Download surgical removal of trans-alveolar mandibular 2nd premolar

Removal of impacted lower 2nd premolar
CASE REPORT
SURGICAL REMOVAL OF TRANS-ALVEOLAR MANDIBULAR
2ND PREMOLAR IMPACTIONS BY LINGUAL APPROACH
ASIF NAZIR, BDS, FCPS
2
SAMERA ASIF, BDS
3
MUHAMMAD ADNAN AKRAM, BDS
1
ABSTRACT
There is an abundance of literature on impacted teeth but only a few papers have addressed
impacted premolars. A case of a young female with bilaterally impacted mandibular 2nd premolars in
trans-alveolar position with their crowns facing lingually and roots buccally is reported. The patient
was under orthodontic treatment for correction of malocclusion with an orthodontic plan for surgical
removal of impacted mandibular 2nd premolars. Due to lingual position of crowns of these impacted
teeth, it was decided to adopt lingual surgical approach rather than conventional buccal approach for
their removal. The surgical approach with discussion on the various management options for
management of impacted premolars is described here.
Key Words: Impacted mandibular premolar, trans-alveolar impaction, lingual approach.
INTRODUCTION
Impacted teeth are those which fail to erupt in
dental arch within expected time.1 Different local causes
of impacted teeth include lack of space in the jaw,
premature loss of primary teeth, abnormal positioning
of tooth bud, inflammatory or pathological lesion etc.2
Mandibular second premolars rank third after
permanent 3rd molars and maxillary canines, in frequency of impacted teeth.3 Overall prevalence of impacted premolars is 0.5% and that of mandibular
premolars is 0.2 to 0.3%. Mandibular second premolars
alone account for 24% of all dental impactions excluding molars.4,5 Premolar impactions may be due to local
factors e.g. mesial drift of teeth by premature loss of
primary molars, ectopic positioning of premolar buds;
or pathology e.g. dentigerous cyst.2,6,9 Various treatment methods have been suggested including observation, interceptive orthodontics, surgical exposure with
2
3
For correspondence: 1Dr. Asif Nazir, Assistant Professor, Oral
& Maxillofacial Surgery de,Montmorency College of Dentistry,
Lahore. Res: 309 Shaheen Block, Sector B, Bahria Town, Lahore.
Cell: 0333-4397017. E-mail: [email protected]
Postgraduate Resident (orthodontics)
Postgraduate Resident (oral surgery)
Received for Publication:
Revision Received:
Revision Accepted:
February 5, 2013
March 12, 2013
March 14, 2013
Pakistan Oral & Dental Journal Vol 33, No. 1 (April 2013)
orthodontic intervention, auto-transplantation and extraction depending on position of impacted tooth, relationship with adjacent teeth and need for orthodontic
treatment.1,3,4,5
CASE REPORT
A 22 years old female was referred to oral and
maxillofacial surgery department from orthodontic
department of Punjab Dental Hospital with query for
surgical consultation of impacted teeth. On clinical
evaluation, there were missing bilateral mandibular
2nd premolar teeth (Fig 1a). There was also crowding in
mandibular arch. On radiological evaluation (Periapical, lower occlusal and OPG) both of these teeth
were found to be impacted in trans-alveolar position
with their crowns facing lingually and roots buccally
(Fig 1b,c,d). Due to abnormal positioning of these
premolars, it was not possible to bring these teeth in
the arch with conventional orthodontic traction with
or without surgical intervention. The auto-transplantation of these teeth was also not possible due to their
peculiar position and lack of space in the arch. So, it
was decided to extract these premolars. Due to lingual
position of crowns of these teeth, it was decided to
adopt lingual surgical approach for their removal
rather than conventional buccal approach.
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Removal of impacted lower 2nd premolar
After achieving proper local anaesthesia, incision
was made with Bard Parker blade # 15 in the gingival
crevice on lingual aspect of right mandibular premolar
teeth. A full thickness mucoperiosteal flap was raised
with Molt periosteal elevator. The flap and tongue
were retracted with Lacs tongue depressor. The bone
bulge on lingual cortex due to crown of impacted tooth
was identified and decortication of lingual cortex was
carried out with surgical hand piece & round bur
under coolant irrigation. The crown of impacted tooth
was visualized and drilling was performed around the
crown for creation of a gutter (Fig 1e,f). Then the crown
was sectioned and some of its portion was removed.
The rest of the tooth was also chased by bone drilling
and was retrieved with a Cryer elevator by making a
purchase point. The wound was irrigated with normal
saline and flap was repositioned. The suturing was
performed with 3/0 black silk sutures which were
removed after seven days. Post-surgical healing was
good without any significant complications.
After a time period of two weeks, the other sided
(i.e. left) 2nd pre-molar was also extracted with the
same technique and without any significant complications (Fig 1g,h).
DISCUSSION
Treatment options for impacted teeth include observation, surgical exposure with or without orthodontic intervention, auto-transplantation, and extraction.3,4 In selecting an appropriate treatment option,
underlying etiological factors, space requirements,
need for extractions of primary molars, degree of
impaction and root formation of the impacted premolar should be considered. Factors such as patient’s age,
medical and dental status, oral hygiene, functional
and occlusal relationship and attitude towards and
compliance with treatment will also influence choice of
treatment options.5
In this particular case, age of patient, degree of
impaction, trans-alveolar position of impacted teeth,
complete root formation and interference with orthodontic alignment of adjacent teeth made monitoring
a bad choice of treatment. Moreover, leaving these
Pakistan Oral & Dental Journal Vol 33, No. 1 (April 2013)
Figure 1.
(a & b): Intra-oral view showing the absence of mandibular 2nd pre-molars in the arch & mandibular occlusal view showing bilateral transalveolar 2nd pre-molar impactions.
(c & d): Pre-operative peri-apical radiographs showing mandibular 2nd pre-molar impactions (R
& L).
(e & f):
Intra-operative view of impacted 2nd pre-molars (R & L).
(g & h): Post-operative peri-apical x-rays after removal of 2nd pre-molars (R & L).
teeth in situ may lead to root resorption of adjacent
teeth and cyst or tumor formation in the jaw.7 The
position of the transversely impacted second premolars
was so unfavorable that no orthodontic intervention
was planned and hence extraction was done. Andreasen
suggests that surgical exposure with or without orth36
Removal of impacted lower 2nd premolar
odontic intervention should be confined to cases with
no more than 45æ% tilting and limited deviation from
the normal position.4,8 Hence, this case definitely required removal of the impacted teeth. As the crown
was on lingual aspect and root on buccal side, through
lingual approach, crown sectioning and retrieval of
root was the logical choice. The buccal approach may
jeopardize the mental nerve emerging from mental
foramen and the apices of the adjacent teeth. But
lingual approach comes with the inherent risk of
damage to sublingual gland and infection in sublingual space. Careful tissue handling and irrigation of
the surgical area can prevent many complications.
Correct knowledge of regional anatomy and application of mechanical principles of tooth extraction allow
surgical success. This peculiar and rare case will
contribute towards the minimal literature available
regarding impacted second premolar teeth and offers
lingual approach as an alternative in such situations.
The unusual (trans-alveolar) orientation of the crown
and root of impacted 2nd premolars makes this case
report unique and interesting.
Pakistan Oral & Dental Journal Vol 33, No. 1 (April 2013)
REFERENCES
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Hupp JR, Ellis III E, Tucker MR. Contemporary Oral and
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Kalia V, Aneja M. Mandibular Premolar Impaction. Schol Res
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