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Unformatted text preview: Oral and Maxillofacial Surgery
October 2003 Terminology
Unerupted tooth (retained tooth): is that fail to erupt
into the oral cavity at the normal time and age.
Impacted tooth: is a retained tooth that is completely or
partially buried in the soft tissue or the bone.
Aberration: is a tooth that develop distant from its
Ectopic eruption: eruption of a tooth outside the arch
line based on clinical evaluation.
Agenesis: failure of a tooth to develop due to many
reasons and genetic factor is highly contributed.
reasons Common unerupted and impacted teeth:
Mandibular third molars
Mandibular second premolars
Maxillary second premolar
Mandibular canines Etiology of failure of eruption
Injury to tooth germ and
displacement of tooth
teeth size and jaw.
Premature loss of a
and gingival fibromatosis
supernumerary Presence of tumors or
Cleft palate and alveolus
Klipped feil syndrome
(Rational for treatment)
Majority removed because of pain or being a foci
Involvement in pathology like cyst and tumors.
Resorption of roots of adjacent teeth.
Interference in line of osteotomies and fractures.
Infection of surrounding soft or hard tissue.
For prophylactic reasons. CONTRAINDICATIONS
(Relative) Asymptomatic unerupted teeth that removal
is possibly complicated by an injury to
inferior dental or lingual nerve during
surgery Teeth of favorable position that can be
monitored at time intervals to detect the
development of any complications.
development Recognition of the problem:
The existence, position, orientation of the
impaction and diagnosis of associated
problems are based on:
Missing tooth or teeth with or without history of pain
and swelling of underlying mucosa (agenesis??)
In case of pain, effort must be paid to eliminate other
possible causes of dental pain from another tooth
such as pulpitis and periodontitis.
Pain at posterior aspect of the mouth that can be a
refereed type of pain such as earache, eye pain,
artherolgia, etc …..,)
Inflammation around the crown of the tooth that
make more acute symptoms (pericoronitis).
Recording of missing teeth.
Recording of retained deciduous teeth.
Identify caries and periodontal diseases.
(pain might be from adjacent carious tooth, this would influence the
proposed treatment planning)
proposed Vitality test of all teeth in doubt.
Examination for sign of infection.
(swelling, discharge, trismus and enlarged lymph nodes)
Facial asymmetry and jaw bone expansion. Radiography
To disclose the unerupted tooth and the texture of
the surrounding bone.
To disclose the position in the jaw and its relation to
adjacent teeth and other vital structures (sinuses,
To disclose the crown-root ratio and roots
(curvature, numbers, hypercemntosis, bulbous, fused or diverged)
(curvature, To disclose the degree and orientation of impaction.
To disclose atrophy of dental follicles and existence
of pathological development.
of Preoperative assessment
Asymptomatic unerupted teeth most often
discovered following radiographical
screening (accidental findings).
Partially erupted teeth might be associated with pain
Impacted lower wisdom tooth may cause crowding
upon anterior teeth.
Impacted tooth may erode or cause cavitation of
Impacted teeth may be associated with pathological
Infection involves the soft tissue surrounding the
crown of partially erupted tooth.
Usually caused by streptococci and anaerobic
It may presented as an acute or chronic infection.
Acute infection developed over hours and days and
associated possibly with systemic manifestation.
Chronic infection distinguished by redness and or
discharge of pus with few acute symptoms lasting
over weeks to months.
It may be associated with poor oral hygiene and
upper respiratory infection.
upper Sings and symptoms:
Swelling of retro-molar tissue
Erythemia of overlaying soft tissue or operculum
Facial swelling of the affected side
General malaise Contributory factors:
Trauma from an opposing over-erupted
Entrapment of food debris and bacterial
infection under the operculum
Physical and mental stress
Pregnancy and suppression of the immune
Upper respiratory tract infection Management of pericoronitis
Local irrigation by hot salt mouthwash.
Antibiotics if signs of spreading infection are
evident. (amoxycillin, metronidazole)
Analgesic and non-steroidal anti-inflammatory agent.
Extraction of upper opposing wisdom tooth if
traumatizing the lower operculum.
Removal of lower wisdom tooth when acute infection
Hospital admission in case of severe infection that
may compromise the airway.
may Considerations in clinical examination of an
impacted/ partially erupted tooth
Patient age and tooth eruption
Caries and restoration
Dental status of the adjacent tooth
State of the TMJ Status of tooth in question
based on clinical evaluation
Erupted but non-functional
(no opposing, tilted, carious, etc…..) Partially erupted
(covered partially with soft tissue)
(covered Partially erupted with sign of recurrent
Truly impacted (bony or soft tissue)
Association with pathological lesions Methods of radiographical examination
Radiographs in two planes at right angles are needed
to show clearly the position of the tooth and the
degree of impaction
degree Orthopantomogram (OPG)
Lateral oblique view of the jaw
Vertex occlusal view
Parellex method of Clark Radiographical assessment
Orientation (mesioangular, vertical,
distoangular and transalveolar)
Depth below the occlusal plane
Crown size and follicular width
Root morphology (number, length, shape:
fused or separate, curved apex, bulbous,
Condition of the crown and the adjacent
Approximation of an ascending ramus,
IDC, maxillary sinus, ptrygoid plates and
pyriform Management of impacted/
partially erupted teeth
partially Options of management
Surgical repositioning and transplantation
Exposure of the teeth with or without
Surgical removal No treatment
(Choices of putting tooth in probation) Asymptomatic tooth
When it acts as a buttress for the root of
When vital structures are at risk of injury in
the course of operation
In case of acute preicoronitis Conservative management
Tooth that might be brought into occlusion
provided that space is adequate in the
When adjacent tooth is carious, heavily
filled or missing.
Mesial drifting may allow tooth to replace poorly
prognosis or missing anterior one
prognosis Surgical repositioning and transplantation
Aimed to move tooth bodily into the dental arch
Careful surgical extraction is required to minimize
the damage to the apical vessels and periodentium
Imobilization within the prepared socket for 4 weeks
Success determined by the dental age (unclosed
apices), patient age and atrumatic surgery
Resorption of root might be evident in 2-5 years
Early endondontic treatment might be of help to
minimize the failure
minimize Third molar transplantation Surgical aids to orthodontics
It is mostly prescribed for impacted canine
Other teeth might be considered as well
Aimed to help in establishing optimum occlusion
The canine is very important esthetically
The success is very high
Surgery for exposure is much easier than for removal of
the impaction Surgery-assisted orthodontic traction
Reflection of mucoperiosteal flap
Crown is to be freed to its greatest circumference
Preservation of attached ginigiva for labially and buccally
Orthodontic device ( button, hock and ligature wire) is to be
Flap is to be then sutured back in position
For palatal placed teeth, soft tissue excision for exposure is to
be packed with whitehead’s varnish, BIPS, coepack
Orthodontist visit to be arranged one week post op for traction
application Removal of unerupted teeth
Best timing for removal
Earlier to sclerosis of bone
Earlier to follicle atrophy
When it is infection-free
Before fully development of roots
When 2/3 of the roots are formed Surgical Considerations
Localization of unerupted tooth
Morphology of the tooth and roots
Relationship to the inferior dental
Relationship to adjacent teeth
Relationship to inferior border of the
mandible and anterior border of the ramus
mandible Planning for operation
“Reverse in order”
The tooth position in jaw
The natural line of withdrawal
Overcome obstacles (ascending ramus and adjacent
tooth or teeth)
Point of application for elevation
Access by removing bone and design flap
accordingly Natural line of withdrawal
Teeth extracted by moving them away from
sockets or bone along their pathway
The course of movement is dictated by the
curvature of the roots
Unfavorable elevation refers to tooth goes
deeper in bone or impacted against another
tooth Violation of the principles of line of
Fracture of bone (the whole entity or part of
Displacement of tooth into soft tissue or
Damage of inferior dental nerve Obstacles to elevation
√ shape of the tooth and root
√ Constriction at the neck of the tooth
√ bone and depth of the tooth
√ adjacent tooth (impaction against a tooth )
√ adjacent vital structures (the inferior dental neurovascular bundle) Overcoming the obstacles
Removing sufficient bone to allow tooth to be
rotated and delivered
Division of the tooth horizontally or vertically
or by both using:
√ drill and large fissure bur
Removal of lingual plate using:
√ chisels and mallet Point of application
Dental elevators is the best for removal of
Point of application must be determined
Point of application is to be prepared
simultaneously during access preparation
No tooth division until adequate point of
application has been prepared.
application Preparation for surgery
Preparation Hospital and general anesthesia
Outpatient clinic with either intravenous
sedation or local anesthesia
sedation Surgical access
Flap must be sufficient enough to allow direct vision
with no chance of tension and trauma
Bone removal should permit tooth with its greatest
crown dimension to pass freely (tooth division may
minimize the need for more bone removal)
Curved and bulbous root must be made free of bone
Cutting of bone and tooth division must be
completed before attempting elevation
Flap is to be replaced and rests on bone before
suturing Closure of wound
Debridment and smoothening of sharp edges of the
Removal of dental follicle (sack) without
endangering vital structure (lingual nerve)
Primary closure as long as flap is not under tension
Resorbable or non-resorbable suture may be used
Suture notes should be kept to a minimum Position
Transbuccally (crown facing lingually or
Apparent position; ramus or close to inferior
border of the mandible Surgical considerations
Position of unerupted tooth (3rd molar or canine)
Relationship to adjacent teeth
Relationship to maxillary sinus
Morphology of the roots
Status of adjacent teeth
Presence of supernumerary and supplemental teeth Upper third molar
The envelop flap
Two sided flap (triangular type)
Establishment of OAF
Closure Removal of unerupted teeth from
Difficulty is owing to sclerotic bone and loss of periodontal
Gentle force via a well prepared point of application would
minimize the risk of fracture of brittle bone
Alveolar ridge preservation by accurate assessment and
minimal bone removal
Osteoplastic flap to preserve the alveolar bone in height and in
Bone reduction and fixation in the incident of
atrophic jaw fracture
atrophic Difficulties-associated surgery
Narrow space between anterior border of the ramus
and distal aspect of second molar
Tooth buried deeply in bone
Approximation of inferior dental canal and sinuses
Existence of fusion and ankylosis
Devitalizations and cavitations complications associated with
unerupted and impacted teeth
√Fractured root, tuberosity
√Damage to adjacent tooth, tooth displacement
√ oroantraloronasal communication
√ pain, swelling, bruising, trismus, aneathesis, infection ...
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This note was uploaded on 11/10/2011 for the course PDBIO 220 taught by Professor Tomco during the Winter '09 term at BYU.
- Winter '09