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Differences in surgery regarding age
DIFFERENCES IN SURGERY REGARDING AGE
16-25 y/o > 30 y/o
Periodontal Healing Bone Epithelial attachments
goodbone growth possiblereadily established
limitedbone resorption likelypoor; positions apically
Surgical difficulty Bone Periodontal ligament Follicle Teeth
easypliable, little removedwide, supplelargenormal, little sectioning
tough!!!rigid, much removal requiredabsent, rigid or ankylosedsmall or absentbrittle, much sectioning
Patient health usually excellent systemic disease common
Surgical morbidity little with fast recovery great with slow recover
Complication Surgical Anesthetic
fewfew
many, often seriousgreater, potentially serious
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Lecture 2
Objective is to familiarize and help understand Classification of third molar Assess degree of difficulty while
performing the procedure
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Predicting Difficulty Accessibility (Risk evaluation factors)
Radiographic evaluation Location of the IAN Third molar position-Angulation Bone mass density
Clinical evaluation Age Obesity Large tongue Dilacerated roots Strong gag reflex Complaining patient Surgical access space Interincisal opening
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Ideal time for extraction of Impacted teeth Average age: 20years Ideal time for extraction
When the roots are 1/3 formed and before they reach 2/3 formation
Early removal Low morbidity Tolerate procedure better Quick recovery
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Classification Winter 1926 Based on the position of their long axis in
relation to the long axis of the second molars Angulation and Position
Vertical Mesioangular Horizontal Distoangular Buccoangular Lingoangular Inverted Unusual
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Angulation- Mesioangular
When the third molar is titled towards the second molar in a mesial direction
Most common 43% of impacted teeth
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Angulation- Vertical
Long axis of the third molar runs parallel to the second molar
Second largest frequency-38%
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Angulation- Horizontal
Long axis of the third molar perpendicular to the second molar
More difficult to remove 3% of all mandibular impactions
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Angulation- Distoangular
Long axis of the third molar is distally or posteriorly angled away from the second molar
Most difficult-(runs into the ramus of the mandible)
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Comprehensive classification Based on Pell and Gregory and includes
a portion of George B. Winter’s classification is most comprehensive: A. Relation of the tooth to the ramus of the
mandible and the second molar (class I,II,III) B. Relative Depth of the third molar in bone
(Position A, B,C) C. The position of the long axis of the
impacted Mandibular third molar in relation to the long axis of the second molar (from Winter’s classification)
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Relation of the tooth to the ramus of the mandible and the second molar
Class I : There is sufficient space between the ramus and the distal side of the second molar for accommodation of mesiodistal diameter of the crown of the third molar
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Class II
The space between the ramus and distal side of the second molar is less than the mesiodistal diameter of crown of the second molar
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Class III
Class III : All or most of the third molar is located within the ramus
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Relative Depth of the third molar in Bone
Position A: The highest portion of the tooth is on a level with or above the occlusal line
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Relative Depth of the third molar in Bone
Position B: The highest portion of the tooth is below the occlusal plane, but above the cervical line of the second molar
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Relative Depth of the third molar in Bone
Position C: The highest portion of the tooth is below the cervical line of the second molar
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Mesioangular Class I ramus Position A
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Horizontal Impaction- Class II Position B
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Vertical Impaction-Class II Position C
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Difficulty index
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Other difficulty factors Root Morphology
Length Conical or fused roots Divergent Curvature
Direction Number Width Periodontal ligament space
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Size of the follicular sac
Wide- (almost cystic) Extraction is easier Less bone removal Younger patients
No Space Difficult extraction More bone removal Older patients
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Density of Bone Age determining factor 17-25years favorable for extraction
Less dense More pliable, Expands easily Easy to cut with a dental bur
>35years unfavorable for extraction More dense Decreased flexibility, does not expand Difficult to cut with a dental bur
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Other factors of difficulty
Relationship with IA nerve Close proximity
with the roots Damage Parasthesia or
anesthesia of the lower lip and chin on the affected side
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Other factors of difficulty
Contact with Mandibular second molar
Cautious with Horizontal and distoangular extraction
Safe application of elevators
Check for large restorations, crowns, endodontic treatment on second molars
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Nature of Overlying Tissue
Soft tissue impacted Height of the contour of the tooth is
above the level of the alveolar bone and the superficial part of the tooth is covered with soft tissue
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Nature of Overlying Tissue
Partial bony impacted Superficial portion of the tooth is
covered by soft tissue but at least a portion of the height of contour of tooth is below the level of the alveolar bone.
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Nature of Overlying Tissue
Full bony impacted Completely encased in the bone.
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Pell and Gregory class A, B, C
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Erupted-Soft tissue impacted
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Partial Bony
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Full Bony
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Why is Buccal position easy
Accessibility-Good Accessibility-Better
instrumentation Overlying Bone Lower surgical morbidity
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Why is Palatal impaction difficult ?
Accessibility-Poor Accessibility-Poor instrumentation More bone removal High surgical morbidity
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Difficulty factors specific to Impacted Maxillary 3rd Molars Maxillary Sinus
Roots are in intimate contact Tooth may form the posterior wall of sinus
Sinusitis Oroantral communication
Maxillary tuberosity fracture Dense, non elastic bone Large maxillary sinus Divergent roots Mesioangular impactions Excessive force
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Impacted Maxillary Cuspids
Positioning in the alveolar process Labial Palatal Middle
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Impacted Maxillary Cuspids –
Degree of Difficulty Based on determination of position
Labial (easy) Palatal (difficult)/Middle (difficult)
Potential damage to adjacent teeth Potential Periodontal deficits due to bone
removal
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Impacted Maxillary Cuspids
Treatment Options Wait and watch Surgical extraction Surgical exposure with Orthodontic
movement in Arch
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Factors that make impaction more difficult
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Factors that make impaction surgery less difficult
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Thank you!!
Have a Great weekend!