Oral and Maxillofacial Surgery CASE REPORT

Abstract

Impaction of permanent teeth is a common phenomenon, but the impaction of a few permanent teeth such as the mandibular first molars is an atypical condition and very few cases have been reported in the literature. The extraction of impacted mandibular first molar requires delicate technique as well as careful management to minimize the risks of injury to the adjacent teeth, neurovascular bundle and mandibular fracture. This case presents an unusual case of an impacted mandibular first molar in a male patient aged 28 years.

Full text

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Clinical Dentistry, Mumbai • December 2017
Abstract
Impaction of permanent teeth is a common phenomenon,
but the impaction of a few permanent teeth such as the
mandibular first molars is an atypical condition and very few
cases have been reported in the literature. The extraction of
impacted mandibular first molar requires delicate technique
as well as careful management to minimize the risks of injury
to the adjacent teeth, neurovascular bundle and mandibular
fracture. This case presents an unusual case of an impacted
mandibular first molar in a male patient aged 28 years.
|| Key Words
Impacted teeth, Mandibular First Molar, Oral Surgery.
Impacted mandibular
rst molar:
A Rarity Decoded
Correspondence Address
Dept. of Oral and Maxillofacial Surgery
Mahatma Gandhi Postgraduate Institute
of Dental Sciences, Pondicherry.
Oral and
Maxillofacial Surgery
CASE REPORT
Vivek Sunil Nair
Junior Resident, II MDS
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Clinical Dentistry, Mumbai • December 2017
|| Introduction
A tooth which is completely or partially unerupted
and is positioned against another tooth, bone, or soft
tissue so that its further eruption is unlikely, described
according to its anatomic position, is known as an
impacted tooth [1]. Partially impacted tooth is the one
which is not completely encased in bone and has
communication in the oral cavity through periodontal
pocket. It might lead to caries also. On the other
hand, completely impacted tooth is the one which is
completely encased in the bone and does not have
any communication with the oral cavity.
Usually, permanent dentition is affected and deciduous
teeth impaction is extremely rare, but when occurs,
it is seen mostly in second molars [2]. The impaction
of permanent teeth usually occurs in the descending
order of third molars, followed by maxillary cuspids,
mandibular premolars, mandibular canine, maxillary
premolars, maxillary central incisors and mandibular
second molars. First mandibular molars and maxillary
second molars are rarely impacted [3].
Treatment options for these impacted molars include
extraction, surgical uprighting, transplantation,
surgical-orthodontic approach, and dental implant
replacement.[4,5,6] While choosing the treatment plan
for impacted molars, one should be very cautious as a
result of the uncertain aetiology, the lack of standard
therapy, and the paucity of cases reported.
This case report presents the management of an
impacted mandibular rst molar by transalveolar
surgery.
|| Case Report
A 28-year old male patient reported to the Department
of Oral and Maxillofacial Surgery at Mahatma Gandhi
Postgraduate Institute of Dental Sciences, Puducherry,
complaining of pain in the lower right back region
of the jaw since 3 months. The pain existed at rest
and aggravated on chewing. The region was tender
on palpation. Clinical examination revealed a partially
impacted lingually tipped right mandibular rst molar
(Fig. I). The second molar was mesially tipped and the
second premolar distally tipped occupying the space
of the rst molar. On radiographic examination in an
Orthopantomogram, it was found that rst molar was
impacted near the inferior border of the mandible
(Fig. II). All of the permanent teeth had erupted except
Fig.1: Intra Oral Pre-Operative View
Fig.2: OPG revealing the impacted lower right rst molar
Fig.3: Extracted fragments of the impacted tooth
for the right mandibular rst molar. The patient gave
history of getting the fully erupted left mandibular
rst molar extracted 2 years back as it was grossly
decayed. Review of the patient’s medical and family
history revealed no signicant ndings. Treatment
planned in this case was trans-alveolar extraction
of the right mandibular rst molar with buccal
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Clinical Dentistry, Mumbai • December 2017
Fig.4: Intra Oral Post-Operative View
approach. Routine blood investigations were carried
out prior to the surgical procedure which was within
the normal limits. The surgery was performed under
local anaesthesia after obtaining a written informed
consent. A crevicular incision extending from the
right lower second molar to the right lower second
premolar with vertical releasing incisions on either
side was made for exposure of the tooth site. With a
surgical bur the bone along the buccal aspect of the
impacted tooth was removed along with copious ow
of normal saline.
Sectioning of the tooth was done to avoid pressure
on adjacent teeth and neurovascular bundle, thereby
facilitating careful removal of the tooth in four
segments (Fig. III). The surgical eld was irrigated with
normal saline to remove any bony spicules and debris.
The haemorrhage was arrested with pressure pack.
Suturing was done with mersilk 3.0 suture (Fig. IV). The
patient was asked to maintain good oral hygiene and
a chlorhexidine mouth rinse was prescribed for plaque
control. Follow up was made after 8 days for suture
removal. The patient was advised to get a xed partial
denture done using the adjacent teeth as abutments.
On six month follow up appointment, there was
good healing of wound without paresthesia of the
concerned side and any other untoward complications.
On OPG a good healing with healthy bone was noted.
A written informed consent was obtained for the case
report and disclosure of photographs, radiographs for
scientic purposes
|| Discussion
First molar impactions are still rare when compared
with other impactions and very few cases have
been reported in the literature. Overall incidence of
impacted mandibular molars is 18% [7]. However,
according to the study by Grover and Norton, the
incidence of impaction of rst molar and second
molar was 0% and 0.06%, respectively [8]. According
to the literature, the maxillary canine tooth was the
most frequent non-third molar impaction identied,
followed by premolars and second molars. [9,10]
Dachi and Howell in 1961 found the incidence of
impacted canine in maxilla as 0.92% and of other
nonthird molar impaction to be 0.38% [7]. Moreover,
rst permanent molar impaction is rare, with
prevalence rates of 0.02% for the maxillary rst molar
and of less than 0.01% for the mandibular rst molar
[8,11]. Thilander & Myrberg in 1973 found a 5.4%
prevalence of the impacted teeth excluding third
molars. [12]
While reviewing the literature, it was found that
the impaction of rst permanent molars was due to
ectopic eruption, which may cause resorption of distal
root of deciduous second molars or even premature
exfoliation of the same, whereas the impaction of
second molars is usually associated with arch-length
deciency. The aetiology for impaction is both systemic
and local. Systemic factors, such as cleidocranial
dysplasia, endocrine deciency (hypothyroidism and
hypopituitarism), febrile disease, Down Syndrome
and irradiation, other systemic factors may inuence
impaction of permanent teeth . In all these conditions
generally multiple teeth are involved.
The local factors which more commonly contribute to
permanent tooth impaction are prolonged retention
of deciduous tooth, premature loss of primary
molars, ankylosis of primary molars, arch length
deciency, supernumerary tooth, malposed tooth
germ, dentigerous cyst, odontogenic tumors (such
as ameloblastic broma, odontogenic broma and
odontoma), abnormal path of eruption, mucosal
barrier due to gingival brosis, trauma and cleft lip and
palate [13,14,15,16,17]. Normally, the gubernacular canals
are said to guide erupting permanent teeth into their
correct positions [18]. Heredity is also mentioned as an
aetiologic factor. Recently mutations in parathyroid
hormone receptor 1 has been identied in several
familial cases of primary failure of eruption [19,20]. In the
case presented herewith, the cause of the impacted
permanent right mandibular rst molar might have
been inuenced by local factors, such as malposed
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Clinical Dentistry, Mumbai • December 2017
tooth germs. Kokich in 1993 described the surgical
and orthodontic management of impacted tooth and
identied the position and angulation of the impacted
tooth, length of treatment time, space availability and
the presence of keratinized gingiva as critical factors
that will affect the prognosis and treatment outcome.
[21] In this case we did not go for orthodontic traction
because it was impacted for almost 20 years. Also,
the time needed for orthodontic traction and patient
compliance made surgical extraction the most suitable
option.
|| Conclusion
While choosing any treatment option for impacted
tooth, the patient’s medical history, dental status, oral
hygiene, functional and occlusal relationship, attitude
towards orthodontic treatment and compliance with
the treatment must be considered. At the same time,
leaving such cases untreated always has a constant
threat of development of dentigerous cyst, pre-
eruptive caries, periodontal problems or infection from
the impacted tooth.
It is essential to diagnose and treat eruption
disturbances as early as possible, ideally during the
early mixed-dentition period because treatment at
a later stage is usually more complicated. Therefore,
an impacted permanent molar should be treated as
and when it is diagnosed. Surgical removal of the
impacted permanent rst molar is indicated where
there is no hope for its eruption and when it causes
pathological root resorption of the adjacent tooth.
Most importantly, clinicians must inform the patient of
the potential risks and possible benets of treatment
alternatives before making the nal decision, which
should be evaluated on an individual case basis.
Co-authors
N. J. Eswari
Professor
K. Sankar
Professor and Head
Latha Ashokan
Professor
M. R. R amesh Babu
Professor
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Clinical Dentistry, Mumbai • December 2017
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