Tooth impaction

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Mandibular canine impacted in the chin
Impacted mandibular canine.Gif
3D CT of mandibular canine impacted in the chin

An impacted tooth is one that fails to erupt into the dental arch within the expected developmental window. Because impacted teeth do not erupt, they are retained throughout the individual's lifetime unless extracted or exposed surgically. Teeth may become impacted because of adjacent teeth, dense overlying bone, excessive soft tissue or a genetic abnormality. Most often, the cause of impaction is inadequate arch length and space in which to erupt. That is the total length of the alveolar arch is smaller than the tooth arch (the combined mesiodistal width of each tooth). The wisdom teeth (third molars) are frequently impacted because they are the last teeth to erupt in the oral cavity. Mandibular third molars are more commonly impacted than their maxillary counterparts.

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Some dentists believe that impacted teeth should be removed [1] except, in certain cases, canine teeth: canines may just remain buried and give no further problems, thus not requiring surgical intervention. [2] However, removal of asymptomatic, pathology-free, impacted teeth is not a medical consensus: [3] [4] watchful monitoring may be a more prudent and cost-effective strategy [5] [6] [7] and make the future placement of a dental implant through such impacted tooth a feasible approach. [8]

Classification

Classifications enable the oral surgeon to determine the difficulty in removal of the impacted tooth. [9] The primary factor determining the difficulty is accessibility, which is determined by adjacent teeth or other structures that impair access or delivery pathway. The majority of classification schemes are based on analysis on a radiograph. The most frequently considered factors are discussed below.

Angulation of tooth

Very rare case of vertical premolar impaction: the permanent second premolar on the lower right side of the mouth is impacted, inverted and pierces the mandibular bone. Notice that the deciduous second molar is also present, which is uncommon because the patient is a 37-year-old man. Milk-tooth and impacted inverted 2nd premolar.jpg
Very rare case of vertical premolar impaction: the permanent second premolar on the lower right side of the mouth is impacted, inverted and pierces the mandibular bone. Notice that the deciduous second molar is also present, which is uncommon because the patient is a 37-year-old man.

Most commonly used classification system with respect to treatment planning. Depending on the angulation the tooth might be classified as:

Relationship of tooth to anterior border of ramus

This type of classification is based on the amount of impacted tooth that is covered with the mandibular ramus. It is known as the Pell and Gregory classification, classes 1, 2, and 3. [10]

Relationship of tooth to occlusal plane

The depth of the impacted tooth in relation to the adjacent second molar serves as the foundation for this type of classification. This was also given by Pell and Gregory and is known as the Pell and Gregory A, B, and C classification. Relationship to the occlusal plane A-C classes

Complications

Erupted teeth that are adjacent to impacted teeth are predisposed to periodontal disease. Since the most difficult tooth surface to be cleaned is the distal surface of the last tooth, in the presence of an impacted tooth there is always gingival inflammation around the second molar that is invariably present. Even this minor amount of inflammation can provide bacteria access to a larger portion of the root surface that results in early formation of periodontitis compromising the tooth. Even in situations in which no obvious communication exists between the mouth and the impacted third molar there may be enough communication to initiate dental caries (tooth decay).

Pericoronitis

Pericoronitis is an infection of the soft tissue that covers the crown of an impacted tooth and is usually caused by the normal oral microbiota. For most people there exists a balance between the host defenses and the oral micriobiota but if the host defenses are compromised like during minor illness such as influenza or an upper respiratory tract infection, pericoronitis results. Another common cause is entrapment of food beneath the gum flap (also called an operculum). Pericoronitis can present as a mild infection or severe infection. In its mildest form it is just a localized tissue swelling and soreness whereas in severe forms the swelling is slightly larger even sometimes creating trismus (difficulty opening the mouth).

Occasionally, an impacted tooth causes sufficient pressure on the roots of adjacent teeth causing it to resorb.

An impacted tooth occupies space that is usually filled with bone. This weakens that area of bone and renders the jaw more susceptible to fracture.

When impacted teeth are retained completely within the alveolar process, the associated follicular sac is also retained along with it. Though in most persons the dental follicle maintains its original size sometimes it may undergo cystic degeneration and become a dentigerous cyst or a keratocyst.

Symptoms

Most commonly, the individual complains of food becoming lodged beneath the gums and soreness, which is frequently misdiagnosed as a throat infection. Swelling is visible in milder forms, and opening the mouth becomes difficult in severe cases. Pain is always present.

Management

Depending on the dentist (and the health authority's guidelines in that country), and the situation, impacted teeth may be extracted or left alone. Extraction may be contraindicated, simple, or surgical, depending on the location of the teeth.

Sometimes, a surgeon may wish to expose the canine for aesthetic purposes. This may be achieved through open or closed exposure. Studies show no advantage of one method over another. [11] A laser can be used to uncover superficially impacted teeth with no bleeding and quick recovery. [12] [13] [14]

Related Research Articles

<span class="mw-page-title-main">Human tooth</span> Calcified whitish structure in humans mouths used to break down food

Human teeth function to mechanically break down items of food by cutting and crushing them in preparation for swallowing and digesting. As such, they are considered part of the human digestive system. Humans have four types of teeth: incisors, canines, premolars, and molars, which each have a specific function. The incisors cut the food, the canines tear the food and the molars and premolars crush the food. The roots of teeth are embedded in the maxilla or the mandible and are covered by gums. Teeth are made of multiple tissues of varying density and hardness.

<span class="mw-page-title-main">Wisdom tooth</span> Large tooth at the back of the human mouth

The third molar, commonly called wisdom tooth, is the most posterior of the three molars in each quadrant of the human dentition. The age at which wisdom teeth come through (erupt) is variable, but this generally occurs between late teens and early twenties. Most adults have four wisdom teeth, one in each of the four quadrants, but it is possible to have none, fewer, or more, in which case the extras are called supernumerary teeth. Wisdom teeth may become stuck (impacted) against other teeth if there is not enough space for them to come through normally. Impacted wisdom teeth are still sometimes removed for orthodontic treatment, believing that they move the other teeth and cause crowding, though this is not held anymore as true.

<span class="mw-page-title-main">Hyperdontia</span> Condition of having extra teeth beyond the regular number of teeth

Hyperdontia is the condition of having supernumerary teeth, or teeth that appear in addition to the regular number of teeth. They can appear in any area of the dental arch and can affect any dental organ. The opposite of hyperdontia is hypodontia, where there is a congenital lack of teeth, which is a condition seen more commonly than hyperdontia. The scientific definition of hyperdontia is "any tooth or odontogenic structure that is formed from tooth germ in excess of usual number for any given region of the dental arch." The additional teeth, which may be few or many, can occur on any place in the dental arch. Their arrangement may be symmetrical or non-symmetrical.

<span class="mw-page-title-main">Toothache</span> Medical condition of the teeth

Toothache, also known as dental pain or tooth pain, is pain in the teeth or their supporting structures, caused by dental diseases or pain referred to the teeth by non-dental diseases. When severe it may impact sleep, eating, and other daily activities.

<span class="mw-page-title-main">Alveolar osteitis</span> Medical condition

Alveolar osteitis, also known as dry socket, is inflammation of the alveolar bone. Classically, this occurs as a postoperative complication of tooth extraction.

Hypodontia is defined as the developmental absence of one or more teeth excluding the third molars. It is one of the most common dental anomalies, and can have a negative impact on function, and also appearance. It rarely occurs in primary teeth and the most commonly affected are the adult second premolars and the upper lateral incisors. It usually occurs as part of a syndrome that involves other abnormalities and requires multidisciplinary treatment.

<span class="mw-page-title-main">Human tooth development</span> Process by which teeth form

Tooth development or odontogenesis is the complex process by which teeth form from embryonic cells, grow, and erupt into the mouth. For human teeth to have a healthy oral environment, all parts of the tooth must develop during appropriate stages of fetal development. Primary (baby) teeth start to form between the sixth and eighth week of prenatal development, and permanent teeth begin to form in the twentieth week. If teeth do not start to develop at or near these times, they will not develop at all, resulting in hypodontia or anodontia.

<span class="mw-page-title-main">Malocclusion</span> Medical condition

In orthodontics, a malocclusion is a misalignment or incorrect relation between the teeth of the upper and lower dental arches when they approach each other as the jaws close. The English-language term dates from 1864; Edward Angle (1855-1930), the "father of modern orthodontics", popularised it. The word "malocclusion" derives from occlusion, and refers to the manner in which opposing teeth meet.

<span class="mw-page-title-main">Dental extraction</span> Operation to remove a tooth

A dental extraction is the removal of teeth from the dental alveolus (socket) in the alveolar bone. Extractions are performed for a wide variety of reasons, but most commonly to remove teeth which have become unrestorable through tooth decay, periodontal disease, or dental trauma, especially when they are associated with toothache. Sometimes impacted wisdom teeth cause recurrent infections of the gum (pericoronitis), and may be removed when other conservative treatments have failed. In orthodontics, if the teeth are crowded, healthy teeth may be extracted to create space so the rest of the teeth can be straightened.

<span class="mw-page-title-main">Pericoronitis</span> Inflammation of the soft tissues surrounding the crown of a partially erupted tooth

Pericoronitis is inflammation of the soft tissues surrounding the crown of a partially erupted tooth, including the gingiva (gums) and the dental follicle. The soft tissue covering a partially erupted tooth is known as an operculum, an area which can be difficult to access with normal oral hygiene methods. The hyponym operculitis technically refers to inflammation of the operculum alone.

A dental emergency is an issue involving the teeth and supporting tissues that are of high importance to be treated by the relevant professional. Dental emergencies do not always involve pain, although this is a common signal that something needs to be looked at. Pain can originate from the tooth, surrounding tissues or can have the sensation of originating in the teeth but be caused by an independent source. Depending on the type of pain experienced an experienced clinician can determine the likely cause and can treat the issue as each tissue type gives different messages in a dental emergency.

<span class="mw-page-title-main">Veterinary dentistry</span> Branch of veterinary medicine

Veterinary dentistry is the field of dentistry applied to the care of animals. It is the art and science of prevention, diagnosis, and treatment of conditions, diseases, and disorders of the oral cavity, the maxillofacial region, and its associated structures as it relates to animals.

<span class="mw-page-title-main">Odontoma</span> Benign tumour of dental tissue

An odontoma, also known as an odontome, is a benign tumour linked to tooth development. Specifically, it is a dental hamartoma, meaning that it is composed of normal dental tissue that has grown in an irregular way. It includes both odontogenic hard and soft tissues. As with normal tooth development, odontomas stop growing once mature which makes them benign.

<span class="mw-page-title-main">Tooth eruption</span> Process in tooth development

Tooth eruption is a process in tooth development in which the teeth enter the mouth and become visible. It is currently believed that the periodontal ligament plays an important role in tooth eruption. The first human teeth to appear, the deciduous (primary) teeth, erupt into the mouth from around 6 months until 2 years of age, in a process known as "teething". These teeth are the only ones in the mouth until a person is about 6 years old creating the primary dentition stage. At that time, the first permanent tooth erupts and begins a time in which there is a combination of primary and permanent teeth, known as the mixed dentition stage, which lasts until the last primary tooth is lost. Then, the remaining permanent teeth erupt into the mouth during the permanent dentition stage.

A dental laser is a type of laser designed specifically for use in oral surgery or dentistry.

A gum lift is a cosmetic dental procedure that raises and sculpts the gum line. This procedure involves reshaping the tissue and/or underlying bones to create the appearance of longer or symmetrical teeth, thereby making the smile more aesthetically pleasing. This procedure is typically done to reduce excessively gummy smiles or to balance out an asymmetrical gum line. The procedure, also known as crown-lengthening, has historically been used to treat gum disease. It is only within the past three to five years that dentists have commonly used this procedure for aesthetic purposes. The practice of cosmetic gum lifts was first developed in the late 1980s, but there were few oral surgeons and dental practitioners available to perform the procedures. Gum lifts can also include bone shaping to reduce the prominence of the upper jaw and even out the tooth and gum ratio. This method provides permanent results, while simple gum contouring may result in relapse or regrowth of the gingiva.

<span class="mw-page-title-main">Impacted wisdom teeth</span> Teeth that do not fully grow out of the gums due to being blocked by other teeth

Impacted wisdom teeth is a condition where the third molars are prevented from erupting into the mouth. This can be caused by a physical barrier, such as other teeth, or when the tooth is angled away from a vertical position. Completely unerupted wisdom teeth usually result in no symptoms, although they can sometimes develop cysts or neoplasms. Partially erupted wisdom teeth or wisdom teeth that are not erupted but are exposed to oral bacteria through deep periodontal pocket, can develop cavities or pericoronitis. Removal of impacted wisdom teeth is advised for the future prevention of or in the current presence of certain pathologies, such as caries, periodontal disease or cysts. Prophylactic (preventative) extraction of wisdom teeth is preferred to be done at a younger age to take advantage of incomplete root development, which is associated with an easier surgical procedure and less probability of complications.

Tooth ankylosis refers to a fusion between a tooth and underlying bony support tissues. In some species, this is a normal process that occurs during the formation or maintenance of the dentition. By contrast, in humans tooth ankylosis is pathological, whereby a fusion between alveolar bone and the cementum of a tooth occurs.

Laser gingivectomy is a dental procedure that recontours or scalpels the gingival tissue to improve long term dental health or aesthetics. Compared to conventional scalpel surgery, soft-tissue dental lasers, such as Laser diode, Nd:YAG laser, Er:YAG laser, Er,Cr:YSGG laser, and CO2 lasers, can perform this procedure, offering a precise, stable, bloodless, often less painful, and accelerated healing experience. However, the Laser diode gained more popularity due to its versatility, less interaction with hard tissue, ease of use, and the less expensive set up.

Tooth transplantation is mainly divided into two types:

References

  1. Miloro M, Ghali GE, Larsen P, Waite P (2004). Peterson's Principles of Oral and Maxillofacial Surgery. Vol. 1. B C Decker. ISBN   9781550092349 . Retrieved 2015-08-22.
  2. "Impacted teeth including surgery for canine teeth". Cambridge University Hospitals. Cambridge, UK. Retrieved 2015-08-22.
  3. "Wisdom tooth removal". The National Health Service .
  4. Friedman JW (September 2007). "The prophylactic extraction of third molars: a public health hazard". American Journal of Public Health. 97 (9): 1554–1559. doi:10.2105/AJPH.2006.100271. PMC   1963310 . PMID   17666691.
  5. Ghaeminia H, Nienhuijs ME, Toedtling V, Perry J, Tummers M, Hoppenreijs TJ, et al. (May 2020). "Surgical removal versus retention for the management of asymptomatic disease-free impacted wisdom teeth". The Cochrane Database of Systematic Reviews. 5 (5): CD003879. doi:10.1002/14651858.CD003879.pub5. PMC   7199383 . PMID   32368796.
  6. Anjrini AA, Kruger E, Tennant M (July 2015). "Cost effectiveness modelling of a 'watchful monitoring strategy' for impacted third molars vs prophylactic removal under GA: an Australian perspective". British Dental Journal. 219 (1): 19–23. doi:10.1038/sj.bdj.2015.529. PMID   26159980. S2CID   7178870.
  7. Kandasamy S (July 2011). "Evaluation and management of asymptomatic third molars: Watchful monitoring is a low-risk alternative to extraction". American Journal of Orthodontics and Dentofacial Orthopedics. 140 (1): 11–17. doi:10.1016/j.ajodo.2011.05.008. PMID   21724081.
  8. Mithridade D, Serge SM, Keyvan D, Nedjoua CO, Georgy D, Philippe R (January 2015). "Unconventional Implant Placement IV. Implant Placement through Impacted Teeth to Avoid Invasive Surgery. Long-term Results of 3 Cases". The Open Dentistry Journal. 9: 15–20. doi: 10.2174/1874210601509010015 . PMC   4319210 . PMID   25674167.
  9. Unwerawattana W (September 2006). "Common symptoms and type of impacted molar tooth in King Chulalongkorn Memorial Hospital". Journal of the Medical Association of Thailand = Chotmaihet Thangphaet. 89 Suppl 3: S134–9. PMID   17718279.
  10. Fragiskos FD (2007). Oral Surgery. Springer. p. 126. ISBN   9783540499756 . Retrieved 2015-08-22.
  11. Parkin N, Benson PE, Thind B, Shah A, Khalil I, Ghafoor S (August 2017). "Open versus closed surgical exposure of canine teeth that are displaced in the roof of the mouth". The Cochrane Database of Systematic Reviews. 8 (8): CD006966. doi:10.1002/14651858.CD006966.pub3. PMC   6483459 . PMID   28828758.
  12. Borzabadi-Farahani A, Cronshaw M (2017). "Lasers in Orthodontics". In Coluzzi D, Parker S (eds.). Lasers in Dentistry—Current Concepts. Textbooks in Contemporary Dentistry. Springer, Cham. pp. 247–271. doi:10.1007/978-3-319-51944-9_12. ISBN   978-3-319-51943-2.
  13. Borzabadi-Farahani A (April 2017). "The Adjunctive Soft-Tissue Diode Laser in Orthodontics". Compendium of Continuing Education in Dentistry. 38 (eBook 5): e18–e31. PMID   28509563.
  14. Borchers A, Pieler T (November 2010). "Programming pluripotent precursor cells derived from Xenopus embryos to generate specific tissues and organs". Genes. 1 (3): 413–426. doi: 10.3390/photonics9040265 . PMID   24710095.

See also