1. Management of Impacted Teeth Part I
Dr. Rahaf Al-Habbab BDS. MsD. DABOMS
Diplomat of the American Boards of OMFS
Consultant of Oral and Maxillofacial Surgery
Head of Orthognathic Unit
Saudi Boards Residents Director
Hospital Education and Residency Director
2013

2. What is the Difference between Impacted and Unerupted Teeth?

3. Impacted Teeth Teeth that fails to erupt into the dental arch
within the expected time, because of:
An adjacent teeth
Dense overlying bone
Excessive soft tissue
Genetic abnormality prevents eruption
Retained for the patient’s lifetime unless surgically removed or exposed because of resorption of overlying tissue.

4. Include impacted teeth and teeth that are in the process of erupting
Unerupted Teeth
Include impacted teeth and teeth that are in the process of erupting

5. Most Common Cause of Impaction
Inadequate dental arch length and space, where the total length of the alveolar dental arch is smaller than the total length of the dental arch
Most common impacted teeth are:
Maxillary and mandibular third molars (last to erupt)
Maxillary canines (crowding of other teeth)
Mandibular premolars, most commonly 2ed PM
(after molars and canine)

6. General Rule
All impacted teeth should be removed before complications arise unless removal is contraindicated or will cause more serious problems
Extraction should take place as soon as the dentist determines that the tooth is impacted
Dentist should not recommend to leave impacted teeth in place until they cause difficulty
Removal becomes more difficult with advanced age

7. Causes of Third Molar Impaction
Average age of third molar eruption completion is age 20, it may continue in some patients until age of 25.
Normal development of lower third molar begins in a
horizontal angulation (as the tooth develop and the jaw grow)→ mesioangular angulation → vertical angulation

8. Causes of Third Molar Impaction
Failure of rotation from mesioangular to vertical direction is the most common cause of third molar impaction
Lack of mesiodistal dimension of the arch length to the teeth anterior to the ramus

9. Advantages of Early Removal
Early removal reduces the postoperative morbidity and allows
for the best healing:
Young patients tolerate the procedure better and recover more quickly
Better periodontal healing because of better more complete regeneration of periodontal tissue
Better nerve recovery
Less dense bone and incomplete root formation

10. Ideal Impacted Third Molar Removal Time
When the roots are one third formed and before it is two third formed
Between the age of 17-20

11. Indications of Impacted Teeth Removal
Prevention of Periodontal Disease
Prevention of Dental Caries
Prevention of Pericoronitis
Prevention of Root Resorption
Impacted Teeth Under a Dental Prosthesis
Prevention of Odontogenic Cysts and Tumors
Treatment of Pain of Unexpected Origin
Prevention of Jaw Fracture
Facilitation of Orthodontic Treatment
Optimal Periodontal Healing

12. Prevention of Periodontal Disease

13. Prevention of Dental Caries

14. Prevention of Pericoronitis
Pericoronitis: Infection of the soft tissue (operculum) around the crown of a partially impacted tooth and its usually caused by normal oral flora

15. Trauma → swelling→ more trauma→ more swelling
Pericoronitis causes
If the host defenses are compromised (e.g., during minor illness, such as influenza or upper respiratory infection, or immune-compromising drugs)
Minor trauma from maxillary third molar
Trauma → swelling→ more trauma→ more swelling
Food entrapment under the operculum
Streptococci and a large variety of anaerobic bacteria causes pericoronitis (present normally in the gingiva)

16. Treatment Depending on the severity of the infection: Mild infection:
Mechanical debridement of the large periodontal pocket under
the operculum, using Hydrogen Peroxide, chlorhexidine,
iodophors, and normal saline.
Hydrogen Peroxide:
Mechanically removes bacteria with its foaming action
Release oxygen into the usually anaerobic environment reducing their number

17. Treatment
Chlorhexidine or Iodophors: Reduce the bacterial count of the pocket Normal Saline: If delivered under pressure it can reduce the bacterial number, and flush away food debris

18. Treatment Slightly more severe infection:
Large amount of local soft tissue swelling, being traumatized by
the maxillary third molar.
Management:
Local irrigation
Dentist should consider immediately extracting the maxillary third molar

19. Management More sever infection:
Patient with swelling, pain, and mild facial swelling
Mild trismus ??
Low grade fever
Management:
Local irrigation under pressure
Extraction of opposing tooth
Administration of Antibiotics (Penicillin, clindamycin in case of allergy)

20. Management Severe infection:
Involve facial spaces of the mandibular ramus and the lateral neck
Trismus (less than 20mm)
Temperature (greater than 101.2°F)
Pain and malaise
Management:
Refer the patient to OMFS
Patient hospital admission
I.V antibiotics and fluids administration
Careful monitoring

21. General Rules
Patient who develops one episode of pericoronits, is more likely to have another episode, unless the offending tooth is removed
The mandibular third molar should not be removed UNTIL the signs and symptoms of pericoronitis have completely resolved
If removed during active infection phase
(The incident of postoperative complications increase):
Dry socket
postoperative infection
Bleeding
Slower healing

22. Prevention
Removal of the third molar before they penetrate the soft tissue into the oral cavity
Operculectomy
painful
usually ineffective
recurs
The distal gingival pocket remains deep

23. Prevention of Root Resorption

24. Root Resorption??

25. Impacted Teeth Under a Dental Prosthesis
Slow alveolar bone resorption usually follow extraction, resulting in closer tooth to the bone
Overlying soft tissue ulceration
Initiation of odontogenic infection
Alteration of the alveolar ridge with extraction after bridge construction
Avoid removing it late at an older age (poor health, atrophic mandible)

26. Prevention of Odontogenic Cysts and Tumors
Dental follicle → Cystic Degeneration→ Dentigerous Cyst or Keratocyst
Epithelium within Dental Follicle → Odontogenic Tumors (Ameloblastoma)

27. Treatment of Pain of Unexpected Origin
Unexplained Pain at retromolar region
Exclude myofascial pain dysfunction syndrome and other facial pain disorders
Resolution of the pain sometimes result from the wisdom tooth removal

28. Prevention of Jaw Fracture

29. Facilitation of Orthodontic Treatment
Allows premolars retraction
Retromolar implants placement

30. Optimal Periodontal Healing
Two most important
factors:
Extent of preoperative infrabony defect on the distal aspect of the second molar.
Patients age

31. Contraindications for Removal of Impacted Teeth

32. Contraindications for Removal of Impacted Teeth
When the risks are greater than the potential benefits, the procedure should be Deferred Contraindications primarily involve the patient’s physical status

33. Contraindications for Removal of Impacted Teeth
Extremes of Age
Compromised Medical Status
Probable Excessive Damage to Adjacent Structures

34. Extreme of Age Young Age:
Third molar tooth bud can be radiographically visualized by age 6
It is not possible to predict accurately if the forming third molar will be impacted
Removal should be deferred until an accurate diagnosis of impaction can be made

35. Most common contraindication of impaction removal
Extreme of Age Old Age
Most common contraindication of impaction removal
As patient age:
Bone becomes highly calcified, therefore, less flexible and less likely to bend under extraction force
More possible postoperative complications and sequelae
Absence of periodontal disease, caries, or cystic degeneration at that age (over 35), makes it unlikely to develop at that age
But should be followed every 1-2 years

36. Compromised Medical Status
Usually go hand in hand with advanced age
If the cardiovascular or respiratory function or host defenses for combating infection are seriously compromised or the patient has a serious acquired or congenital coagulopathy
The surgeon should consider leaving the tooth UNLESS symptomatic
Should consider working with the patient’s physician for proper planning

37. Probable Excessive Damage to Adjacent Structures
Nerve, teeth, previously constructed bridge.
Have to look at the age of the patient too, and
Reason should be weighed against potential future complications

38. Case
Older patient with a sever periodontal defect on the distal aspect of the second molar, but its removal will surely result in the loss of the second molar
What should you do?

39. Summary
Patients with one or more pathologic symptoms or problems should have their impacted teeth removed
Most problems result from partially erupted teeth and less commonly with complete bony impaction
Less clear is what should be done with impacted teeth before they cause symptoms or problems
How to make a decision?

40. Factors to be considered
Available space in the arch into which the tooth will erupt.
The status of the impacted tooth and the age of the patient
Mesioangular third molar in 17 years old?
By the age of 18 the dentist should be able to predict whether there will be adequate room for the third molar to erupt

41. Reference: Contemporary Oral and Maxillofacial Surgery, 5th Edition James R. Hupp, Edward Ellis III, Myron R. Tucker Chapter 9, Principles of Management of Impacted Teeth

42. March, 2, 2013: Clinical Cases (Quiz) March, 9, 2013: Quiz (written)