OS2-2

TOOTH ERUPTION

• refers to the physiologic process associated with root development in which the developing tooth move from its area of formation inside the jaw into the oral cavity to become part of the dental arch

• it is said to be complete before apex closure

THREE CONDITIONS OF TEETH WITH ARRESTED ERUPTION (3)

→ impaction

→ primary retention

→ secondary retention

IMPACTION

• refers to the cessation of eruption of a tooth caused by clinically or radiographically detectable physiologic or physical barrier in the eruption path, or due to an abnormal tooth position

OTHER BARRIERS THAT MAY PREVENT ERUPTION (4)

→ cysts

→ crowded tooth germ or erupting teeth

→ supernumerary teeth

→ odontoma

PRIMARY RETENTION

• refers to the eruption of a normally placed or normally developed tooth or tooth germ before gingival emergence without a recognizable barrier in the eruption path and is usually caused by a disturbance in the dental follicle

• is clinically manifested as a delay in tooth eruption that is >2 years

PRIMARY RETENTION IS SYNONYMOUS WITH: (2)

→ unerupted tooth

→ embedded tooth

UNERUPTED TOOTH

• refers to a tooth that has failed to perforate the oral mucosa

EMBEDDED TOOTH

• refers to a tooth that did not erupt due to lack or eruptive forces

SECONDARY RETENTION

• refers to the eruption of a tooth after gingival emergence where in there is no ectopic eruption or any physical barrier in the eruption path

• is clinically manifested when the tooth did not reach the normal occlusal plane at the scheduled or predicted time

SECONDARY RETENTION IS SYNONYMOUS WITH: (3)

→ reimpaction

→ submerged teeth

→ reinclusion

REIMPACTION

• defines a situation in which a tooth has completely erupted in the occlusal plane and then submerged again into the alveolar bone, producing a clinical aspect of infraocclusion

INFRAOCCLUSION

• a term that describes a tooth that is situated below the normal occlusal plane following partial eruption or reimpaction

SUBMERGED TEETH

• refers to a teeth that have undergone root resorption and are ankylosed to the alveolar bone after gingival emergence

REINCLUSION

• refers to the inability of a tooth to maintain the continuous eruptive potential as the jaw grows

TYPES OF ERUPTION ABNORMALITIES (5)

→ premature eruption

→ delayed eruption

→ embedded tooth

→ eruption sequestrum

→ impacted tooth

PREMATURE ERUPTION

• refers to the situation in which a tooth has erupted into the oral cavity much before the normal time of eruption

• involves only 1-2 teeth, usually the primary mandibular lateral incisors

TYPES OF PRENATAL ERUPTION (2)

→ natal tooth

→ neonatal tooth

NATAL TOOTH

• refers to an erupted primary teeth present at birth

NEONATAL TOOTH

• refers to the primary teeth that erupt during the first 30 days of life

DELAED ERUPTION

• refers to the 1st appearance of the teeth in the oral cavity at a much later time than the normal eruption time

EMBEDDED TOOTH

• refers to a tooth that did not erupt due to lack of eruptive forces

ERUPTION SEQUESTRUM

• a situation wherein there is a small fragment of necrosed bone that sometimes seen overlying an erupting tooth

• can cause pain, soreness, and difficulty in mastication

IMPACTED TOOTH

• refers to a tooth that is prevented from completely erupting into a normal functional position due to lack of space, obstruction by another tooth, or an abnormal eruption path

THEORIES OF IMPACTION (5)

→ orthodontic theory

→ phylogenic theory

→ mendelian theory

→ pathological theory

→ endocrinal theory

ORTHODONTIC THEORY

• states that as much as the normal growth of the jaw and the movement of the developing teeth is in a forward direction, anything that interferes with such development causes an impaction

PHYLOGENIC THEORY

• states that changes in nutritional habits of our civilization have resulted to a decrease in size of the maxilla and mandible, leaving a limited space for third molar to erupt in some people

• views third molars as vestigial organs without current purpose or function

MENDELIAN THEORY

• states that inheritance traits and hereditary is the common etiologic factor of impaction

PATHOLOGICAL THEORY

• states that any chronic infection affecting an individual may bring condensation of the osseous tissue which further prevents the growth and development of the jaws

ENDOCRINAL THEORY

• states that any increase or decrease in growth hormone secretion may affect the size of the jaws

INCIDENCE/ FREQUENCY OF ERUPTION (8)

1. mandibular third molar

2. maxillary third molar

3. maxillary canine

4. mandibular premolars

5. maxillary premolars

6. mandibular canine

7. maxillary central incisors

8. maxillary lateral incisors

SYSTEMIC CAUSES OF IMPACTION (5)

→ prenatal causes

→ postnatal causes

→ endocrine disorders

→ hereditary linked disorders

→ rare conditions

LOCAL CAUSES OF IMPACTION (16)

→ inadequate space in the dental arch

→ presence of supernumerary tooth

→ inclination or rotated tooth

→ obstruction of tooth eruption

→ long continued chronic inflammation

→ irregularity in the position and pressure of an adjacent tooth

→ over retained primary tooth

→ premature loss of primary tooth

→ ankylosis of primary and secondary tooth

→ dilaceration of roots

→ non absorbing alveolar bone

→ inflammtory changes in the bone

→ acquired disease

→ associated soft tissue or bony lesions

→ individual parafunctional habits

INDICATION OF REMOVAL OF IMPACTED TEETH (16)

→ tooth is in line of a fracture or prevention of jaw fracture

→ tooth is in line of fire

→ prevention of dental caries and unrestorable caries

→ prevention of an overt infection

→ prevention of root resorption

→ facilitation for implant placement

→ faciliation of orthodontic treatment

→ facilitation of orthognathic surgery

→ prevention of periodontal disease

→ management of preprosthetic concerns

→ prevention of odontogenic cysts or tumors

→ management of an abscess, cyst, or tumor

→ obstruction of the normal eruption of a permanent tooth

→ preventon of pain of unexplained roigin

→ prophylactic removal

CONTRAINDICATIONS FOR REMOVAL OF IMPACTED TOOTH (11)

→ extremes of age

→ probable excessive damage to adjacent structures

→ compromised medical status or condition

→ prosthetic consideration

→ presence of adequate arch space

→ uncontrolled active pericoronal infection

→ fracture of the atrophic mandible may occur

→ underlying pathologic disease

→ deep seated impacted teeth with no history of pathology

→ socio economic status

→ when there is a question about the future status of the second molar

RISKS OF INTERVENTION (3)

→ minor transient risks

→ minor permanent risks

→ major risks

MINOR TRANSIENT RISKS (7)

includes:

→ sensory nerve alteration

→ alveolitis

→ trismus

→ infection

→ hemorrhage

→ dentoalveolar fracture

→ displacement of the tooth

MINOR PERMANENT RISKS (3)

includes:

→ periodontal injury

→ temporomandibular injury

→ adjacent tooth injury

MAJOR RISKS (4)

includes:

→ altered sensation

→ vital organ infection

→ fracture or injury of the mandible and maxillary tuberosity

BENEFITS OF INTERVENTION (2)

→ relative to the patient’s age

→ in relation to different therapeutic measures

IN RELATION TO DIFFERENT THERAPEUTIC MEASURES

• includes local measures against pain, swelling, and trismus

RISKS OF NON INTERVENTION (3)

→ crowding of the dentition based on growth predilection

→ resorption of adjacent teeth and periodontal status

→ development of athological lesions or conditions such as cysts, tumors, and infection

BENEFITS OF NON INTERVENTION (3)

→ avoidance of risks

→ preservation of functional teeth

→ preservation of residual ridge

PREOPERATIVE ASSESSMENT (2)

→ clinical assessment

→ radiographic assessment

CLINICAL ASSESSMENT

• refers to proper treatment planning that is based on a thorough clinical evaluation of the patient with respect to genral and local factors relevant to possible postoperative sequelae

• aims to assess the status of the impacted teeth

THESE RESULTS TO POOR ACCESS TO THE SURGICAL/ OPERATIVE FIELD: (3)

→ retruded mandible

→ restricted mouth opening

→ small mouth commissures

THESE RESULTS TO BETTER ACCESS TO THE SURGICAL/ OPERATIVE FIELD: (2)

→ protruded mandible

→ large mouth opening

RADIOGRAPHIC ASSESSMENT

• pertains to the logical, sequential, and consistent method of interpreting a radiograph which is an essential part of the diagnostic process

STEPS FOR RADIOGRAPHIC ASSESSMENT (5)

• has an acronym of LOGIC

  • localization

  • observation

  • general considerations

  • interpretation

  • correlation

LOCALIZATION

• gives data about the position, size, if it is generalized or localized, and if it is single or multiple

OBSERVATION

• all radiolucent and radiopaque areas must be taken into consideration

GENERAL CONSIDERATION

• a radiograph is a two dimensional image of a three dimensional object which means that it involves the weight and height but depth is not included

INTERPRETATION

• evaluation of the entire tooth, bone, and other surrounding structures

CORRELATION

• considered as the final step to draw a diagnosis after inclusion of other data from case history, clinical examination, and other diagnostic aids

TWO MAIN TYPES OF DENTA XRAYS (2)

→ intraoral radiograph

→ extraoral radiograph

RADIOGRAPHIC ASSESSMENT INVOLVES ANY OR ALL OF THE FOLLOWING: (10)

→ intraoral radiographic techniques

→ extraoral radiographic techniques

→ assessment of the access to the tooth

→ condition of the crown and root of the tooth involves

→ condition of adjacent structures

→ relationship to vital structures

→ follicular width

→ periodontal status of the impacted tooth and adjacent tooth

→ wharfe’s assessment

→ winter’s line

INTRAORAL RADIOGRAPHIC TECHNIQUE

→ refers to the most common technique for radiographic interpretation which provides a clear and intricate image of minute structures

INTRAORAL RADIOGRAPHIC TECHNIQUE (3)

→ periapical radiograph

→ occlusal radiograph

→ clark’s rule

PERIAPICAL RADIOGRAPH

• gives a detailed view of the entire tooth as well as surrounding structures

• provides information regarding the following: state of tooth development, tooth resorption, and presence of dental follicle

OCCLUSAL RADIOGRAPH

• it tracks the development and placement of a tooth in either the maxilla or mandible by placing the film in the occlusal surace

MAXILLARY OCCLUSAL PROJECTIONS (3)

→ upper standard or anterior occlusal

→ upper oblique occlusal

→ vertex occlusal

MANDIBULAR OCCLUSAL PROJECTIONS (3)

→ lower 90º occlusal

→ lower 45º or anterior occlusal

→ lower oblique occlusal

SIMPSON

• most frequently used projection wherein the beam is positioned perpendicular to the film through the glabella

CLARK’S RULE

• is used in the localization of an impacted teeth

• uses 2 exposures

2 EXPOSURES OF CLARK’S RULE

• 1st exposre

  • is in the usual position

• 2nd exposure

  • done with the tube shifted 2cm in one direction

LINGUAL OR PALATAL POSITION INTERPRETATION

• interpretation if in the 2nd film, the impacted tooth has shifted in the same direction as the tube

LABIAL OR BUCCAL POSITION INTERPRETATION

• interpretation if in the 2nd film, the impacted tooth has shifted in the opposite direction as the tube

EXTRAORAL RADIOGRAPHIC TECHNIQUES

• useful for evaluating large areas of the skull and jaws, but are inadequate for detection of subtle changes such as early stages of dental caries or periodontal disease

TECHNIQUES FOR DETECTION OF IMPACTED TEETH IN THE MANDIBLE (2)

→ panoramic radiograph

→ lateral oblique view of the mandible

PANORAMIC RADIOGRAPH

• provides a two dimensional image and curvilinear variant of conventional tomography that shows the mandible/maxilla and temporomandibular joints/maxillary sinus

• trade names: panorex and orthopanthomograph

LATERAL OBLIQUE VIEW OF THE MANDIBLE

• refers to lateral radiograph that gives an excellent view of the body and ramus of the mandible

TECHNIQUES FOR DETECTION OF IMPACTED TEETH IN THE MAXILLA (2)

→ panoramic radiograph

→ posterior anterior view and water’s view

POSTERIOR - ANTERIOR VIEW/ P-A VIEW

• demonstrates the mediolateral dimensions of the skull

WATER’S VIEW

• demonstrates the occipitomental dimensions of the skull

TECHNIQUES FOR DETECTION OF IMPACTED TEETH IN THE MANDIBLE AND MAXILLA (3)

→ lateral radiographs

→ cephalometric radiographs

→ three dimensional radiographs (ct scam and cbct)

LATERAL RADIOGRAPHS

• is divided into true laterals, oblique laterals, and bimolars

• has an important role for he following: position of the unerupted tooth, detection of jaw fractures, evaluation of jaw lesions, and specific views for the salivary glands and tmj

CEPHALOMETRIC RADIOGRAPHS

• a skull radiography that describes the relationship of the teeth to the jaw, and the jaw to the different facial skeleton

• mre commonly utilized for orthognathic and orthodontic procedures

• has different types: lateral ceph, postero anterior ceph, and antero posterio ceph

THREE DIMENSIONAL RADIOGRAPH

• included computed tomography scan (CT scam) and cone beam computed tomography (CBCT)

CT SCAN

• uses a fan beam which radiates in a spiral or helix and the data is interpolated by a scanner into a set of slices making up a volume

CBCT

• uses a cone beam that radiates in a cone shape and image is reconstructed into algorithms to produce high resolution image

ASSESSMENT OF THE ACCESS TO THE TOOTH

• involves the type and orientation of the impaction

CONDITION OF THE CROWN AND ROOT OF THE TOOTH INVOLVED

• pertains to the crown in referece to size, root number, and morphology of the impacted tooth

CONDITION OF THE ADJACENT STRUCTURES

• indicates the condition of the bone with regards to the depth, density, and the absence of bone

RELATIONSHIP TO VITAL STRUCTURES

• refers to the proximity or relationship of the impacted tooth to vital structure

ROOT APEX IS RELATED BUT NOT INVOLVING THE CANAL (3)

• root and canal are separated

• both are adjacent

• superimposition

ROOT CANAL IN RELATION TO THE CHANGES IN THE ROOTS OR ROOT APICES (4)

• darkeing of the root or root apex

• dark bifid root apex

• narrowing of the root or root apex

• deflection of the root apex

ROOT APEX IS RELATED WITH THE CHANGES IN THE ROOT CANAL (3)

• converging canal

• interruption of the superior border of the canal

• diversion of the canal

ROOD AND SHEHAB’S 7 RADIOGRAPHIC SIGNS

1. darkening of the root or root apex

2. dark bifid root apex

3. narrowing of the root or root apex

4. deflection of the root

5. converging or narrowing of the canal

6. interruption of the superior border of the canal

7. diversion of the canal

PERIODONTAL STATUS OF THE IIMPACTED TOOTH AND ADJACENT TEETH

• determined by the presence of pocket formation and or bone loss

WHARFE’S ASSESSMENT

• refers to a very detailed assessment that would indicate the difficulty of impaction

WINTER LINES

• also called WAR lines (white, amber, and red) which is an acronym of the three distinct imaginary lines that are drawn on a radiograph