Impaction of teeth Dr. Rafik Al Kowafi BDS, MSc, German board of - - PDF document

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Impaction of teeth

• Dr. Rafik Al Kowafi BDS, MSc, German board of Oral and

Maxillofacial Surgery ( Berlin- Germany), Doctoral degree by LBMS

Definition

• The impacted tooth is a tooth that fails to

erupt into its normal functioning position in the dental arch within the expected time.

• The term unerupted includes both impacted

teeth and teeth that are in the process

• f

eruption.

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Causes of impaction

1. Hereditary factors that result in a disproportion in size between teeth and jaws. 2. Local causes include:

a) Retention or premature loss of a deciduous predecessor. b) The presence of supernumerary teeth. c) Abnormal position of or injury to the tooth germ.

3. Tumours and cysts (e.g. dentigerous cyst, OKC, ameloblastoma). 4. Certain conditions such as:

a) Cleft palate. b) Cleidocranial dysostosis. c) Hypopituitarism. d) Cretinism. e) Rickets f) Facial hemiatrophy predispose to delay or failure of eruption.

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• 1. Mandibular 3rd molars.
• 2. Maxillary 3rd molars.
• 3. Maxillary canines.
• 4. Mandibular premolars.
• 5. Maxillary premolars.
• 6. Mandibular canines.
• 7. Maxillary central and lateral incisors.

Frequency of impaction

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Indications for removal of impacted teeth

1. Prevention of Dental Caries. 2. Prevention of Pericoronitis. 3. Prevention of Periodontal Disease. 4. Prevention of Root Resorption. 5. Impacted Teeth Under a Dental Prosthesis. 6. Prevention of Odontogenic Cysts and Tumors. 7. Treatment of Pain of Unexplained Origin. 8. Prevention of Jaw Fractures. 9. Facilitation of Orthodontic Treatment.

• 10. Optimal Periodontal Healing.
• 11. Facilitation of Orthognathic / Reconstruction Surgery
• 12. Autogenous Transplantation to First Molar Socket
• 13. Prophylactic removal - Patients with Medical or Surgical Conditions

Requiring Removal of Third Molar (e.g. chemotherapy, radiotherapy).

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1.Prevention of Dental Caries

• When a third molar is

impacted

• r

partially impacted, the bacteria that cause dental caries can be exposed to the distal aspect

• f

the second molar, as well as to the third molar.

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• 2. Prevention of Pericoronitis.
• When a tooth is partially

impacted with a large amount of soft tissue over the axial and

• cclusal

surfaces, the patient frequently has one or more episodes of pericoronitis.

• Pericoronitis is an infection
• f the soft tissue around the

crown of a partially impacted tooth.

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• 3. Prevention of Periodontal Disease
• Erupted teeth adjacent to

impacted teeth are predisposed to periodontal disease.

• The presence of an impacted

mandibular third molar decreases the amount

• f

bone on the distal aspect of an adjacent second molar and causes food impaction and deep pockets.

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• 4. Prevention of Root Resorption.
• Occasionally,

an impacted tooth causes sufficient pressure on the root of an adjacent tooth to cause root resorption.

• Although the process by which

root resorption occurs is not well defined, it appears to be similar to the resorption process primary teeth undergo during the eruptive process of the succedaneous teeth.

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• 5. Impacted Teeth Under a Dental

Prosthesis

• After teeth are extracted, the

alveolar process slowly undergoes resorption. Thus the impacted tooth becomes closer to the surface of the bone.

• The denture may compress the

soft tissue onto the impacted tooth, the result is ulceration

• f the overlying soft tissue and

initiation of an odontogenic infection.

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• 6. Prevention of Odontogenic Cysts

and Tumors.

• When

impacted teeth are retained completely within the alveolar process, the associated follicular sac is also frequently retained and it may undergo cystic degeneration and become a dentigerous cyst or keratocyst.

• Odontogenic tumors can arise

also from the epithelium contained within the dental follicle. The most common

• dontogenic tumor to occur in

this region is the ameloblastoma.

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• 7. Treatment of Pain of Unexplained

Origin.

• Occasionally, patients come to the dentist

complaining of pain in the retromolar region

• f the mandible for no obvious reasons.
• If

conditions such as myofascial pain dysfunction syndrome and other facial pain disorders are excluded and if the patient has an impacted tooth, removal of the tooth sometimes results in resolution of the pain.

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• 8. Prevention of Jaw Fractures
• An impacted third molar in the

mandible occupies space that is usually filled with bone. This weakens the mandible and renders the jaw more susceptible to fracture at that site.

• If the jaw fractures through

the area of an impacted third molar, the impacted third molar is frequently removed before the fracture is reduced.

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• 9. Facilitation of Orthodontic

Treatment

• When patients require retraction of first and

second molars by orthodontic techniques, the presence of impacted third molars may interfere with the treatment. It is therefore recommended that impacted third molars be removed before

• rthodontic therapy is begun.
• Some orthodontic approaches to a malocclusion

might benefit from the placement of retromolar implants to provide distal anchorage. When this is planned, removal of impacted lower third molars is necessary.

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• 10. Optimal Periodontal Healing
• Patients whose third molars are removed before

age 25 are more likely to have better bone healing and the infra bony pockets distal to the second molar can be decreased than those whose impacted teeth are removed after age 25.

• In the younger patient, not only is the initial

periodontal healing better, but the long-term continued regeneration of the periodontium is clearly better.

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• 11. Facilitation of Orthognathic

Surgery

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Contraindications

• 1. Extremes of age.
• 2. Patients with compromised medical status.
• 3. Probable excessive damage to adjacent

structures.

• 4. When there is a question about the future

status of the second molar.

• 5. Acute pericoronal infection.

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Classification Of Impacted teeth

• Maxillary and mandibular third molar molars

are classified radiographically by:

A. Degree of impaction. B. Angulation of the tooth. C. Proximity to the inferior alveolar canal.

• The most common classification systems used

are:

– Pell And Gregory Classification. – George B. Winter’s Classification.

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• A. Degree of impaction
• 1. No impaction – fully erupted tooth which may be in :

– Functional occlusion with tooth in opposing arch or – Non – functional.

• 2. Soft- tissue impaction :

– Partly erupted tooth. – Unerupted tooth.

• 3. Bony impaction – unerupted tooth with crown that may be;

– Partially surrounded by bone. – Totally surrounded by bone.

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• B. Angulation of the tooth

In the sagittal and transverse planes 1. Vertical:

– bucco-version – linguo- version

• 2. Mesio – angular :

– bucco – version – linguo- version

• 3. Disto – angular :

– bucco – version – linguo – version

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• B. Angulation of the tooth
• 4. Horizontal:

– bucco – version – linguo-version

• 5. Heterotopic :

– Tooth is found in unusual places along the lower border

• f the mandible or high up the ascending ramus, usually

in an inverted position.

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• B. Angulation of the tooth
• Classification of impaction
• f mandibular third

molars, according to the angulations of the tooth.

1. Mesioangular. 2. Distoangular. 3. Vertical. 4. Horizontal. 5. Bucco-version. 6. Linguo-version. 7. Inverted.

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• C. Proximity to the inferior alveolar

canal

• No contact.
• Root apices in direct

contact.

• Root crossing canal on
• ne side only – no imprint
• f canal on root surface.
• Roots partially encircling

canal – imprint of canal clearly visible on root surface.

• Roots completely

encircling canal – canal passes between the roots

• f the tooth.

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• C. Proximity to the inferior alveolar

canal

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Pell And Gregory Classification

• In Relation Of The Tooth To The Ramus Of The

Mandible And The Second Molar:

– Class I. – Class II. – Class III.

• Relative Depth Of The Third Molar In Bone:

– PositionA. – PositionB. – PositionC.

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Class I

• The available Space, at the

level of the retromolar triangleIs sufficient to accommodate the mesiodistal diameter of the crown of the third molar.

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Class II

• The space available

between the anterior border of the ramus and distal side of the second molar is less than the mesiodistal width of the crown of the third molar.

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Class III

• The third molar totally

embedded in the bone from the ascending ramus because of the absolute lack of space.

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Position A

• The highest position of

the tooth is on a level with or above the

• cclusal line.

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Position B

• Highest position is

below the occlusal plane, but above the cervical level of the second molar.

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Position C

• Highest position of the

tooth is below the cervical level of the second molar.

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Winter’s Classification

• According to the position of the impacted third molar to the long

axis of the second molar. The winter’ classification suggests: 1. Mesioangular 2. Horizontal 3. Vertical 4. Distoangular 5. Bucco-version 6. Linguo-version 7. Heterotopic

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Winter lines

• George Winter determined three imaginary lines on the

standard dental radiograph:

• The white line.

– A line Drawn Along The Occlusal Surface Of The Erupted Mandibular Molars And Extended Posteriorly Over The Third Molar Region.

• Amber line.

– A Line Drawn From Bone Lying Distally To The Third Molar To The Crest Of The Interdental Septum Between The First And Second Mandibular Molars.

• Red line.

– Line Used To Measure The Depth At Which The Impacted Tooth Lies Within The Mandible, It Is Perpendicular Dropped From The Amber Line To An Imaginary Point Of Application of An Elevator.

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Winter lines

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White line

Red line Amber line

Distoangular impaction Mesioangular impaction

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Winter lines

• Clinical experience revealed that any increase of the length
• f the red line by one mm. The extraction becomes about

three times more difficult.

• Any tooth with a red line 5mm or more in length is better

removed under general anaesthesia.

• If red line is 9mm or more in length, the inferior surface of

the crown of the impacted third molar may be with or even below the apex of the second molar tooth.

• The red line lies usually on the mesial side of the impacted

lower third molars, except distoangular impaction, as it lies

• n the distal side.
• Its better to remove the second molar with a denuded root

at the time the third molar is extracted.

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Difficulty assessment of surgical removal of the lower third molars

• 1. Patient cooperation.
• 2. Mouth opening.
• 3. Space available distal to the second molar.
• 4. Depth and angulation of the impacted tooth.
• 5. Condition of the crown.
• 6. Root morphology:

– The length of the root. – The curvature of the tooth roots. – The total width of the roots in the mesiodistal direction. – The periodontal ligament space.

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Difficulty assessment of surgical removal of the lower third molars

• 7. Size of follicular sac.
• 8. Density of surrounding bone.
• 9. Contact with mandibular second molar.
• 10. Relationship to inferior alveolar nerve.
• 11. Nature of overlying tissue.

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Factors that make impaction surgery less difficult

• 1. Mesioangular position.

2 .Class 1 ramus.

• 3. Class A depth.
• 4. Roots one third to two thirds formed.

5 . Fused conical roots.

• 6. Wide periodontal ligament.
• 7. Large follicle.
• 8. Elastic bone (young patient).
• 9. Separated from second molar.

1 0. Separated from inferior alveolar nerve. 1 1 . Soft tissue impaction.

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Factors that make impaction surgery more difficult

• 1. Distoangular position.
• 2. Class 3 ramus.
• 3. Class C depth.
• 4. Long, thin roots.
• 5. Divergent curved roots.
• 6. Narrow periodontal ligament.
• 7. Thin follicle.
• 8. Dense, inelastic bone (Old patient).
• 9. Contact with second molar

1 0 . Close to inferior alveolar canal. 1 1 . Complete bony impaction.

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Classification of impacted maxillary third molar

• Angulation and depth

classification is same as mandibular third molars.

1. Mesioangular. 2. Distoangular. 3. Vertical. 4. Horizontal. 5. Bucco-version. 6. Linguo-version. 7. Inverted.

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Classification of impacted maxillary third molar

In relation to the maxillary sinus floor:

• a. Sinus approximation:

No bone or thin bony partition between maxillary third molar and the floor of the maxillary sinus.

• b. No sinus approximation:

2 mm or more bone is present between the sinus floor and the impacted maxillary third molar.

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Classification of impacted maxillary canine

Class 1: Palatally placed maxillary canine:

• a. Horizontal
• b. Vertical
• c. Angulated

Class 2: Labially or buccally placed maxillary canine:

• a. Horizontal
• b. Vertical
• c. Angulated

Class 3: Involving both buccal and palatal bone: e.g. crown is placed on the palatal aspect and the root is toward the buccal alveolar process or vice versa.

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Classification of impacted maxillary canine

• Class 4: Vertically impacted

canine in alveolar process between lateral incisor and first premolar.

• Class 5: Canine impacted in

the edentulous maxilla.

• Class 6: Maxillary canines in

unusual positions: e.g. in naso-antral wall or infraorbital margin.

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Diagnosis

• The diagnosis of unerupted teeth is based on:
• 1. History.
• 2. Clinical examination.
• 3. Radiographs.

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• 1. History
• In the absence of infection the patient often has no

complaint other than that a tooth is missing. The crown may cause a symptomless swelling under the mucosa. Where pain is thought to be a symptom from a completely buried tooth, every effort must be made to eliminate other possible causes, particularly pulpitis from another tooth.

• Where infection is present, more acute symptoms are

expected.

• Inflammation about the crown of an unerupted or partly

unerupted tooth is known as pericoronitis and is particularly serious when it arises from a lower third molar

• wing to the tendency of the infection to spread into the

neck.

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2.Examination

• Age of the patient.
• Medical history.
• Patient cooperation and compliance .
• Access to the surgical site (amount of the mouth opening and size of the

tongue).

• Missing permanent teeth, retained deciduous teeth.
• Presence or absence of acute or chronic infection.
• Caries and periodontal disease, caries in a neighbouring tooth can often

be the actual cause of the patient’s symptoms of pain or infection, or may influence the plan of treatment where extraction of the carious tooth may allow the unerupted one to come into the space.

• Vitality tests.
• The mouth is examined for signs of infection such as swelling, discharge,

trismus and enlarged tender lymph nodes.

• Associated fracture of maxilla/mandible.

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3.Radiographic examination

• The radiographic examination provides all the necessary

information to program and correctly plan the surgical removal of impacted teeth. This information includes:

1. Position and type of impaction. 2. Relationship of impacted tooth to adjacent teeth. 3. Size and shape of impacted tooth. 4. Root size, length and configuration. 5. Depth of impaction in bone. 6. Density of bone surrounding impacted tooth. 7. Presence of any associated pathological condition (e.g cysts and tumors). 8. The relationship of the impacted tooth to various anatomic structures, such as the mandibular canal, mental foramen, and the maxillary sinus.

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3.Radiographic examination

• These informations can be provided

by the following radiographs: 1. Periapical radiographs. 2. Occlusal radiographs. 3. Panoramic radiographs. 4. Advanced three-dimensional (3D) imaging techniques: Cone-beam computed tomography (CBCT). 5. CT-scan.

• Localisation of the impacted tooth (e.g.

impacted maxillary canine).

1. Periapical film or OPG + Occlusal film. 2. Tube shift technique. 3. CT-scan (coronal and axial). 4. Lateral oblique views.

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Management of impacted third molars

• 1. Conservative method.
• 2. Surgical removal of the overlying flap.
• 3. Surgical removal of the tooth.

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Management of impacted third molars

1. Conservative method:

In case of partially impacted third molar with pericoronitis, irrigation with warm saline or iodine solution should be done beneath the flap (operculum).

2. Surgical removal of the

• verlying flap (Operculectomy):

Operculectomy is not easy to be performed by scalpel or scissors. This flap can be best removed with the help of electrosurgical scalpel or radiosurgical loop.

3. Auto-transplantation. 4. Surgical removal of the entire tooth.

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Surgical removal of impacted teeth

1. ASEPSIS AND ISOLATION 2. LOCAL OR GENERAL ANAESTHESIA /SEDATION. 3. INCISION AND FLAP DESIGN 4. REFLECTION OF MUCOPERIOSTEAL FLAP 5. BONE REMOVAL 6. SECTIONING (DIVISION ) OF THE TOOTH 7. ELEVATION AND REMOVAL OF THE TOOTH 8. DEBRIDEMENT AND SMOOTHENING OF BONE 9. CONTROL OF BLEEDING

• 10. CLOSURE – SUTURING
• 11. MEDICATIONS – ANTIBIOTICS, ANALGESICS
• 12. FOLLOW UP AND SUTURE REMOVAL

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Asepsis and isolation

• Painting solutions.

– Povidine –iodine 5% for skin, 1% for oral mucosa – Chlorohexidine – 7.5% for skin, 0.2%for rinsing

• ral mucosa
• Drape the patient.

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Anaesthesia

• Mostly procedure performed under local anaesthesia
• GA is indicated when:
• 1. Impacted tooth situated deep in jaw bone (red line > 5

mm ).

• 2. Multiple impacted teeth have to be removed at one time.
• 3. Emotional inability like in case of fear of pain &

apprehension.

• 4. Lengthy procedure.
• 5. Uncooperative patient.
• 6. LA may not achieved desired effect.

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Flap design

• The following are the different common types
• f the flaps used for removal of impacted third

molars: 1.Envelop flap. 2.Ward’s and modified ward’s flap. 3.Bayonet flap. 4.Triangular flap.

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Flap design

• 1. Envelope flap.

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Flap design

• 2. Ward’s (A) and modified

ward’s flap (B).

• 3. Bayonet flap.

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Flap design

• 4. Triangular flap

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Flap design

• 4. Triangular flap.

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Bone removal

• Aims:

– To exposed the crown by removing the bone overlying it. – To remove the bone

• bstructing the pathway for

removal of the tooth. – To create point of application for a dental elevator.

• Two ways of bone removal:

1. High torque handpiece and bur technique (round & fissure burs) 2. Chisel and mallet technique

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Bone removal

1. Handpiece and bur technique:

• First step

The bur is used in sweeping motion around the 3rd molar crown except lingual aspect to expose it.

• Second step

Once the crown has been located, the buccal surface of the tooth is exposed with the bur to the cervical level of the contour & a buccal trough or gutter is created. The bone removal around the crown is done till CEJ and the expose the crown beyond the greatest width.

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Bone removal

• Precautions while drilling the bone:

– Protect the overlaying tissue by retraction with either periosteal elevator, Austin or langenbeck retractor . – Continuous irrigation to reduced thermal necrosis of the bone. 2. Chisel and mallet technique

– Historical important – Very rarely used under L.A as most of the patients do not tolerate it, mainly used under G.A. – Faster than drilling. – Less bone necrosis than bur technique (no heat generation). – Can cause unexpected fracture of the bone – The jaw bone should be supported, while using this technique.

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Tooth Sectioning and removal

• Reduce the amount of bone removal.
• Reduces the risk of damaging the neighbouring

teeth.

• The direction of sectioning depends on the

angulation of impacted tooth.

• Can be performed either with a bur or osteotome

and mallet.

• The tooth is usually sectioned ½ to ¾ with the bur

then completely sectioned with the elevator.

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Tooth Sectioning and removal

• Mesioangular Impaction

– Distal half of the crown is sectioned off from buccal groove till the CEJ. – A straight elevator is placed in the cut and rotated to fracture the distal portion of the crown which is removed. – Then a straight elevator is placed

• n the mesial aspect of 3rd molar

below the cervical area. – If the access to the elevator is not possible then a cryer or crane pick elevator can be used to elevate the tooth.

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Tooth Sectioning and removal

• Distoangular Impaction:
• Most difficult.
• Large amount of distal bone

removal is required.

• The crown is sectioned from the

roots just above the cervical line after sufficient bone is removed from the occlusal and distobuccal aspect.

• The entire crown is removed to

improve the visibility and access to the roots.

• If the roots are divergent they are

further sectioned into two pieces and delivered Individually.

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Tooth Sectioning and removal

• Horizontal impaction:

– The second most difficult impaction. – After sufficient bone has been removed down to the cervical line to expose the superior aspect

• f the distal root and the majority
• f the buccal surface of the

crown, the tooth is sectioned by dividing the crown of the tooth from the roots at the cervical line. – The crown of the tooth is removed, and the roots are displaced with a Cryer elevator into the space previously

• ccupied by the crown.

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Tooth Sectioning and removal

• Vertical Impaction:

– The occlusal, buccal and distal bone is removed. – The distal half of the crown is sectioned and removed, and the tooth is elevated by applying an elevator at the mesial aspect of the cervical line of the tooth. – This is more difficult than a mesioangular removal because access around the mandibular second molar is difficult to

• btain and requires the

removal of substantially more bone on the buccal and distal sides

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Tooth Sectioning and removal

• Maxillary third molars rarely

require sectioning because the

• verlying bone is thin and

relatively elastic. Usually extraction is accomplished by removing additional bone that overlying the impacted tooth also at the buccal side rather by sectioning.

• Delivery of maxillary third molars is

accomplished with small straight elevators or warwick james elevator, which distobuccally luxate the tooth.

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Debridment and smoothing of bone

• Round off the margins of the socket with bone

file.

• Curettage to remove any remnants.
• Look for pieces of coronal portion of the tooth,

bone ships, granulation tissue, and irrigate with sterile saline.

• Mosquito hemostat can be used to remove any

remnants of the dental follicle if present.

• A final irrigation and a thorough inspection

should be performed before the wound is closed.

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Closure – Suturing

• 3-0 or 4-0 (black silk, vicryl and polyester) can

be used.

• Interrupted suture given and maintained for 7

days.

• In case of molars, suture distal to second

molar should be placed first and should be water tight to prevent pocket formation.

• In case of palatally impacted canines, incisive

papilla should be sutured carefully.

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Medications and follow up

• Pre-operative medications:

– For anxiety control e.g. Diazepam 5 mg PO. – For control of surgical odema: Intravenous administration of a glucocorticoid e.g. 8 mg dexamethasone. – For control of post-operative pain: Long-acting local anesthetics e,g. Bupivacaine 0.5% with 1:200000 epinephrine.

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Medications and follow up

• Post-operative instructions:
• 1. A pressure pack is held in place for 1hour.
• 2. Cold packs on outside of face 20 min/h 5 time daily
• 3. Analgesics e.g Ibuprofen 400mg tab. PO.
• 4. Proper antibiotic therapy e.g Amoxicilline 500 mg t.d.s, or

Augmentine 625 mg t.d.s. In case of penicillin allergy erythromycin 500mg q.d.s or Azithromycin 500 mg o.d.

• 5. Mouth wash after 24 h.
• 6. Soft diet.
• 7. Patient return back for check up after two days
• 8. Suture removal after 7 days

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Impacted maxillary canine

• Clinical signs:

1. Over-retention of the primary canine. 2. Delayed eruption of the permanent canine. 3. Absence of a labial bulge in a 10- or 11- year-old patient. 4. Presence of a palatal bulge. 5. Distal crown tipping of the lateral incisor.

• Management:

1. Left in-situ (No treatment and continuous monitoring). 2. Interceptive treatment by extraction of the deciduous canine. 3. Auto-transplantation 4. Surgical exposure and orthodontic alignment. 5. Surgical removal.

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Impacted maxillary canine

• Removal using labial approach:

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Impacted maxillary canine

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Impacted maxillary canine

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Removal using palatal approach

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Impacted maxillary canine

12 April 2014 LIMU 76

• Dr. Rafik Al Kowafi

39

Complications associated with surgical removal impacted teeth Complications associated with surgical removal impacted teeth

• A. Pre-extraction:
• 1. Difficulty in achieving anaesthesia.
• 2. Difficulty in patient co-operation.
• 3. Difficult access:
• Trismus.
• Microstomia.
• Crowded or misplaced teeth.

12 April 2014 LIMU 78

• Dr. Rafik Al Kowafi

40

Complications associated with surgical removal impacted teeth

• B. During extraction:

1. Abnormal resistance. 2. Laceration of the flap: a) Improper incision b) Improper elevation of the flap and improper retraction this leads to delayed healing and sever discomfort. 3. Fracture of the alveolar bone. 4. Fracture of the impacted tooth. 5. Damage to the adjacent teeth.

12 April 2014 LIMU 79

• Dr. Rafik Al Kowafi

Complications associated with surgical removal impacted teeth

6. Laceration of the tongue, lips, cheek, palate and floor of the mouth. 7. Fracture of the jaw: In angle of mandible ,improper use

• f elevator with uncontrolled force.

8. Fracture of maxillary tuberosity: This occurs with erupted rather than unerupted tooth due to improper use of force. 9. Aspiration or swallowing of impacted tooth (general anesthesia).

• 10. Dislocation of the TMJ.
• 11. Fracture instrument.

12 April 2014 LIMU

• Dr. Rafik Al Kowafi

80

41

Complications associated with surgical removal impacted teeth

12.Comlication related to injury of adjacent structure:

a-Injury to inferior alveolar nerve (IAN) and lingual nerve (LN):

• IAN can be injured during root manipulation and elevation.
• Lingual nerve can be injured by elevating a lingual flap or by perforating the

lingual bony plate during sectioning of the tooth.

• Pinching the lingual tissues with a forceps can also cause lingual nerve injury

b-Damage to nasal floor: During surgical removal of impacted maxillary canine and it causes profuse bleeding from nasal mucosa. c- Involvement of maxillary sinus: During removal of impacted maxillary third molar. oroantral fistula results

12 April 2014 LIMU 81

• Dr. Rafik Al Kowafi

Complications associated with surgical removal impacted teeth

d- Pushing of impacted tooth into maxillary sinus. e- Pushing of impacted maxillary molar into pterygopalatine fossa or pterygomandibular space: Due to application of uncontrolled force mesially in deep impaction f- Pushing impacted mandibular third molar into sub- mandibular space: Due to application of uncontrolled force buccally and fracture of the lingual plate.

12 April 2014 LIMU

• Dr. Rafik Al Kowafi

82

42

Complications associated with surgical removal impacted teeth

C. Post-operative complication

1. Swelling (odema). 2. Surgical emphysema:

• Surgical emphysema is a collection of air that has been forced into

the tissue spaces through the extraction wound and forms a swelling which characteristically crackles on palpation. It results from increased air pressure in the mouth from using an air spray, or turbine high speed handpiece.

• Surgical emphysema seldom gives rise to discomfort and settles

without treatment as the air is slowly absorbed. 3. Pain.

12 April 2014 LIMU 83

• Dr. Rafik Al Kowafi

Complications associated with surgical removal impacted teeth

• 6. Delayed healing and infection
• 7. Dry socket.
• 8. Hemorrhage (reactionary and secondary).
• 9. Anesthesia or parenthesis of the lingual or inferior alveolar

nerve

• 10. Trismus, limitation of jaw movement
• 11. Osteomylitis.
• 12. Sinusitis.
• 13. Pain at tmj
• 14. Pain on swallowing due to edema of pharynx and hematoma

formation.

12 April 2014 LIMU

• Dr. Rafik Al Kowafi

84

43

Complications associated with surgical removal impacted teeth

12 April 2014 LIMU

• Dr. Rafik Al Kowafi

85

Complications associated with surgical removal impacted teeth

12 April 2014 LIMU

• Dr. Rafik Al Kowafi

86

44

Complications associated with surgical removal impacted teeth

12 April 2014 LIMU

• Dr. Rafik Al Kowafi

87

Complications associated with surgical removal impacted teeth

12 April 2014 LIMU

• Dr. Rafik Al Kowafi

88

45

Complications associated with surgical removal impacted teeth

12 April 2014 LIMU

• Dr. Rafik Al Kowafi

89

Complications associated with surgical removal impacted teeth

12 April 2014 LIMU

• Dr. Rafik Al Kowafi

90

46

Complications associated with surgical removal impacted teeth

12 April 2014 LIMU

• Dr. Rafik Al Kowafi

91

Complications associated with surgical removal impacted teeth

12 April 2014 LIMU

• Dr. Rafik Al Kowafi

92