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IMPACTION IMPACTION IMPACTION Surgical _ Orthodontic

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					                                                      IMPACTION




          IMPACTION                                   IMPACTION




  Surgical & Orthodontic                            Tooth Impaction
Considerations of Exposing                Third Molars – Most common
                                          Maxillary Cuspids
     Impacted Teeth
                                          Maxillary Central Incisors
                                          Mandibular/Maxillary second premolar
Anne-Marie Hoa Nguyen, DDS, MS
        Houston, Texas

2006 Vietnamese American Medical-Dental
     Association National Convention




                                                                                 1
          Tooth Impaction                             Tooth Impaction
             Complications                                Complications


External resorption
Infection                                                  Root resorption
Cyst Formation                                             Tooth transposition
Loss of arch length
Resorption of the roots of adjacent teeth
Periodontal defects




 Pre-Operative Orthodontics                    Pre-Surgical Preparation
Provide adequate anchorage
Create sufficient space
                                             Localization
                                                                       Inspection


                                                                        Palpation


                                                                       Radiography


                                                          Periapical    Occlusal     Panoramic




   Pre-Surgical Preparation                             Radiography
                                            Parallax: the apparent displacement of an image,
Determine the location                      relative to the image of a reference object, caused
Radiographs at different angles             by an actual change in the angulation of the X-ray
                                            beam.
Buccal Object Rule [S.L.O.B.]
                                            Reference Object: root of adjacent tooth




                                                                                                  2
          Surgical Exposure                                    Surgical Exposure
                Armamentarium                                        Techniques

Local anesthetic agents
    1:50K Epi for hemostasis                            Excisional Uncovering
Blades [15C, 12] & periosteal elevator
                                                        Apically Positioned Flap
Surgical Round Bur [Size 4, 6]
Periodontal curettes                                    Closed-Eruption Technique
Bonding brackets or gold chain
Bonding materials
Sutures [4.0 Plain Gut]
Camera




          Surgical Exposure                                   Canine Impaction
                   CRITERIA

Facio-Lingual Position
    Intra-alveolar – NEVER used excisional uncovering
nor APF

Vertical Position
Relative to the CEJ
   If below – any of the 3
   If above – NEVER excisional

Amount of keratinized gingiva

Mesiodistal position




          Surgical Exposure                                    Surgical Exposure
                  Techniques                                         Techniques

Curette follicular sac                                  NEED to remove all bone off up
Hemostasis controlled                                   to the CEJ!
   Surgicel [Johnson & Johnson]                         ENAMEL DOES NOT RESORB
   Gel – Foam [Upjohn Co.]
Acid-etch
                                                        BONE.
Bracket or gold chain




                                                                                         3
          Surgical Exposure
                Techniques




         Canine Impaction                                  Canine Impaction
Most common in maxillary arch
2% of orthodontic patients                    Width: 7.5 to 8 mm
Palatal > Labial [ 2 : 1]                     1 to 1.5 mm wider than the first premolars
Female > Male [3x]
Cause: Retained primary tooth, Diversion
of tooth bud, idiopathic




                                                           Canine Impaction
         Canine Impaction
                                                            Transposition
Advantages of delaying extraction 1o canine
  * Space preservation
  * Maintaining ridge width                         A      B

  * One surgical procedure
                                                                              C


                                                       C

                                                                         A    B

                                                   A           B




                                                                                           4
Canine Impaction                         Canine Impaction




Canine Impaction                         Canine Impaction




Canine Impaction                         Canine Impaction
         Bracket attached to tooth
         Closed – flap technique
         Gold chain to archwire for
          stabilization and attachment
         Immediate activation




                                                            5
      Canine Impaction              Canine Impaction

                   *

  Primary
  Canine




 Oops Factor!!!




Bilateral Canine Impaction   Bilateral Canine Impaction




Bilateral Canine Impaction   Bilateral Canine Impaction




                             Palatal View       Occlusal XR




                                                              6
       Bilateral Canine Impaction                                          Bilateral Canine Impaction



                                              R Buccal
               (R) PAR




                                                                    R Buccal View after surgical exposure with
                                                                    gold chain attachment

                (L) PAR                       L Buccal




       Bilateral Canine Impaction                                          Bilateral Canine Impaction

                                       *Closed eruption technique

                                         *Traction wire tunnelled
                                        through extraction socket




L Palatal View after surgical exposure with
gold chain attachment




       Bilateral Canine Impaction                                          Bilateral Canine Impaction




                                                                                                        25 y.o. Hispanic Male, referred by a
                                                                                                       local orthodontist, for an exposure of
                                                                                                           Upper Right and Left Canine.

                                                                                                            NOTE multiple external root
                                                                                                          resorption to the anterior teeth.

                                                                                                             WARN patient BEFORE
                                                                                                                 SURGERY!




                                                                                                                                                7
 Bilateral Canine Impaction         Bilateral Canine Impaction




                                  Mandibular Canine Impaction
                                  Impaction : Rare, 0.05% to 0.4%
                                  Causes: Ectopic position, Lack of space,
                                  Obstruction of the eruption pathway, defects in
                                  the follicle.




Mandibular Canine Impaction         Mandibular Canine Impaction
      Orthodontic Repositioning             Orthodontic Repositioning


 Space availability
 Tooth axis

                            *
       *

                                                        *




                                                                                    8
  Mandibular Canine Impaction        Mandibular Canine Impaction
         Orthodontic Repositioning        Orthodontic Repositioning




  Mandibular Canine Impaction
         Orthodontic Repositioning




  Central Incisors Impaction         Central Incisors Impaction
2nd most common in maxillary
Cause: Mesiodens




                                                                      9
   Central Incisors Impaction




  OCR before Surgery           PAR after extraction




         Premolar Impaction                                  Premolar Impaction
                    Etiology
                                                      Maxillary 2nd Premolar impaction: 0.1% to 0.3%
                                                      Mandibular Premolar impaction: 0.2% to 0.3%
                                                      Last tooth to erupt
Space loss
Ectopic position
Obstacles in the eruption path
   Ankylosed primary molars
   Supernumerary teeth (Odontomas)




          Premolar Impaction                          Upper 2nd Premolar Impaction
          Pre-Operative Orthodontics
 Determine to Extract primary 2nd molar
 Delayed Ortho → space maintainer
 Wait for all permanent teeth eruption
 Provide adequate space




                                                                                                       10
Upper 2nd Premolar Impaction            Upper Premolars Impaction

                                                                        Impacted Left
                                                                         2nd Premolar




                                                 Impacted Right 1st & 2nd Premolars




 Upper Premolars Impaction         Lower 1st Premolar Impaction

                               Buccal
                                View




                               Lingual
                                View




Lower 1st Premolar Impaction       Lower 2nd Premolar Impaction




                                              Clark’s Rule : SLOB




                                                                                        11
 Lower 2nd Premolar Impaction                                                       Lower 2nd Premolar Impaction




                                                                                38 y.o. Asian female, referred by an orthodontist, for:
                                                                                     • Extraction of Upper Left 1st premolar #12
                                                                                • Surgical Extraction of Lower Right 2nd premolar #29




 Lower 2nd Premolar Impaction                                                       Lower 2nd Premolar Impaction


                                                                                 18 –mm
                                                                                Root Length




Based solely on Panoramic radiograph, referring doctor cited reasons for Ext:
                    • Severe External Root Resorption
                               • Weak tooth
          • Replace with a single endosseous implant after Ortho




                                                                                                     Molar Impaction




                                                                                                                                          12
           Molar Impaction                         Molar Impaction
                                                  Pre-Operative Orthodontics

Physical obstacle in the eruption path
                                         Evaluate 3rd molars
Ectopic eruption path
                                         Place ortho appliances on all teeth
                                         Refer for surgical exposure




            Molar Impaction                    2nd Molar Impaction
     ??? Wisdom Teeth Extraction ????


Insufficient space → Ext.
Disadvantages
        Trauma & Postop Discomfort
        Flap Management




       2nd Molar Impaction                   Upper Molars Impaction




                                                                               13
   Upper Molars Impaction                        Potential Problems
                                           Immobile
                                           Resist movement
                                             Insufficient bone removal
                                             Inappropriate orthodontic mechanics
                                             Ankylosed tooth




       Potential Problems                         Potential Problems
                                                      Tissue Overgrowth

Loss of attached gingiva
Tissue Overgrowth
“Pigeon Hole” --- damage to the crown or
adjacent roots, inadequate bone removal,
poor isolation




       Potential Problems                            Conclusion

Closed Eruption Technique                  Early detection and treatment
   Debonding of Brackets
                                           Proper diagnosis and treatment
   Mucogingival Defects
                                           Periodic follow up




                                                                                   14
Thank you for your
    attention!
   Comments !!!!
  Questions?????




                     15

				
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posted:12/22/2011
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