SlideShare a Scribd company logo
1 of 192
Impacted Wisdom Teeth
Dr. Hesham Marei MSc, PhD, MFDS (Eng)
Assistant Professor of oral and Maxillofacial Surgery
King Faisal University
Outline
•Definitions
•Incidence
•Classification of impaction
•Imaging, evaluation and assessment
•Indications/ contraindications for removal
•Benefits Vs risks of prophylactic removal of impacted 3rd
molars
•Complications
•Conclusion
Definition
An impacted tooth is one that has failed to fully
erupt into the oral cavity within its expected
developmental time period and can no longer
be expected to do so.
Theories of Impaction
Smaller jaws/fast growth
Diet changes
Mechanical obstacles
Vestigial theory
Commonest affected teeth
• mandibular third molars
• maxillary canines
• mandibular
premolars/canines
• maxillary incisors
• maxillary third molars
• 95% of all teeth that will
erupt are erupted by age
24.
• 75% of mandibular third
molars are impacted
Classification Systems
 Angulations
 Vertical
 Distoangular
 Mesioangular
 Horizontal
 Buccal/Lingual
 Relationship to anterior border of ramus
 Depth of impaction
 Nature of overlying tissue
VERTICAL HORIZONTAL
MESIOANGULAR DISTOANGULAR
According to the long axis of the neighbouring mesial tooth
Angulations of embedded 3rd
molars
Maxilla % Mandible%
Vertical 68.3 38.7
Mesio-angular 13.3 44.0
Desto-angular 17 8.5
Meso-horizantal 0.19 7.7
Desto-horizantal 0.66 0
Bucco-lingual 0.37 0.92
Inverted 0.04 0.02
Impacted teeth
Relationship to Anterior Border of
Ramus
(Pell and Gregory)
 Class I - adequate room to erupt
 Class II - one half covered
 Class III- completely embedded
Pell and Gregory Classification (relation to the ramus)
Imaging, Evaluation and
Assessment
Radiographic Assessment
• Minimum of an OPG
• Visualize all the teeth and
adjacent structures
including bone,
morphology and number of
roots, hypercementosis
• Depth of bone around
tooth
• Follicular pathology
Other Important Factors
 Size of Follicular Sac
 Density of Surrounding Bone
 Contact with Mandibular Second Molar
 Relationship to Inferior Alveolar Nerve
Other Important Factors
8
Relation to IACRelation to IAC
Darkening of the root.Darkening of the root.
Deflection of the root.Deflection of the root.
Narrowing of the root.Narrowing of the root.
Dark and bifid root apex.Dark and bifid root apex.
Interruption of the whiteInterruption of the white
line of the canal.line of the canal.
Diversion of the canal.Diversion of the canal.
Narrowing of the canal.Narrowing of the canal.
Indications & Contraindications
Problem #1 – Soft Tissue
 Even with adequate arch length and full eruption,
3rd
molars are often surrounded by thin,
unkeratinized, highly distensible lining mucosa of
the buccal vestibule.
 Encourages pathogenic bacteria retention
 Poorly withstands hygiene measures
Problem #2 – Periodontal
Compromise
 Bone loss distal to the 2rd
molar after
removal of the 3rd
molar is controversial, at
best. Even with some loss of bone, the
result is stable and cleansable – the goal of
periodontal therapy.
Measuring Bone Height
Impacted teeth
Impacted teeth
Impacted teeth
Impacted teeth
Impacted teeth
Problem #3 – 3rd
Molar Caries
Problem #3 – 3rd
Molar Caries
Impacted teeth
Impacted teeth
Impacted teeth
Problem #4 – 2nd
Molar Caries
Impacted teeth
Impacted teeth
Impacted teeth
Impacted teeth
Problem #5 - Infection
 Can turn an elective procedure into an
urgent or emergent situation
 Unscheduled loss of work
 Increased pain and healing time
 Compromise of adjacent teeth
 Compromise of patient’s systemic health
Types of Infection
1. Simple dental caries
and periodontal disease
2. Pericoronitis
3. Abscess
4. Cellulitis
5. Abscess extension into
adjacent fascial spaces
5. Abscess spread to
distant sites
6. Recurrent infections
7. Infections resistant to
initial local and systemic
treatment measures
Infection
Pericoronitis
The most
common cause
of therapeutic
3rd
molar
removal.
Pericoronitis
 Inflammation of
the tissues around
the crown of any
partially erupted/
impacted tooth.
 It is either acute
or chronic
Pericoronitis
 A failure of preventive measures
 A failure of early recognition, or a failure to
seek proper treatment
 A step along the pathway of infection
 Pericoronitis should be a warning sign that
initiates immediate and aggressive
treatment with careful observation.
Pericoronitis
 Features of pericoronitis
 Trismus, pain, dysphagia, malaise, bad taste
 Signs of inflammation of the pericoronal tissues, with
frank pus from under the operculum
 Cheek biting and cuspal indentations on the operculum
 Halitosis, food packing
 Can progress with systemic symptoms and spread to
adjacent tissue spaces
Pericoronitis
• Treatment for pericoronitis
• Local measures
 Irrigation, oral hygiene measures
 Remove trauma, i.e. Extract upper 8, consider lower 8
later
• General measures
 Soft diet, analgesics, antibiotics, admission in
some cases
Problem #6 - Resorption
Problem #7 - Supereruption
Problem #8 - Cysts
Dentigerous
Cyst
Dentigerous
Cyst
Dentigerous Cyst
Supernumerary
4th
Molar
Impacted teeth
Types of Cysts
 Follicular cyst (Dentigerous Cyst)
 OKC (Odontogenic Keratocyst)
 Ameloblastoma (several varieties)
 Not all radiolucencies are cysts!
- Lymphoma
- Myeloma
- Metastatic carcinoma
Without the
radiolucency, would
you have
recommended
removal?
Is the removal of
this better or worse
with the
radiolucency?
When would you
recommend removal
of this 3rd
molar?
Impacted teeth
Cysts – A Few Facts
 May be prevented by early removal – when
normal dental follicle is still evident.
 The pericoronal pocket, or residual follicle,
is responsible for most cystic pathology.
 All cystic tissues should be removed and
biopsied.
Cysts
 Cysts themselves are not catastrophic – the
problem is that we don’t know exactly what
they are until they are histopathologically
examined – which necessitates removal.
 All cysts result in bone loss.
 Some cysts recur more than others.
Problem #9 - Tumors
 Benign vs. malignant
 Odontogenic vs. non-odontogenic
 Each of these factors has important
treatment implications.
Tumors
Impacted teeth
Impacted teeth
Impacted teeth
Impacted teeth
Problem #10 – Risk of Fracture
Immediate Pre-extraction
Immediate Post-extraction
3 Days Post-extraction
8 Days Post-extraction
Problem #11 - Fracture
Problem #12 - Orthodontics
 Prevent loss of post-
retention stability
 Allow distalization of
2nd
molars
 These are
controversial
indications
Impacted teeth
Possible Contraindications to Removal
of Impacted Teeth
• Extremes of age
• Compromised medical
status
• Probable excessive
damage to adjacent
structures
• Asymptomatic teeth
Impacted teeth
Impacted teeth
Factors that Contribute to Risk
Assessment for Patients
 Age
 Location of IAN
 Body mass index
 Drug history
 Systemic conditions
 Surgical access space
 Tongue size
 Anesthesia history
 Maxillary sinus location
 Root contour
 Third molar position
 Interincisal opening
 Health of second molar
 Bone mass and density
Factors that makes surgery
Less difficult
 Mesio-angular position
 Class I ramus
 Position A depth
 Roots ½ to 2/3 formed
 Fused conical roots
 Wide periodontal ligament
 Large follicle
 Elastic bone
 Separated from 2nd
molar
 Separated from inferior
alveolar nerve
More difficult
 Disto-angular position
 Class III ramus
 Position C depth
 Long, thin roots
 Divergent curved roots
 Narrow periodontal ligament
 Thin follicle
 Dense, inelastic bone
 Contact with 2nd
molar
 Close to inferior alveolar nerve
 Complete bone impaction
Presurgical Patient Counseling
• Decision on method of anaesthesia [LA,+/- IV sedation, GA]
• Preoperative warnings of pain, swelling, bruising, possible
hypoesthesia of lip/ tongue ,trismus, diet advice,
• Verbal and written warnings (information sheet), enter into notes,
nursing staff as witness
• Warn patient of post operative complications with a greater than 5%
incidence and permanent complications even if less than 1%
• If patient declines treatment need to be informed of likely long term
problems
Impacted teeth
conclusion
• Emerge between 18-24 yrs in 95% of the
population.
• Fail to develop in 1:4 adults
• 72% mandibular molars impacted
• Decision to remove based on balance of
risks/benefits of retention observation against
risks/benefits of removal.
conclusion
• Adequate patient assessment ensuring good case
selection
• More conservative approach
• Essential to give explanation of procedure with its
associated potential complications and
alternatives reinforced with information leaflet
• Details noted for medicolegal reasons
conclusion
The third molar controversy is still going-on.
As with all surgical procedures, the surgeon
wants to do surgery, it is his or her
profession!
From a patient point of view, non-surgical
treatment should be the first option in an
asymptomatic environment.
Management of impacted
third molars
RemovalRemoval
Risks
•Crowding of
dentition.
• Resorption of
adjacent tooth
and periodontal
status.
• Development
of infection, cyst
and tumor
RetentionRetention
Benefits
•Preservation of
functional teeth.
•Preservation of
residual ridge
Risks
Minor Complications:
•Alveolitis
•Paresthesia
•Trismus
•Fractures
•Hemorrhage
Major
Complications:
Dysesthesia
Bacteremia
Benefits
•Decreased
morbidity in
younger patients
•Therapeutic
control
The Procedure
Anatomy
Impacted teeth
Impacted teeth
 ≈ 7.8mm at the
3rd molar
 ≈ 10mm
Between the
first and second
molar
Canal diameter ≈ 2 mm
Course of the Inferior Alveolar
canal
Results
 Buccal cortex mean
thickness = 2.3mm at the
first molar
 Buccal cortex mean
thickness = 1.7mm at the
third molar
At the 3rd
molar site
 Linear distance from the IA
canal to the lingual surface of
the buccal cortex = 1.7mm
Assessment of the lingual nerve in the third molar
region using MRI
Miloro, JOMS 55:134-37, 1997
Purpose: Determine the precise insitu
location of the lingual nerve in the third
molar region using high-resolution magnetic
resonance imaging
Methods
 Ten healthy volunteers (20 sites) with mandibular third molars
underwent axial and coronal high-resolution MRI of the
posterior mandible and floor of mouth
 Three individuals measure the horizontal and vertical position
of the LN
Diagram: Fig 1 and Fig 2
Results
 The mean vertical 2.75± 0.97
(range 1.52-4.61mm)
 The mean horizontal 2.53± 0.67
(range 0.00-4.35mm)
Results
10% of LN were superior to the lingual crest
25% of LN were in contact with the lingual cortex
Lack of Root Development
Impacted teeth
Impacted teeth
Impacted teeth
Impacted teeth
Impacted teeth
Impacted teeth
Impacted teeth
Impacted teeth
Impacted teeth
Impacted teeth
Complications
Factors that may influence the occurrence of complications
 Age
 Gender “F”
 Medical condition
 Presence of pericoronitis
 Poor oral hygiene
 Type of impaction
 Relationship to inferior alveolar nerve
 Surgical time and technique
 Surgeon experience
 Use of perioperative antibiotics
 Use of topical antiseptics
 Anesthetic technique
Complications
•Alveolar Osteitis (dray Socket)
•Infection
•Bleeding
•Damage TO adjacent teeth
•Mandibular fracture
•Maxillary tuberosity fracture
•Displacement of third Molars
•Aspiration
•Oro-antral communication/fistula
•IAN/lingual nerve damage
Complications
 Intraoperative:
• Haemorrhage
• Fractured root apex
• damage to adjacent teeth/restoration/ soft tissues
• Fracture mandible
• Tooth ingestion or aspiration
 Postoperative:
• Dry socket [1-5%] or infection with purulent discharge
• Sensory deficit-IAN=5% temp, lingual temp=10%, perm=<1%
• Pain, swelling, bruising & trismus
• Fracture mandible
Definition of Sensory Disturbances
Paresthesia:
an abnormal sensation, such as burning,
pricking, tickling or tingling
Dysesthesia:
condition in which a disagreeable sensation
is produced by ordinary stimuli
Anesthesia;
state characterized by loss of sensation, the
result of pharmacologic depression of nerve
function or of neurological disease
Partial Odentectomy
 Indicated if intimate
relationship with IAN
 Root should be 3mm
below bone level
 Contraindicated if there
is root pathology or
loose tooth
Management of
Impacted Maxillary
Third Molar
Impacted teeth
Impacted teeth
Impacted teeth
Impacted teeth
Impacted teeth
Impacted teeth
AAOMS Workshop on the Management of
Patients With Third Molar Teeth 1993
 Little evidence that antibiotics decreases
pain, edema, alveolar osteitis or infection
 Lavage of the surgical site reduces risk of
complications
AAOMS Workshop on the Management of
Patients With Third Molar Teeth 1993
 Tight primary closure increases frequency
and severity of postoperative pain and
swelling
 Pericoronitis is a risk factor for alveolar
osteitis and postoperative infection
Prophylactic
Antibiotics for Third
Molar Surgery
Five Possible Reasons
 An infection is present and must be treated
 The patient is medically compromised and requires antibiotic
prophylaxis against metastatic infection
 Patient or patient’s family demands antibiotics
 The standard of care in the oral surgery community is to use
antibiotics
 The risk of postoperative infection is high
Risk/Benefit Assessment
 Incidence of serious infections is low (estimated
risk of 1-5%)
 Cost of antibiotic therapy is low
 Risk of development of resistant strains of
bacteria is undetectable for individual practitioner
 Risk of allergic reaction is higher than risk of
infection
JOMS 53:53-60 1995
 Piecuch JF et al- A Supportive Opinion
 January 1994 survey of Connecticut Society of Oral and
Maxillofacial Surgeons
 N=104 (of 122)
 58% routinely used antibiotics for surgical removal of fully
submerged (impacted) mandibular third molars in patients
who are not medically compromised
 Dose regimens and method of application varied widely
Variations
 Preoperative use
 Postoperative use
1. Systemic
Oral, parenteral
2. Topical
Socket site
JOMS 53:53-60 1995
 Zeitler D, A Dissenting Opinion
 The low complication rate associated with the procedure
does not support the routine use of antibiotic prophylaxis
 The use of antibiotics to decrease the incidence of other
adverse outcomes (alveolar osteitis, or dry socket) has not
been determined to be successful
“Antibiotic Therapy in Impacted Third Molar Surgery” Monaco
G, et al, Eur J Oral Sci 107 (6): 437-41, Dec 1999
 N = 141 patients
 66 patients with 2 gm amoxicillin daily for 5 days
 75 patient without antibiotic therapy
 No significant difference between groups
 Association between smoking, habitual drinking and
increase post op pain and fever
Analgesic Strategies
Impacted teeth
Acetylsalicylic
Acid
(aka aspirin)
Class : Analgesic, Anti-pyretic (Gr. puretos fever) & Anti-
inflammatory
MOA : irreversible inhibition of cyclooxgenase
clinical correlation: stop ASA 7d p surgery
(exception)
MOE : Excreted in urine
Supplied: 325-650 mg
Adult Dosage: PO 600 - 1000 mg q 4 - 6º
Major Side effects : Bleeding & GI disturbances
Interactions: anti-coagulants, alcohol
Membrane
Phospholipids
Arachidonic Acid
PhospholipaseSTEROIDS
Cyclooxygenase
PROSTAGLANDINS
NSAIDs
Lipoxygenase
LEUKOTRIE
THROMBOXANE
Acetaminophen
(aka Tylenol®)
Class : Analgesic, Anti-pyretic, not anti-inflammatory
MOA : Possible weak inhibition of cyclooxygenase
MOE : Metabolized in liver, excreted in urine
Peak plasma levels: 30 - 60 mins
t1/2: 2 hrs
Supplied: 325-650 mg
Adult Dosage: PO 325-650 mg q 4 - 6º
Max = 4g/day
Major Side effects : Liver toxicity
Ibuprofen
(aka Advil ®)
Class : Analgesic, Anti-pyretic, Anti-inflammatory
MOA : Inhibition of cyclooxgenase (both isoforms)
MOE : Metabolized and excreted in kidney
Peak plasma levels: 60 - 120 mins
Half time: 120 mins
Supplied: 200 mg
Adult Dosage: PO 400 - 600 mg q 4 - 6º
PO 800 mg q 8 - 10º
Max = 3.2 g/day
Major Side effects : GI Bleeding
Selective COX-2 inhibitors
Celecoxib (Celebrex ®)
Class : Analgesic, Anti-pyretic, Anti-
inflammatory
MOA : Inhibition of cyclooxgenase 2
MOE : Metabolized in liver and excreted in
kidney
Peak plasma levels: 3 hours
Half time: 11
hours
Supplied: 100, 200 mg
Adult Dosage: 100-200 mg PO BID
Major Side effects : renal dysfunction, GI
ulcerations, contraindication with pts with
sulfa,NSAID allergies
Supplied in 12.5mg &
25mg tablets
Contraindications:
- allergies to sulfa,
NSAIDs
- GI bleeding,
ulcerations
- liver and kidney
diseases
- pregnancy
Rx: 25-50mg PO daily prn
pain
Supplied in 10mg & 20mg table
Rx: 10-20mg PO daily prn pain
Opioids
µ
κ
δ
Codeine
Class : Opioid
MOA : binds to
opioid receptors
MOE : urine
Peak plasma levels: 30 - 60 mins
Half time: 3 -4 hrs
Supplied: 15, 30, 60 mg
Adult Dosage: PO 15 - 60 mg q 4 - 6º
Max = 360 mg/day
• Sedation
• respiratory
depression
• constipation
• nausea Opioid
triad: stupor,
pupillary
constriction &
respiratory
depression
SIDE EFFECTS &
COMPLICATIONS
Hydrocodone
Class : Opioid analgesic
MOA : opioid receptors
MOE : urine
Peak plasma levels: 30 - 60 mins
Half time: 3 - 4 hrs
Supplied: 5 mg
Adult Dosage: 5 - 10 mg q 4º
Major Side effects :
Dizziness, sedation, nausea,
vomiting, respiratory depression
Oxycodone
Class : Opioid analgesic
MOA : opioid receptor
MOE : urine
Peak plasma levels: 30 - 60 mins
Half time: 3 -4 hrs
Supplied: 5 mg
Adult Dosage: PO 5 mg q 4 - 6º
Major Side effects : Dizziness, sedation,
N / V, respiratory depression
Propoxyphene
Class : Opioid analgesic
analgesic efficacy questionable
MOA : opioid receptors
MOE : urine
Peak plasma levels: 2 - 3 hrs
Half life: 12 hrs
Supplied: 100 mg
Common Combination
Analgesic Drugs
Common Combination Analgesic
Drugs
POST-SURGICAL PAIN
Dionne RA. 1999. JOMS. 57:
673-678.
 Sample size: 118 subjects
 Surgical removal of 2 or 4 impacted third molars with
sedation and local anesthetic
 Subjects were questioned 15, 30, and 45 min. after loss
of anesthesia about their pain
Methods
 treatment groups:
 Ibuprofen 400 mg
 Ibuprofen 400 mg + Oxycodone 2.5 mg
 Ibuprofen 400 mg + Oxycodone 5 mg
 Ibuprofen 400 mg + Oxycodone 10 mg
Results
- Only Ibuprofen 400 mg + oxycodone 10
mg provided better analgesia than
Ibuprofen alone
- Increasing doses of oxycodone α side
effects
Flexible AnalgesicFlexible Analgesic
StrategiesStrategies
Mild
Pain
Moderate
Pain
Severe
Pain
400 -600 mg Ibuprofen
or
650 mg ASA
650 - 1000 mg
Acetaminophen
Continue as
needed
Adequate
analgesia
Inadequate
pain relief
600 - 800 mg
Ibuprofen +
Codeine
650 - 1000 mg
Acetaminophen +
Codeine
Continue as
needed
Adequate
analgesia
Inadequate
pain relief
600 - 800 mg Ibuprofen
+
Hydrocodone oroxycodone
650 - 1000 mg Acetaminophen
+
Hydrocodone or oxycodone
Continue as
needed
Adequate
analgesia
Pre-emptive Analgesia:Pre-emptive Analgesia:
he pre-operative administration of
analgesics
Analgesic Strategies
 Use of long acting local anesthetic does
display a synergistic effect with NSAIDs
 Pre-emptive analgesia/anesthesia still
being researched-recent data does not
support presurgical administration for pain
control
Use of Corticosteroids
with Third Molar
Removal
Esen E, et al, “Determination of the anti-inflammatory effects
of methylprednisolone on the sequelae of third molar
surgery”, J Oral Maxillofac Surg 57(10):1201-6, Oct 1999
 N =20
 Double blind crossover study
 125 mg methylprednisolone vs. placebo
 Pain and trismus evaluated
Esen E, et al, “Determination of the anti-inflammatory effects
of methylprednisolone on the sequelae of third molar
surgery”, J Oral Maxillofac Surg 57(10):1201-6, Oct 1999
 Significant decrease in edema, trismus
and pain in the methylprednisolone group
 Normal HPA axis before and after
 Plasma cortisol nonsignificant decrease
in both groups
Esen E, et al, “Determination of the anti-inflammatory effects
of methylprednisolone on the sequelae of third molar
surgery”, J Oral Maxillofac Surg 57(10):1201-6, Oct 1999
 No clinically apparent infection or
disturbance of wound healing
 90 % preferred the post operative course
associated with steroid administration
What We Don’t Know
What are the
risks/complications/morbidities
when impacted third molars
are not removed?
What we do know
 Cost in both time and risk exists with third
molar removal in the older adult
Increased Costs Associated with Third Molar
Removal in the Older Adult
 Increased number of symptomatic post
operative days requiring convalesence
 Increased overhead costs due to increase in
surgical complexity
Increased Costs Associated with Third Molar
Removal in the Older Adult
 Increase in complication management requiring
an increase in the number of office visits
 Increase in litigation costs
observe
asymptomatic
rem ove
symptomatic
<25
observe
asymptomatic
rem ove
symptomatic
>25
Patient with Third M olars
remove
symptomatic
remove
pathology
observe
no observable pathology
asymptomatic
Patient with Third Molars
[>25 yrs]
Obligations to observe
 Frequency of imaging evaluation
 every two years?
 every five years?
 Frequency of clinical evaluation
 regular basis?
 only when symptomatic?
Conclusions
 Elective removal of symptomatic third
molars in older adults is more costly and
engenders greater risk than with
prophylactic removal of third molars
 Risks can be reduced with proper surgical
technique
Conclusions
 Modeling with computer enhanced “virtual
reality” may allow study of predictability
 More study is needed as the debate
continues
IMPACTED MAXILLARY CANINE
 The surgical removal of a deeply seated maxillary canine in relation to
the maxillary sinus and the nasal cavity is one of the most difficult
oral surgical procedures
Frequency :
 Maxillary canine is 20 times more than mandibular canine
 More frequent in females than males
 Palatal impaction is 3 times more than buccal impaction
Classification of impacted maxillary canine:
ARCHER,S CLASSIFICATION
Class I
Palatally Impacted canine
a) Horizontal
b) Vertical
c) semivertical
Class II
Buccally impacted canine
a) Horizontal
b) Vertical
c) Semivertical
Class III
Impacted canine located in both the palatal and labial surfaces.
Class IV
Impacted canine located in the alveolar process.
Class V
Impacted canine located in an edentulous maxilla.
Contra-indications for the removal of an impacted maxillary
canine:
When it can be brought into normal position either by surgical
repositioning or a combination of surgery and orthodontic
treatment..
Factors complicating the removal of the impacted canine:
Close relationship to the roots of the neighboring teeth.
Intimate relation to the maxillary sinus.
Curvature or hypercementosis of the root.
Difficulty in localization most important factor.
SURGICAL REMOVAL OF IMPACTED
MAXILLARY CANINE
Planning the operative procedure
X-ray examination
Classify the impaction
Extent of the flap
Sectioning of the tooth is needed or not
Impacted teeth
Impacted teeth
Impacted teeth
Impacted teeth
Localization of impacted maxillary canine:
 clinical examination
 Radiographic examination
Clinical examination:
 By palpation:
 Presence of distinct bulge
 Deflection of crowns: mostly of lateral incisors pr
premolars.
Radiological examination:
 a) Intra-oral periapical films
 b) Occlusal radiographs ( topographical & cross
sectional ): Canine will appear as a round radioapaque
structure.
 c) Shift sketch technique:
In This technique, the films are in the same
position while the cone is shifted, if the
canine moves with same direction of the
cone , it indicates that it is located far
(palatally), while if the canine moves
opposite to the direction of the cone , it
indicates that it is near (buccally).
 e) Tomograms:
Sections are taken, if the canine is impacted
buccally , it's tip will appear first , while if
impacted palatally, the apex will appear
first.
f) Extra-oral oblique or true lateral:
g) Panoramic films:
To determine relation to maxillary sinus.
Object Localization
A periapical film will identify the location of an object vertically
and in a horizontal (mesiodistal) direction. However, we cannot
tell where the object is located buccolingually, since the
periapical film is two-dimensional. Therefore we need another
method for locating objects in a buccolingual direction. The two
primary methods of determining the buccolingual location of
objects are:
Right-Angle Technique (Occlusal projection)
Primarily identifies buccolingual location, but may
also confirm mesiodistal location seen on periapical
Tube-shift Technique (SLOB rule, Clark’s rule)
Utilizes two films with different horizontal or vertical
angulations
Right Angle (Occlusal) technique
Right Angle Technique
Once you have identified an object on the periapical
film, you can take an occlusal film with the beam at a
right angle (perpendicular) to the direction of the beam
for the periapical. The beam may also be perpendicular
to the film, especially in the mandible. The occlusal film
below shows that the impacted canine is lingually
positioned.
The SLOB rule is used to identify the buccal or
lingual location of objects (impacted teeth, root
canals, etc.) in relation to a reference object
(usually a tooth). If the image of an object moves
mesially when the tubehead is moved mesially
(same direction), the object is located on the
lingual. If the image of the object moves distally
when the tubehead moves mesially (opposite
direction), the object is located on the buccal.
Tube-Shift Localization (Clark)
SLOB Rule
Same Lingual Opposite Buccal
For the SLOB rule to work, there must be a
change in the horizontal or vertical
angulation of the x-ray beam as the tubehead
is moved. This change in angulation will alter
the relationship between the object of
interest and the reference object, allowing
you to determine the buccal or lingual
location.
The closer the object to be localized is to the
reference object, the less the amount of
movement of the image of the object in
relation to the reference object.
In the diagram at right, the
tubehead is moved, but there is no
change in direction of the x-ray
beam, which results in no change
in location of the object of interest
in relation to reference object (see
below). Moving the tubehead
without changing the beam
direction would often result in a
cone cut , depending on how far
the tubehead is moved (see below
right).
premolar molar
For the films above, we know that the tubehead was moved distally from
the premolar to the molar film. The zygomatic process (red arrows) is
located at the distal aspect of the 2nd molar on the premolar film and it is
located over the distal aspect of the 1st molar on the molar film. This
indicates that it moved mesially as the tubehead moved distally. We know
that the zygomatic process is buccal to the teeth and, using the SLOB
rule, it follows that the x-ray beam was directed more mesially on the
molar film (Buccal object moved opposite to tubehead movement).
premolar molar
Another way of determining the change in the direction of the beam is to
look at the angulation of the teeth. In the premolar film, the roots of the
teeth are angled distally, indicating that the beam was directed distally
(from the mesial). In the molar film, the roots are more upright or angled
slightly mesially, indicating the beam was directed more mesially (from
the distal). Therefore, the tubehead shifted distally and the beam was
angled in the opposite direction, allowing the use of the SLOB rule (These
films were taken from Slide 3 in the review films to follow).
Is the composite restoration on tooth # 8 (arrows)
located on the buccal or lingual?
canine film incisor film
1The restoration is located on the buccal. The tubehead moves mesially
from the canine film to the incisor film (x-ray beam projected more
distally) and the composite moves distally, which is the opposite
direction.
canine film
premolar film
The arrow in the canine film is pointing to the gutta
percha in which canal of the maxillary first premolar?
2
The arrow identifies the lingual canal. The tubehead moves
mesially from the premolar film to the canine film (beam
directed more distally) and the gutta percha indicated by
the arrow also moves mesially. (See following slide).
PID
PID
lingual
buccal
When the tubehead is moved mesially, with the beam
directed distally, the two canals, which are initially
superimposed (premolar periapical above) will separate. The
lingual canal (red arrow) will follow the tubehead movement
and the buccal canal (blue arrow) will move in the opposite
direction, as seen on the canine film.
Is the maxillary second
premolar (arrows) displaced
to the buccal or the lingual?
premolar film molar film
premolar bitewing
3
The tubehead moves distally from the
premolar film to the molar film. The
second premolar also moves distally,
overlapping the first molar more in the
molar film. In moving from the premolar
periapical to the bitewing, the tubehead
moves down and the premolar also
moves down. The displacement is to the
lingual.
Impacted teeth
Impacted teeth
Impacted teeth

More Related Content

What's hot

Trauma from occlusion
Trauma from occlusionTrauma from occlusion
Trauma from occlusionAnkita Dadwal
 
Dry socket, alveolar ostitis
Dry socket, alveolar ostitisDry socket, alveolar ostitis
Dry socket, alveolar ostitisEliud Ebei
 
Management of impacted teeth
Management of impacted teethManagement of impacted teeth
Management of impacted teethMohammed Rhael
 
Abnormalities of the pulp
Abnormalities of the pulpAbnormalities of the pulp
Abnormalities of the pulpChelsea Mareé
 
Normal Radiographic Anatomical Landmarks
Normal Radiographic Anatomical LandmarksNormal Radiographic Anatomical Landmarks
Normal Radiographic Anatomical LandmarksDivya Rana
 
Class I , II Composites Cavity preparations
 Class I , II Composites Cavity preparations Class I , II Composites Cavity preparations
Class I , II Composites Cavity preparationsPalaniselvi Kamaraj
 
PULP AND PERIAPICAL LESIONS OF THE TOOTH ppt
PULP AND PERIAPICAL LESIONS OF THE TOOTH pptPULP AND PERIAPICAL LESIONS OF THE TOOTH ppt
PULP AND PERIAPICAL LESIONS OF THE TOOTH pptK BHATTACHARJEE
 
Vital Pulp Therapy
Vital Pulp TherapyVital Pulp Therapy
Vital Pulp TherapyIAU Dent
 
Peripheral and central giant cell granuloma
Peripheral and central giant cell granulomaPeripheral and central giant cell granuloma
Peripheral and central giant cell granulomaRijuwana77
 
Mandibular fractures
Mandibular fracturesMandibular fractures
Mandibular fracturesArjun Shenoy
 
PERIAPICAL DISEASES
PERIAPICAL DISEASESPERIAPICAL DISEASES
PERIAPICAL DISEASESAshok Kumar
 
Juvenile Periodontitis
Juvenile Periodontitis Juvenile Periodontitis
Juvenile Periodontitis Nusrat Fahmida
 
Diseases of pulp and periapical tissues
Diseases of pulp and periapical tissues Diseases of pulp and periapical tissues
Diseases of pulp and periapical tissues madhusudhan reddy
 

What's hot (20)

Trauma from occlusion
Trauma from occlusionTrauma from occlusion
Trauma from occlusion
 
Dry socket, alveolar ostitis
Dry socket, alveolar ostitisDry socket, alveolar ostitis
Dry socket, alveolar ostitis
 
Management of impacted teeth
Management of impacted teethManagement of impacted teeth
Management of impacted teeth
 
Abnormalities of the pulp
Abnormalities of the pulpAbnormalities of the pulp
Abnormalities of the pulp
 
Transalveolar Extraction
Transalveolar ExtractionTransalveolar Extraction
Transalveolar Extraction
 
Normal Radiographic Anatomical Landmarks
Normal Radiographic Anatomical LandmarksNormal Radiographic Anatomical Landmarks
Normal Radiographic Anatomical Landmarks
 
Class I , II Composites Cavity preparations
 Class I , II Composites Cavity preparations Class I , II Composites Cavity preparations
Class I , II Composites Cavity preparations
 
Impacted teeth
Impacted teethImpacted teeth
Impacted teeth
 
Pericoronitis
Pericoronitis  Pericoronitis
Pericoronitis
 
PULP AND PERIAPICAL LESIONS OF THE TOOTH ppt
PULP AND PERIAPICAL LESIONS OF THE TOOTH pptPULP AND PERIAPICAL LESIONS OF THE TOOTH ppt
PULP AND PERIAPICAL LESIONS OF THE TOOTH ppt
 
Vital Pulp Therapy
Vital Pulp TherapyVital Pulp Therapy
Vital Pulp Therapy
 
Peridontal pocket
Peridontal pocketPeridontal pocket
Peridontal pocket
 
Peripheral and central giant cell granuloma
Peripheral and central giant cell granulomaPeripheral and central giant cell granuloma
Peripheral and central giant cell granuloma
 
Mandibular fractures
Mandibular fracturesMandibular fractures
Mandibular fractures
 
Pericoronitis
PericoronitisPericoronitis
Pericoronitis
 
PERIAPICAL DISEASES
PERIAPICAL DISEASESPERIAPICAL DISEASES
PERIAPICAL DISEASES
 
Oroantral Communication and Fistula
Oroantral Communication and FistulaOroantral Communication and Fistula
Oroantral Communication and Fistula
 
Juvenile Periodontitis
Juvenile Periodontitis Juvenile Periodontitis
Juvenile Periodontitis
 
Diseases of pulp and periapical tissues
Diseases of pulp and periapical tissues Diseases of pulp and periapical tissues
Diseases of pulp and periapical tissues
 
Odontogenic cysts
Odontogenic  cystsOdontogenic  cysts
Odontogenic cysts
 

Viewers also liked

6. peptic ulcer drugs 323
6. peptic ulcer drugs 3236. peptic ulcer drugs 323
6. peptic ulcer drugs 323IAU Dent
 
7. Adrenocorticosteriods
7. Adrenocorticosteriods7. Adrenocorticosteriods
7. AdrenocorticosteriodsIAU Dent
 
5. opioid analgesics
5. opioid analgesics5. opioid analgesics
5. opioid analgesicsIAU Dent
 
7.b. sedative hypnotics
7.b. sedative hypnotics 7.b. sedative hypnotics
7.b. sedative hypnotics IAU Dent
 
Maxillofacial injuries
Maxillofacial injuriesMaxillofacial injuries
Maxillofacial injuriesIAU Dent
 
Plaque control
Plaque controlPlaque control
Plaque controlIAU Dent
 
8 anticancer drugs
8  anticancer drugs8  anticancer drugs
8 anticancer drugsIAU Dent
 
6. anti drenergic
6. anti drenergic 6. anti drenergic
6. anti drenergic IAU Dent
 
5 aminoglycosides,macrolides, anti tb dental
5 aminoglycosides,macrolides, anti tb dental5 aminoglycosides,macrolides, anti tb dental
5 aminoglycosides,macrolides, anti tb dentalIAU Dent
 
7.a. histamine & antihistaminics
7.a. histamine & antihistaminics7.a. histamine & antihistaminics
7.a. histamine & antihistaminicsIAU Dent
 
8. hypotension & hypertension
8. hypotension & hypertension8. hypotension & hypertension
8. hypotension & hypertensionIAU Dent
 
Odontogenic Tumors
Odontogenic TumorsOdontogenic Tumors
Odontogenic TumorsIAU Dent
 
Complications of Exodontia
Complications of ExodontiaComplications of Exodontia
Complications of ExodontiaIAU Dent
 
Complication and management of tooth extraction or exodontia
Complication and management of tooth extraction or exodontiaComplication and management of tooth extraction or exodontia
Complication and management of tooth extraction or exodontiaDr.Rahul Tiwari
 
Odontogenic Infection
Odontogenic InfectionOdontogenic Infection
Odontogenic InfectionIAU Dent
 

Viewers also liked (17)

6. peptic ulcer drugs 323
6. peptic ulcer drugs 3236. peptic ulcer drugs 323
6. peptic ulcer drugs 323
 
7. Adrenocorticosteriods
7. Adrenocorticosteriods7. Adrenocorticosteriods
7. Adrenocorticosteriods
 
5. opioid analgesics
5. opioid analgesics5. opioid analgesics
5. opioid analgesics
 
7.b. sedative hypnotics
7.b. sedative hypnotics 7.b. sedative hypnotics
7.b. sedative hypnotics
 
Maxillofacial injuries
Maxillofacial injuriesMaxillofacial injuries
Maxillofacial injuries
 
Plaque control
Plaque controlPlaque control
Plaque control
 
8 anticancer drugs
8  anticancer drugs8  anticancer drugs
8 anticancer drugs
 
6. anti drenergic
6. anti drenergic 6. anti drenergic
6. anti drenergic
 
5 aminoglycosides,macrolides, anti tb dental
5 aminoglycosides,macrolides, anti tb dental5 aminoglycosides,macrolides, anti tb dental
5 aminoglycosides,macrolides, anti tb dental
 
TMJ 2
TMJ 2TMJ 2
TMJ 2
 
7.a. histamine & antihistaminics
7.a. histamine & antihistaminics7.a. histamine & antihistaminics
7.a. histamine & antihistaminics
 
8. hypotension & hypertension
8. hypotension & hypertension8. hypotension & hypertension
8. hypotension & hypertension
 
Odontogenic Tumors
Odontogenic TumorsOdontogenic Tumors
Odontogenic Tumors
 
Maxillofacial injuries
Maxillofacial injuries Maxillofacial injuries
Maxillofacial injuries
 
Complications of Exodontia
Complications of ExodontiaComplications of Exodontia
Complications of Exodontia
 
Complication and management of tooth extraction or exodontia
Complication and management of tooth extraction or exodontiaComplication and management of tooth extraction or exodontia
Complication and management of tooth extraction or exodontia
 
Odontogenic Infection
Odontogenic InfectionOdontogenic Infection
Odontogenic Infection
 

Similar to Impacted teeth

Impacted Teeth
Impacted TeethImpacted Teeth
Impacted TeethHadi Munib
 
Mandibular third moalr impaction
Mandibular third moalr impactionMandibular third moalr impaction
Mandibular third moalr impactionAshish Soni
 
Impacted third molar management
Impacted third molar management Impacted third molar management
Impacted third molar management Chamara Atukorala
 
4 EVALUATION OF IMPACTED THIRD MOLARS seminar 4.pptx
4 EVALUATION OF IMPACTED THIRD MOLARS seminar 4.pptx4 EVALUATION OF IMPACTED THIRD MOLARS seminar 4.pptx
4 EVALUATION OF IMPACTED THIRD MOLARS seminar 4.pptxsneha
 
IMPLANT related complications
IMPLANT related complicationsIMPLANT related complications
IMPLANT related complicationsAfsana Kader A
 
Impacted teeth /certified fixed orthodontic courses by Indian dental academy
Impacted teeth /certified fixed orthodontic courses by Indian dental academy Impacted teeth /certified fixed orthodontic courses by Indian dental academy
Impacted teeth /certified fixed orthodontic courses by Indian dental academy Indian dental academy
 
Impacted mandibular third molars
Impacted mandibular third molarsImpacted mandibular third molars
Impacted mandibular third molarsPrasun Dubey
 
Third molar surgery
Third molar surgeryThird molar surgery
Third molar surgeryJacob John
 
Prevention and managment of extraction complication
Prevention and managment of extraction complicationPrevention and managment of extraction complication
Prevention and managment of extraction complicationanila20
 
Extraction in Orthodontic Treatment
Extraction in Orthodontic TreatmentExtraction in Orthodontic Treatment
Extraction in Orthodontic Treatmentfattahaa
 
11 management of furcation defects
11 management of furcation defects 11 management of furcation defects
11 management of furcation defects Perio Files
 
Principles, indications and contraindications of removal of
Principles, indications and contraindications of removal ofPrinciples, indications and contraindications of removal of
Principles, indications and contraindications of removal ofijazkhan2222
 
Impacted lower 3rd molar
Impacted lower 3rd molar Impacted lower 3rd molar
Impacted lower 3rd molar OlaMR
 
conservative approach OPERATIVE DENTISTRY
conservative approach OPERATIVE DENTISTRYconservative approach OPERATIVE DENTISTRY
conservative approach OPERATIVE DENTISTRYalbrwaz
 
Management of Impacted third molars
Management of Impacted third molarsManagement of Impacted third molars
Management of Impacted third molarsDr Rayan Malick
 
Diagnosis and treatment planning in removable partial denture
Diagnosis and treatment planning in removable partial dentureDiagnosis and treatment planning in removable partial denture
Diagnosis and treatment planning in removable partial dentureVinay Kadavakolanu
 
Ch1 lec2 Orthodontics Introduction
Ch1 lec2 Orthodontics IntroductionCh1 lec2 Orthodontics Introduction
Ch1 lec2 Orthodontics IntroductionCezar Edward Lahham
 

Similar to Impacted teeth (20)

Impacted Teeth
Impacted TeethImpacted Teeth
Impacted Teeth
 
Mandibular third moalr impaction
Mandibular third moalr impactionMandibular third moalr impaction
Mandibular third moalr impaction
 
Impacted third molar management
Impacted third molar management Impacted third molar management
Impacted third molar management
 
4 EVALUATION OF IMPACTED THIRD MOLARS seminar 4.pptx
4 EVALUATION OF IMPACTED THIRD MOLARS seminar 4.pptx4 EVALUATION OF IMPACTED THIRD MOLARS seminar 4.pptx
4 EVALUATION OF IMPACTED THIRD MOLARS seminar 4.pptx
 
IMPLANT related complications
IMPLANT related complicationsIMPLANT related complications
IMPLANT related complications
 
Impacted teeth /certified fixed orthodontic courses by Indian dental academy
Impacted teeth /certified fixed orthodontic courses by Indian dental academy Impacted teeth /certified fixed orthodontic courses by Indian dental academy
Impacted teeth /certified fixed orthodontic courses by Indian dental academy
 
Impacted mandibular third molars
Impacted mandibular third molarsImpacted mandibular third molars
Impacted mandibular third molars
 
Third molar surgery
Third molar surgeryThird molar surgery
Third molar surgery
 
Prevention and managment of extraction complication
Prevention and managment of extraction complicationPrevention and managment of extraction complication
Prevention and managment of extraction complication
 
Extraction in Orthodontic Treatment
Extraction in Orthodontic TreatmentExtraction in Orthodontic Treatment
Extraction in Orthodontic Treatment
 
11 management of furcation defects
11 management of furcation defects 11 management of furcation defects
11 management of furcation defects
 
Principles, indications and contraindications of removal of
Principles, indications and contraindications of removal ofPrinciples, indications and contraindications of removal of
Principles, indications and contraindications of removal of
 
Impacted lower 3rd molar
Impacted lower 3rd molar Impacted lower 3rd molar
Impacted lower 3rd molar
 
Impaction
ImpactionImpaction
Impaction
 
conservative approach OPERATIVE DENTISTRY
conservative approach OPERATIVE DENTISTRYconservative approach OPERATIVE DENTISTRY
conservative approach OPERATIVE DENTISTRY
 
Management of Impacted third molars
Management of Impacted third molarsManagement of Impacted third molars
Management of Impacted third molars
 
Minor oral surgery.
Minor oral surgery.Minor oral surgery.
Minor oral surgery.
 
Diagnosis and treatment planning in removable partial denture
Diagnosis and treatment planning in removable partial dentureDiagnosis and treatment planning in removable partial denture
Diagnosis and treatment planning in removable partial denture
 
Impaction 27.8.6
Impaction 27.8.6Impaction 27.8.6
Impaction 27.8.6
 
Ch1 lec2 Orthodontics Introduction
Ch1 lec2 Orthodontics IntroductionCh1 lec2 Orthodontics Introduction
Ch1 lec2 Orthodontics Introduction
 

More from IAU Dent

Odontogenic Cysts
Odontogenic CystsOdontogenic Cysts
Odontogenic CystsIAU Dent
 
Chronic gingivitis
Chronic gingivitisChronic gingivitis
Chronic gingivitisIAU Dent
 
8. Prescription Writing
8. Prescription Writing8. Prescription Writing
8. Prescription WritingIAU Dent
 
7 antibiotic-dental
7 antibiotic-dental7 antibiotic-dental
7 antibiotic-dentalIAU Dent
 
6 beta lactum drugs dental
6  beta lactum drugs dental6  beta lactum drugs dental
6 beta lactum drugs dentalIAU Dent
 
4.anti colinergic
4.anti colinergic 4.anti colinergic
4.anti colinergic IAU Dent
 
5. adrenergic drugs
5. adrenergic drugs5. adrenergic drugs
5. adrenergic drugsIAU Dent
 
4 introduction to antimicrobials
4  introduction to antimicrobials4  introduction to antimicrobials
4 introduction to antimicrobialsIAU Dent
 
3.general anesth
3.general anesth3.general anesth
3.general anesthIAU Dent
 
3.cholinergic drugs
3.cholinergic drugs3.cholinergic drugs
3.cholinergic drugsIAU Dent
 
2.pharmacodynamics
2.pharmacodynamics2.pharmacodynamics
2.pharmacodynamicsIAU Dent
 
3. drug affecting git motility rt h
3. drug affecting git motility rt h3. drug affecting git motility rt h
3. drug affecting git motility rt hIAU Dent
 
1z Intro to Pharma
1z Intro to Pharma1z Intro to Pharma
1z Intro to PharmaIAU Dent
 
2.dental local anesth new
2.dental  local anesth new2.dental  local anesth new
2.dental local anesth newIAU Dent
 
Pharma 1st midterm
Pharma 1st midtermPharma 1st midterm
Pharma 1st midtermIAU Dent
 
1 anticoagulant, antiplatelets & hematinics for dentistry
1 anticoagulant, antiplatelets & hematinics for dentistry1 anticoagulant, antiplatelets & hematinics for dentistry
1 anticoagulant, antiplatelets & hematinics for dentistryIAU Dent
 

More from IAU Dent (17)

Odontogenic Cysts
Odontogenic CystsOdontogenic Cysts
Odontogenic Cysts
 
Chronic gingivitis
Chronic gingivitisChronic gingivitis
Chronic gingivitis
 
8. Prescription Writing
8. Prescription Writing8. Prescription Writing
8. Prescription Writing
 
7 antibiotic-dental
7 antibiotic-dental7 antibiotic-dental
7 antibiotic-dental
 
6 beta lactum drugs dental
6  beta lactum drugs dental6  beta lactum drugs dental
6 beta lactum drugs dental
 
4.anti colinergic
4.anti colinergic 4.anti colinergic
4.anti colinergic
 
5. adrenergic drugs
5. adrenergic drugs5. adrenergic drugs
5. adrenergic drugs
 
4 introduction to antimicrobials
4  introduction to antimicrobials4  introduction to antimicrobials
4 introduction to antimicrobials
 
4. NSAID
4. NSAID4. NSAID
4. NSAID
 
3.general anesth
3.general anesth3.general anesth
3.general anesth
 
3.cholinergic drugs
3.cholinergic drugs3.cholinergic drugs
3.cholinergic drugs
 
2.pharmacodynamics
2.pharmacodynamics2.pharmacodynamics
2.pharmacodynamics
 
3. drug affecting git motility rt h
3. drug affecting git motility rt h3. drug affecting git motility rt h
3. drug affecting git motility rt h
 
1z Intro to Pharma
1z Intro to Pharma1z Intro to Pharma
1z Intro to Pharma
 
2.dental local anesth new
2.dental  local anesth new2.dental  local anesth new
2.dental local anesth new
 
Pharma 1st midterm
Pharma 1st midtermPharma 1st midterm
Pharma 1st midterm
 
1 anticoagulant, antiplatelets & hematinics for dentistry
1 anticoagulant, antiplatelets & hematinics for dentistry1 anticoagulant, antiplatelets & hematinics for dentistry
1 anticoagulant, antiplatelets & hematinics for dentistry
 

Recently uploaded

Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptxWINCY THIRUMURUGAN
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptPradnya Wadekar
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE Mamatha Lakka
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologyDeepakDaniel9
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptPradnya Wadekar
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptxNIKITA BHUTE
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdfHongBiThi1
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyMedicoseAcademics
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu Medical University
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfDolisha Warbi
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfDolisha Warbi
 

Recently uploaded (20)

Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
 
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
GOUT UPDATE AHMED YEHIA 2024, case based approach with application of the lat...
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
 
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
Immune labs basics part 1 acute phase reactants ESR, CRP Ahmed Yehia Ismaeel,...
 
Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologyppt
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacology
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.ppt
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before Pregnancy
 
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
 

Impacted teeth

  • 1. Impacted Wisdom Teeth Dr. Hesham Marei MSc, PhD, MFDS (Eng) Assistant Professor of oral and Maxillofacial Surgery King Faisal University
  • 2. Outline •Definitions •Incidence •Classification of impaction •Imaging, evaluation and assessment •Indications/ contraindications for removal •Benefits Vs risks of prophylactic removal of impacted 3rd molars •Complications •Conclusion
  • 3. Definition An impacted tooth is one that has failed to fully erupt into the oral cavity within its expected developmental time period and can no longer be expected to do so.
  • 4. Theories of Impaction Smaller jaws/fast growth Diet changes Mechanical obstacles Vestigial theory
  • 5. Commonest affected teeth • mandibular third molars • maxillary canines • mandibular premolars/canines • maxillary incisors • maxillary third molars • 95% of all teeth that will erupt are erupted by age 24. • 75% of mandibular third molars are impacted
  • 6. Classification Systems  Angulations  Vertical  Distoangular  Mesioangular  Horizontal  Buccal/Lingual  Relationship to anterior border of ramus  Depth of impaction  Nature of overlying tissue
  • 7. VERTICAL HORIZONTAL MESIOANGULAR DISTOANGULAR According to the long axis of the neighbouring mesial tooth
  • 8. Angulations of embedded 3rd molars Maxilla % Mandible% Vertical 68.3 38.7 Mesio-angular 13.3 44.0 Desto-angular 17 8.5 Meso-horizantal 0.19 7.7 Desto-horizantal 0.66 0 Bucco-lingual 0.37 0.92 Inverted 0.04 0.02
  • 10. Relationship to Anterior Border of Ramus (Pell and Gregory)  Class I - adequate room to erupt  Class II - one half covered  Class III- completely embedded
  • 11. Pell and Gregory Classification (relation to the ramus)
  • 13. Radiographic Assessment • Minimum of an OPG • Visualize all the teeth and adjacent structures including bone, morphology and number of roots, hypercementosis • Depth of bone around tooth • Follicular pathology
  • 14. Other Important Factors  Size of Follicular Sac  Density of Surrounding Bone  Contact with Mandibular Second Molar  Relationship to Inferior Alveolar Nerve
  • 17. Darkening of the root.Darkening of the root. Deflection of the root.Deflection of the root. Narrowing of the root.Narrowing of the root. Dark and bifid root apex.Dark and bifid root apex. Interruption of the whiteInterruption of the white line of the canal.line of the canal. Diversion of the canal.Diversion of the canal. Narrowing of the canal.Narrowing of the canal.
  • 19. Problem #1 – Soft Tissue  Even with adequate arch length and full eruption, 3rd molars are often surrounded by thin, unkeratinized, highly distensible lining mucosa of the buccal vestibule.  Encourages pathogenic bacteria retention  Poorly withstands hygiene measures
  • 20. Problem #2 – Periodontal Compromise  Bone loss distal to the 2rd molar after removal of the 3rd molar is controversial, at best. Even with some loss of bone, the result is stable and cleansable – the goal of periodontal therapy.
  • 27. Problem #3 – 3rd Molar Caries
  • 28. Problem #3 – 3rd Molar Caries
  • 32. Problem #4 – 2nd Molar Caries
  • 37. Problem #5 - Infection  Can turn an elective procedure into an urgent or emergent situation  Unscheduled loss of work  Increased pain and healing time  Compromise of adjacent teeth  Compromise of patient’s systemic health
  • 38. Types of Infection 1. Simple dental caries and periodontal disease 2. Pericoronitis 3. Abscess 4. Cellulitis 5. Abscess extension into adjacent fascial spaces 5. Abscess spread to distant sites 6. Recurrent infections 7. Infections resistant to initial local and systemic treatment measures
  • 40. Pericoronitis The most common cause of therapeutic 3rd molar removal.
  • 41. Pericoronitis  Inflammation of the tissues around the crown of any partially erupted/ impacted tooth.  It is either acute or chronic
  • 42. Pericoronitis  A failure of preventive measures  A failure of early recognition, or a failure to seek proper treatment  A step along the pathway of infection  Pericoronitis should be a warning sign that initiates immediate and aggressive treatment with careful observation.
  • 43. Pericoronitis  Features of pericoronitis  Trismus, pain, dysphagia, malaise, bad taste  Signs of inflammation of the pericoronal tissues, with frank pus from under the operculum  Cheek biting and cuspal indentations on the operculum  Halitosis, food packing  Can progress with systemic symptoms and spread to adjacent tissue spaces
  • 44. Pericoronitis • Treatment for pericoronitis • Local measures  Irrigation, oral hygiene measures  Remove trauma, i.e. Extract upper 8, consider lower 8 later • General measures  Soft diet, analgesics, antibiotics, admission in some cases
  • 45. Problem #6 - Resorption
  • 46. Problem #7 - Supereruption
  • 47. Problem #8 - Cysts Dentigerous Cyst
  • 51. Types of Cysts  Follicular cyst (Dentigerous Cyst)  OKC (Odontogenic Keratocyst)  Ameloblastoma (several varieties)  Not all radiolucencies are cysts! - Lymphoma - Myeloma - Metastatic carcinoma
  • 52. Without the radiolucency, would you have recommended removal? Is the removal of this better or worse with the radiolucency?
  • 53. When would you recommend removal of this 3rd molar?
  • 55. Cysts – A Few Facts  May be prevented by early removal – when normal dental follicle is still evident.  The pericoronal pocket, or residual follicle, is responsible for most cystic pathology.  All cystic tissues should be removed and biopsied.
  • 56. Cysts  Cysts themselves are not catastrophic – the problem is that we don’t know exactly what they are until they are histopathologically examined – which necessitates removal.  All cysts result in bone loss.  Some cysts recur more than others.
  • 57. Problem #9 - Tumors  Benign vs. malignant  Odontogenic vs. non-odontogenic  Each of these factors has important treatment implications.
  • 63. Problem #10 – Risk of Fracture
  • 68. Problem #11 - Fracture
  • 69. Problem #12 - Orthodontics  Prevent loss of post- retention stability  Allow distalization of 2nd molars  These are controversial indications
  • 71. Possible Contraindications to Removal of Impacted Teeth • Extremes of age • Compromised medical status • Probable excessive damage to adjacent structures • Asymptomatic teeth
  • 74. Factors that Contribute to Risk Assessment for Patients  Age  Location of IAN  Body mass index  Drug history  Systemic conditions  Surgical access space  Tongue size  Anesthesia history  Maxillary sinus location  Root contour  Third molar position  Interincisal opening  Health of second molar  Bone mass and density
  • 75. Factors that makes surgery Less difficult  Mesio-angular position  Class I ramus  Position A depth  Roots ½ to 2/3 formed  Fused conical roots  Wide periodontal ligament  Large follicle  Elastic bone  Separated from 2nd molar  Separated from inferior alveolar nerve More difficult  Disto-angular position  Class III ramus  Position C depth  Long, thin roots  Divergent curved roots  Narrow periodontal ligament  Thin follicle  Dense, inelastic bone  Contact with 2nd molar  Close to inferior alveolar nerve  Complete bone impaction
  • 76. Presurgical Patient Counseling • Decision on method of anaesthesia [LA,+/- IV sedation, GA] • Preoperative warnings of pain, swelling, bruising, possible hypoesthesia of lip/ tongue ,trismus, diet advice, • Verbal and written warnings (information sheet), enter into notes, nursing staff as witness • Warn patient of post operative complications with a greater than 5% incidence and permanent complications even if less than 1% • If patient declines treatment need to be informed of likely long term problems
  • 78. conclusion • Emerge between 18-24 yrs in 95% of the population. • Fail to develop in 1:4 adults • 72% mandibular molars impacted • Decision to remove based on balance of risks/benefits of retention observation against risks/benefits of removal.
  • 79. conclusion • Adequate patient assessment ensuring good case selection • More conservative approach • Essential to give explanation of procedure with its associated potential complications and alternatives reinforced with information leaflet • Details noted for medicolegal reasons
  • 80. conclusion The third molar controversy is still going-on. As with all surgical procedures, the surgeon wants to do surgery, it is his or her profession! From a patient point of view, non-surgical treatment should be the first option in an asymptomatic environment.
  • 81. Management of impacted third molars RemovalRemoval Risks •Crowding of dentition. • Resorption of adjacent tooth and periodontal status. • Development of infection, cyst and tumor RetentionRetention Benefits •Preservation of functional teeth. •Preservation of residual ridge Risks Minor Complications: •Alveolitis •Paresthesia •Trismus •Fractures •Hemorrhage Major Complications: Dysesthesia Bacteremia Benefits •Decreased morbidity in younger patients •Therapeutic control
  • 86.  ≈ 7.8mm at the 3rd molar  ≈ 10mm Between the first and second molar
  • 88. Course of the Inferior Alveolar canal
  • 89. Results  Buccal cortex mean thickness = 2.3mm at the first molar  Buccal cortex mean thickness = 1.7mm at the third molar
  • 90. At the 3rd molar site  Linear distance from the IA canal to the lingual surface of the buccal cortex = 1.7mm
  • 91. Assessment of the lingual nerve in the third molar region using MRI Miloro, JOMS 55:134-37, 1997 Purpose: Determine the precise insitu location of the lingual nerve in the third molar region using high-resolution magnetic resonance imaging
  • 92. Methods  Ten healthy volunteers (20 sites) with mandibular third molars underwent axial and coronal high-resolution MRI of the posterior mandible and floor of mouth  Three individuals measure the horizontal and vertical position of the LN
  • 93. Diagram: Fig 1 and Fig 2
  • 94. Results  The mean vertical 2.75± 0.97 (range 1.52-4.61mm)  The mean horizontal 2.53± 0.67 (range 0.00-4.35mm)
  • 95. Results 10% of LN were superior to the lingual crest 25% of LN were in contact with the lingual cortex
  • 96. Lack of Root Development
  • 107. Complications Factors that may influence the occurrence of complications  Age  Gender “F”  Medical condition  Presence of pericoronitis  Poor oral hygiene  Type of impaction  Relationship to inferior alveolar nerve  Surgical time and technique  Surgeon experience  Use of perioperative antibiotics  Use of topical antiseptics  Anesthetic technique
  • 108. Complications •Alveolar Osteitis (dray Socket) •Infection •Bleeding •Damage TO adjacent teeth •Mandibular fracture •Maxillary tuberosity fracture •Displacement of third Molars •Aspiration •Oro-antral communication/fistula •IAN/lingual nerve damage
  • 109. Complications  Intraoperative: • Haemorrhage • Fractured root apex • damage to adjacent teeth/restoration/ soft tissues • Fracture mandible • Tooth ingestion or aspiration  Postoperative: • Dry socket [1-5%] or infection with purulent discharge • Sensory deficit-IAN=5% temp, lingual temp=10%, perm=<1% • Pain, swelling, bruising & trismus • Fracture mandible
  • 110. Definition of Sensory Disturbances Paresthesia: an abnormal sensation, such as burning, pricking, tickling or tingling Dysesthesia: condition in which a disagreeable sensation is produced by ordinary stimuli Anesthesia; state characterized by loss of sensation, the result of pharmacologic depression of nerve function or of neurological disease
  • 111. Partial Odentectomy  Indicated if intimate relationship with IAN  Root should be 3mm below bone level  Contraindicated if there is root pathology or loose tooth
  • 119. AAOMS Workshop on the Management of Patients With Third Molar Teeth 1993  Little evidence that antibiotics decreases pain, edema, alveolar osteitis or infection  Lavage of the surgical site reduces risk of complications
  • 120. AAOMS Workshop on the Management of Patients With Third Molar Teeth 1993  Tight primary closure increases frequency and severity of postoperative pain and swelling  Pericoronitis is a risk factor for alveolar osteitis and postoperative infection
  • 122. Five Possible Reasons  An infection is present and must be treated  The patient is medically compromised and requires antibiotic prophylaxis against metastatic infection  Patient or patient’s family demands antibiotics  The standard of care in the oral surgery community is to use antibiotics  The risk of postoperative infection is high
  • 123. Risk/Benefit Assessment  Incidence of serious infections is low (estimated risk of 1-5%)  Cost of antibiotic therapy is low  Risk of development of resistant strains of bacteria is undetectable for individual practitioner  Risk of allergic reaction is higher than risk of infection
  • 124. JOMS 53:53-60 1995  Piecuch JF et al- A Supportive Opinion  January 1994 survey of Connecticut Society of Oral and Maxillofacial Surgeons  N=104 (of 122)  58% routinely used antibiotics for surgical removal of fully submerged (impacted) mandibular third molars in patients who are not medically compromised  Dose regimens and method of application varied widely
  • 125. Variations  Preoperative use  Postoperative use 1. Systemic Oral, parenteral 2. Topical Socket site
  • 126. JOMS 53:53-60 1995  Zeitler D, A Dissenting Opinion  The low complication rate associated with the procedure does not support the routine use of antibiotic prophylaxis  The use of antibiotics to decrease the incidence of other adverse outcomes (alveolar osteitis, or dry socket) has not been determined to be successful
  • 127. “Antibiotic Therapy in Impacted Third Molar Surgery” Monaco G, et al, Eur J Oral Sci 107 (6): 437-41, Dec 1999  N = 141 patients  66 patients with 2 gm amoxicillin daily for 5 days  75 patient without antibiotic therapy  No significant difference between groups  Association between smoking, habitual drinking and increase post op pain and fever
  • 130. Acetylsalicylic Acid (aka aspirin) Class : Analgesic, Anti-pyretic (Gr. puretos fever) & Anti- inflammatory MOA : irreversible inhibition of cyclooxgenase clinical correlation: stop ASA 7d p surgery (exception) MOE : Excreted in urine Supplied: 325-650 mg Adult Dosage: PO 600 - 1000 mg q 4 - 6º Major Side effects : Bleeding & GI disturbances Interactions: anti-coagulants, alcohol
  • 132. Acetaminophen (aka Tylenol®) Class : Analgesic, Anti-pyretic, not anti-inflammatory MOA : Possible weak inhibition of cyclooxygenase MOE : Metabolized in liver, excreted in urine Peak plasma levels: 30 - 60 mins t1/2: 2 hrs Supplied: 325-650 mg Adult Dosage: PO 325-650 mg q 4 - 6º Max = 4g/day Major Side effects : Liver toxicity
  • 133. Ibuprofen (aka Advil ®) Class : Analgesic, Anti-pyretic, Anti-inflammatory MOA : Inhibition of cyclooxgenase (both isoforms) MOE : Metabolized and excreted in kidney Peak plasma levels: 60 - 120 mins Half time: 120 mins Supplied: 200 mg Adult Dosage: PO 400 - 600 mg q 4 - 6º PO 800 mg q 8 - 10º Max = 3.2 g/day Major Side effects : GI Bleeding
  • 135. Celecoxib (Celebrex ®) Class : Analgesic, Anti-pyretic, Anti- inflammatory MOA : Inhibition of cyclooxgenase 2 MOE : Metabolized in liver and excreted in kidney Peak plasma levels: 3 hours Half time: 11 hours Supplied: 100, 200 mg Adult Dosage: 100-200 mg PO BID Major Side effects : renal dysfunction, GI ulcerations, contraindication with pts with sulfa,NSAID allergies
  • 136. Supplied in 12.5mg & 25mg tablets Contraindications: - allergies to sulfa, NSAIDs - GI bleeding, ulcerations - liver and kidney diseases - pregnancy Rx: 25-50mg PO daily prn pain Supplied in 10mg & 20mg table Rx: 10-20mg PO daily prn pain
  • 138. Codeine Class : Opioid MOA : binds to opioid receptors MOE : urine Peak plasma levels: 30 - 60 mins Half time: 3 -4 hrs Supplied: 15, 30, 60 mg Adult Dosage: PO 15 - 60 mg q 4 - 6º Max = 360 mg/day
  • 139. • Sedation • respiratory depression • constipation • nausea Opioid triad: stupor, pupillary constriction & respiratory depression SIDE EFFECTS & COMPLICATIONS
  • 140. Hydrocodone Class : Opioid analgesic MOA : opioid receptors MOE : urine Peak plasma levels: 30 - 60 mins Half time: 3 - 4 hrs Supplied: 5 mg Adult Dosage: 5 - 10 mg q 4º Major Side effects : Dizziness, sedation, nausea, vomiting, respiratory depression
  • 141. Oxycodone Class : Opioid analgesic MOA : opioid receptor MOE : urine Peak plasma levels: 30 - 60 mins Half time: 3 -4 hrs Supplied: 5 mg Adult Dosage: PO 5 mg q 4 - 6º Major Side effects : Dizziness, sedation, N / V, respiratory depression
  • 142. Propoxyphene Class : Opioid analgesic analgesic efficacy questionable MOA : opioid receptors MOE : urine Peak plasma levels: 2 - 3 hrs Half life: 12 hrs Supplied: 100 mg
  • 146. Dionne RA. 1999. JOMS. 57: 673-678.  Sample size: 118 subjects  Surgical removal of 2 or 4 impacted third molars with sedation and local anesthetic  Subjects were questioned 15, 30, and 45 min. after loss of anesthesia about their pain
  • 147. Methods  treatment groups:  Ibuprofen 400 mg  Ibuprofen 400 mg + Oxycodone 2.5 mg  Ibuprofen 400 mg + Oxycodone 5 mg  Ibuprofen 400 mg + Oxycodone 10 mg
  • 148. Results - Only Ibuprofen 400 mg + oxycodone 10 mg provided better analgesia than Ibuprofen alone - Increasing doses of oxycodone α side effects
  • 150. Mild Pain Moderate Pain Severe Pain 400 -600 mg Ibuprofen or 650 mg ASA 650 - 1000 mg Acetaminophen Continue as needed Adequate analgesia Inadequate pain relief 600 - 800 mg Ibuprofen + Codeine 650 - 1000 mg Acetaminophen + Codeine Continue as needed Adequate analgesia Inadequate pain relief 600 - 800 mg Ibuprofen + Hydrocodone oroxycodone 650 - 1000 mg Acetaminophen + Hydrocodone or oxycodone Continue as needed Adequate analgesia
  • 151. Pre-emptive Analgesia:Pre-emptive Analgesia: he pre-operative administration of analgesics
  • 152. Analgesic Strategies  Use of long acting local anesthetic does display a synergistic effect with NSAIDs  Pre-emptive analgesia/anesthesia still being researched-recent data does not support presurgical administration for pain control
  • 153. Use of Corticosteroids with Third Molar Removal
  • 154. Esen E, et al, “Determination of the anti-inflammatory effects of methylprednisolone on the sequelae of third molar surgery”, J Oral Maxillofac Surg 57(10):1201-6, Oct 1999  N =20  Double blind crossover study  125 mg methylprednisolone vs. placebo  Pain and trismus evaluated
  • 155. Esen E, et al, “Determination of the anti-inflammatory effects of methylprednisolone on the sequelae of third molar surgery”, J Oral Maxillofac Surg 57(10):1201-6, Oct 1999  Significant decrease in edema, trismus and pain in the methylprednisolone group  Normal HPA axis before and after  Plasma cortisol nonsignificant decrease in both groups
  • 156. Esen E, et al, “Determination of the anti-inflammatory effects of methylprednisolone on the sequelae of third molar surgery”, J Oral Maxillofac Surg 57(10):1201-6, Oct 1999  No clinically apparent infection or disturbance of wound healing  90 % preferred the post operative course associated with steroid administration
  • 157. What We Don’t Know What are the risks/complications/morbidities when impacted third molars are not removed?
  • 158. What we do know  Cost in both time and risk exists with third molar removal in the older adult
  • 159. Increased Costs Associated with Third Molar Removal in the Older Adult  Increased number of symptomatic post operative days requiring convalesence  Increased overhead costs due to increase in surgical complexity
  • 160. Increased Costs Associated with Third Molar Removal in the Older Adult  Increase in complication management requiring an increase in the number of office visits  Increase in litigation costs
  • 163. Obligations to observe  Frequency of imaging evaluation  every two years?  every five years?  Frequency of clinical evaluation  regular basis?  only when symptomatic?
  • 164. Conclusions  Elective removal of symptomatic third molars in older adults is more costly and engenders greater risk than with prophylactic removal of third molars  Risks can be reduced with proper surgical technique
  • 165. Conclusions  Modeling with computer enhanced “virtual reality” may allow study of predictability  More study is needed as the debate continues
  • 166. IMPACTED MAXILLARY CANINE  The surgical removal of a deeply seated maxillary canine in relation to the maxillary sinus and the nasal cavity is one of the most difficult oral surgical procedures Frequency :  Maxillary canine is 20 times more than mandibular canine  More frequent in females than males  Palatal impaction is 3 times more than buccal impaction
  • 167. Classification of impacted maxillary canine: ARCHER,S CLASSIFICATION Class I Palatally Impacted canine a) Horizontal b) Vertical c) semivertical Class II Buccally impacted canine a) Horizontal b) Vertical c) Semivertical Class III Impacted canine located in both the palatal and labial surfaces. Class IV Impacted canine located in the alveolar process. Class V Impacted canine located in an edentulous maxilla.
  • 168. Contra-indications for the removal of an impacted maxillary canine: When it can be brought into normal position either by surgical repositioning or a combination of surgery and orthodontic treatment.. Factors complicating the removal of the impacted canine: Close relationship to the roots of the neighboring teeth. Intimate relation to the maxillary sinus. Curvature or hypercementosis of the root. Difficulty in localization most important factor.
  • 169. SURGICAL REMOVAL OF IMPACTED MAXILLARY CANINE Planning the operative procedure X-ray examination Classify the impaction Extent of the flap Sectioning of the tooth is needed or not
  • 174. Localization of impacted maxillary canine:  clinical examination  Radiographic examination Clinical examination:  By palpation:  Presence of distinct bulge  Deflection of crowns: mostly of lateral incisors pr premolars. Radiological examination:  a) Intra-oral periapical films  b) Occlusal radiographs ( topographical & cross sectional ): Canine will appear as a round radioapaque structure.
  • 175.  c) Shift sketch technique: In This technique, the films are in the same position while the cone is shifted, if the canine moves with same direction of the cone , it indicates that it is located far (palatally), while if the canine moves opposite to the direction of the cone , it indicates that it is near (buccally).
  • 176.  e) Tomograms: Sections are taken, if the canine is impacted buccally , it's tip will appear first , while if impacted palatally, the apex will appear first.
  • 177. f) Extra-oral oblique or true lateral:
  • 178. g) Panoramic films: To determine relation to maxillary sinus.
  • 179. Object Localization A periapical film will identify the location of an object vertically and in a horizontal (mesiodistal) direction. However, we cannot tell where the object is located buccolingually, since the periapical film is two-dimensional. Therefore we need another method for locating objects in a buccolingual direction. The two primary methods of determining the buccolingual location of objects are: Right-Angle Technique (Occlusal projection) Primarily identifies buccolingual location, but may also confirm mesiodistal location seen on periapical Tube-shift Technique (SLOB rule, Clark’s rule) Utilizes two films with different horizontal or vertical angulations
  • 180. Right Angle (Occlusal) technique Right Angle Technique Once you have identified an object on the periapical film, you can take an occlusal film with the beam at a right angle (perpendicular) to the direction of the beam for the periapical. The beam may also be perpendicular to the film, especially in the mandible. The occlusal film below shows that the impacted canine is lingually positioned.
  • 181. The SLOB rule is used to identify the buccal or lingual location of objects (impacted teeth, root canals, etc.) in relation to a reference object (usually a tooth). If the image of an object moves mesially when the tubehead is moved mesially (same direction), the object is located on the lingual. If the image of the object moves distally when the tubehead moves mesially (opposite direction), the object is located on the buccal. Tube-Shift Localization (Clark) SLOB Rule Same Lingual Opposite Buccal
  • 182. For the SLOB rule to work, there must be a change in the horizontal or vertical angulation of the x-ray beam as the tubehead is moved. This change in angulation will alter the relationship between the object of interest and the reference object, allowing you to determine the buccal or lingual location. The closer the object to be localized is to the reference object, the less the amount of movement of the image of the object in relation to the reference object.
  • 183. In the diagram at right, the tubehead is moved, but there is no change in direction of the x-ray beam, which results in no change in location of the object of interest in relation to reference object (see below). Moving the tubehead without changing the beam direction would often result in a cone cut , depending on how far the tubehead is moved (see below right).
  • 184. premolar molar For the films above, we know that the tubehead was moved distally from the premolar to the molar film. The zygomatic process (red arrows) is located at the distal aspect of the 2nd molar on the premolar film and it is located over the distal aspect of the 1st molar on the molar film. This indicates that it moved mesially as the tubehead moved distally. We know that the zygomatic process is buccal to the teeth and, using the SLOB rule, it follows that the x-ray beam was directed more mesially on the molar film (Buccal object moved opposite to tubehead movement).
  • 185. premolar molar Another way of determining the change in the direction of the beam is to look at the angulation of the teeth. In the premolar film, the roots of the teeth are angled distally, indicating that the beam was directed distally (from the mesial). In the molar film, the roots are more upright or angled slightly mesially, indicating the beam was directed more mesially (from the distal). Therefore, the tubehead shifted distally and the beam was angled in the opposite direction, allowing the use of the SLOB rule (These films were taken from Slide 3 in the review films to follow).
  • 186. Is the composite restoration on tooth # 8 (arrows) located on the buccal or lingual? canine film incisor film 1The restoration is located on the buccal. The tubehead moves mesially from the canine film to the incisor film (x-ray beam projected more distally) and the composite moves distally, which is the opposite direction.
  • 187. canine film premolar film The arrow in the canine film is pointing to the gutta percha in which canal of the maxillary first premolar? 2 The arrow identifies the lingual canal. The tubehead moves mesially from the premolar film to the canine film (beam directed more distally) and the gutta percha indicated by the arrow also moves mesially. (See following slide).
  • 188. PID PID lingual buccal When the tubehead is moved mesially, with the beam directed distally, the two canals, which are initially superimposed (premolar periapical above) will separate. The lingual canal (red arrow) will follow the tubehead movement and the buccal canal (blue arrow) will move in the opposite direction, as seen on the canine film.
  • 189. Is the maxillary second premolar (arrows) displaced to the buccal or the lingual? premolar film molar film premolar bitewing 3 The tubehead moves distally from the premolar film to the molar film. The second premolar also moves distally, overlapping the first molar more in the molar film. In moving from the premolar periapical to the bitewing, the tubehead moves down and the premolar also moves down. The displacement is to the lingual.