2.

6 Impaction of Other Teeth

2.6.1 Maxillary Canine
1. Field & Ackerman Classification
Labial position
Crown in intimate relationship with incisors and well above apices of incisors.
Palatal position
Crown near surface in close relation to roots of incisors and deeply embedded in close relation to
apices of incisors.
Intermediate position
Crown between lateral incisor and 1st premolar root ; above lateral incisor and 1st premolar with
crown labially placed and root palatally placed or vice versa.
Unusual position
In nasal or antral wall or in infraorbital region.
2. Archer Classification (1975)
Class I : Impacted cuspids located in the palate either in horizontal, vertical or semi-vertical
position.
Class II : Impacted cuspids located in the labial or buccal surface of the maxilla either in
horizontal, vertical or semi-vertical position
Class III : Impacted cuspids located in both the palatal process and labial or buccal maxillary
bone, e.g. the crown is on the palate and the root passes between the roots of the adjacent teeth in
the alveolar process, ending in a sharp angle on the labial or buccal surface of the maxilla.
Class IV : Impacted cuspids located in the alveolar process, usually vertically between the incisor
and first premolar.
Class V : Impacted cuspids located in an edentulous maxilla.

Figure 2.6.1.1 Maxillary canine impaction

2.6.2 Mandibular Canine
Level A : Crown of impacted canine tooth at the cervical line of adjacent tooth.
Level B : Crown of impacted canine tooth at the between of cervical line and tooth root apical.
Level C : Crown of impacted canine tooth at the apex of adjacent tooth root apical.
2.6.3 Premolar
Premolar impactions may be due to local factors such as mesial drift of teeth arising from
premature loss of primary molars, ectopic positioning of the developing premolar tooth buds,
pathology such as inflammatory or dentigerous cyst or over retained or infraocclusal ankylosed
primary molars. People with syndromes such as cleidocranial dysostosis are also susceptible to
premolar impaction
2.6.4 Mandibular second premolars rank third after third permanent molars and maxillary
permanent canines, in frequency of impactions . It has an Incidence of 2.1% to 2.7%.
Impacted mandibular premolars may be localized lingually or buccally, in a vertical position, and
with their crowns often wedged underneath adjacent teeth. However, the direction for
mandibular is more to lingual and for maxilla to palatal.
2.6.5 Central Incisors
The most commonly impacted tooth is the maxillary canine, followed by the maxillary central
incisor. Incisor teeth that have a higher prevalence of the incisor impaction are maxillary central
incisors.

Obstruction which caused the impaction are supernumerary teeth, odontoma, ectopic tooth
position.
Dental impaction caused by trauma such as inhibition of repair of soft tissue, dilacerations,
posted retained tooth development, acute traumatic intrusion (intrusion luxasion) cause
impactions too.

2.7 Indication and Contraindication

2.7.1 Indication for removal of impacted tooth
1. Pericoronitis Prevention or Treatment
Constitute of most cases for removal of impacted tooth, usually in the mandible where partial
eruption is observed. Microbes like Peptostreptococcus, Fusobacterium, and Bacteroides
(Porphyromonas) could cause pericoronitis. Initial treatment involves dbridement followed by
disinfection with irrigation solution (H2O2 / chlorhexidine). For the surgical management step,
the opposing max 3rd molar is extracted. In severe cases with systemic effect, antibiotic is
provided; For recurrent pericoronitis, the involved tooth is then removed.
2. ii. Prevention of Dental Disease
Caries often occurs at the mandibular 3rd molar and its adjacent tooth at cervical line region
because patients are unable to clean effectively and inaccessibility to the restorative dentist. This
often advances to periodontal disease.
3. Orthodontic Considerations
4. Prevention of Odontogenic
Cysts and Tumors
Follicular sac (formation of the crown) cystic degeneration dentigerous cyst -->
odontogenic tumor (rare)
Reason for removal of asymptomatic teeth because pathology occurs
5. Root Resorption of Adjacent Teeth
Misaligned erupting teeth may resorb the roots of adjacent teeth.For most cases, the adjacent
tooth has recalcified (deposition of a cementum over the resorbed area) & formation of 2o dentin.
If severe resorption & the mandibular 3rd molar displaces significantly into the roots of the 2nd
molar
6. Teeth under Dental Prostheses

Removable tissue borne prosthesis constructed on a ridge where an impacted tooth is covered
by only soft tissue /1-2 mm of bone overlying bone resorbed, mucosa perforate & painful &
inflamed.
7. Prevention of Jaw Fracture
For patients that engage in contact sports (football, rugby, martial arts) & noncontact sports
(basketball) impacted teeth is often removed to prevent jaw fracture.
An impacted third molar causes a decrease in resistance to fracture in mandible, which is a
common site for fracture, which treatment is more complicated than impacted tooth removal
8. Management of Unexplained Pain
Jaw pain in the area of an impacted third molar but without clinical or radiological signs of
pathology. The surgeon must make sure that all other sources of pain are ruled out before
suggesting surgical removal of the tooth. Patient must be informed that removal of the tooth may
not relieve the pain completely
2.7.2 Contraindication for removal of impacted tooth
1. Age
For patients at older ages, there is decreased healing, thus increased recuperation period greater
bony defect postoperatively. The operation is also more difficult due to densely calcified bone
(decreased flexibility & increased fracture risk). If there is no complication, extraction is usually
contraindicated.
2. Surgical Damage to adjacent Structures
Tooth removal may compromise adjacent nerves, teeth & other vital structures (sinus structures).
If complications outweigh the benefits, extraction is contraindicated.
3. Compromised Medical Status
For old patients, medical conditions such as pulmonary diseases; For young patients, congenital
coagulopathies asthma and epilepsy.

2.9 Management of Impacted tooth

2.9.1 Management for impacted tooth other than 3rd molar

1. Exposure (with/ without orthodontic band)
This allows natural eruption of impacted teeth. The most common technique is using the bonded
orthodontic bracket to conserve exposure of the tooth, remove only enough soft tissue and bone
to place bracket and avoid exposure of CEJ
2. Uprighting
A common procedure for impacted molars . The normal time for uprighting molar teeth : 2/3 of
the root has formed. If root is fully formed there is poor prognosis.
3. Transplantation
For adults who do not undergo conventional orthodontic movement of canine / premolar,
transplantation if an option. Transplantation is done by
Exposing the impacted tooth, then moving the tooth into position & stabilizing with orthodontic
appliance. This is followed by endodontic treatment : calcium hydroxide paste 6-8 weeks after
surgical procedure. 1 year following surgery, conventional root canal filing is done.
4.

Removal

The final treatment option for canines, premolar, molar impaction. Surgical and Radiographic
assessment is done prior to treatment.

2.9.2 Management of mandibular 3rd Molar

There are many factors that simplify and complicate the treatment procedure compare to
mandibular third molar. The instruments used for extraction of maxillary third molar are:
1.
2.
3.
4.
5.

Syringe for anesthesia

Scalpel for making a flap design and open the flap
Miller elevator and Potts elevator to move the impacted tooth to distobuccal.
Cryer elevator to take out the impacted maxillary third molar.
The maxillary forcep that is used is Bayonet forcep because its design suits and does not
pinch the tongue while extracting.
6. Lane needle for flap suturing.
7. Needle holder for hold the needle while suturing the flap.
Stage of impacted upper third molar extraction:

1.
2.
3.
4.
5.
6.
7.

Sedation
Flap opening
Removing bone
Planned cut
Taking out the tooth
Wound cleaning
Closing the wound

2.9.2.1 Flap opening

1. Triangular flap:
The incision for creating the flap begins at the maxillary tuberosity and extends as far as the
distal aspect of the second molar, continuing obliquely upwards and anteriorly (vertical incision)
to the vestibular fold. In rare cases, when impaction is deep and a satisfactory surgical field is
necessary or when the impacted tooth covers the roots of the second molar buccally, then the
vertical incision may be made at the distal aspect of the first molar.

Figure 2.9.2.1 Triangular flap

http://www.slideshare.net/

2. Horizontal (envelope) flap:

The incision for creation of this flap also begins at the maxillary tuberosity and extends as far as
the distal aspect of the second molar, continuing buccally along the cervical lines of the last two
teeth, and ending at the mesial aspect of the first molar.

Figure 2.9.2.2 Horizontal flap

http://www.slideshare.net/

2.9.1.2 Removal of Bone

Often, after reflection of the flap, part of the crown of the impacted tooth is visible or there is
bone protuberance over the crown. Because the bone in this case is thin and spongy, it may be
removed from the buccal surface using a sharp instrument.If the buccal bone is dense and thick,
then its removal is achieved using a surgical bur.
Two techniques:
1. Bur technique
No 7/8 round bur or straight no 703 fissure bur is used. The bur is used in sweeping motion
around the occlusal, buccal and distal aspect of the crown to expose it. Once the crown has been
located, the buccal surface of the tooth is exposed with the bur to the cervical level of the crown
and a buccal trough or gutter is created. Continous irrigation with 1% prvodine iodine or with
normal saline to reduce thermal necrosis of bone.
2. Lingual split bone technique
Quick and clean technique. Creates saucerization of the socket, thereby reduces the size of
residual blood clot. Used for mandibular third molar especially those placed lingually. A 3mm or
5mm wide chisel is used. Vertical stop cut is made by placing the chisel with the bevel facing
posteriorly, distal to second molar. With chisel bevel downward, a horizontal cut is made
backward from the lower end of vertical limiting stop cut. The buccal bone plate is removed
above the horizontal cut .The distolingual bone is then fractured inward by placing the cutting
edge of the chisel. Bevel side of the chisel facing upward and cutting edge is pratallel to the
external oblique ridge. Finally small wedge of bone, which then remaining distal to the tooth and
between the buccal and lingual cut, is excised and removed. A sharp straight elevator is then
applied and minimum force is used to elevate the tooth, as the tooth moves upward and
backward, the lingual plate gets fractured and facilitates the delivery of the tooth.
2.9.1.3 Extraction of third molar
After making a triangular incision, the mucoperiosteal flap is reflected and the buccal bone is
then removed until the entire crown of the impacted tooth and part of its roots are exposed.
Because extraction of the tooth in segments is not indicated, sufficient space must be created
around its crown to be able to luxate the tooth. Reflection of the flap and exposure of the crown
of the impacted tooth. Placement of the broad end of the periosteal elevator in the posterior
position is indicated to protect the tooth from becoming accidentally displaced into the
infratemporal fossa or into soft tissues. Thus, using a straight or double-angled elevator on the

mesial aspect of the tooth, always buccally, the tooth is luxated carefully, posteriorly, outwards
and downwards.
2.9.1.4 Wound cleaning and wound closure
The surgeon should irrigate the wound with sterile saline.The periapical curette is used to
mechanically debride both the superior aspect of the socket and the inferior edge of the reflected
soft tissue to remove any particulate material that might have accumulated during surgery. The
bone file is used to smooth any sharp, rough edges of bone. A mosquito hemostat can be used to
remove any remnants of the dental follicle. Once the follicle is grasped, it is lifted with a slow,
steady pressure and will pull free from the surrounding hard and soft tissue. A final irrigation and
a thorough inspection should be performed before the wound is closed.
Interrupted sutures given and maintained for 7 daysUse as few sutures as possible. They should
not be excessively tight. Suture should penetrate the lingual flap close to and behind the third
molar and buccal flap further distally
The surgeon should check for adequate hemostasis. If brisk generalized ooze is seen, after the
sutures are placed the surgeon should apply firm pressure with a small, moistened gauze pack.
Postoperative bleeding occurs relatively frequently after third molar extraction, and therefore
adequate hemostasis at the time of the operation is important.

2.9.1.5 Postoperative instruction

1.
2.
3.
4.

Pressure pack for 1 hr

Ice application
Soft diet for first two days
First dose of analgesic should be taken before the anesthetic effect of local anesthesia
wear off
5. Avoid gargling/ spitting/smoking/ drinking with straw
6. Warm water saline gargle after 24 hours, and use mouthwash regularly thereafter

References:
http://www.slideshare.net/
(Farish & Bouloux, 2007)Farish, S. E., & Bouloux, G. F. (2007). General Technique of Third
Molar Removal. Oral and Maxillofacial Surgery Clinics of North America, 19(1), 2343.
http://doi.org/10.1016/j.coms.2006.11.012