Category Archives: Principles of Management of Impacted Teeth

Prevention of Periodontal Disease

Prevention of Periodontal Disease

Erupted teeth adjacent to impacted teeth are predisposed to periodontal disease (Figs. 9-1 and 9-2). The mere presence of an impacted mandibular third molar decreases the amount of bone on the distal aspect ofan adjacent second molar (see Fig.’ 9-1). Because the most difficult tooth  urface to keep clean is the distal aspect of the last tooth in the arch, the patient may have gingival inflammation with apical migration of the ingival attachment  on the distal aspect of the second molar. Wjth even minor gingivitis the causative bacteria have access to a large portion of the root surface, which results in the early formation of severe periodontitis (see Fig. 9-2). Patients with impacted mandibular third molars often have deep periodontal pockets on the distal aspect of the secondmolars but have normal sulcular depth in the remainder of themouth. . The accelerated periodontal problem resulting from an impacted third molar is especially serious in the maxilla. As a periodontal pocket expands apically, i~ becomes involved with the distalfurcation of the maxillary second molar relatively early, which makes advancement of the periodontal disease more rapid and severe: In addition, treatment of the· localized periodontal disease around the maxillary second molar is more difficult because of the
distal furcation involvement. By removing the impacted third molars early, periodontal disease can be prevented and the likelihood of bonv bealing and bone fill into the area previously occupied by the crown of the third molar is increased.!”

INDICATIONS FOR REMOVAL OF IMPACTED TEETH

INDICATIONS FOR REMOVAL OF IMPACTED TEETH

All impacted teeth- should be considered for removal as .soon as the diagnosis’ is made. The average age for completion of the eruption of the third molar is age 20 although eruption may continue in some patients until age 25. During normal development the lower third molar begins its development in a horizontal angulation, and as the tooth develops and the jaw grows, the angulation changes from horizontal to mesioangular to vertical. Failure of rotation from the mesioangular to the vertical direction is the most common cause of the tooth remaining impacted. The second major factor is that the mesiodistal dimension of the teeth versus the length of the jaw’ is such that inadequate room exists in the alveo- “Iar process anterior to the anterior border of the ramus to allow the tooth to erupt into position. . As noted earlier, some third molars will continue to erupt after age 20, coming into final position by age 25. Multiple factors are associated with continued eruption. When late eruption occurs.ithe unerupted tooth is usually covered only with soft tissueor very slightly with bone. These teeth are almost always.in a vertical positionand are relatively superficially positioned with r\”rLct to the occlusal plane of the adjacent second molar.
Finally and perhaps most importantly, sufficient space exists- between the anterior border of the ramus and the second molar tooth to allow eruption.l-? Likewise, if the tooth does not erupt after age 20, it is most likely covered with bone. In addition, the tooth is likely a mesioangular
impaction and ocated lower in the alveolar process near the cervical level of the adjacent second molar. Finally, inadequate space exists to allow eruption. Therefore the dentist and surgeon can use these parameters to predict whether or not a tooth will erupt into the archor remain
impacted. Early removal reduces the postoperative morbidity and
allows for the best healing.I” Younger patients tolerate the procedure better and recover more quickly and with less interference to their daily lives. Periodontal.healing is . better in the younger patient, because of better and more complete regeneration of the periodontal tissues. Moreover, the procedure is easier to perform in younger patients. The ideal time tor removal of impacted third molars is when the roots of the teeth are one-third formed and before they are two-thirds formed, usually during the late teenage years, between ages 17 and 20. If impacted teeth are left in the alveolar process,it is highly probable that one or more of several problems will resuIt.l,8 To prevent this, impacted teeth should be removed.

 

 

Principles of Management of Impacted Teeth

Principles of Management of Impacted Teeth

INDICATIONS FOR REMOVAL OF IMPACTED-TEETH
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 Unexplained Origin
Prevention of Fracture of the Jaw
Facilitation of Orthodontic Treatment
Optimal Periodontal Healing
CONTRAINDICATIONS FOR REMOVAL OF IMPACTED
TEETH
Extremes of Age •
Compromised Medical Status, .
Probable Excessive Damage to Adjacent Structures
Summary
CLASSIFICATION SYSTEMS OF IMPACTED TEETH
Angulation
Relationship to Anterior Bordet of Ramus
Relationship to Occlusal Plane
Summary
ROOT MORPHOLOGY
Size of Follicular Sac
Density of Surrounding. Bone
Contact with Mandibular Second Molar
Relationship to Inferior Alveolar Nerve
Nature of Overlying TIssue
MODIFICATION OF CLASSIFICATION SYSTEMS FOR
MAXILLARY IMPACTED TEETH
DIFFICULTY OF REMOVAL OF OTHER IMPAETED TEETH
SURGICAL PROCEDURE
PERIOPERATIVE PATIENT MANAGEMENT

A impacted tooth is one that fails to erupt into the dental arch within the expected time. The tooth becomes impacted because adjacent teeth, dense overlying bone, or  xcessive soft tissue prevents eruption. Because impacted teeth do not erupt, they are retained for the patient’s lifetime unless surgically removed. The term unerupted includes both impacted teeth and teeth that are in the process of erupting. The term embedded
is occasionally used interchangeably with the term impacted teeth most often become impacted because of inadequate dental arch length and space in which to erupt; that is, the total length of the alveolar bone arch is small:’
er than the total length of the tooth arch. The most com mon impacted teeth are the maxillary and mandibular hird molars, followed by the maxillary canines ana mandibular premolars. The third molars are the most frequently impacted, because they are the last’ teeth to erupt; therefore they a e the most likely to have inadequate space for eruption n the anterior maxilla, the canine tooth is also comruonlv revented from erupting by crowding from other eeth I he canine tooth usually erupts after the maxillary ateral incisor and maxillary first premolar. If space is nadequate to allow eruption, the canine tooth becomes mpacted. In the anterior mandible a similar situation ffects the mandibular premolars, because they erupt fter the mandibular first molar and mandibular canine. herefore if room for eruption is inadequate, one of the remolars, usually the second premolar, remains un-> rupted and becomes impacted as a general rule, all impacted teeth should be removed nless removal is contraindicated. Extraction shuld be performed as soon as the dentist determines that  the tooth is impacted. Removal of impacted teeth become more difficult with advancing age. The dentit should not recommend that impacted teeth be left in place until they cause difficulty. If the tooth is left In until problems arise, the patient may experience anincreased incidence of local tissue morbidity, loss of adjacentteeth and bone, and potential injury to adjacentvital structures. Additionally, if removal of impacted eth is deferred until they cause problems later in life, urgery is more likely to be complicated and hazardous,because the patient may have compromising systemicdiseases. A fundamental precept of the philosopJiy of ,. dentistry is that problems should be prevented. Preventive dentistry dictates that impacted teeth are to be removed before complications arise. This chapter discusses the· management of impacted teeth. It is not a thorough or in-depth discussion of the ‘technical aspects of .swrgical impaction removal. Instead its goal is to provide both the information necessary for proper management and a basis for determining the difficulty of surgery.