it is better to say dry socket occurs 10 times as frequently as compared to other site in
mandibular 3rd molar. Dry socket occurs twice as frequently when infiltration anesthesia
given which was compared with block anesthesia
Pathophysiology
Alling and Kerr studied on rhesus monkeys. They concluded that the delay of healing in
tooth extraction sockets is inversely proportional to the amount of residual periodontal
ligament remains after extraction. That is fewer periodontal membrane fragments remains
in the socket, the more likelihood of developing delayed healing/dry socket.
Theories of etiology
Dental practitioners throughout world have put their own theories about etiology of dry
socket.
Trauma
Poor blood supply
Pre-existing infections
Increased bone density
The nature of anesthesia
Fibrinolytic activity
The oral flora endemic to 3rd molar. .
1. Pre-existing pericoronits.
Incidence of dry socket is more. According to Kay its 71%. According to Meyer it is
14.1% of cases.
2. Smoking
More incidences in smokers 6.4% vs. 1.4%
3. Effects of Anesthesia
Lehmer study under LA - 3.1% developed dry socket, under GA - 2.2% developed dry
socket.
4.Poor Blood Supply-
The regional blood supply at the site of dry socket has been cited as a / contributing to
etiology. This speculation is based on the belief there is relatively greater density at bone
in the mandible than in maxilla. Very little scientific research available supports this fact.
Birn 1966 from his experimental study fond that blood supply gradually increases from
tooth to tooth towards posterior sections of dentations. It felt that blood supply greatest in
the gingival 3rd of periodontal membrane and least in middle third. He concluded that
blood supply in lower molar region is so poor, than in other regions of the jaws and
therefore above they does not suites. Dry socket hardly observed in gingival region.
5.Fibrinolysis
Birn was able to show that the pathogens at dry socket could be explained by increased
fibrinolysis actively in an around the tooth socket leading to partial/complete lysis and
destruction of blood clot. It may be due to invasion of extraction wound by enzymes
produced by bacteria or tissue kinases liberated during inflammation of wound repair.
Birn's hypothesis - sequence of event leading to dry socket
1. Inflammation of the marrow spaces (trauma/infections)
2. Subsequent release of tissue activators by injury of the cell.
3. The transformation of plasminogen to plasmin.
4. Which in turns dissolves the fibrin, thus producing loss of blood clot.
Birn also concluded that high fibrinolytic actively in dry socket and the resulting plasmin
formation came activation of prekininogen and kininogen, which are present in high
concentrations in bone marrow. The kinins thus formed give rise to the severe pain in dry
socket.
6.Sex Predisposition-
A study by Sweet and Butler showed incident of dry socket 4.1% in the female, 0.5% is
male patients (5:1).
Incidence twice high in patients taking oral contraception. Schow found that incidence of
dry socket is 15.4% in the male, 24.5% in the female not taking contraceptive pills, 44.6%
in the female taking contraceptive pills.
PREVENTIVE MEASURES
Many serious attempts have been made to over the years to find a technique a method a
drug/a combination that would eliminate this particularly offensive post extraction
complication.
Intra alveolar topical Medications-
1937 Sinclair 1st used Sulfonamides in Dry socket Barab (1940) Guinn, Greiss, Kraston,
Davis; Rudd (1963) used it subsequently.
1942 Ostronder and Hartman questioned efficacy of sulfonamides in prevention of dry
socket.
1951 Olech used placebo and sulfonamides. No statistically significant benefit derived.
1947 - ADA disapproved these preparations
* Researches tried Penicillin; high incidence of allergy was problem. ADA
contraindicated its use locally.
* As search for prophylactic antibiotic continued tetracycline came under scrutiny.
• Study by Quinly shown there dry socket incidence when tetracycline placed 5.78%
whereas the incidence when nothing was used was 33.5%.
Systemic Agents-
In 1961 Alty tried penicillin.8.6% in penicillin group developed Dry socket.33.7% without
penicillin group developed dry socket.1973 Helen and Nordensam - studied Lincomycin,
Penicillin and Whitehead varnish local bandage. After 3rd day incidence was 16% in
Penicillin V group.10% in lincomycin group.21% in control group. Curren and his co-
worker in his study stated that there is no justification for any systemic antibiotic use
routinely for third molar surgery.
Metonidozole-
* Rood and Murgatroyd carved out double blind study. Incidence in metronidazole group
is1%. In the placebo group is 4.2%.
* Kezies carried clinical trial using Metronidazole, Arnica montena (Homeopathic
medicine) and placebo concluded that metronidazole reduced incidence of pain and edema
and enhanced the healing process after surgery but had no effect on trismus.
* Bystedt assessed the effects of azidicillin, erythromycin, clindamycin and doxycycline
on postoperative complications after surgical removal of mandibular 3rd molar. They
concluded that systematically administered antibiotic offer only slight advantage in routine
operations of impacted 3rd molar (8% Vs 4 %).
* Treiger studied Clindamycin as a topical agent .Out of 172 mandibular 3rd molar
impactions 7 resulted in dry socket all in placebo gap.
Non-antibiotic agent-
Butler and Sweet studied sites receiving higher volume of irrigations (175ml) experienced
5.7% incidences. Whereas the sites receiving minor volume (25ml) experienced 10.7%
incidence. They concluded that simple lavage could reduce the incidence of dry socket by
58%.
* Lilly and colleagues studied use of phenol based antiseptic mouth rinse prior to
extraction of mandibular 3rd molar. They reported decreased incidence of dry socket.
* Tjernberg studied effect of 0.2% chlorhexidine gluconate mouth rinse or incidence of dry
socket. The result in test group 3.3% and in the correlation group 16.7%.
* Julies and associates carried out studied gelatin sponge soaked with oxytetracycline and
a corticosteroid was used as a socket dressing on one side, the other side of mandible. The
results indicate a incidence of 6.6% on the treated side and 28.8% incidence on the
untreated side. The study correlates when tetracycline alone used as the socket dressing.
TREATMENT
Despite the attempts to prevent dry socket none has been 100% successful. Prescribing
analgesic is one measure but itself, it is not enough. The degenerated and lost blood clot in
the tooth socket must be replaced. A protective dressing diminishes and protects against
irritants, diminishes pain, thereby decreases the need of analgesics.
* A number of agents like oil of clove, eugenol, zinc oxide, polyethylene glycol, benzoine,
glycerol, lignocaine, white heads varnish, thymol iodide and many other substances have
been used.
Requirements
1. It should not be irritating/caustic to oral tissue
2. The agent should not be complicated and simpler
3. Long effective
A common formula used is
Eugenol - 46%
Balsam of Peru - 46%
Chlorobutanol - 4%
Benzocaine - 4%
* Strip of iodoform gauze is used as the vehicle. Inspect the socket and confirm diagnosis
* Gently irrigate the socket, with warm saline; no attempt is made to curette the socket.
* Using cotton applicator/suction tip gently absorb fluids. Then the medicated strip - gauze
dressing is inserted into the socket. The dressing should not be packed forcefully, but
merely gently folded on it. While covering the exposed bone of the socket wide as much
as possible. Rare occasions LA may be necessary.
* Within 2/3 hours patient will notice significant relief and from pain. The need of strong
analgesics should be diminished.
* Patient recalled after 24 hours, frequently patients are completely comfortable, socket
irrigated and dressing changed.
* After 48 hours procedure repeated.
* Most of the cases two/three dressing will be sufficient
* Dressing should not be continued until patient is 100% free of discomfort because
dressing is foreign body and delays healing. It should be discontinued at the earliest
reasonable opportunity.
* Final measures to be taken, after dressings discontinued, are to instruct the patient in
keeping the socket clean. Patients can use disposable, plastic syringe with curved tip to
irrigate site with warm salt water.
* As the socket heals, the defect become shallower and finally it will be completely filled
and confluent with the surrounding gingiva. Once the healing socket no longer collects
debris, the irrigations may be discontinued. This stage is usually achieved in 3 to 4 weeks.
Extra oral and intra oral radiographs used. Atleast two views are necessary for each tooth.
It is a must that the position of the tooth is defined. The location of the crown, the location
of the apex, and the relations with adjacent sinal and dental structures, periapical views,
and occlussal views are used for the purpose.
Surgical steps
An impacted maxillary tooth is managed by
1. Surgical exposure
2. Attachment to an appliance to help in eruption.
3. Removal
4. Observations
I. Incision-
The incision usually made with the No.15 blade. The various incisions are the
1.labial gingival crevice incision.
2. An alternative gingival crevice incisions involving base of the papilla.
3. The oblique/vertical extension incision
4. Fenestration incision
5. Free mucosal incision
6. Labial push back flap incision
7. Palatal flap incision
8. Palatal cruciform incision
II Elevation of soft tissues
Most gingival and palatal soft tissue flaps are raised in one block from the subperiosteal
region with sweeping motion of a subperiosteal elevator.
III Retraction of soft tissues-
Retracting instrument should be placed on bone and flap should rest on instrument. This
technique will produce minimal amount of inflammation to the flap as it rests on the
instrument.
IV Operation on Bone
It consists of
1.Removing bone impeding a normal eruption
2. Removing bone over a tooth that is destined to have an orthodontic appliance
3. Removing the bone over the tooth, which is scheduled for removal.
Usually round bur at low speed under lavage of saline and suctioning used. Sometimes on
lateral aspect of alveolar bone unibevel chisel, a periosteal elevator may be used to remove
bone.
V Operation on Teeth
The possible operations on the tooth as
a. Surgical exposure
b. Application of devices
c. Removal of the tooth
d. Surgical repositioning /auto transplantation
Ideal time surgery is <20 years old this will reduce incidence of pathologic conditions and
postoperative sequels.
Surgical exposure
For a palatally impacted teeth surgery, begin with fenestrated flap/cruciform incision,
uncovering the crown overt its greatest curvature, avoiding placing instruments on the root
and provide a trough with a bur toward the direction planned for tooth eruption and the
area may be dressed with a periodontal pack for patients comfort. Similar procedure
employed for labia/buccal impacted tooth using fenestrated flap/a push back flap.
Application of devices
Various devices used are
a. Orthodontic brackets
b. Hooks
c. Chains
d. Wires
e. Pins
f. Crowns
* Devices applied to the coronal portion of the tooth especially to the incisal/ occlussal half
are indicated to the best directional control.
* Chains/wires placed around the radicular surface may critically injure the root.
* Orthodontic brackets and hooks are ideal for providing guidance but it difficulty in
obtaining dry field encountered other options like placement of plastic crown form,
placement of pin in the crown, or often preferred option, awaiting partial eruption of
crown.
Removal of the teeth-
Removal of maxillary impacted tooth considered, when it is not feasible to move impacted
tooth into the oral cavity. It requires certain knowledge about the location of tip of crown
and tip of the root, to minimize damage to adjacent important structures.
Surgical Repositioning and Transplantation
Selected impacted teeth may require repositioning by removing overlying soft tissue and
bony impediment and the possible use of gentle movement with an elevator, or it may
involve bodily movement of the tooth laterally/medially within the alveolar process/it may
be removing the tooth from its alveolus and transplanting it to another location.
TRANS ALVEOLAR TRANSPLANTATION - includes removing alveolar bone in the
direction toward which the tooth is to be moved, taking care to avoid touching the
cementum with surgical instrument. The transplanted from stabilized with an orthodontic
appliances 2 to 3 hours and endodontic treatment is performed. The tooth being
repositioned should have an immature apical orifice. When transplanting a tooth great care
taken to protect the gelatinous apical soft tissue.
Conclusion
The management of impacted teeth is the most common treatment oral and maxillofacial
surgeons do in day today practice. The tooth becomes impacted due to prevention of
eruption by adjacent teeth, excessive soft tissue etc. As a general rule, all impacted teeth
should be removed unless removal is contraindicated. Extraction should be performed as
soon as dentist determines impacted tooth should be removed .As the age advances
removing impacted teeth becomes more difficult. If the tooth left in place until the problem
arises, there is an increased incidence of local tissue morbidity, loss of adjacent teeth and
bone, and potential injury to adjacent vital structures un necessary delay makes surgery
more difficult, complicated and hazardous, because patient may have compromising
systemic disease. Preventive dentistry dictates that impacted teeth should be as soon as
detected.
REFERENCES
• IMPACTED TEETH: TEXT BOOK BY ALLING C.C.
SRINIVASAN
LORRY J. PETERSON
ARCHER