Impaction S
Impaction S
Impaction S
Contents
Introduction Definition Causes Indications and contraindications Classification Clinical examination Assessment Surgical procedure Post operative care Complications
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Introduction
Origin- Latin -- Impactus
"IMPINGO", "IN" and Pingo or strike.
sapientia et intellectus. Dens sapientia Dens serotinus lateness Allen - wisdom tooth (1685)
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Impaction -Definitions
Impacted Tooth : A tooth which is completely or
partially unerupted and is positioned against another tooth, bone or soft tissue so that its further eruption is unlikely, described according to its anatomic position. American society of oral surgeons 1971
Andreason:
Is defined as a cessation of the tooth eruption caused by a clinical or radiographically detectable physical barrier in the path or by an ectopic position of tooth.
Archer:
A tooth which is completely or partially un erupted and is positioned against another tooth , bone, or soft tissue so that its further eruption is unlikely, described according to its anatomic position
Lytle (1979):
Peterson:
WHO:
Impaction is any tooth that is prevented from reaching its normal position in the mouth by tissue or bone or another tooth
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Theories of impactionDurbeck
Phylogenic theory Mendelein theory Orthodontic theory Pathological theory Endocrine theory
Phylogenic theory: Nature tries to eliminate the disused theory: organs i.e., use makes the organ develop better, disuse causes slow regression of organ. organ. [More[More-functional masticatory force better the development of the jaw] Changing nutritional habits of modern civilized man in last 2000 years have practically eliminated needs for large powerful jaws, thus, over centuries the mandible and maxilla decreased in size leaving insufficient room for third molars. molars.
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Orthodontic theory: Jaws develop in downward and theory: forward direction. Growth of the jaw and movement of direction. teeth occurs in forward direction. Any thing that direction. interfere with such movement will cause an impaction (small jaw-decreased space). jawspace). A dense bone decreases the movement of the teeth in forward direction. direction. Causes for increased density of bone a) Acute infection, b) Local inflammation of PDL c) Malocclusion, d) trauma, e) Early loss of primary teeth arrested growth of the jaw. jaw.
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Mendelian theory: Heredity is most common theory: cause. cause. The hereditary transmission of small jaws and large teeth from parents to siblings. siblings. This may be important etiological factor in the occurrence of impaction. impaction. Pathological affecting an condensation preventing the jaws. jaws. theory: Chronic infections theory: individual may bring the of osseous tissue further growth and development of the
Endocrinal theory: Increase or decrease in theory: growth hormone secretion may affect the size of the jaws 10
Causes -Berger
Local causes
A. Obstruction of the eruption Compact bone Dense soft tissue Premature loss /Retained deciduous tooth Scar tissue Gingival fibromatosis Cyst formation, Odontogenic tumor Ankylosis
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Change in angulations of the tooth Chronic inflammation Reduced jaw growth Irregularities of adjacent tooth Arch length tooth material discrepancy Ectopic position of tooth bud
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Systemic causes
Prenatal causes: Heredity Post natal causes Rickets Anemia Congenital syphilis Tuberculosis Malnutrition Endocrinal causes- thyroid, parathyroid
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Indications
Pain Infection - Pericoronitis, Abscess Pathological resorption of 2nd , 3rd
molar Jaw going for irradiation Mobility of 2nd molar Unrestorable caries
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Facilitate orthodontic treatment Tooth in fracture line Retained tooth in edentulous jaw Periodontal diseases Prior to orthognathic surgery Radiological evidence of pathology
cyst, tumor
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Prophylactic removal Prosthodontic reasons Autogenous transplantation Previous attempted extraction To prevent jaw fracture Recurrent trauma
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Mandibular Fracture
Weak areas : angle, condyle & parasymphysis region. Frequency of occurrence of mand. angle # is higher in
pts, with impacted lower third molars & that of condylar # is higher in pts, without it. (Lida & colleagues,2004) Mechanism: occupy osseous space decreasing crosssectional area of bone.
associated with higher incidence of condylar #. Combination of symphysis & condyle # seen in cases without impacted lower third molars. 18 (Zhu et al , 2005)
impactions and those who are scheduled for rigid fixation without maxillomandibular fixation. 1 year prior to the planned orthognathic surgery.
Simultaneous with orthognathic surgery : Teeth where in intra-
operative removal is facilitated by the planned osteotomies and the surgical flap design does not compromise the vascular supply to adjacent dentoalveolar structures may be extracted intraoperatively.
Following orthognathic surgery : rarely planned following SSRO
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Additional considerations
Data suggests that asymptomatic patients
with a pocket depth around third molars greater than 5mm, have significantly increased levels of inflammatory mediators vs patients with pocket depths less than 5mm. White, R; et al. JOMS 60:1241-1245, 2002
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associated with pre-term birth. Data from 1,020 obstetric patients Results more significant if perio disease around third molars Moss, K; et al. JOMS 64:652-658, 2006
Patients with visible third molars are more
likely to have progression of periodontal disease than patients without third molars Blakey, G; et al. JOMS 64:189-193, 2006
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Contraindications
Local contraindications: Adequate space Abutment tooth Deeply placed tooth Acute infections Recently irradiated jaw
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Systemic contraindicationsrelative
Uncontrolled diabetes Uncontrolled hypertension Cardiac diseases Liver diseases Steroid therapy Blood dyscrasias
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Fever of unexplained origin Congestive cardiac failure Renal failure Pregnancy-1 & 3
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Absolute contraindications
Acute pericoronitis Acute necrotising ulcerative gingivitis Haemangioma Thyrotoxicosis
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A strong indication for removal of impacted third molar should be complemented with a strong contraindication to its retention
Mercier P, Precious D, Risk and benefits of removal of impacted third molars, IJOMS 21:17, 1992.
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Sequelae
Infection Eruption cyst Periodontal Orthodontic Ankylosis Proximal caries Pain
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DEVELOPMENT:
Most common age : 20- 25 years. Incidence of cyst formation-2.31% al,2000) (Guven et
Incidence of dentigerous cyst- 1.6% (Keith,1973) Incidence of ameloblastoma 0.14- 2% (Shear,1978) Risk of surgical morbidity increases with age
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Mandibular Angle Fractures (3.8 times more) (-Monty Reitzik ,J Oral Maxillofac Surg 1995:53:649) Trismus
Eye blindness, Iritis, Dimness of vision Ear ringing sound, otitis Damage to adjacent tooth
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9 yrs. tooth germ visible cusp mineralization completed - located with in ant. border of ramus facing anteriorly at the level of occlusion plane crown formation complete 50% roots formation completed - body of mandible grows at the expense of ant. border of ramus - position changes to approx. root level of 2nd molar - angulation becomes more horizontal root formation complete with wide apex 95% of 3rd molars have already erupted
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11 yrs.
14 yrs. 16 yrs.
18 yrs. 24 yrs.
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WINTERS CLASSIFICATION
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mesioinverted, distoinverted
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Bony impaction
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POSITION B
POSITION C
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4. Complications
Abnormal root curvature Hypercementosis Proximity to mandibular canal Bone density Adipose tissue Lack of accessibility Inflexibility of muscles of mouth
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Killey & Kay's classificationA. Angulation and position -Vertical - Mesioangular - Distoangular - Horizontal - Transverse - Buccoangular, lingoangular - Inverted - Aberrant position
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B. State of eruption- Erupted - Partially erupted - Unerupted soft tissue impaction - Complete bony impaction C. Number of roots Unfavorable impaction- Mesial curvature of
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Assessment
Preoperative assessment:
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Clinical assessment
General assessment
* Age * Systemic condition * Medical risk * General examination * Drug history * Anesthesia history
Extraoral examination
Intraoral examination * Mouth opening * Tongue size * Status of dentition * Extensibility of lips
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Radiographic assessmentIndications
For orthodontic treatment plan. Rule out pathologic changes Eruption predilection For treatment plan in surgical removal Identify proximity of vital structures.
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Indications : Tooth in alveolus Adequate mouth opening Relationship with inferior alv canal
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Special techniques: CT scans ( Dodson 2005) MRI Indications: Trismus Tooth in aberrant position Associated pathology Relationship with inf alv canal
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Radiological assessment
Angulation, Depth , Space available Crown size Roots - Configuration , Length , development, Curvature, size Bone texture & density Nature of covering tissue Follicular size Accessibility Inferior alveolar vascular bundle
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Relative depth
Class A Class B Class C
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- Extraction requiring forceps only Easy II - Extraction requiring osteotomy Difficult III - Extraction requiring osteotomy and coronal section Difficult IV - Complex extraction (root section)
(Marcio Deniz ,The British asso of oral maxillofac surg 2005)
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Angle of the second Root shape and development. molar. (degrees) a. Less than1/3complete - 2 1-59 0 b. 1/3-2/3 complete - 1 60-69 1 c. More than 2/3 70-79 2 Complex - 3 80-89 3 Unfavourable curve - 2 90+ 4 Favourable curve - 1
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Follicle Normal 0 Possible enlarged (-1) Enlarged (-2) Impaction relieved (-3)
Exit path. Space - 0 Distal cusp covered- 1 Mesial cusp covered- 2 All covered - 3
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Related with changes in the canal Interruption of lines Converging canal Diverted canal
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Darkening of root
Deflection of root
Narrowing of canal
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Diversion of mandibular canal Darkening of root Interruption of white lines Narrowing of roots Deflection of roots Narrowing of mandibular canal Dark and bifid root
Br Jr of Oral and Maxillofacial Surgery 1990; 28: 20-25 J Oral Maxillofac Surg 2003; 61: 417- 421 65 J Oral Maxillofac Surg 2005; 63: 3-7
Surgical procedure
John tomes-1848-extn of 2nd molar-
Impaction Steele-1895- Grinding of distal surface of 2nd molar NOVITSKY-1890-1st to raise the flap and remove bone Edmund kells-1918-tooth sectioning. Winter-1926-chisel (ossisector)
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Treatment plan
9 to 10 years prophylactic removal
formed
2/3 of root is developed (NIH Health consensus
development conference)
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Instrumentation
Mouth mirror Probe No 15 blade on a Bard Parker handle. Mosquito artery forcep Howarths nasal raspirator Retractors Chisel Mallet Bur: No 8 rose head, straight fissure Elevators Bone file Needle holder Tissue forceps Scissors
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SURGICAL PROCEDURE
Asepsis and isolation Anesthesia Incision and flap design Reflection of mucoperiosteal flap Bone removal Tooth sectioning Elevation & Extraction Debridement Closure Postoperative care
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Choice of anesthesia
Apprehension level
The patients acceptance of the procedure The length and technical difficulty of the
procedure
Physical status of the patient
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Indications of GA/sedation
Fear of pain during the procedure Emotionally unstable patient Anticipated lengthy procedures Removal of all four impacted molars in one sitting Uncooperative patients Allergy to LA Tooth in aberrant position
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Advantages of LA
Less expensive Less bleeding Less complications Patient will be conscious Medically compromised patients Simple, short time procedures
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MUCOPERIOSTEAL FLAP
Incision 3 parts: Anterior, Posterior & Intermediate limb
Not to be extended too distally Bleeding from buccal vessels & other arteries. Postoperative trismus temporalis muscle damage. Herniation of buccal fat pad. Damage to lingual nerve (lingual extension).
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L-shaped incisionss
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Bayonet-shaped incision
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Envelope incision
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Wards incision
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FLAP DESIGN
ENVELOPE FLAP
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SZMYD DESIGN
TRIANGULAR DESIGN
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MOORES FLAP
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tongue shaped flap. Extended into the buccal shelf of the mandible.
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Comma incision
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Paragingival single flap, distal end incision Prof Kapadia`s cunicular incision
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Flap reflection
Instruments: Howarth nasal raspirator
Le cluse elevator Hopkin & molt periosteal elevator Aim- Exposure of tooth & Bone
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Flap retraction
Howarth nasal raspirator Thimble Austin retractor Ward killner retractor Dysons Malleable copper retractor Mac gregor periosteal elevator Fickling periosteal elevator Read periosteal elevator
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Criteria
Access Instruments Procedure Operating time Technique Bone removal Post op pain Post op edema Dry socket Bruising of face
Buccal Approach
Easy Chisel or Bur Tedious Time consuming Easy Less More High Possible
Lingual Approach
Difficult Only chisel Easy Less Difficult More Less Less Absent
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Bone Removal
Aim:
1. To expose the crown by removing the bone overlying it. 2. To remove the bone obstructing the pathway for removal of the impacted tooth.
Types:
1. By consecutive sweeping action of bur (in layers). 2. By chisel or osteotomy cut (in sections).
performed under G A External oblique ridge should be below the level of bone enclosing tooth. Internal oblique ridge should be behind the tooth.
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1.Buccal guttering technique 2.Postage stamp technique 3.Collar technique (Moore & Gillbe) 4.Lateral trepanation technique [Bowdler Henry] With Chisel: 1.Window technique 2.Shaving technique 3.Lingual split technique 4.Distal lingual split technique
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Chisel vs Bur
Sl.No Criteria. Chisel&Mallet Bur Easy. Controlled. 1. 2. Technique Control over bone cutting Difficult Uncontrolled
3. 4. 5. 6. 7.
Patient acceptance. Healing of bone. Postoperative edema Dry socket. Postoperative Infection.
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along the buccal side & distal aspect of tooth. A point of elevation is created with bur. Amount of bone sacrificed is less. Can be used in old patient. Convenient for patient.
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Incision
Horizontal cut
Distal cut
Elevation
Removal of tooth
Closure
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Incision
Distal cut
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Tooth elevation
Closure
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Kamanishi modification: Do not raise the lingual flap Advance to the lingual side under the bone only to the extent which is necessary. Lewis modification: Flap was made lingual to second molar instead of third. Vertical lingual step cut just distal to second molar. Lingual plate was hinged like an osteoplastic flap. It is considered as combination of both lingual and buccal approach 101
Employed to remove any partially formed unerupted 3rd molar that has not breached the overlying hard & soft tissues.
GA/LA with sedation. Excellent PDL healing on distal surface of 2nd molar. Bone healing is excellent as there is no loss of alveolar bone around 2nd molar.
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Tooth Division
Rationale of tooth sectioning is to create a space into which impacted tooth can be displaced & then removed. Tooth is sectioned in various ways depending on the type & degree of impaction.
Mesioangular Impaction
Vertical Impaction
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curettage.
Smoothening of sharp bony margins by Bone file / burs. Thorough irrigation of the socket Betadine solution +
Saline .
Initial wound closure is achieved by placing 1stsuture
Wound closure
Principle:
Use as few sutures as possible. Suture should penetrate the lingual flap close to
and behind the third molar and the buccal flap further distally. Should not be excessively tight. Suture distal to second molar - importance. Determination of suture requirment is done in half closed mouth position.
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LA wears off.
Avoid strenuous exercises for 1st 24 hrs. Avoid gargling / spitting / smoking / drinking with straw. Warm water saline gargling after 24 hrs + mouth wash regularly
thereafter.
Suture removal on 7th POD.
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Complications
Intra Operative 1. During incision a. Injury to facial artery b. Injury to lingual nerve c. Hemorrhage careful history 2. During bone removal
a. Damage to second molar b. Slipping of bur into soft tissue & causing injury c. Extra oral/ mucosal burns d. Fracture of the mandible when using chisel & mallet e. Subcutaneous emphysema 3. During elevation or tooth removal
Luxation of neighbouring tooth/ fractured restoration Soft tissue injury due to slipping of elevator Injury to inferior alveolar neurovascular bundle Fracture of mandible Forcing tooth root into submandibular space or inferior alveolar nerve canal f. Breakage of instruments g. TMJ Dislocation careful history 111
a. b. c. d. e.
Nerve Injuries
0.6-5% of all the third molar surgeries are involved
Permanent - 0-2%
96% IAN injuries show spontaneous recovery within 9
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Post operative
Hemorrhage Pain Trismus Swelling Hematoma Sorethroat Pyrexia Surgical emphysema Wound dehiscence Paresthesia Alveolar ostitis Periodontal defect of the adjacent tooth
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Dry socket
Coined by Crawford(1896) Alveolitis sicca dolorosa Empty socket Focal osteomyelitis Painful socket Postoperative osteitis Sloughing socket Alveolalgia Necrotic socket Fibrinolytic alveolitis Delayed extraction Alveolitic osteitis Fibrinolytic osteitis Sclerosing osteomyelitis Alveolar osteitis Localized acute alveolar osteomyelitis Post extraction osteomyelitic syndrome
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Dry socket-Definition
Shafer-a focal osteomyelitis in which the
blood clot has disintegrated or been lost, with the production of a foul odour and severe pain, but no suppuration MacGregor 1968- classically occurs after forceps extraction and the diagnosis is made by excluding the other causes of pain.
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Dry socket-Definition
Post operative pain in and around the
alveolus which increases in severity at some moment between 2-3 days after a dental extraction accompanied by partial or total disintegration of the intra alveolar clot accompanied with a foul smell.
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Aetiology
Alling and kerr-gross amount of peridontal
membrane adherent to teeth after extraction appeared to predispose development of dry socket. Lysis of formed clot Trauma Reduced blood supply- Diabetes, vasoconstrictors Generalised debilitation Dense bone Smoking
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Local factors
Birns theory of fibrinolysis
Fibrinolytic activity of alveolar bone than the bacteria. Nitzins theory Trauma reduced resistance to infection Bacterial theory
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Clinical features
Pain
-Dull aching pain -2-3 days after extraction Empty socket -Sensitive, gray Foul smell Bad taste
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Treatment
Mechanical debridement Zinc oxide eugenol Curettage Tetracycline Topical metronidazole Benzocaine Formula as given by AllingEugenol--46% Balsam of peru 46% Chlorobutanol 4% Benzocaine 4%
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Adv: Less tissue damage Good illumination Clear magnified visualization of operative field More conservative surgery with precision dissection. Disadv: Costly Needs specific equipments Good hand-eye coordination and training required
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Serriah A.Ayoub : Bjoms 2004; 42: 203-208] 203Adv: Less stressful Less unpleasant No vibrations & sound Sharp clean cut through the bone & tooth Can be used in anxious patients Dis adv: It is more technique sensitive. more chances of Trismus. Time consuming Costly
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Conclusion
Impacted teeth are a medical deformity with variable
presentations, brought about by the dietary changes of modern civilization, or genetic predisposition. the problem of the underdeveloped jaw and resulting Class II or class III malocclusion to the extent present in modern society.
devastation that impacted teeth can cause to the jaws and overall health of an individual and hence should undertake a rational treatment approach after performing a clear clinical and radiographic assessment of the patients mouth & reviewing the pathological ramifications resulting from impacted teeth.
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References
Harry Archer Oral & Maxillofacial Surg. Vol I Geoffrey Howe Minor Oral Surg. Kelley & Kay The Impacted Wisdom tooth. Pederson- Oral surgery Peterson Contemporary Oral & Maxillofacial Surg. Dental Clinics of North America Textbook & colour atlas of tooth impaction- Andreasen. Impacted teeth- Alling & Alling. Textbook of oral & maxillofacial surgery-Srinivasan. Textbook of oral & maxillofacial surgery-Nilima Malik
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Journals
JOMS 1995; 53:1178-1181. JOMS 2006; 64:94-99 JOMS 2005; 63:1443-1446 OOO 2001; 92:377-83 OOO 2006; 102:448-52 OOO 2006; 102:300-6 JOMS 2006; 64:1371-1376 OOO 2006; 102:154-8 JOMS 2005; 63:3-7
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