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BY: KARISHMA ASHOK [IV/I ] ROLL NO: 33IMPACTED MAXILLARY THIRD MOLARS &CANINE

INTRODUCTION

2nd largest bone of face

2 maxillae forms whole of upper jaw

Each maxilla contributes in formation of FaceNoseMouth OrbitInfratemporal fossaPterygopalatine fossa

BODY OF MAXILLA

Shape pyramidal

Each maxilla has A body4 processes frontal zygomatic alveolar palatine

It has Base directed medially at nasal surfaceApex - directed laterally at zygomatic process4 surfaces anterior / facial posterior / infratemporal medial / nasal superior / orbitalEncloses a cavity maxillary sinus

TERMINOLOGIESUnerupted teeth: tooth in the process of eruption & is likely to erupt.

Impacted teeth: that has failed to erupt completely or partially to its correct position in the dental arch &its eruption potential is lost.

More common in females than males, in maxilla than in mandible and on right side than left.

Frequency of impactionmandibular 3rd molarsmaxillary 3rd molarsmaxillary cuspidmandibular bicuspidsMaxillary bicuspidsMandibular caninemaxillary central and lateral incisors

EtiologyLocal causes:Density of overlying boneLack of space due to undedeveloped jawsObstruction-Over-retained deciduous toothThick fibrous alveolar mucosaCyst/tumorsDialcerationEctopic tooth eruption

Systemic causes:Pre-natal: heredityPost-natal: factors that interfer with development-RicketsMalnutritionanaemiaRare conditions:Cleft liposteoporosis

Indications for removalInfectionCariesPeriodontal diseasesDentigerous cystExternal resorptionProphylactic removal

PERICORONITISPericoronitis was found to be common in vertical (23.0%) followed by mesioangular (15.0%), distoangular(8.0%) and horizontal angulatio(3.0%).Common in females than malesStreptococcus Viridans is the most common facultative isolate.

Clinical featuresMarkedly red, swollen suppurating lesion

Marked tenderness

toxic systemic complications - fever, leukocytosis and malaise.

Contraindications Teeth which can be used as abutments of FPDAge (Longer recovery periodsDifficult - more densely calcified boneBone removal more due to reduced PDL spaceLonger healing time )Medical history Deeply impacted teeth; in relation with vital structures (vessels, sinus)

Classifications Based on nature of overlying tissueSoft tissueHard tissueSIGNIFICANCE - Each type of impaction has some definitepath of withdrawalof theteeth.

Winters classification:

Pell & Gregorys classification

Relationship with occlusal plane

Sinus approximation

Clinical Assesment GeneralSystemic disordersRadiation therapyAge

Extra oral:

Signs of swelling & redness of the cheek. Lymph node - enlargment & tenderness.Anesthesia or paraesthesia of lower lip.

Intra oral:State of eruption of tooth, signs of pericoronitisCondition of 1st & 2nd molarsElasticity of oral tissues

RadiographicINTRA ORAL RADIOGRAPHSIOPAOcclusal

EXTRAORAL RADIOGRAPHSOPGLateral cephalometric

DIGITAL IMAGINGCTCBCT

LOCALIZATION TECHNIQUES: -Buccal object rule (SLOB) -CBCT(3D)

ARMAMENTARIUMAnasthetic syringe and catridgesMouth mirror Tissue forceps ; retractorsCurved scalpel Periosteal elevatorsBurs ; bone filesChisels ; rongeursIrrigation syringe Forceps Elevators Suture material ; needle holder Hemostats

SURGICAL REMOVALAnasthesiaIncision and flapBone removalSectioningElevationTooth removalWound toilet and closure

Flap

Bone removal

To remove the bone obstructing the pathway for removal of the impacted tooth.Bone should be removed till we reach below the height of contour, where we can apply the elevator.

Tooth sectioningRationale of tooth sectioning is to create a space into which impacted tooth can be displaced & then removed.Impacted maxillary teeth are rarely sectioned, because the overlying bone is relatively thin & elastic.Also, in no case should a chisel be used, for it may cause displacement of tooth in the sinus.Sectioning when done, is done at the cervical line.

Wound debridement and closurePeriapical curettage.Smoothening of sharp bony margins by Bone file / burs.Thorough irrigation of the socket with Betadine solution + Saline .Suturing

Management of maxillary canine impaction

Assesment

Amount of space available in dental arch for impacted canine is assessed in model.Study model analysisGives clue of position of impacted tooth.Morphology of adjacent toothCanine bulge present buccally or palatally.Contours of adjacent alveolar boneRoot resorption. Mobility of adjacent tooth

FACTORS INFLUENCING THE TREATMENT DECISION OF AN IMPACTED CANINE

Age of patient

Suitability of 1st premolar to replace a permanent caninePatient motivation for orthodontic applaincesGeneral dental health and oral hygieneRadiographic position of canineAvailability of space

Treatment options

monitoringInterceptive removalSurgical exposure with orthodontic tractionautotransplantationSurgical removal

FLAP DESIGN:canine is located buccally-Angulated flap

canine is high & buccally Semilunar flap

Labial impactionInitial orthodontic treatment was aimed at creating space in the maxillary arch with fixed appliance therapy.Surgical exposure and orthodontic traction.

Flap is elevatedAttachment placed on impacted toothLigature or chain placed over the attachment to activate after a weekRaised flap is repositioned in its original locationPermit eruption of impacted canine in normal direction

Complications 1. During incision a. Injury to facial arteryb. Injury to lingual nerve

2. During bone removal a. Damage to second molar b. Slipping of bur- soft tissue injury c. Extra oral/ mucosal burns d. Fracture of the mandible when using chisel & mallet e. Subcutaneous emphysema

3. During elevation or tooth removal

a. Luxation of neighbouring tooth/ fractured restorationb. Soft tissue injury due to slipping of elevatorc. Forcing tooth root INTO MAXILAARY SINUS or BUCCAL SPACE d. Breakage of instruments

Post-operative ComplicationsImmediate- Hemorrhage- Pain- Edema- Drug reactionDelayed - Alveolitis- Infection

Displacement of tooth into maxillary sinus

patient complains of mild pain and heaviness in the left maxillary sinus area and the left maxillary sinus was tender on palpation. maxillary sinus was exposed through a Caldwell-Luc approach. The sinus was irrigated with sterile saline solution under pressure and the tooth was removed only by negative pressure of the suction pump

DISPLACEMENT INTO BUCCAL SPACE

CT image of the case depicting the displaced tooth between the buccinator and masseter muscle in the buccal space..3D CT image of the displaced maxillary third molar seen as localized obliquely in front of the anterior border of the ramus of the mandible in the buccopalatine direction.