Impacted tooth

Question 1

What is wisdom tooth extraction?

Answer 1

• Wisdom tooth extraction is a surgical procedure to remove one or more wisdom teeth — the four permanent adult teeth located at the back corners of the mouth.
• Erupted or impacted.

Question 2

Basic principles for extraction

Answer 2

The impacted tooth is removed

• according to the direction of the longitudinal axis of the root
• or of each root if they have a different axis.

(In this case the crown of the tooth is cut.) (sectioning impacted tooth)

Question 3

Sectioning impacted teeth.

Answer 3

• The surgeon may be able to minimize the amount of bone tissue that must be removed during the extraction of a third molar by cutting the tooth into pieces.
• Since each individual part is smaller than the tooth as a whole, they can be removed through a smaller access opening. (less bone removal)

Question 4

The direction extraction force depends on according to:

Answer 4

The direction extraction force depends on according to the direction of the longitudinal axis of the root and proper sectioning the tooth

Question 5

Technique for removal

Answer 5

• Mucoperiosteal Flap
• Adequate in size to permit access
• The most commonly used flaps are the envelope flap and the 3 cornered (triangular) flap
• Both provide favorable access for the buccal-occlusal removal of impacted third molars

Question 6

Basic principles for extraction

Answer 6

1. Good local anesthesia
2. Good surgical field visibility (light-suction - assistant)
3. Νo violence and power
4. Οperation planning

Question 7

The tooth’s position in the jaw.

Answer 7

A. The half-impacted molar is easier than the impacted
B. Impacted molar covered with soft tissues is easier than the impacted molar covered by bone
C. Impacted molar in the bone is easier with vertical position and oblique forwards position rather than those with a oblique backrward position and horizontal position

Question 8

Impacted tooth depth.

Answer 8

• The degree of difficulty of the extraction process increases as the depth increases.
• A primary factor for this relationship is that the deeper a tooth lies, the harder it is to access it .
• Additionally, deeply positioned teeth are more likely to be near anatomical structures such as nerves or sinuses.
• If so, the risk for surgical complications involving them elevates the complexity of the extraction process.

Question 9

Winters Classification (Spatial relationship)

Answer 9

Question 10

———— impaction is the easiest to extract
____________ is the hardest

Answer 10

• Mesioangular impaction is the easiest to extract
• Distoangular is the hardest

Question 11

Pell and Gregory Classification

Answer 11

Question 12

Pederson Index

Answer 12

It is a combination of Winte’s and Pell/ Gregory classification to provide a difficulty index number .

• 7- 10 Very difficult
• 5- 7 moderately difficult
• 3- 4 minimally difficult

Question 13

Root anatomy:

Answer 13

• Wisdom teeth have multiple roots ( lower ones typically have two , uppers usually three ).
• And there can be quite a bit of variation in the way each of them are shaped. As examples, in some cases each root will be separate and distinct . With others, one or more may have irregular contours or curvature .
• It’s also possible for a tooth’s roots to be fused together (either fully or partially).
• Each of these anatomical variations will affect the relative ease with which the tooth can be removed .

Question 14

The assessment is based on the clinical picture and the radiographic imaging of the area with:

Answer 14

1. Dental xray
2. Panoramic (usually)
3. 3D lower or upper jaw CBCT
4. CT scans

Question 15

What we see on Xrays from a surgical point of view?

X-ray study

Answer 15

1. Position and level of eruption
2. Relationship to the second molar
3. Root shape
4. Bone adjacent
5. Thickness of bone
6. Nerve position
7. cyst in the area

Question 16

Perioperative complications:

Answer 16

1. Bleeding
2. Injury of alveolar nerve
3. Injury of lingual nerve
4. Fracture of the root
5. Injury of adjacent tooth
6. Tool breakage
7. Tooth promotion in soft tissue
8. Fracture of the alveolar bone
9. Fracture of the mandible

Question 17

Postoperative complications:

Answer 17

1. Oedema
2. Pain
3. Secondary bleeding
4. Inflammation
5. abscess
6. Dry socket
7. Osteomyelitis
8. paraesthesia

Question 18

Dry socket

What is Dry socket?

Answer 18

Dry sockets (alveolar osteitis) are

• a painful, foul-smelling and tasting postoperative complication that typically becomes apparent 3 or 4 days following the patient’s extraction .

Question 19

Dry socket

A dry socket’s symptoms typically include:

Answer 19

1. A dull, often throbbing, pain that doesn’t first appear until three or four days after the tooth has been extracted.
2. The pain can be moderate to quite severe .
3. The socket typically has a foul odor or taste coming from it .

Question 20

Dry socket

Tx

Answer 20

• The treatment is placement of medicated dressing down into the socket that will soothe and moderate its pain.
• This dressing is typically removed and replaced every 24 hours until symptoms have subsided .

Question 21

What are “impacted” wisdom teeth?

Answer 21

• An “impacted” tooth refers to one that has failed to erupt into its expected position in the mouth, within the expected time frame .
• It’s been estimated that about 25% of people are lacking one or more of their third molars. (Faculty, 1997)
• The lower impacted 3rd molars are more frequent than the upper ones.

Question 22

This failure may be related to:

(failure of eruption=> impaction)

Answer 22

• A lack of jawbone space to accommodate the tooth . (A mismatch between the total “arch” length needed for the person’s teeth vs. the available arch length provided by their jawbone.)
• The tooth’s eruption has been prevented by some type of physical barrier , such as neighboring teeth, dense overlying bone or excessive soft tissue.

Question 23

Age of eruption:

Answer 23

• The most common time frame for the eruption process is 18 to 24 years (Faculty).
• The average age for completed eruption is 20 years , with some cases not reaching completion until as late as age 25 (Hupp).
• In these ages must be estimated if the impacted tooth is in phase of erruption before decision of the surgical removal.

Question 24

The best age removal of the impacted
tooth:

Answer 24

• There is no rule what is the ideal age for extracting the third molar. It can be done at all ages
• Based on statistics, however, the older the more likely complications
• But we usually expect the age of 18 where the root in most of them has grown beyond 2/3 of its length .
• Avoid shorter root lengths because the tooth is a ball shape and increases the degree of difficulty of handling extraction as well as remaining follicle residue , dynamically developing future cysts . 24-years old statistics have the lowest rate of complications

Question 25

Indications for removal impacted tooth:

Answer 25

• Pain, swelling, atypical syptoms
• If it is clear that they have insufficient erruption space and cause damage to adjacent teeth.
• They are partially erupted.