Management of Impacted TeethPart I

Dr. Rahaf Al-Habbab BDS. MsD. DABOMSDiplomat of the American Boards of OMFSConsultant of Oral and Maxillofacial SurgeryHead of Orthognathic UnitSaudi Boards Residents DirectorHospital Education and Residency Director2013

What is the Difference between Impacted and Unerupted Teeth?

Impacted Teeth

Teeth that fails to erupt into the dental archwithin the expected time, because of:

• An adjacent teeth • Dense overlying bone • Excessive soft tissue• Genetic abnormality prevents eruption

• Retained for the patient’s lifetime unless surgically removed or exposed because of resorption of overlying tissue.

Unerupted Teeth

Include impacted teeth and teeth that are in the process oferupting

Most Common Cause of Impaction

• Inadequate dental arch length and space, where the total length of the alveolar dental arch is smaller than the total length of the dental arch

Most common impacted teeth are:1) Maxillary and mandibular third molars (last to erupt)2) Maxillary canines (crowding of other teeth)3) Mandibular premolars, most commonly 2ed PM (after molars and canine)

General Rule

All impacted teeth should be removed before complications arise unless removal is contraindicated or will cause more

serious problems

• Extraction should take place as soon as the dentist determines that the tooth is impacted

• Dentist should not recommend to leave impacted teeth in place until they cause difficulty

• Removal becomes more difficult with advanced age

Causes of Third Molar Impaction

• Average age of third molar eruption completion is age 20, it may continue in some patients until age of 25.

• Normal development of lower third molar begins in a horizontal angulation (as the tooth develop and the jaw

grow)→ mesioangular angulation → vertical angulation

Causes of Third Molar Impaction

• Failure of rotation from mesioangular to vertical direction is the most common cause of third molar impaction

• Lack of mesiodistal dimension of the arch length to the teeth anterior to the ramus

Advantages of Early Removal

Early removal reduces the postoperative morbidity and allowsfor the best healing:

• Young patients tolerate the procedure better and recover more quickly

• Better periodontal healing because of better more complete regeneration of periodontal tissue

• Better nerve recovery

• Less dense bone and incomplete root formation

Ideal Impacted Third Molar Removal Time

• When the roots are one third formed and before it is two third formed

Between the age of 17-20

Indications of Impacted Teeth Removal

• Prevention of Periodontal Disease• Prevention of Dental Caries• Prevention of Pericoronitis• Prevention of Root Resorption• Impacted Teeth Under a Dental Prosthesis• Prevention of Odontogenic Cysts and Tumors• Treatment of Pain of Unexpected Origin• Prevention of Jaw Fracture• Facilitation of Orthodontic Treatment• Optimal Periodontal Healing

Prevention of Periodontal Disease

Prevention of Dental Caries

Prevention of Pericoronitis

Pericoronitis: Infection of the soft tissue (operculum) around the crown of a partially impacted tooth and its usually caused by normal oral flora

Pericoronitiscauses

• If the host defenses are compromised (e.g., during minor illness, such as influenza or upper respiratory infection, or immune-compromising drugs)

• Minor trauma from maxillary third molarTrauma → swelling→ more trauma→ more swelling

• Food entrapment under the operculum

• Streptococci and a large variety of anaerobic bacteria causes pericoronitis (present normally in the gingiva)

Treatment Depending on the severity of the infection:Mild infection:Mechanical debridement of the large periodontal pocket underthe operculum, using Hydrogen Peroxide, chlorhexidine,iodophors, and normal saline.

Hydrogen Peroxide:• Mechanically removes bacteria with its foaming action• Release oxygen into the usually anaerobic environment

reducing their number

Treatment Chlorhexidine or Iodophors:Reduce the bacterial count of the pocket

Normal Saline:If delivered under pressure it can reduce the bacterial number,and flush away food debris

Treatment Slightly more severe infection:Large amount of local soft tissue swelling, being traumatized bythe maxillary third molar.

Management: • Local irrigation• Dentist should consider immediately extracting the maxillary

third molar

Management

More sever infection:• Patient with swelling, pain, and mild facial swelling• Mild trismus ??• Low grade fever

Management:• Local irrigation under pressure• Extraction of opposing tooth• Administration of Antibiotics (Penicillin, clindamycin in case of

allergy)

Management

Severe infection:• Involve facial spaces of the mandibular ramus and the lateral neck• Trismus (less than 20mm)• Temperature (greater than 101.2°F)• Pain and malaise

Management:• Refer the patient to OMFS• Patient hospital admission• I.V antibiotics and fluids administration• Careful monitoring

General Rules

• Patient who develops one episode of pericoronits, is more likely to have another episode, unless the offending tooth is removed

• The mandibular third molar should not be removed UNTIL the signs and symptoms of pericoronitis have completely resolved

If removed during active infection phase (The incident of postoperative complications increase): • Dry socket• postoperative infection• Bleeding• Slower healing

Prevention 1) Removal of the third molar before they penetrate the soft

tissue into the oral cavity

2) Operculectomy • painful • usually ineffective • recurs• The distal gingival pocket remains deep

Prevention of Root Resorption

Root Resorption??

Impacted Teeth Under a Dental Prosthesis

Slow alveolar bone resorption usually follow extraction, resulting in closer tooth to the bone

Overlying soft tissue ulceration

Initiation of odontogenic infection

Alteration of the alveolar ridge with extraction after bridge construction

Avoid removing it late at an older age (poor health, atrophic mandible)

Prevention of Odontogenic Cysts and Tumors

Dental follicle → Cystic Degeneration→ Dentigerous Cyst or Keratocyst

Epithelium within Dental Follicle → Odontogenic Tumors (Ameloblastoma)

Treatment of Pain of Unexpected Origin

• Unexplained Pain at retromolar region

• Exclude myofascial pain dysfunction syndrome and other facial pain disorders

• Resolution of the pain sometimes result from the wisdom tooth removal

Prevention of Jaw Fracture

Facilitation of Orthodontic Treatment

• Allows premolars retraction• Retromolar implants placement

Optimal Periodontal Healing

Two most importantfactors:

1. Extent of preoperative infrabony defect on the distal aspect of the second molar.

2. Patients age

Contraindications for Removal of Impacted Teeth

Contraindications for Removal of Impacted Teeth

When the risks are greater than the potential benefits, the procedure should be Deferred

Contraindications primarily involve the patient’s physical status

Contraindications for Removal of Impacted Teeth

1. Extremes of Age

2. Compromised Medical Status

3. Probable Excessive Damage to Adjacent Structures

Extreme of Age

Young Age:

• Third molar tooth bud can be radiographically visualized by age 6

• It is not possible to predict accurately if the forming third molar will be impacted

• Removal should be deferred until an accurate diagnosis of impaction can be made

Extreme of AgeOld Age

Most common contraindication of impaction removal

As patient age:• Bone becomes highly calcified, therefore, less flexible and less

likely to bend under extraction force

• More possible postoperative complications and sequelae

• Absence of periodontal disease, caries, or cystic degeneration at that age (over 35), makes it unlikely to develop at that age

• But should be followed every 1-2 years

Compromised Medical Status

• Usually go hand in hand with advanced age

• If the cardiovascular or respiratory function or host defenses for combating infection are seriously compromised or the patient has a serious acquired or congenital coagulopathy

• The surgeon should consider leaving the tooth UNLESS symptomatic

• Should consider working with the patient’s physician for proper planning

Probable Excessive Damage to Adjacent Structures

• Nerve, teeth, previously constructed bridge.

• Have to look at the age of the patient too, and

• Reason should be weighed against potential future complications

Case

Older patient with a sever periodontal defect on the distal aspect of the second molar, but its removal will surely result in the loss of the second molar

What should you do?

Summary

• Patients with one or more pathologic symptoms or problems should have their impacted teeth removed

• Most problems result from partially erupted teeth and less commonly with complete bony impaction

Less clear is what should be done with impacted teeth before they cause symptoms or problems

How to make a decision?

Factors to be considered

• Available space in the arch into which the tooth will erupt.

• The status of the impacted tooth and the age of the patientMesioangular third molar in 17 years old?

• By the age of 18 the dentist should be able to predict whether there will be adequate room for the third molar to erupt

Reference: Contemporary Oral and Maxillofacial Surgery, 5th EditionJames R. Hupp, Edward Ellis III, Myron R. Tucker

Chapter 9, Principles of Management of Impacted Teeth

March, 2, 2013: Clinical Cases (Quiz)

March, 9, 2013: Quiz (written)