Tooth impaction

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Jaspinder Kaur, MBBS[2]

Synonyms and keywords:

Overview

Impacted and embedded teeth are the two main types of unerupted teeth found in the mouth, and can sometimes be confused with each other. In both cases, the teeth remain below the surface of the gum, rather than erupting into an exposed position within the mouth, but the reason for the failure to erupt differs. Impacted teeth result from a situation in which an unerupted tooth is wedged against another tooth or teeth or otherwise located so that it cannot erupt normally. In contrast, an embedded tooth is an unerupted tooth that is covered, usually completely, with bone. That is to say, something that is physically blocking the pathway of eruption (such as another tooth) is the case for an impacted tooth, whereas the lack of eruptive force results in an embedded tooth.

Mandibular third molars are the most commonly found unerupted teeth, while maxillary third molars are second most common.

Classification

• Tooth impaction is classified based on various factors which are elaborated in following tables:

Table 1: Winter’s and Pell & Gregory’s criteria

Classification	Clinical description	Type
Pell and Gregory classification	Impaction depth: the relation of the cementoenamel junction (CEJ) of the third molar with the bone level is graded	Level A: The occlusal plane of the impacted tooth is the same level as the occlusal plane of the 2nd molar Level B: The occlusal plane of the impacted tooth is between the occlusal plane and the cervical line of the 2nd molar. Level C:The impacted tooth is below the cervical line of the 2nd molar.
Pell and Gregory classification	Ramus relationship: the position of the distal surface of the third molar crown in relation to the anterior border of the ascending ramus is categorized	Class I: There is sufficient space between the ramus and the distal part of the 2nd molar for the accommodation of the mesiodistal diameter of the 3th molar. Class II: The space between the 2nd molar and the ramus of the mandible is less than the mesiodistal diameter of the 3th molar. Class III: All or most of the 3th molar is in the ramus of the mandible.
Winter’s classification	Impaction angulation: the angle between the longitudinal axis of the second and third molars (which was measured by an orthodontic protractor) is categorized	Vertical: Long axis of the 3th molar parallel to the 2nd molar. Horizontal: Long axis of the 3th molar perpendicular to the 2nd molar. Mesioangular: Long axis of the 3th molar inclined in mesial direction to 2nd molar. Distoangular: Long axis of the 3th molar inclined in distal direction to 2nd molar. Inverted: Crown of the 3th molar directed to basilar of the mandible.
Nature of overlying tissue	This system is used by most dental insurance companies and one by which surgeon charges for his services.	Soft tissue impaction Partial bony impaction Fully bony impaction

Differentiating Tooth Impaction from other Diseases

Table 2: Enlist the differential diagnosis for tooth impaction

System involved	Characteristic features
Cleidocranial dysostosis	Short tapered fingers and broad thumbs; flat feet; knock knees; short shoulder blades (scapulae); scoliosis; short skull (brachycephaly); a prominent forehead; wide-set eyes (hypertelorism); a flat nose; small upper jaw; impacted and crowded teeth.
Gardners syndrome	Multiple impacted and supernumerary teeth, multiple jaw osteomas, multiple odontomas, congenital hypertrophy of the retinal pigment epithelium (CHRPE), and multiple adenomatous colonic polyps.
Gorlin–Sedano syndrome	Short hands, short foot bones, short and straight collar bone, and multiple impacted teeth.
Yunis–Varon Syndrome	Agenesis or hypoplasia of clavicle, severe micrognathia, digital anomalies, hypodontia, spinal defects, and impacted teeth.

Diagnosis

Staging | History & Symptoms | Physical Examination | Laboratory Tests | Chest X Ray | CT | MRI | Echocardiography or Ultrasound | Other Imaging Findings | Other Diagnostic Studies

Treatment

Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies