By

Dr: Waleed A Abdullah

Bds, Msc, Phd
Ass. Prof. of Oral and Maxillofacial
Surgery
King Saud University
 Definition :-
is a tooth that fails to erupt into its normal
functioning position in the dental arch
within the expected time.
The term Unerupted includes both
impacted teeth and teeth that are in the
process of erupting.
Causes of impaction
 Systemic Causes
A. a hereditary syndrom of
cliedocranial dysistosis
termed primary Retention.
B. endocrinal deficiency
(hypothyrodism,
hypopituitarism).
C. febrile disease, down
syndrom, irradiation (all
cause multiple teeth
impaction).
 Local Factors
A. prolonged deciduous tooth retention
B. malposed tooth germ
C. arch length deficiency
D. odontoginic tumors abnormal eruption
path
E. cleft lip and palate
frequency of impaction

- The order of frequency of impacted

teeth is as follow:-
 frequency of impaction
1. mandibular 3rd molar
2. maxillary 3rd molar
3. maxillary cuspid
4. mandibular cuspid
5. Mandibular premolar
6. maxillary premolars
7. maxillary central and lateral incisors
Evaluation
1. Include clinical inspection to disclose
tooth not in position or absent in place
and radiographic assessment Showing
the unerupted position of the tooth
2. Standard radiographic techs used to
localize the unerupted teeth, these
include:

 The tube shift method

 Periapical & occlusal films
 Panoramic view
 CT
 The tube shift method
• Uses two periapical radiographs, shifting
the tube horizontally between exposures.
• If the unerupted teeth moves in the same
direction in which the tube is shifted, its
located on the lingual or palatal side
• A facial or buccally located tooth moves in
the opposite direction to the tube shift.
 The periapical &occlusal
method
• Uses the periapical radiograph taken with
standard technique and an occlusal
radiograph to give different views of the
impacted tooth.
• Panoramic film can be used to assess
maxillary canine position
 Complication of
impacted teeth
(indication for removal):
• the presence of impacted teeth in the jaw
can create a variety of problems, so it
should be removed as soon as diagnosis
is made:
A. Pericoronitis
• when a tooth is partially
impacted with a large
amount of soft tissue over
the axial and occlusal
surfaces, the patient
frequently has
one or more episodes of
pericronitis.
 Definition of pericoronitis
• is an infection of the soft
tissue around the crown of
partially impacted tooth and
is caused by the normal
oral flora.
 Causes
1. If the patient experience a mild transient
decrease in host defense, pericoronitis may
result.
2. pericronitis may arise secondary to minor trauma
from maxillary third molar. The soft tissue that
covers the occlusal surface of the partially
erupted mandibular third molar known as the
operculum can be traumatized and become
swollen this can be treated by removal of
maxillary third molar.
3. entrapment of food under
operculum, in the pocket under
operculum and impacted
teeth ,this pocket can not be
cleaned ,bacteria invade it and
pericoronitis begins.
4. streptococci and anaerobic
bacteria (the usual bacteria
inhabit the gingival sulcus)
cause pericronitis .
Treatment and Management
• pericronitis can present as a very mild infection
or as a sever infection that requires
hospitalization of the patient .
A. In its mildest form:-
- Percronitis is present as a localized swelling
and soreness.
- Mild irrigation and curettage by dentist and
home irrigation by pt is suffice.
B. In sever infection with local tissue swelling:
that is traumatized by maxillary third molar ,the dentist
should consider the maxillary third molar and local
irrigation .
• for the patient who have in addition to local swelling
and pain, mild facial swelling ,mild trismus
secondary to inflammation extending into muscle of
mastication ,and a low grade fever, the dentist
should consider administration of antibiotics along
with irrigation and extraction, (penicillin is the
antibiotic of choice).
• the mandibular third molar shouldn't be
removed until sign and symptoms of
pericronitis have been completely resolved

• the incidence of post operative complication

as dry socket and post operative infection
,increases if tooth is removed during time of
active infection.
 B. Dental Caries
• When third molar is
impacted or partially
impacted ,the bacteria
that cause dental
caries can be
exposed to the distal
aspect of the 2nd
molar, as well as to
third molar
 C. Periodontal Disease
• Erupted teeth adjacent to
impacted teeth are
predisposed to periodontal
disease.
• As it decrease amount of
bone on the distal aspect of
adjacent 2nd molar, with
deep periodontal pocket on
the distal aspect of the 2nd
molar.
 D. Root Resorption
• Impacted teeth cause
sufficient pressure on
the root of an adjacent
tooth to cause root
resorption.
 E. Pain of unexplained
origin:

• Pain in the retro

molar region with
no obvious reason.
 F. Odontogenic cyst and
Tumors
• The dental follicle
may undergo cystic
degeneration and
become a dentigerios
cyst or keratocyst.
• A meloblastoma may
developed from
epithelium within the
dental follicle
 G. Fracture of the jaw

• impacted third molar

occupies space that is
usually filled with
bone, this weaken the
mandible and render
the mandible to
fracture.
 H. impacted teeth under dental
prosthesis:

I. Facilitation of orthodontic
treatment

• to relief crowding
of mandibular
anterior teeth.
Contraindication for
removal of impacted
teeth:
1. extreme of age:
- as the bone become highly calcified, less
flexible, less likely to bend under force of
tooth extraction
the result ,bone more surgically removed to
displace tooth from its socket and less post
operative sequla
2. compromised medical status:
3. probable excessive damage to adjacent
structure:
 Classification system
of impacted teeth

- this is done to help dentist in evaluation of

the extent of the surgical procedure and in
the planning of this procedure.
1-Classification of impacted
mandibular third molar:
A - Relation of the tooth to the ascending
ramus of the mandible and to the distal
surface of the 2nd molar: (Pell
&Gregory)
– this show the anterioposterior relationship of the
tooth to the arch and the amount of resistance
offered by the bone of the ascending ramus that
may influence the tooth removal
 Class1
• the space between
the anterior part of the
ascending ramus and
the distal surface of
the 2nd molar is
sufficient to
accommodate the
mesiodistal diameter
of the crown of the
third molar.
 Class2
• the space between
the anterior part of the
ascending ramus and
distal surface of the
2nd molar is less than
the mesiodistal
diameter of the crown
of the third molar (part
of the tooth located
within the ramus)
 Class3
• all the third molar is
located within the
ascending ramus of
the mandible.
 B - Relative depth of the third molar in
bone:
- this show the superior inferior
relationship of the tooth in
relation to the occlusal plan.
(Pell & Gregory)
• Position A:
the highest portion of the tooth is on level
with or above the occlusal plane.
• Position B:
the highest portion is below the occlusal
plane but above the cervical margin of the
2nd molar
• Position C:
the highest point of the tooth is below the
cervical margins of the 2nd molar (deep
impaction)
C - the position of the long axis of the impacted tooth in
relation to the long axis of the 2nd molar (winter's
classification):
1-vertical: the long axis of the third
molar is parallel to that of the 2nd
molar.
2-horizontal:the long axis of the third
molar is at right angle to that of
the 2nd molar .
3-mesioangular impaction.
4-destoangular impaction:
all the previous four classes can come in:
a - lingual deflection.
b - buccal deflection.
5-inverted impaction
2 -Classification of impacted
maxillary third molar:
1. The relationship of the tooth to occlusal plane of the
2nd molar (as before)
2. The relationship of tooth to maxillary sinus :
a-sinus approximation :
(s.a) where no bone or very thin bone exist
between the impacted teeth and floor of sinus.
b-no sinus approximation :
(n.s.a) where 2 mm or more of bone exist
between the floor of sinus and impacted teeth.
3-Classification of impacted
maxillary cuspids:
• Class1:
palatally impacted cuspids ,these could be in vertical,
horizontal, semivertical position.
• Class2:
labialy impacted cuspide which could be in vertical,
horizontal, semivertical.
• Class3:
impacted cuspid located both in the palatal and labial
surfaces.
• Class4:
impacted cuspid that are present in an edentulous
maxilla and may assume any of the previous three
classes.
Surgical removal of
impacted teeth:
1- Proper radiographic and clinical evaluation of
the condition:
A- periapical radiograph
B- occlusal radiograph
C- panoramic radiograph
2- Classification of impaction to help in planning
the surgical procedure:
3- Selection of the time for surgical procedure:
 surgical removal of impacted third molar is not as a
surgical emergency, it is an elective procedure which
shouldn't be postponed for along period of time until
several complication arises.
4- The condition should be explained to patient in
a simple easy way directing his attention to
possible complication that may arise from
leaving tooth in position
5- Surgical removal can be made under local
anesthesia as well as general anesthesia the
choice of the anesthetic technique depends on:
a- general condition of the patient and his ability
psychologically and physically take the procedure. in
very apprehensive patient, general anesthesia is
preferred.
b- position of impaction and extent of surgical procedure
c- patient co-operation
d- number of impaction that will be removed in the
setting
the surgical procedure is divided
into following stages:
 1- gaining access to impacted tooth:
A- elevation of an adequate
mucoperosteal flap to expose the
field of surgery:
 Pyramidal flap used in all third molar
impaction, the anterior incision of
the flap could extend from the distal
aspect to 2nd molar running at 45
degree angel and extend to the
mucobucal fold.
 In deep impaction ,a bigger flap is
advisable. the anterior incision could
start from the mesial aspect of 2nd
molar
 Envelope Incision
and reflection

When more
accessibility is
needed , a releasing
incision is made.
Envelope Flap Incision and Reflection

Triangular Flap Incision and Reflection

with palatally impacted maxillary
cuspid
- exposure of the field of surgery can
be done by gingival incision extending
from the palatal side of premolar in
one side to other side all around the
palatal gingiva of the present teeth.

with labially placed impaction

- a labial pyramidal flap is adequate
 2- bone removal

This is done for :-

A- exposure of impaction
B- reduction of resistance
C- making a point for application of the elevator
Bone Removal With a
Fissure Surgical Bur
 3- tooth delivery
1- total delivery by application of force using elevators:
a- mesial application of force :straight elevators and pot's
elevators.
b- buccal application of force :winter elevator
2-delivery of the tooth after tooth division :
- division is indicated to reduce resistance ,create a space or remove
interlocked cusps of the tooth
a- decapitation:- division of the crown of the tooth at cervical
margin level .
- indicated in horizontal mandibular and maxillary third molar
impaction and pallataly impacted maxillary cuspid
b- longitudinal tooth division:
- indicated when the impacted tooth has a widely divergent straight
roots, or when one root is straight and the other is curved
c- division of the interlocking cusp:
- this is done with mesioangular impaction ,removal of the inter
locking segment of the tooth usually located under the distal
surface of 2nd molar
Bone is removed with the surgical bur Decapitation is then performed
to expose the whole crown

A purchase point is prepared in the The second root is removed in the

root, which is then removed with an same way
elevator
 Preparation for wound closure:
- after removal of the tooth from it's socket the
wound is gently irrigated with sterile normal
saline solution and inspected for:
a- any remnant of the residual tooth sac is removed
b- remnant of tooth structure or fragments of bone
debris is gently removed
c- small fragments of the detached bone
d- sharp edges of interseptal or alveolar bone is
trimmed and smoothed
- then final irrigation and wound now is ready for
closure.
 closure of the wound:
• well designed and properly reflected flap fall back easily
into place. using have circle a traumatic needle and 000
black silk suture to hold flap into place

• post operative care:

1. a pressure pack is held in place for 1hour
2. post operative instruction given to pt:
3. cold packs on outside of face 20 min/h 5 time daily
4. proper antibiotic therapy
5. mouth wash
6. soft diet
7. patient return back for check up after two days
8. suture removal after 5 days
Complication associated with
surgical removal pf impacted
tooth:
1- laceration of the soft tissue flap:
a-improper incision
b-improper elevation of the flap and improper retraction
this leads to delayed healing and sever discomfort
2- affection of the alveolar bone:
3- fracture of the jaw:
- in angle of mandible ,improper use of elevator with
uncontrolled force
4- fracture of tuberosity:
this occurs with erupted rather than unerupted tooth
due to improper use of force
5-comlication related to injury of adjacent structure:
a-injury to inferior alveolar canal:
- occurs in deeply seated vertical impaction, the nerve pass
between roots of impacted tooth .permanent numbness and
heamorraghe
b-damage to nasal floor:
- during surgical removal of impacted maxillary cuspid, profuse bleeding
from nasal mucosa
c- involvement of maxillary sinus:
- during removal of impacted maxillary third molar. oro anntral
fistula results
d- pushing of impacted tooth into maxillary sinus:
e- pushing of impacted maxillary molar into pterigopalatine fossa:
- uncontrolled mesial application of force in deep impaction
f- pushing impacted mandibular third molar into sub-mandibular
space:
- uncontrolled buccal application pf force and fracture of the
lingual plate
g-aspiration or swallowing of impacted tooth:
- with general anesthesia ,
 post operative complication:
1. pain.
2. infection
3. heamoraghe
4. anesthesia or parenthesis of the lingual or inferior
alveolar nerve
5. trismus,limitation of jaw movement
6. osteomylitis
7. pain at tmj
8. pain on swallowing due to edema of pharynx and
hematoma formation.
Thank you