Hard Tissue Surgical Treatment with Embedded Dental Condition of

Tuberosity Maxillary

Bambang Tri Hartomo

, and Rizka Rachmatika Dewi

Dental Medicine Study Program, Faculty of Medicine, Jenderal Soedirman University, Purwokerto, Indonesia

Student of Dental Medicine Study Program, Faculty of Medicine, Jenderal Soedirman University, Purwokerto, Indonesia

Keywords: Hard tissue surgical, embedded, tuberosity maxillary.

Abstract: An embedded tooth is a tooth condition that cannot erupt due to obstruction by bone. The state of a hidden

tooth located near the nerve will cause pain due to persistent pressure on the nerve. The extraction of the

hidden tooth is performed by surgery, namely odontectomy. This case report aimed to know the hard tissue

surgical treatment performed in an embedded tooth in maxillary tuberosity. The case report is about a 23 years

old woman with frequent headaches since five years ago and pain in the left temple area and the left maxillary

region. The results of the palpation examination on the left temporal site are tender. The supporting

examination results in panoramic radiological radiographs were obtained from tooth 27, which had a

horizontal class IIIC impacted with the crown distally. The removal of the embedded tooth was performed by

odontectomy procedure and administration of medication antibiotics and analgesics.

1 INTRODUCTION

The Indonesian citizen's level of awareness regarding

oral and dental health is still deficient, so it is often

found that patients come for treatment when they are

already experiencing unbearable pain. Patients who

come for treatment when they already experience

unbearable pain dramatically affect the treatment plan

carried out by the dentist. Conditions for tooth decay,

such as teeth with extensive caries and leaving

minimal tooth structure, require several treatment

types to get maximum results (Taufiqurrachman and

Mulyo, 2016).

Hard tissue surgery is a branch of oral surgery in

dentistry that studies things related to hard tissue

surgery in the oral cavity. Some of the oral surgery

treatments are tooth extraction, and odontectomy in

an impacted an embedded tooth. The bone reduction

to assist in the extraction of teeth with difficult

conditions and alveolectomy in exostotic conditions.

Tooth extraction can be performed using two

methods: the intra alveolar extraction technique and

the trans alveolar extraction technique or surgery. The

trans alveolar extraction technique is used to extract a

tooth with difficult conditions, such as teeth with root

https://orcid.org/0000-0002-9791-1200

https://orcid.org/0000-0003-4583-2145

deformities, namely dilation and fusion,

hypersementosis, ankylosis, and the tooth that enter

the maxillary sinus. Extraction of a tooth with

difficult conditions is an extraction that requires

opening the soft tissue flap, removing bone or cutting

the tooth (Lande et al., 2015).

Hard tissue surgery is a surgical procedure in the

field of oral surgery to eliminate the infection in the

tooth and hard tissue in the patient's oral cavity.

Several kinds of conditions in the tooth and oral

cavity that require hard tissue surgery include the

state of the impacted tooth, buried root tooth and

exostosis. Impaction is a tooth condition that cannot

erupt in the jaw arch at the time of eruption (Arisetiadi

et al., 2017).

The embedded tooth is tooth conditions that

cannot erupt due to obstruction by bone. Extraction is

performed when embedded tooth causes various

symptoms that can interfere with the patient's

activities, such as disrupting the chewing function

and causing complications. Complications include

pathological resorption of the adjacent tooth, the

formation of follicular cysts, pericoronitis and

neuralgic pain (Saleh et al., 2015). The condition of

the embedded tooth located near the nerve will cause

pain due to persistent pressure on the nerve (Hupp et

278

Hartomo, B. and Dewi, R.

Hard Tissue Surgical Treatment with Embedded Dental Condition of Tuberosity Maxillary.

DOI: 10.5220/0010491402780283

In Proceedings of the 1st Jenderal Soedirman International Medical Conference in conjunction with the 5th Annual Scientiﬁc Meeting (Temilnas) Consortium of Biomedical Science Indonesia

(JIMC 2020), pages 278-283

ISBN: 978-989-758-499-2

al., 2019). Embedded conditions can cause

complaints such as pain so that the patient feels

uncomfortable and disturbed. The pain results from

persistent pressure on the nerves around the

embedded tooth. Pain that occurs as a result of dental

problems is included in myofascial pain. Myofascial

pain is a condition of muscle pain or facial pain, acute

and chronic and interferes with sensory and motor

functions (Bahrudin, 2017). The tooth that is often

impacted or embedded in the posterior tooth,

including mandibular third molars, maxillary third

molars, mandibular premolars, and maxillary

premolars. Anterior tooth such as canines and incisors

can also be impacted on either the maxilla or the

mandible. The maxillary second molar's Impaction is

relatively rare, with a prevalence rate of 0.08%

(Zakaria, 2015).

The angulation positions of the impacted teeth of

the maxillary and mandibular third molars had the

opposite degree of difficulty. The most difficult to

remove for the maxillary third molar was

mesioangular angulation (directly opposite to the

impacted mandibular third molar) versus vertical or

distoangular angulation. The mesioangular impact is

the most challenging difficulty to remove because the

bone lining or covering the impacted tooth requires

removal or expansion in the tooth's posterior aspect.

Access to the teeth in the mesioangular position is

complicated to reach if the maxillary second molar's

eruption is in place.1 The angulation of impacted

teeth of the maxillary and mandibular third molars

have the opposite degree of difficulty. The most

difficult to remove for the maxillary third molar was

mesioangular angulation (directly opposite to the

impacted mandibular third molar) versus vertical or

distoangular angulation. The mesioangular impact is

the most challenging difficulty to remove because the

bone lining or covering the impacted tooth requires

removal or expansion in the tooth's posterior aspect.

Access to the teeth in the mesioangular position is

complicated to reach if the maxillary second molar's

eruption is in place (Tammama, 2018).

The extraction of the embedded tooth is

performed by surgery. Extraction with a surgical

technique is called omentectomy (Fitri et al., 2016).

Odontectomy is a treatment performed to remove a

tooth that can erupt, partially erupt and non-erupted

tooth (Fakhrurrazi et al., 2015). Odontectomy is a

surgical extraction procedure that requires creating a

mucoperiosteal flap and removing the bone blocking

the tooth. This action requires good preparation and

accuracy in planning. It is done not to cause unwanted

complications, such as oedema, trismus and

paresthesia (Roi et al., 2019). The aim of this case

report is knowing the hard tissue surgical treatment

performed in the condition of embedded tooth in

maxillary tuberosity.

2 CASE

A 23 years old female patient came with complaints

of frequent headaches since five years ago. Patients

often feel pain in the left temple area as well as the

left maxilla area. The patient has a habit of chewing

using both sides of the jaw. The extraoral examination

results, when the palpation examination was carried

out in the left temporal area, there was mild

tenderness. A temporomandibular joint investigation

found no abnormalities and pain. The intraoral study

results were no teeth 18, 17, 27, 28, and 38.

Examination of palpation in the left maxillary

tuberosity felt a slight bulge in the distal part.

Analysis of the vestibule of tooth 27 showed mild

tenderness. It was found that both maxillary second

molars had horizontal class IIIC impactions with the

crown distally and there were no images of the right

and left third molars in the upper jaw and the lower

left third molar.

Figure 1. Panoramic radiograph

The diagnosis in the case was embedded tooth 37.

The treatment plan, in this case, was odontectomy.

The odontectomy procedure begins with

performing asepsis of the work area using povidone-

iodine. The buccal anaesthesia in the space of tooth

was performed. An anaesthetize posterior superior

alveolar nerve and tooth 27 to anaesthetize palatinus

major nerve was conducted in the palatal region.

Anaesthesia checks are carried out using an excavator

or tweezers by comparing the area under anaesthesia

with the area that was not anaesthetized. The next step

was to make an incision to create the mucoperiosteum

flap and the left maxillary second molar. The flap is

opened using a raspatorium, and then the alveolar

processus is taken from the buccal part that covers the

tooth with a bone bur. The visible tooth was removed

Hard Tissue Surgical Treatment with Embedded Dental Condition of Tuberosity Maxillary

279

using beins and extraction forceps. The socket where

it was removed is debrided by taking the granulation

tissue and smoothing the sharp bone. The next step is

to perform irrigation using sterile saline and continues

with suturing. The patient is instructed to bite the

tampon. The patient was given postoperative

instructions and medication in the form of antibiotics

and analgesics.

Figure 2. The left maxillary second molar after

omentectomy

3 DISCUSSION

A hard tissue surgery is a branch of oral surgery that

studies things related to hard tissue surgery in the oral

cavity, such as odontectomy in the case of impacted

and embedded tooth, bone reduction to help the

extraction process of the tooth with challenging

conditions and alveolectomy in cases exostosis or

bony prominence (Haggerty and Laughlin, 2015).

The state of an impacted tooth is a condition of the

tooth which partially or cannot fully erupt due to

obstruction or obstruction by an adjacent tooth or

pathological tissue (Lande et al., 2015).

The embedded tooth is a tooth condition that

cannot wholly erupt due to obstruction by bone. The

implanted root is a condition where the remaining

root of the tooth is not treated when the tooth is

necrotic so that over time the alveolar and gingiva

will cover the remaining root of the tooth. The

embedded tooth usually occur in mandibular third

molars and maxillary third molars (Saleh et al., 2015).

The tooth cannot erupt because of the tooth's small

arch or horizontal position (Roi et al., 2019). The

tooth that is often impacted or embedded in the

posterior tooth, including mandibular third molars,

maxillary third molars, mandibular premolars and

maxillary premolars. Anterior tooth such as canines

and incisors can also impact either the maxilla or the

mandible (Zakaria, 2015).

Winter's classification divides the conditions of

impacted mandibular third molars based on the long

axis of the tooth or the position of the impacted

mandibular third molar against the mandibular

second molar, among others:

Table 1. Winter Classification

Class Description Figure

Class 1 It is called a

mesioangular impacted

tooth, or it is oblique to

the mesial direction

because the third molar is

tilting the second molar

in a mesial direction.

Figure 2. Class 1

Source: Hupp et

al. (2019)

Class 2 It is called a distoangular

or tilted distally impacted

tooth because the

condition of the third

molar's long axis is

directed distally or

posteriorly so that it is

away from the second

molar.

Figure 3. Class 2

Source: Hupp et

al. (2019)

Class 3 It is called a vertical

impacted tooth because

of the third molar points'

long axis in the same

direction as the second

molar axis.

Figure 4. Class 3

Source: Hupp et

al. (2019)

Class 4 It is called a horizontally

impacted tooth because

the third molar's long axis

is flat or horizontal to the

second molar's long axis.

Figure 5. Class 4

Source: Hupp et

al. (2019)

Class 5 It is called a bucoangular

impacted tooth because

the long axis of the third

molar is directed buccal

to the second molar's

long axis.

Figure 6. Class 5

JIMC 2020 - 1’s t Jenderal Soedirman International Medical Conference (JIMC) in conjunction with the Annual Scientiﬁc Meeting

(Temilnas) Consortium of Biomedical Science Indonesia (KIBI )

280

Source: Hupp et

al. (2019)

Class 6 It is called a

linguoangular impacted

tooth because the long

axis of the third molar

points lingually towards

the second molar's long

axis.

Figure 7. Class 6

Source: Hupp et

al. (2019)

Class 7 It is called an inverted

impacted tooth because

the third molar is

embedded with the third

molar's long axis

pointing apically.

Figure 8. Class 7

Source: Hupp et

al. (2019)

(Hupp et al., 2019)

Pell and Gregory's classification divided the

impacted conditions of the third molars based on two

factors: the relationship of the ramus to the space

available and the relative depth of the third molars.

The relationship between the ramus and the available

space is divided into three classes, including class I,

class II, and class III. Class I is the space available

between the mandibular ramus and the mandibular

second molar's distal surface, sufficient for the

mesiodistal size of the mandibular third molar crown.

Class II, the space available between the mandibular

ramus and the mandibular second molar's distal

surface is smaller than the mesiodistal size of the

mandibular third molar crown. Class III, namely that

there is no space available between the ramus of the

mandibular and the distal surface of the mandibular

second molar so that the tooth is mostly or entirely

located in the ramus. Based on the third molar's

relative depth, it is divided into three positions,

namely position A, position B, and position C.

Position A is that the occlusal plane of the third molar

is at the same level as the occlusal plane of the second

molar. Position B is the third molar's occlusal plane

between the occlusal plane and the cervical line of the

second molar. Position C, which is the third molar's

occlusal plane, is below the cervical line of the second

molar (Lita and Hadikrishna, 2020).

Figure 9. Pell and Gregory classification

Source: Lita and Hadikrishna (2020)

The embedded tooth condition occurs because the

crown cannot erupt either partially or entirely. After

all, it is blocked by bone. According to Winter, the

implanted tooth in the classification is included in

class 7, whereas according to Pell and Gregory, the

embedded tooth are in class IIC and class IIIC (Hupp

et al., 2019).

Embedded conditions can cause complaints such

as pain so that the patient feels uncomfortable and

disturbed. The pain results from persistent pressure

on the nerves around the embedded tooth. Pain that

occurs as a result of dental problems is included in

myofascial pain. Myofascial pain is a condition of

muscle pain or facial pain, acute and chronic and

interferes with sensory and motor functions. Pain

occurs due to tissue damage that secretes histamine

and bradykinin so that C fibres will increase the

response to the peripheral areas by serotonin,

prostaglandins, thromboxane and leukotrienes

(Bahrudin, 2017). Substance P is released in the

periphery, and increase peripheral vasodilation,

sensitisation C fibres. C fibres will deliver impulses

to the spinal cord's dorsal horn (Atmadja, 2016).

The procedure for the embedded tooth is

odontectomy. This treatment aims to prevent the

occurrence of a pathological condition originating

from the follicle and infection caused by the inability

to erupt or not fully erupt so that it can cause various

kinds of pain complaints (Domingos et al., 2019).

Odontectomy is a tooth extraction procedure for a

tooth that cannot erupt, partially erupt or a tooth that

cannot be extracted (Fakhrurrazi et al., 2015).

The odontectomy procedure begins with

investigations, flap creation, bone reduction and tooth

extraction. Studies are needed before an odontectomy

is performed. The supporting examination function is

to find out the anatomy around the tooth to be

Hard Tissue Surgical Treatment with Embedded Dental Condition of Tuberosity Maxillary

281

performed, the condition around the bones, the shape

of the roots, the number of roots, the length of the

roots, and whether there is hypersementosis or not.

The supporting examination used before an

odontectomy is taking extra-oral X-rays using a

panoramic technique (Saptadi et al., 2019).

Odontectomy for embedded tooth requires precision

and precision when extracting tooth using beins and

extraction forceps. Anatomical structures such as

blood vessels and sinuses and nerves around the tooth

also need to be considered in the odontectomy of the

embedded tooth. The management of odontectomy in

the implanted tooth's condition begins with the

asepsis procedure followed by anaesthesia (Sahetapy

et al., 2015).

The stage after the supporting examination is

making a flap. A flap is a surgical procedure that

separates the mucosa from the underlying tissue. The

flap aims to obtain visitability and accessibility to the

alveolar bone. The flap in surgery has several

conditions, including forms with a surgical incision,

must have an adequate blood supply, sufficient flap

size, have good visualization, flap design does not

damage the anatomical structure, can return the tissue

to its original or initial position and can be sutured

with a sound healing process. There are various

classifications of flaps, namely based on thickness

and based on an outline. Based on the thickness, there

are two types of flap: full-thickness flap or

mucoperiosteal flap and partial thickness flap of the

mucosal flap. A full-thickness flap is a flap used to

gain access to the bone surface by separating the

bone's soft tissue. This flap consists of the gingiva,

mucosa, submucosa and alveolar periosteum (Yolcu

and Acar, 2015).

The next step was to make an incision to create

the mucoperiosteum flap, and the flap was opened

using a raspatorium, and then the alveolar process

was taken that covered the teeth using a bone bur. The

visible tooth is cut into two parts to make it easier to

retrieve. A tooth that has been cut is removed using a

bein and extraction forceps. The socket where it was

removed was debrided in taking granulation tissue

and smoothing the sharp bone and then doing

irrigation using sterile saline. The next step was

suturing the socket, and the patient was instructed to

bite the tampon. The patient was given postoperative

instructions and medication in antibiotics and

analgesics (Sahetapy et al., 2015).

Medication after hard tissue surgery is needed to

prevent post-surgical complications. Medicines used

after hard tissue surgery are antibiotics, analgesics

and anti-inflammatory. Antibiotics, analgesics and

anti-inflammatory agents in postoperative and simple

tooth extraction procedures are slightly different. The

difference in medication is in choosing the type of

medicine, which is the size or not the wound healing

after the action. Antibiotic medication can be given as

a prophylaxis to prevent infection in patients with a

high risk of disease. It can be given post-surgery to

prevent infection after the procedure(Lukito, 2019).

Analgesic medication is given after surgery to

relieve pain or relieve pain. A few hours after the

surgery, the numbness or numbness from anaesthesia

will slowly return to normal, causing pain. The pain

that appears can be reduced if given analgesic

medication. Analgesics are divided into two groups,

namely non-opioid anaesthetics and opioid

analgesics. Non-opioid painkillers, also called

NSAID analgesics, are the anaesthetics most often

used in dentistry. NSAID anaesthetics inhibit

cyclooxygenase, where cyclooxygenase synthesizes

prostaglandins, thromboxane and prostacyclin which

are pain mediators. Based on the way NSAID

analgesics work, it can be used as a drug to treat pain

due to inflammation after extraction and surgery

(Taufiqurrachman and Mulyo, 2016).

4 CONCLUSIONS

The tooth condition that has been impacted,

embedded, exostotic, and the state of the tooth with

complications, namely having variations in the roots'

anatomical shape, such as bent or macerated roots,

mostly cause complaints and pain. Pain and

complaints can be relieved by taking care or treatment

for these conditions. The treatment that can be given

is by performing hard tissue surgery.

Hard tissue surgery that can be done is extraction

with surgical techniques, namely odontectomy. The

odontectomy procedure aims to remove the infection

source so that complaints of pain and discomfort will

disappear. Providing medication in the form of

prophylactic medication and post-surgery

significantly affects infection prevention, wound

healing process, and overcoming patients' pain after

surgery.

REFERENCES

Arisetiadi, K. N. ., Hutomo, L. ., & Septarini, N. . (2017).

Hubungan Antara Gigi Impaksi Molar Ketiga dengan

Kejadian Karies Molar Kedua Berdasarkan Jenis

Kelamin dan Usia pada Mahasiswa Fakultas

Kedokteran Universitas Udayana. Bali Dental Journal,

1(1), 29–38.

JIMC 2020 - 1’s t Jenderal Soedirman International Medical Conference (JIMC) in conjunction with the Annual Scientiﬁc Meeting

(Temilnas) Consortium of Biomedical Science Indonesia (KIBI )

282

Atmadja, A. S. (2016). Sindrom Nyeri Myofasial. Cermin

Dunia Kedokteran, 43(3), 176–179.

http://www.cdkjournal.com/index.php/CDK/article/do

wnload/29/26

Bahrudin, M. (2017). Patofisiologi Nyeri (Pain). Saintika

Medika, 13(1), 7–13.

https://doi.org/10.22219/sm.v13i1.5449

Domingos, J., Suwarman, & Kestriani, N. D. (2019).

Pengaruh Deksametason 0,2 mg/KgBB sebagai

Adjuvan Analgesia terhadap Waktu Kejadian Nyeri

Pascaoperasi Odontektomi dengan Nrs>3. Jurnal

Anestesi Perioperatif, 7(3), 168–174.

Fakhrurrazi, Hakim, R. F., & Rifani, R. (2015). Hubungan

Tingkat Kesulitan dengan Komplikasi Post

Odontektomi Gigi Impaksi Molar Ketiga Rahang

Bawah pada Pasien di Instalasi Gigi dan Mulit

RSUDZA Banda Aceh. Cakradonya Dent J, 7(1), 761–

767. https://doi.org/10.1017/CBO9781107415324.004

Fitri, A. M., Kasim, A., & Yuza, A. T. (2016). Impaksi gigi

molar tiga rahang bawah dan sefalgia. J Ked Gi Unpad,

28(3), 148–154.

https://doi.org/10.24198/jkg.v28i3.18691

Haggerty, C. J., & Laughlin, R. M. (2015). Atlas of

Operatie Oral and Maxillofacial Surgery. WILEY

Blackwell.

https://doi.org/10.1002/9781118993729.ch2

Hupp, J. R., Ellis, E., & Tucker, M. R. (2019).

Contemporary Oral and Maxillofacial Surgery (7th

ed.). Elsevier.

https://doi.org/10.1017/CBO9781107415324.004

Lande, R., Kepel, B. J., & Siagian, K. V. (2015). Gambaran

Faktor Risiko Dan Komplikasi Pencabutan Gigi Di

Rsgm Pspdg-Fk Unsrat. Jurnal E-GIGI, 3(2), 476–481.

https://doi.org/10.35790/eg.3.2.2015.10012

Lita, Y. A., & Hadikrishna, I. (2020). Klasifikasi Impaksi

Gigi Molar Ketiga Melalui Pemeriksaan Radiografi

sebagai Penunjang Odontektomi. Jurnal Radiologi

Dentomaksilofasial Indonesia, 4(1), 1–5.

https://doi.org/10.32793/jrdi.v4i1.467

Lukito, J. I. (2019). Antibiotik Profilaksis pada Tindakan

Bedah. Cermin Dunia Kedokteran, 46(12), 777–783.

Roi, C. I., Ianes, E., Gaje, P. N., Nica, D. F., Roi, A., & Roi,

A. (2019). The predictability of Difficultness of Lower

Third Molar Odontectomy. REV.CHIM, 70(4), 1342–

1345. https://doi.org/10.37358/rc.19.4.7123

Sahetapy, D. T., Anindita, P. S., & Hutagalung, B. S. P.

(2015). Prevalensi Gigi Impaksi Molar Tiga Partial

Erupted Pada Masyarakat Desa Totabuan. Jurnal E-

GIGI, 3

(2), 641–646.

https://doi.org/10.35790/eg.3.2.2015.10810

Saleh, E., Prihartiningsih, & Rahardjo. (2015).

Odontektomi Gigi Molar Ketiga Mandibula Impaksi

Ektopik dengan Kista Dentigerous secara Ekstraoral.

Majalah Kedokteran Gigi Klinik, 1(2), 85–91.

https://doi.org/10.22146/mkgk.11956

Saptadi, A., Lilies, D. S., Menik, P., & Latief, B. S. (2019).

Evaluation of Impacted Mandibular Third Molar

Position in Relation to Mandibular Canal on Panoramic

Radiography compared to Cone-Beam Computed

Tomography. Journal of International Dental and

Medical Research, 12(2), 591–596.

Tammama, T. (2018). Impaksi Horizontal Gigi Molar

Kedua Maksila Bilateral Simptomatis yang

Menyebabkan Nyeri Kepala Rekuren Horizontal

impaction of symptomatic bilateral maxillary second

molar causing recurrent headache. J Ked Gi Unpad,

30(3), 158–161.

https://doi.org/10.24198/jkg.v30i3.18082

Taufiqurrachman, T., & Mulyo, K. (2016). Perbandingan

Pengaruh Pemberian Analgetik Etoricoxib Dengan

Natrium Diclofenak Terhadap Rasa Nyeri Pasca

Odontektomi (Impaksi Kelas 1, Molar 3 Rahang

Bawah). Jurnal Kedokteran Diponegoro, 5(3), 222–

234.

Yolcu, U., & Acar, A. H. (2015). Comparison of a New

Flap Design with The Routinely used Triangular Flap

Design in Third Molar Surgery. International Journal

of Oral and Maxillofacial Surgery, 1–8.

https://doi.org/10.1016/j.ijom.2015.07.007

Zakaria, K. (2015). Sistem Pakar Diagnosa Penyakit THT

Menggunakan Metode Dempster Shafer. Prosiding

Seminar Informatika Aplikatif Polinema, 175–178.

https://doi.org/10.22219/repositor.v2i9.776

Hard Tissue Surgical Treatment with Embedded Dental Condition of Tuberosity Maxillary

283