I. of swelling on the lower left back

I.                  IntroductionImpactionof teeth is a diagnosis made when the tooth has failed to fully erupt into oralcavity within its expected development time period and can no longer reasonablybe expected to do so. Impaction can lead to various clinical complications likemalocclusion, loss of arch length, migration or loss of neighboring teeth,periodontal disease, resorption (internal or external) of the teeth, cysticchanges around the impacted teeth like dentigerous cyst and tumors.1Permanent teeth are more commonly impacted compared to deciduous teeth. Theincidence of impacted permanent teeth has been said to have increasingfrequency in reverse of eruption order.

Most commonly impacted teeth aremaxillary and mandibular third molars, followed by maxillary canines,mandibular premolars, maxillary premolars, and second molars.2Impaction of first and second molars is reported as very uncommon, withreported prevalence of less than 0.01% and 0.06 to 0.

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3% respectively.3Here we report a case of impacted permanent first molar, which is an extremelyrare and sparingly reported in the literature. II.

               CaseReport      A 36-year-old otherwise healthy malepatient reported to us with the complaint of swelling on the lower left backregion of the jaw, which started 3 months ago. Swelling was associated withintermittent dull aching pain radiating to his left TMJ region and wasassociated with recurrent pus discharge. His medical, family and habit history wasunremarkable. A thorough intraoral examination revealed, buccal cortical expansionwith respect to 35 to 37 region, which was non tender, hard in consistency withno evidence of any decayed tooth in that region. Permanent left mandibularfirst molar was clinically missing with no space existing between secondpremolar and second molar. Patient reported no history of extraction in thatregion. Hence a provisional diagnosis of dentigerous cyst associated withimpacted 36 was considered and patient was subjected to radiographicinvestigation. Panoramic radiograph showed that 36 was horizontally impacted,in the body of the mandible apical to the mesial root of 37, the inferioralveolar nerve canal is pushed inferiorly from its original course, very closeto inferior border of mandible.

The crown of impacted tooth appeared to havecarious demineralization involving the enamel and dentin and was associatedwith a flame shaped pericoronal radiolucency approximately measuring 5mm x 5mm,indicating the probability of cystic changes.  Hence correlating the clinical andradiological 3D imaging – CBCT was advised for the patient followed by surgicalintervention. However, patient denied for both due to financial constraints andwas lost to follow up. III.            DiscussionImpaction of teeth can becaused by systemic or local factors. Systemic factors such as heredity,post-natal causes such as rickets, anemia, malnutrition, tuberculosis andcongenital syphilis, endocrinal disorders such as hypothyroidism andhypoparathyroidism and other conditions such as cleidocranial dysostosis havebeen implicated in causing teeth impaction. Various local factors such asobstruction of eruption path by cyst, tumors, or supernumerary teeth,infection, lack of space, over retained/ankylosis/premature loss/lack ofresorption of or injuries to deciduous teeth, or mucosal barriers like scartissue left behind by trauma/surgery have also been associated with theimpaction of teeth.4 It is said that first molar impaction is often due to ectopiceruption, which is very likely in this case; whereas impaction of second molarsis usually associated with arch-length deficiency.

5 An impacted tooth, whenleft untreated, may lead to pain due to infection in the affected area. P.Mercier and D. Precious stated that deliberately retaining an impacted thirdmolar poses a threat of developing crowding of dentition, resorption ofadjacent tooth, periodontal problem of the teeth, or development ofpathological condition such as infection, cyst or tumor.6 In ourcase, the follicular space around the impacted first molar was seen to beenlarged, which very likely cystic change taking place.Treatment optionssuggested for an impacted molar include observation, extraction of theobstacle, surgical exposure, luxation and extraction of the tooth.7Appropriate treatment plan is proposed depending on the cause of impaction.When an obstacle blocking the path of eruption of the tooth is the cause forimpaction, the barrier can simply be removed to allow spontaneous eruption ofthe tooth.

Surgical exposure and luxation of the tooth is favorable when enoughspace is available for the impacted tooth in the oral cavity, which sometimescan be achieved with the help of orthodontics. Important factors whichaffect the prognosis and outcome of the treatment include position andangulation of the impacted tooth, length of treatment time, space availabilityand the presence of keratinized gingiva. Other than that, patient’s medicalhistory, dental status, oral hygiene, functional and occlusal relationship,attitude towards orthodontic treatment, compliance with treatment and cost oftreatment also affect treatment options.8 In this case, thepatient was advised for surgical removal of the impacted first permanent molardue to its unfavorable position and angulation of impaction, which ishorizontally impacted apical to the adjacent second molar. It was apparent thatinfection had taken place in and around the tooth judging by the radiographicappearance and the history given by patient.

There was no space for the toothin the oral cavity, and patient did not have problem in his currentocclusion.  Surgicalintervention of the impacted tooth is not without any risk. The complicationthat patient may undergo may be minor and transient, such as sensory nervealteration, alveolitis, trismus and infection, hemorrhage, dentoalveolarfracture and displacement of tooth.

There could also be some permanent changessuch as periodontal injury, injury to adjacent tooth or the temporomandibularjoint. More severe complication may include altered sensation, vital organinfection, fracture of the mandible and maxillary tuberosity, injury andlitigation.6 Due to the close proximity of the impacted tooth toinferior alveolar nerve in this case, the patient might suffer injury to thenerve and experience some neurosensory disturbances.