Unerupted and impacted I

Unerupted and impacted I - Oral and Maxillofacial Surgery...

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Unformatted text preview: Oral and Maxillofacial Surgery 311 MDS October 2003 Terminology Unerupted tooth (retained tooth): is that fail to erupt Unerupted (retained into the oral cavity at the normal time and age. into Impacted tooth: is a retained tooth that is completely or partially buried in the soft tissue or the bone. partially Aberration: is a tooth that develop distant from its normal location. normal Ectopic eruption: eruption of a tooth outside the arch line based on clinical evaluation. line Agenesis: failure of a tooth to develop due to many reasons and genetic factor is highly contributed. reasons Common unerupted and impacted teeth: Common Mandibular third molars Maxillary canines Mandibular second premolars Maxillary second premolar Mandibular canines Etiology of failure of eruption Etiology Tooth agenesis. Injury to tooth germ and Injury displacement of tooth follicle. Crowding and disproportion between teeth size and jaw. teeth Premature loss of a Premature deciduous predecessor and gingival fibromatosis and Presence of Presence supernumerary teeth supernumerary Presence of tumors or Presence cysts cysts Cleft palate and alveolus Cleidocranial dysostosis Conginital brevicollis Conginital dystrophy dystrophy Klipped feil syndrome Hypopituitarism Cretinism (infantile Cretinism hypothyrodism) hypothyrodism) Rickets INDICATIONS (Rational for treatment) (Rational Majority removed because of pain or being a foci Majority of infection. of Involvement in pathology like cyst and tumors. Involvement Resorption of roots of adjacent teeth. Resorption Interference in line of osteotomies and fractures. Infection of surrounding soft or hard tissue. For prophylactic reasons. CONTRAINDICATIONS CONTRAINDICATIONS (Relative) Asymptomatic unerupted teeth that removal is possibly complicated by an injury to inferior dental or lingual nerve during surgery treatment. surgery Teeth of favorable position that can be Teeth monitored at time intervals to detect the development of any complications. development Recognition of the problem: Recognition The existence, position, orientation of the impaction and diagnosis of associated problems are based on: problems History Clinical examination Radiography Radiography HISTORY HISTORY Missing tooth or teeth with or without history of pain Missing and swelling of underlying mucosa (agenesis??) and In case of pain, effort must be paid to eliminate other In possible causes of dental pain from another tooth such as pulpitis and periodontitis. pulpitis Pain at posterior aspect of the mouth that can be a Pain refereed type of pain such as earache, eye pain, artherolgia, etc …..,) artherolgia, Inflammation around the crown of the tooth that Inflammation make more acute symptoms (pericoronitis). make EXAMINATION EXAMINATION 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) (swelling, Facial asymmetry and jaw bone expansion. Radiography (objective indications) (objective To disclose the unerupted tooth and the texture of To the surrounding bone. the To disclose the position in the jaw and its relation to To adjacent teeth and other vital structures (sinuses, IDC, …..). IDC, To disclose the crown-root ratio and roots To configuration. configuration. (curvature, numbers, hypercemntosis, bulbous, fused or diverged) (curvature, To disclose the degree and orientation of impaction. To disclose atrophy of dental follicles and existence To of pathological development. of Preoperative assessment Preoperative Asymptomatic unerupted teeth most often discovered following radiographical screening (accidental findings). screening Partially erupted teeth might be associated with pain Partially and infection. and Impacted lower wisdom tooth may cause crowding Impacted upon anterior teeth. upon Impacted tooth may erode or cause cavitation of Impacted adjacent teeth. adjacent Impacted teeth may be associated with pathological Impacted cyst development. cyst Pericoronitis Pericoronitis Infection involves the soft tissue surrounding the crown of partially erupted tooth. crown Usually caused by streptococci and anaerobic Usually bacteria. bacteria. It may presented as an acute or chronic infection. Acute infection developed over hours and days and Acute associated possibly with systemic manifestation. associated Chronic infection distinguished by redness and or Chronic discharge of pus with few acute symptoms lasting over weeks to months. over It may be associated with poor oral hygiene and It upper respiratory infection. upper Sings and symptoms: Sings Swelling of retro-molar tissue Soreness Erythemia of overlaying soft tissue or operculum Trismus Facial swelling of the affected side Raised temperature Regional lymphodenopathy General malaise Contributory factors: Contributory Trauma from an opposing over-erupted Trauma wisdom tooth wisdom Entrapment of food debris and bacterial Entrapment infection under the operculum infection Physical and mental stress Pregnancy and suppression of the immune Pregnancy system system Upper respiratory tract infection Management of pericoronitis Management Local irrigation by hot salt mouthwash. Local chlorhexidine mouthwash chlorhexidine Antibiotics if signs of spreading infection are Antibiotics evident. (amoxycillin, metronidazole) (amoxycillin, Analgesic and non-steroidal anti-inflammatory agent. Extraction of upper opposing wisdom tooth if Extraction traumatizing the lower operculum. traumatizing Removal of lower wisdom tooth when acute infection Removal is resolved. is Hospital admission in case of severe infection that Hospital may compromise the airway. may Considerations in clinical examination of an impacted/ partially erupted tooth impacted/ Patient age and tooth eruption Associated infection Caries and restoration Dental status of the adjacent tooth Periodontal status State of the TMJ Status of tooth in question Status 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 Partially infection infection Truly impacted (bony or soft tissue) Association with pathological lesions Methods of radiographical examination Methods 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) Preapical radiograph Lateral oblique view of the jaw Vertex occlusal view Parellex method of Clark Radiographical assessment Radiographical Orientation (mesioangular, vertical, Orientation distoangular and transalveolar) distoangular Depth below the occlusal plane Crown size and follicular width Root morphology (number, length, shape: Root fused or separate, curved apex, bulbous, ankylosis). ankylosis). Condition of the crown and the adjacent Condition tooth tooth Approximation of an ascending ramus, Approximation IDC, maxillary sinus, ptrygoid plates and pyriform fossa. pyriform Management of impacted/ partially erupted teeth partially Options of management Options No treatment Conservative management Conservative Surgical repositioning and transplantation Exposure of the teeth with or without orthodontic application orthodontic Surgical removal No treatment No (Choices of putting tooth in probation) Asymptomatic tooth When it acts as a buttress for the root of When adjacent tooth adjacent When vital structures are at risk of injury in When the course of operation the In case of acute preicoronitis Conservative management Conservative Tooth that might be brought into occlusion Tooth provided that space is adequate in the arch line. arch When adjacent tooth is carious, heavily When filled or missing. Mesial drifting may allow tooth to replace poorly esial prognosis or missing anterior one prognosis Surgical repositioning and transplantation Surgical Aimed to move tooth bodily into the dental arch Careful surgical extraction is required to minimize Careful the damage to the apical vessels and periodentium the Imobilization within the prepared socket for 4 weeks Success determined by the dental age (unclosed Success apices), patient age and atrumatic surgery apices), Resorption of root might be evident in 2-5 years Early endondontic treatment might be of help to Early minimize the failure minimize Third molar transplantation Surgical aids to orthodontics Surgical It is mostly prescribed for impacted canine Other teeth might be considered as well Other Aimed to help in establishing optimum occlusion Aimed orthodontically orthodontically The canine is very important esthetically The success is very high Surgery for exposure is much easier than for removal of Surgery the impaction Surgery-assisted orthodontic traction Surgery-assisted The procedure: Reflection of mucoperiosteal flap Crown is to be freed to its greatest circumference Preservation of attached ginigiva for labially and buccally Preservation placed teeth placed Orthodontic device ( button, hock and ligature wire) is to be Orthodontic applied applied Flap is to be then sutured back in position For palatal placed teeth, soft tissue excision for exposure is to For be packed with whitehead’s varnish, BIPS, coepack be Orthodontist visit to be arranged one week post op for traction Orthodontist application application Removal of unerupted teeth Removal 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 Surgical Localization of unerupted tooth Morphology of the tooth and roots Relationship to the inferior dental Relationship neurovascular bundle neurovascular Buccolingual position Relationship to adjacent teeth Relationship to inferior border of the Relationship mandible and anterior border of the ramus mandible Planning for operation Planning “Reverse in order” The tooth position in jaw The natural line of withdrawal Overcome obstacles (ascending ramus and adjacent Overcome tooth or teeth) tooth Point of application for elevation Access by removing bone and design flap Access accordingly accordingly Natural line of withdrawal Natural Teeth extracted by moving them away from Teeth sockets or bone along their pathway sockets The course of movement is dictated by the The curvature of the roots curvature Unfavorable elevation refers to tooth goes Unfavorable deeper in bone or impacted against another tooth tooth Violation of the principles of line of withdrawal withdrawal Fracture of bone (the whole entity or part of Fracture it) Displacement of tooth into soft tissue or anatomical spaces anatomical Damage of inferior dental nerve Obstacles to elevation Obstacles Intrinsic √ shape of the tooth and root √ Constriction at the neck of the tooth Extrinsic √ bone and depth of the tooth √ adjacent tooth (impaction against a tooth ) √ adjacent vital structures (the inferior dental neurovascular bundle) Overcoming the obstacles Overcoming Removing sufficient bone to allow tooth to be Removing rotated and delivered rotated Division of the tooth horizontally or vertically or by both using: or √ drill and large fissure bur Removal of lingual plate using: √ chisels and mallet Point of application Point Dental elevators is the best for removal of Dental buried teeth buried Point of application must be determined Point during planning during Point of application is to be prepared Point simultaneously during access preparation simultaneously No tooth division until adequate point of No application has been prepared. application Preparation for surgery Preparation Hospital and general anesthesia Hospital Outpatient clinic with either intravenous Outpatient sedation or local anesthesia sedation Surgical access Surgical Flap must be sufficient enough to allow direct vision with no chance of tension and trauma with Bone removal should permit tooth with its greatest Bone crown dimension to pass freely (tooth division may minimize the need for more bone removal) minimize Curved and bulbous root must be made free of bone Cutting of bone and tooth division must be Cutting completed before attempting elevation completed Flap is to be replaced and rests on bone before Flap suturing suturing Closure of wound Closure Debridment and smoothening of sharp edges of the Debridment socket socket Removal of dental follicle (sack) without Removal endangering vital structure (lingual nerve) endangering Primary closure as long as flap is not under tension Primary is desirable is Resorbable or non-resorbable suture may be used Suture notes should be kept to a minimum Position Vertical Vertical Horizontal Mesioangular Distoangular inverted Transbuccally (crown facing lingually or Transbuccally buccally) buccally) Apparent position; ramus or close to inferior Apparent border of the mandible Surgical considerations Surgical 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 Upper Operative technique The flap The envelop flap Two sided flap (triangular type) Bone removal Establishment of OAF Closure Removal of unerupted teeth from edentulous ridge edentulous surgical consideration Difficulty is owing to sclerotic bone and loss of periodontal Difficulty space space Gentle force via a well prepared point of application would Gentle minimize the risk of fracture of brittle bone minimize Alveolar ridge preservation by accurate assessment and Alveolar minimal bone removal Osteoplastic flap to preserve the alveolar bone in height and in width width Bone reduction and fixation in the incident of Bone atrophic jaw fracture atrophic Difficulties-associated surgery Small mouth Small Narrow space between anterior border of the ramus Narrow and distal aspect of second molar and 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 surgery surgery Intraoperative: √ hemorrahge √Fractured root, tuberosity √Damage to adjacent tooth, tooth displacement √ oroantral­oronasal communication √Fracture mandible Postoperative: √ pain, swelling, bruising, trismus, aneathesis, infection ...
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