3 Impacted Teeth

IMPACTED TEETH

  • Overview of impacted teeth, focusing on third molars and canines.

LEARNING OUTCOMES

  • Discuss the assessment and management of impacted 3rd molars.

  • Outline the risks involved in the removal of impacted 3rd molars.

  • Discuss NICE guidelines for the removal of impacted 3rd molars.

  • Discuss the assessment and management of impacted canines.

  • Outline the risks involved in the management of impacted canines.

  • Discuss the concept of informed consent relevant to impacted teeth.

IMPACTED THIRD MOLAR TEETH

  • Clinical assessment.

  • Radiological assessment.

  • Treatment options.

  • Indications for removal.

  • Risks assessment.

  • Informed consent.

CLINICAL ASSESSMENT

  • History considerations:

    • Pain: Frequency and nature of pain experienced.

    • Swelling: Presence and severity of swelling.

    • Bad taste: Occurrences and duration.

    • Number of episodes: Frequency of symptoms.

    • Severity: Impact on quality of life.

    • Antibiotic usage: Need for antibiotics due to infections.

  • Signs of impact:

    • Facial pain is not a direct cause of impacted teeth.

    • Lower incisor crowding.

    • Movement of adjacent teeth.

    • Episodes of pericoronitis (infection of the gum around a tooth).

CLINICAL ASSESSMENT CONTINUED

  • Past medical history (PMH)/Dental history (PDH):

    • Examination methods:

      • Extra-oral: Check for facial asymmetry or swelling.

      • Intra-oral: Access to impacted teeth.

    • Findings of interest:

      • Degree of eruption of the third molar or second molar.

      • Presence of decay in third molar or second molars (7s).

      • Evidence of food packing.

      • Evaluation of the rest of the mouth, especially other third molars.

RADIOLOGICAL ASSESSMENT

  • Imaging techniques:

    • IOPA: Insufficient for viewing apex or inferior dental nerve (IDN).

    • OPT: Most commonly used imaging technique.

    • CBCT: Used for complex cases; offers 3D visualization for better interpretation of tooth’s relationship to IDN and root anatomy.

RADIOLOGICAL ASSESSMENT CONTINUED

  • Essential aspects of imaging:

    • Visualizing all of the third molar.

    • Understanding type/orientation of impaction.

    • Assessing crown size and condition.

    • Determining root number and morphology.

    • Evaluating alveolar bone level, periodontal status, and adjacent teeth.

    • Analyzing the relationship to ID canal and lower mandible border.

INTERPRETATION OF RADIOGRAPHS

  • Key interpretive aspects:

    • Type of impaction (soft tissue, bony): mesioangular, distoangular, vertical, horizontal.

    • Depth of impaction: Evaluates how embedded the tooth is.

    • Condition of the tooth: Crown size, integrity, and root morphology, including extraction path.

    • Relationships to IDN and other teeth.

    • Identifying associated pathologies.

WINTERS LINES (WAR LINES)

  • Used for estimating impaction depth & angle:

    • White line: Drawn along occlusal surfaces of erupted molars; indicates occlusal level differences.

    • Amber line: Represents the margin of alveolar bone covering the 3rd molar and indicates necessary bone removal.

    • Red line: An imaginary line indicating point of application for extraction techniques.

TREATMENT OPTIONS

  • Options for management of impacted teeth:

    • Surgical removal: Complete extraction of the tooth.

    • Coronectomy: Removal of crown while leaving roots intact.

    • Operculectomy: Removal of gum tissue over the tooth.

    • Remove opposing tooth: If indicated, to relieve pressure.

    • Surgical exposure: Open or closed exposure techniques to encourage eruption.

    • Monitor: Observation without immediate action.

INDICATIONS FOR REMOVAL (NICE GUIDELINES)

  • Removal indicated for:

    • Recurring pericoronitis.

    • Unrestorable caries.

    • Non-treatable pulpal/periapical disease.

    • Resorption of tooth roots.

    • Periodontal disease impacting the third molar.

    • Fracture of the tooth.

    • Presence of a cyst or tumor associated with the follicle.

    • Impeding surgical access.

    • Tooth involved in field of tumor resections.

INDICATIONS NOT TO REMOVE

  • When removal is not recommended:

    • No symptoms present.

    • Minimal symptoms.

    • Presence of lower incisor crowding without severe impact.

    • Treatment of temporomandibular disorders (TMD).

    • Removal coinciding with contralateral tooth extraction without necessity.

    • Anatomical proximity to IDN without symptoms.

CLOSE PROXIMITY TO IDN

  • Surgery may proceed if:

    • Severe symptoms or pathology is evident.

    • Clearly defined indications for surgery.

    • Appropriate imaging techniques are utilized (CBCT if needed).

    • All options and implications discussed with the patient, emphasizing informed consent.

RISK ASSESSMENT

  • Weighing benefits vs risks:

    • Evaluate necessity of treatment.

    • Consider risks associated with leaving tooth untreated.

    • Assess patient's tolerance for procedures.

    • Confirm expertise and capability to perform the needed procedure.

INFORMED CONSENT

  • Essential components of informed consent:

    • Written informed consent required before proceeding.

    • Detailed discussion of risks concerning surgery and the implications of leaving the tooth in place.

    • Risks specifically associated with ID and lingual nerve: potential for temporary or permanent dysaesthesia.

    • 'Cooling off' period after the discussion.

    • Provision of written advice sheets to supplement verbal discussions.

INCLUDED RISKS FOR SURGERY

  • Common postoperative complications include:

    • Swelling.

    • Trismus (restricted mouth opening).

    • Altered sensation (anaesthesia or paraesthesia).

    • Bruising in the labial or lingual regions.

IMPACTED MAXILLARY CANINES

  • Clinical assessment may cover:

    • Estimation of the canine’s position relative to adjacent teeth and structures.

    • Bulges which may be palpable buccally/labially.

    • Proclination of upper incisors.

    • Mobility assessment of upper lateral incisors and retention of deciduous canine.

RADIOGRAPHIC ASSESSMENT

  • Techniques for assessing canines:

    • Parallax method: Two radiographs at different angles for localization purposes.

    • Comparisons of canine position relative to lateral incisors.

    • Movement interpretation for deciding canine position (palatally or buccally ectopic).

    • CBCT sometimes used but rarely necessary.

TREATMENT OPTIONS FOR CANINES

  • Management decisions may include:

    • Leave & monitor: Assess risks of doing nothing.

    • Surgical exposure: Open or closed methods with brackets and chain.

    • Surgical removal if necessary, weighing risks involved.

INFORMED CONSENT FOR CANINES

  • Important considerations:

    • Written informed consent is crucial.

    • Risks of surgical interventions must be discussed, including potential for root resorption or cyst formation.

    • General risks common to all surgical procedures and specific risks related to exposure management.

OTHER IMPACTED TEETH

  • Consideration for other impacted types:

    • Mesiodens: Additional teeth that may fail to erupt.

    • Supernumeraries: Extra teeth beyond the normal count.

    • Lower canines: Impacted canines that may require assessment.

    • Any tooth with significant root formation unlikely to erupt must be given attention.

ASSESSMENT & MANAGEMENT FOR OTHER TEETH

  • Apply principles from previous assessments for other impacted teeth:

    • Comprehensive clinical examination.

    • Radiographic evaluation to localize and assess relationships.

    • Discussion of risks and benefits of removal or monitoring with the patient to assist in an informed decision.