Management of Impacted Teeth

tooth agenesis

-developmental absence of one or more teeth in the mouth

-occurs when the tooth fails to form during the growth process, typically due to genetic, environmental, or systemic factors

tooth malposition

-tooth in an abnormal position

tooth impaction

-tooth that fails to erupt into the dental arch within the usual range of expected time

why do teeth get impacted?

-we don’t really know

-differential growth rate of roots causes under or over rotation leading to impaction

-arch length: impacted third molars are larger than erupting third molars

-ectopic position: abnormal germ position puts teeth in contact with a denser external oblique ridge

-later mineralization: tooth growth lags behind maturation of jaws due to decreased influence of resorption of jaw

-attrition: softer diet leads to less attrition retaining mesiodistal space

options for ectopic teeth

-remove

-facilitate eruption

-monitor

indications for treatment- active surveillance

-if the tooth is malposed but not impacted and may possibly erupt given the patient’s age

-absence of symptoms

indications for treatment- facilitate eruption

-if the tooth is malposed but close to the arch and the patient has passed the age of normal eruption

-if the orthodontist thinks they can bring into the arch

-if there is adequate space in the arch

indications for treatment- prophylactic removal

-preventing periodontal disease

-preventing caries

-preventing pericoronitis

-preventing root resorption

-facilitation of orthodontic treatment

-prevention of odontogenic cysts and tumors

-prevention of jaw fractures

indications for treatment- symptomatic removal

-treating periodontal disease

-treating caries

-treating pericoronitis

-treating root resorption

-unexplained pain

information gathering

-CC

-HPI: OLDCARTS

-PMH

-PSH

-allergies

-medications

-social history

-family history with anesthesia

physical exam

-vitals- bp, SpO2, hr, rr, height, weight

-cranial nerve exam- V2/V3

-LAD
-swellings

-maximum incisal opening

-vestibular swelling

-erythema

-uvula position

-floor of mouth elevation

-palpate for impacted tooth

-probing depths

-oral hygiene

airway exam

-metabolic equivalent tasks

-neck range of motion

-thyromental distance

-neck circumference

-maximum incisal opening

-facial hair

-heart and lung sounds

-Mallampati score

-impacted teeth are generally more difficult to take out- many times requires sedation

-important to do airway exam to determine if they are an appropriate candidate for in-office sedation v. the operating room

METS- activity level, definition, descriptive measures

Mallampati

ASA classification, definition, examples

radiographic predictors of difficulty

-size of the follicular sac

-density of surrounding bone

-contact with mandibular second molar

-relationship to vital structures

-depth of impaction

Rood’s criteria (prediction of IAN injury)

nature of overlying tissue

-PBI: tooth partially erupted but still stuck in bone

-FBI: tooth fully in bone

Winter’s classification of impaction

Pell and Gregory classification

-relates impaction to location of mandibular ramus

Pell and Gregory classification- ABC

-relates depth of impaction to second molar

classification systems for maxillary third molar impactions

factors that make impaction surgery less difficult

-mesioangular position

-pell and gregory class 1 ramus

-pell and gregory class A depth

-roots 1/3 to 2/3 formed (young pt)

-fused conical roots

-wide PDL (young pt)

-large follicle (young pt)

-elastic bone (young pt)

-separated from second molar

-separated from IAN (young pt)

-soft tissue impaction

factors that make impaction surgery more difficult

-distoangular position

-pell and gregory class 2 or 3 ramus

-pell and gregory class B or C depth

-long, thin roots (older patients)

-divergent curved roots

-narrow PDL

-thin follicle (older patients)

-dense, inelastic bone (older patients)

-contact with second molar

-close to inferior alveolar canal

-complete bony impaction (older patients)

surgical procedure

-exposure

-bone removal

-tooth sectioning

-tooth removal

-surgical site closure

procedure- step 1

-access

procedure- step 2

-bone removal

procedure- step 3

-section tooth

maxillary extractions

procedure- step 4

-surgical site closure

coronectomy

-removal all enamel

-3mm below buccal bone

-no mobile roots

post op care

-pain medication: ibuprofen 600 mg q6 PO, acetaminophen 500mg q6 PO, oxycodone 5 mg q6 PO x 6 tabs, amoxicillin 500mg TID x5 days?

-follow up one week

complications

-intra-op: tooth/root displacement (sinus, sublingual space, IAN canal, infratemporal fossa), mandible fracture, bleeding, nerve injury

-early: ecchymosis, thermal injury, bleeding, alveolar osteitis

-late: infection, osteomyelitis