Management of impacted3rd molar

Presented by :
2nd year PG OMFS

CONTENT
 Introduction
 Definition
 Eruption
 Chronology
 Theories of impaction
 Local & systemic causes
 Indication and contra indication
 Classification
 Difficulty index
 Radiographic analysis

introduction
 Removal of impacted teeth is one of the most common surgical
procedures performed by oral and maxillofacial surgeons
 Extensive training, skill, and experience are necessary to perform
this procedure with minimal trauma.
 When the surgeon is untrained and/or inexperienced, the incidence
of complications rises significantly

Definition
 Latin – “impactus” – an organ or structure which because
of an abnormal mechanical condition has been prevented
from assuming its normal position.
 Webster – “wedging of one part into another”
 Rounds (1962)– “the condition in which a tooth is embeded
in the alveolus so that its further eruption is prevented”

 Archer – “ a tooth which is completely or partially unerupted and is positioned
against another tooth or bone or soft tissue so that its further eruption is
unlikely” (1975)
 Lytle (1979) – “ one tooth that has failed to erupt into normal functional
position beyond the time usually expected for such appearance”
 Andreasen et al (1997) – “ a cessation of the eruption of a tooth caused by a
clinically or radio-graphically detectable physical barrier in the eruption path
or by an ectopic position of the tooth”
 Peterson – “ A tooth is considered impacted when it has failed to fully erupt
into the oral cavity within in its expected developmental time period and can
no longer reasonably be expected to do so”

Tooth eruption
 Movement of a tooth from its site of development within
the alveolar bone to its functional position in the oral
cavity.
 6 stage
 Pre-eruptive stage
 Intra-osseous stage/ Alveolar bone stage
 Mucosal penetration/Mucosal stage
 Pre-occlusal stage
 Occlusal stage
 Maturation stage

Eruption stage Eruption mechanism/theory Structures resisting eruption
Pre-eruptive stage
Intra-osseous stage Vascular hydrostatic pressure
Root formation
Bone formation
Bone
Primary predecessors
Mucosal stage Vascular hydrostatic pressure
Root formation
Bone formation
Mucosa
Pre-occlusal stage Vascular hydrostatic pressure
Root formation
Bone formation
Periodontal ligament
Mastication
Occlusal stage Root elongation
Bone formation
Periodontal ligament
Mastication
Occlusion
Maturation Root elongation Periodontal ligament

UNERUPTED TOOTH- NOT HAVING
PERFORATED ORAL MUCOSA
MALPOSED TOOTH- A TOOTH,ERUPTED OR
UNERUPTED WHICH IS IN ABNORMAL POSITION IN
MAXILLA OR MANDIBLE
Partial eruption:
A tooth that is
incompletely erupted is a partial eruption.
The tooth may be seen clinically but is
frequently malposed and always covered
with soft tissue to some extent.

Partial bony impaction:
The tooth is partially covered with the bone. The tooth may
be a complete soft tissue impaction & a partial bony
impaction.
Complete bony impaction:
The tooth is completely contained within the bone
Potential impaction:
An unerrupted tooth that still retains the potential for
eruption, but which will most likely not erupt into normal
position & function because of obstruction, unless surgical
intervention occurs.
Ectopic/ displaced teeth:
a tooth is ectopic if malposed due to congenital factors or
displaced by the presence of pathology.

Chronology of 3rd molar
 Tooth germ visible – 9yrs
 Cusp mineralization – 11 yrs
 Crown formation – 14 yrs
 Roots formed (apex open) – 18 yrs
 Eruption – 18-24 yrs

 Bjork (1956) – 3 factors – significant in development
of mandible & space for third molar
 Vertical direction of condylar growth
 Insufficient growth of mandible
 Backwardly directed trend of eruption
 Hattab (1997) – position changes and eruption of 3rd
molar is an unpredictable phenomenon
 Nance (2006) – if third molars are angled mesial/ horizontal – unlikely to erupt
-- if third molars are vertical/ distal – a period of follow up – they
might erupt.

Why teeth get impacted?
Theories of impaction (Durbeck)
 The Phylogenic theory
 Nature tries to eliminate the disused organs i.e., use makes the organ develop better, disuse causes slow regression of organ.
 Due to evolution increase in brain size and decrease in jaw size as per node’s hypothesis
 Evolution of Masticatory habits- leading to Withdrawal / elimination of stimulus.
 Softer and refined foods / fibrous food / Uncooked meat
 The Mendelian theory
 Heredity is most common cause. The hereditary transmission of small jaws and large teeth from parents to siblings. This may be
important etiological factor in the occurrence of impaction.
 The Endocrine theory
 Increase or decrease in growth hormone secretion may affect the size of the jaws.
 The Pathological theory
 Chronic infections affecting an individual may bring the condensation of osseous tissue further preventing the growth and development
of the jaws.
 The Orthodontic theory
 Jaws develop in downward and forward direction. Growth of the jaw and movement of teeth occurs in forward direction,so any thing that
interfere with such moment will cause an impaction (small jaw-decreased space).
 A dense bone decreases the movement of the teeth in forward direction.

 The Skeletal theory
 Several studies have demonstrated that when there is inadequate bony length, there
is a higher proportion of impacted teeth
 The Belfast Study Group
 They claim that there may be differential root growth between the mesial and distal roots,
which causes the tooth to either remain mesially inclined or rotate to a vertical position
depending on the amount of root development.

Local causes (Berger)
 Lack of space
 Retained deciduous teeth
 Premature loss of deciduous teeth
 Ectopic position of tooth bud
 Obstruction of eruption path
 Cyst tumor and supernumery teeth
 Infection and trauma
 Abnormality of jaw
 Dilaceration : abnormal path of eruption of tooth due to traumatic
forces during the eruption period

SYSTEMIC CAUSES (Berger)
 Prenatal causes
 Heredity
 Postnatal
 Rickets
 Anaemia
 Congenital Syphillis
 Endocrine dysfunction
 Malnutrition
 Rare conditions
 Cleidocranial dysostosis
 Oxycephaly
 Progeria
 Anchondroplasia
 Cleft plate

Commonly impacted tooth
 mandibular third molars
 maxillary third molars
 maxillary cuspids
 mandibular bicuspids
 mandibular cuspids
 maxillary bicuspids
 maxillary central incisior
 maxillary lateral incisor
 supernumerary teeth mainly mesiodens

INDICATION FOR REMOVAL
 prevention of pericoronitis
 Dental caries or prevention of dental caries
 Periodontal disease or its prevention
 Prevention of root resorption
 Odontogenic cysts & tumours – dentigerous cyst
 Pain of unexplained origin
 autogenous transplantation to first molar socket

 Fracture of the jaw/tooth in the line of fracture
 Prosthetic problems e.g. under prosthesis
 Orthodontic relapse/facilitation of orthodontic tooth movement
 Tooth interfering with orthognathic and/or reconstructive surgery
 Prophylactic removal - Patients with medical or surgical
conditions requiring removal of third molar (e.g. organ transplants,
alloplastic implants, chemotherapy, radiation therapy)

Pericoronitis
 There should be a portion of the crown in the oral cavity to actually call it pericoronitis
 Patients with pericoronitis at time of extraction have higher potential for dry socket (loss
of blood clot, causing excruciating pain post-op)
 Partly erupted 3rd molars act as reservoirs of Streptococcus Mutans and Lactobacillus
along with anaerobes Peptostreptococcus, Spirochaetes, fusibacterium and bacteroids.
 Treatment
 I&D
 place patient on antibiotics, let things calm down.
 Removal of 3rd molar tooth

Contraindications for removal
 Extremes of age
 Compromised medical status
 Excessive risk of damage to adjacent structures
 When there is a question about the future status of
the second molar
 Uncontrolled active pericoronal infection
 Socioeconomic status
 fracture of atrophic mandible may occur

Classification of impacted third molars
 NATURE OF OVERLYING TISSUE IMPACTION
 Soft tissue
 Partial bony
 Complete bony
 ANGULATION OF TOOTH (Winter,1926)
 Vertical
 Mesioangular
 Horizontal
 Distoangular
 Buccolangular
 Lingoangular
 Inverted

 RELATIONSHIP OF THE IMPACTED TOOTH TO THE ANTERIOR BORDER
OF RAMUS (Pell & Gregory, 1933)
 Class I -- space available anterior to anterior border of ramus
 Class II -- space less than mesiodistal width of 3rd molar
 Class III – most of the 3rd molars located with in ramus
 DEPTH OF IMPACTION AND THE TYPE OF TISSUE OVERLYING
(Pell & Gregory)
 Position A – highest portion of the tooth is on occlusal level or above
 Position B – highest portion of tooth below occlusal level but above Cervical line
 Position C – highest portion of the tooth is below the cervical line

 STATE OF ERUPTION
 Erupted
 Partially erupted
 Unerpted
 NUMBER OF ROOTS
 Fused root / single
 Two roots
 Multiple roots
 CLASSIFICATION SYSTEM BASED ON DENTAL PROCEDURE CODE
 D7220 -- removal of impacted tooth - overlying soft tissue
 D7230 -- removal of impacted tooth - partially bony impacted
 D7240 -- removal of impacted tooth - completely bony
 D7241 -- removal impacted tooth - completely bony, with unusual surgical
complications

WHARFE assessment - Macgregor 1985
 Winters classification
 Horizontal 2
 Distoangular 2
 Mesioangular 1
 Vertical 0
 Height of the mandible
 1-30 mm 0
 31-34 mm 1
 35-39 mm 2
 Angulation of 3rd molar
 1-59 degrees 0
 60-69 1
 70-79 2
 80-89 3
 90 + 4
 Root shape and development
 favourable curvature 1
 unfavourable curvature 2
 complex 3
 < 1/3 complete 2
 1/3 to 2/3 complete 1
 > 2/3 complete 3
 Follicles
 normal 0
 possibly enlarged 1
 enlarged 2
 impaction relieved 3
 path of Exit
 space available 0
 distal cusps covered 1
 mesial cusp also covered 2
 both covered 3

Difficulty index for removal of third molar (PEDERSON’S SCALE ,1988)
ANGULATION/SPATIAL RELATIONSHIP
Mesioangular 1
Horizontal/Transverse 2
Vertical 3
Distoangular 4
DEPTH
Level A 1
Level B 2
Level C 3
RAMUS RELATIONSHIP
Class I 1
Class II 2

 Difficulty index
 Very difficult : 7 to 10
 Moderately difficult : 5 to 7
 Minimally difficult : 3 to 4

PARANT SCALE
EASY I EXTRACTION REQUIRING FORCEPS ONLY
EASY II EXTRACTION REQUIRING OSTECTOMY
DIFFICULT III EXTRACTION REQUIRING OSTEOTOMY AND CORONAL SECTION
DIFFICULT IV COMPLEX EXTRACTION ( ROOT RESECTION)

Radiography of impacted mandibular teeth
 Radiographic views
 intraoral periapical
 occlusal
 orthopontamograph
 lateral radiograph
 Linear cross sectional tomography
 A diagnostic technique for determining the buccolingual
relationship of impacted mandibular third molar and inferior
alveolar neurovascular bundle

Interpretation of IOPAR
 Access
 By noting inclination of the radio-opaque line – external oblique line
 If horizontal – access is easy
 If vertical – access is difficult
 Position & depth of impacted tooth
 Root pattern of impacted teeth
 Shape of crown
 Texture of investing bone
 Relation to inferior alveolar canal
 Position & root pattern of second molar

Position and depth of impacted tooth
White Line
 Provide information regarding the depth &
inclination
Amber Line
 Indicate the margin of the alveolar bone
enclosing the teeth
 One must differentiate between external
oblique ridge and bone lying distal to
impacted tooth
Red Line
 Provides information about depth at which
elevator should be applied
 Longer the line difficult to remove/access
the tooth
 Length : difficulty :: 1 : 3

 Importance of interdental septum
 Vertical
 Disto-angular

Root pattern
 Root morphology influence the degree
of difficulty of removal
 limited root development – ROLLING
tooth – difficult to remove
 1/3rd to 2/3rd root formation – easy to
remove
 Mesiodistal width of root > crown –
need sectioning longituidinally.
 Sometime multiple root may not be
visible on radiograph due to
superimposition.

Shape of crown
 Large square crown with
prominent cusp – difficult to
remove
 “line of withdrawal” of the
tooth – obstructed by 2nd
molar – “locking of crown”

RADIOGRAPHIC CRITERIA TO DECIDE
SECTIONING OF TOOTH
 THIS CRITERIA DECIDES WHETHER THE TOOTH IS LOCKED OR NOT
 A LINE IS DRAWN FROM THE MESIOLINGUAL CUSP TILL THE DISTAL
ROOT
 THE DISTANCE IS THEN MEASURED
 HALF THE DISTANCE IS TAKEN AS THE RADIUS
 AN ARC IS DRAWN
 IF THE ARC TOUCHES THE 2ND MOLAR INDICATES LOCKING OF TOOTH
 SECTIONING IS MANDATORY

Localization of impacted third molar using radiographs
 Horizontal tube shift tech
 For seperating superimposed objects with vertical long
axis
 For buccal / lingual localisation of impacted third molar
from roots of erupted teeth
 vertical tube shift tech
 For seperating horizontally oriented objects
 For determining bucco-lingual position of third molar
apices that super impose the mand canal

7 radiological signs had been suggested by
HOWE & POYTON (1960)
 Darkening of the root
 Deflected root
 Narrowing of the root
 Dark & bifid root
 Interruption of the white line(s)
 Diversion of inferior alveolar canal
 Narrowing of the inferior alveolar
canal
Related to Root
Related to
inferior alveolar
canal

Use of CT scan
 Helps to show relationship of root apices with inferior dental canal.
 Useful to predict the bone density of mandible

Use of CBCT
 When OPG suggest close relationship
between root apex and ID canal.
 Information about distance between IAN &
lower tooth root
 Prediction for risk of damage of IAN
 Advantage :
 Radiation exposure 10 times less than regular CT
scan
 Required less time(10-40 sec) than conventional CT
 Price is comparatively less than CT scan (<50%)

Assessment of impaction
 Preoperative assessment
 Clinical assessment
 General
 Local
 ERUPTION STATUS OF IMPACTED TOOTH
 RESORPTION OF SECOND MOLAR
 PRESENCE OF LOCAL INFECTION- PERICORONITIS
 ORTHODONTIC CONSIDERATION
 CARIES IN OR RESORPTION OF THIRD MOLAR OR ADJACENT TEETH
 PERIODONTAL STATUS

Local assessment
 Mouth opening
 Size of tongue
 Extensibility of lips and cheeks
 Status of dentition
 Assessment of teeth in particular
 ORIENTATION AND RELATIONSHIP TO IDC
 OCCLUSAL RELATIONSHIP
 REGIONAL LYMPH NODES
 TMJ FUNCTION
 If planned under GA, other impacted teeth should also be
considered for removal

FACTORS THAT MAKE REMOVAL EASIER
SOFT
TISSUE
IMPACTION
SEPRTATED
FROM
II MOLAR
LESS
DENSE
BONE
LARGE
FOLLICE
WIDE
PERIODONTAL
SPACE
FUSED CONIC
ROOTS
ROOT 1/3RD
TO
2/3RD
POSITION A
CLASS 1
MESIOANGULAR

FACTORS THAT MAKE REMOVAL DIFFICULT
COMPLETE
BONY
IMPACTION
CONTACT
WITH
IIMOLAR
DENSE
INELASTIC
BONE
THIN
FOLLICLE
NARROW
PERIODONTAL
SPACE
DIVERGENT
CURVED
ROOTS
LONG
THIN
ROOTS
POSITION C
CLASS 3
DISTOANGULAR

Risk of Intervention: Minor transient
 Sensory nerve alteration
 Dry socket
 Trismus
 Infection
 Hemorrhage
 Dentoalveolar fracture
 Displacement of tooth

Risk of Intervention: Minor Permanent
 Periodontal injury
 Adjacent tooth injury
 TMJ injury

Risk of Intervention: Major
 Altered sensation
 Vital organ infection
 Fracture of the mandible and maxillary
tuberosity
 injury

Risk of Non-intervention
 Crowding of dentition based on growth
prediction
 Resorption of adjacent tooth and periodontal
status
 Development of pathological condition such
as caries, infection, cyst, tumor

Surgical anatomy
 Mandibular third molar
 Neurovascular bundle
 Retromolar trigon
 Facial artery and vein
 Lingual nerve
 Mylohyoid nerve
 Long buccal nerve
 Bone trajectories of mandible
 Lingual plate
 Masticatory musculature

 Mandibular third molar
 Situated at distal end of the body of the mandible
where it meets a relatively thin ramus
 At this point if undue force is applied during
removal – causes fracture.
 Tooth is embedded within thick buccal bone and
thin lingual bone
 Sometime the thickness of lingual cortical plate –
<1mm
 In such cases fractured root apices may displace to
lingual pouch

 Lingual plate:
 Because of its extreme thinness apices of
lower third molar may perforate it
 Rarely but it may happen that the whole
tooth may be pushed into the lingual pouch
 Sir william kelsy Fry popularized the “lingual
split bone technique”
 thin lingual plate joins with thick body of
mandible, when inner plates breaks at junction
then the lingual nerve extend forward
 But a undue force may extend the breakage
till the LINGULA as it is present 25 mm from
the 3rd molar

 Neurovascular bundle
 ID canal positioned apically and slightly buccal
to the 3rd molar root
 Canal encloses – IA artery, vein and nerve –
encloses within fascial sheath
 Sometimes root apices may invade the superior
wall of the canal.
 Forceful intrusion of root in canal may injure
vessels – profound bleeding.
 When root of third molar is in direct contact
with ID canal – radiographicaly loss of lamina
dura may be seen.

 Retromolar Triangle
 Depressed roughened area – bounded by buccal &
lingual crest.
 Lateral to this – retromolar fossa
 Through this branches of mandibular vessels
emerges and supply temporalis tendon, buccinator
muscle & adjacent alveolus
 If the distla incision is extended on ramus instead
of extending over cheek – cause injury to this
vessels – lead to brisk bleeding
 Retromolar pad
 Resist upward displacement of tooth – relieving
incision required through mucoperiosteum
 Striping of tendinous insertion of temporalis – lead to
postoperative pain

 Facial artery & vein
 Cross the inferior border of mandible
anterior to masseter muscle near to
2nd molar
 Injury may occur due to slips of BP
blade during buccal cut
 It is better to start incision from
buccal sulcus then extend upward to
the tooth

Lingual nerve
 LINGUAL NERVE LIES INFERIOR & LINGUAL TO THE
CREST OF LINGUAL PLATE OF MANDIBLE WITH A
MEAN POSITION OF 2.28MM(±0.9)BELOW THE CREST &
0.58MM(=/-(0.9) MEDIAL TO CREST
- KIESSELBACH & CHAMBERLAIN
 15% OF CASES SHOWS IT LIES SUPERIOR TO LINGUAL
PLATE
 CADAVERIC STUDIES SHOWED THAT IT LIES 3.45MM
MEDIAL TO ALVEOLAR CREST & 8.32MM BELOW
 MRI STUDY DEMONSTRATED THAT THE NERVE IS
LOCATED AT A MEAN DISTANCE OF 2.53MM MEDIAL TO
AND 2.75MM BELOW ALVEOLAR CREST

 Lingual version of distoangular impacted lower 3rd molar
 Root of few distoangular 3rd molar directed lingually – lingual version – increase the
vulnerability with lingual nerve
 Lingual plate deficiency
 Root Apices of third molar penetrate the lingual plate – deflected into lingual pouch – injure
the lingual nerve
 High lateral position of lingual nerve
 Lingual nerve can be in full contact with lingual plate / above the lingual plate – increase
vulnerability of lingual nerve
 Local chronic inflammatory condition
 Long standing pericoronal infection lead to scaring of lingual nerve with lingual plate
 If ligual plate is deficient then its tend to attached with the 3rd molar tooth

 Mylohyoid nerve
 Leaves IAN before entering
mandibular canal
 Then penetrate the spheno-
mandibular ligamnet
 In 16% of cases this nerve present in
too close proximity of ID canal
 Damage may take place during
lingual approach for removing 3rd
molar tooth.

 Long Buccal Nerve
 Emerges through the buccinator
and passes anteriorly on its
outer surface
 During wide opening of mouth
it lies above the retro molar
fossa region
 Injury is rare but can occur if
incision is placed too laterally
into the buccal mucosa.

 Bone trajectories of mandible:
 “Grain” of mandible run longitudinally.
 Importance lies in use of chisel for bone
removal.
 Buccal horizontal cut may extend from 1st
molar till distal to 3rd molar till ramus & cause
fracture.
 To prevent from such phenomenon vertical
stop cut need to be placed mesial and distal to
the 3rd molar

Musculature Buccinator
 During surgical removal deeply seated impacted tooth require detachment of this muscle – lead to postoperative swelling,
trismus & pain
 Temporalis
 Ends at anterior border of mandible as tendinous structure
 Outer tendon sectioned during buccal approach – facilitate adequate bone removal
 Masseter
 Rarely involed in third molar surgery
 Postoperative edema may involve posteriorly to the muscle leading to trismus and pain
 Pre and post operative infection may drain into submasseteric space – lead to sub-masseteric abcess formation
 Medial pterygoid
 Not directly involved in third molar surgery
 But during lingual approach – postoperative edema involve this muscle which can lead to trismus.
 Mylohyoid
 During lingual approach – this muscle can partly sever – may lead to transient swallowing difficulty
 Postoperative infection can spread to sublingual / submandibular space through this muscle breakage.

Management of impacted3rd molar

SURGICAL PROCEDURE
ADEQUATE EXPOSURE
ACCESS TO THE TOOTH
SECTIONING OF THE TOOTH(OPTIONAL)
ELEVATION FROM THE ALVEOLAR PROCESS
DEBRIDMENT & IRRIGATION
FIVE BASIC STEPS

ADEQUATE EXPOSURE
 SEVERAL DIFFERENT FLAP TECHNIQUES HAVE BEEN DEVELOPED, AND
DISCUSSED TO MINIMIZE POTENTIAL PERIODONTAL COMPLICATIONS TO
ADJACENT SECOND MOLAR OR IMPROVE SURGICAL ACCESS.
TYPES OF INCISIONS AND FLAPS
L-SHAPED FLAP
BAYONET FLAP(WARDS INCISION)
THREE CORNERED FLAP(MODIFIED WARDS INCISION)
ENVELOPE FLAP
COMMA SHAPED INCISION/FLAP
VESTIBULAR TONGUE SHAPED FLAP
GROOVES AND MOORE FLAPS

L-SHAPED FLAP
 THE ANTERIOR LIMB IS THE VESTIBULAR EXTENSION AT THE LEVEL OF 2ND MOLAR
 IT CAN BE EXTENDED UPTO 1ST MOLAR
 RISK OF DAMAGING FACIAL VESSELS
 THE VERTICAL RELIEVING INCISION DIFFERENTIATE IT FROM WARDS INCISION
 THIS RELIEVING INCISION IS GIVEN AT 45O ANGLE TO THE LONG AXIS OF THE 2ND MOLAR AND RUNS STRAIGHT
ANTERIORLY AND DOWNWARDS
 IT TOTALLY COMMITS AN OPERATOR TO A BUCCAL APPROACH

BAYONET FLAP
 it has three parts
anterior
intermediate or gingival
distal
 Also known as wards incision
 Anteriorly it extends around the gingival margin of 2nd molar and even the 1st
molar before turning into the sulcus usually angled forward
 over extension of the incision into the sulcus may cause brisk oozing of blood from
venous plexus
 can be avoided by making the anterior part more oblique
 intermediate is along the gingiva
 distally it is placed more lingually over the impacted tooth but laterally towards the
ascending ramus.

THREE CORNERED FLAP
 MODIFIED WARDS INCISION
 LARGER LAYER OF MUCOPERIOSTEAL FLAP
 USUALLY FOR DEEPLY IMPACTED MOLARS
 THE ANTERIOR PART SHOULD COMMENCE AT THE
DISTOBUCCAL CORNER OF 1ST MOLAR INSTEAD OF 2ND
MOLAR
 EXTENDS VERTICALLY DOWNWARDS AND THEN
CURVED ANTERIORLY
 FOLLOWED BY GINGIVAL CREVICULAR INCISION ALONG
THE 2ND MOLAR
 DISTALLY IT IS SIMILAR TO WARDS INCISION

ENVELOPE FLAP
 EXTENDS FROM MESIAL PAPILLA OF THE 1ST
MOLAR AROUND THE NECKS OF THE TEETH
TO THE DISTOBUCCAL LINE ANGLE OF THE
2ND MOLAR
 THEN EXTENDS POSTERIORLY AND
LATERALLY UP TO THE ANTERIOR BORDER
OF THE MANDIBLE
 IT SHOULD NOT CONTINUE POSTRIORLY IN
A STRAIGHT LINE BECAUSE THE MANDIBLE
DIVERGE LATERALLY
 EASIER TO CLOSE AND BEST HEALING
 IN 1971, SZMYD DESCRIBED THIS INCISION

COMMA SHAPED INCISION
PROVIDES LAREG ACCESS
INDICATED IN CASE DEEP HORIZONTAL
IMPACTIONS
PERIODONTAL POCKETING DISTAL TO
2ND MOLAR IS LESS

VESTIBULAR TONGUE SHAPED FLAP
 BERWICK, IN 1966, DESIGNED A VESTIBULAR TONGUE-
SHAPED FLAP
 EXTENDED ONTO THE BUCCAL SHELF OF THE MANDIBLE
 INCISION LINE DID NOT LIE OVER THE BONY DEFECT
CREATED BY THE REMOVAL OF THE IMPACTED TOOTH
 ITS BASE AT THE DISTOLINGUAL ASPECT OF THE SECOND
MOLAR
 MAGNUS ET AL WITH THE SAME AIM,
 DESCRIBED A PARAGINGIVAL FLAP IN WHICH THE
ANTERIOR RELEASING INCISION IS LOCATED 0.5 CM APICAL
TO THE GINGIVAL MARGIN OF THE SECOND AND FIRST
MOLARS

GROVES AND MOORE
 IN THE YEAR 1970 THEY DESIGNED THREE FLAPS
 RELATED TO INVOLMENT OF THE GINGIVAL MARGIN OF 2ND MOLAR
 THE TWO FLAPS THAT DID NOT INVOLVED THE GINGIVAL MARGIN OF THE
2ND MOLAR
 PRODUCED AN APPARENT DECREASE IN POCKETING DISTAL TO 2ND MOLAR

ACCESS TO THE IMPACTED TOOTH
 IT IS ACHIEVED BY REMOVAL OF OVERLYING BONE
 AMOUNT OF REMOVAL DEPENDS ON
DEPTH OF THE TOOTH
MORPHOLOGY OF ROOT
ANGULATION OF TOOTH
BONE REMOVAL CAN BE DONE BY
CHISELS
DRILLS
Piezo surgical unit

CHISEL AND MALLET
 TRADITIONAL TECHNIQUE,
 SUPPORT OF MANDIBLE IS MANDATORY
 THE CHISEL IS KEPT PARALLEL TO THE LONG AXIS OF BONE
 INDICATIONS
 YOUNG PATIENTS
 AN EXTERNAL OBLIQUE RIDGE SLIGHTLY BELOW THE LEVEL OF BONE ENCLOSING THE 3RD
MOLAR
 AN EXTERNAL OBLIQUE RIDGE THAT IS SLIGHTLY BEHIND THE 3RD MOLAR SO THAT THE
DISTOLINGUAL CORNER OF THE TOOTH SITS IN A THIN BALCONY OF BONE

 THE CHISEL IS KEPT PARALLEL TO THE LONG AXIS OF BONE
 A VERTICAL LIMITING CUT IS MADE AT THE DISTAL ASPECT OF THE 2ND
MOLAR WITH CHISEL BEVEL FACING POSTERIORLY
 THE LIMITING CUT IS THEN TURNED INTO A VERTICAL GROOVE
 THEN THE CHISEL IS PLACED AT 45O ANGLE TO THE LOWER EDGE OF
LIMITING CUT IN AN OBLIQUE DIRECTION

 A TRINGULAR PIECE OF BUCCAL PLATE DISTAL TO 2ND MOLAR IS THEN
REMOVED
 THE DISTAL BONE IS THEN REMOVED IF REQUIRED
 THE BONY CUT CAN BE ENLARGED TO UNCOVER THE TOOTH
 ELEVATOR IS THEN PLACED AT THE JUCTION OF VERRTICAL LIMITING CUT
AND OBLIQUE BONE CUT

LOW SPEED ENGINE DRIVEN DRILLS
INDICATIONS
OLD PATIENTS
AN EXTERNAL OBLIQUE RIDGE AND INTERNAL OBLIQUE RIDGE OR BOTH ARE FAR
FORMED IN RELATIONSHIP TO THE TOOTH
HENCE GUTTERING IS NECESSARY TO AVOID EXCESS REMOVAL OF BONE
COMPLICATIONS
ACCIDENTAL DENUDEING OF ROOTS OF 2ND MOLAR
WHILE GUTTERING THE BONE THE MANDIBULAR CANAL MAY BE OPENED AND DAMAGE TO
NERVE MAY OCCUR
WHILE CUTTING DISTOLINGUAL SPUR OF BONE HIGH CHANCE OF LINGUAL NERVE DAMAGE
HENCE IT SHOULD BE MOVED LINGUAL TO BUCCAL TO PREVENT SUDDEN SLIPPING INTO LINGUAL
SIDE

BUCCAL BONE GUTTERING
 begins at the mesiobuccal line angle of the 3rd molar
 initial bone cut is made vertically down to expose the
height of covexity of the 3rd molar
 the bur is passed distally at this depth to the distobuccal
line angle
 then lingually around the distal surface
 if tooth cannot be delivered then again bur is used to
increase the depth of ossisection to the level of
bifurcation

 INITIALLY HOLES ARE DRILLED AT A DISTANCE OF 4-5MM FROM EACH OTHER
AROUND THE BUCCAL ASPECT (FROM THE MESIOBUCCAL LINE ANGLE TO THE
DISTOBUCCAL LINE ANGLE OF THE TOOTH)
 LARGE ROUND NO-8 BUR IS PREFFERED
 THESE HOLES ARE THEN JOINED WITH A FLAT FISSURE BUR NO.701,702 DOWN TO
THE CERVICAL MARGIN OF TOOTH
 THIS PROVIDES ACCESS FOR ELEVATORS TO GAIN PURCHASE POINT AND A
PATHWAY FOR DELIVERY OF TOOTH
 THE BONE CUTTING SHOULD BE DONE WITH A CONTINOUS JET OF NORMAL
SALINE

SECTIONING OF THE TOOTH
 IT ALLOWS PORTIONS OF THE TOOTH TO BE REMOVED SEPERATELY
DEPENDS PRIMARILY ON
ANGULATION OF THE TOOTH
UNFAVOURABLE ROOT PATTERN
TO PROTECT IMPORTANT STRUCTURES
ADVANTAGES
THE INCISION IS LESS EXTENSIVE
OPERATION FIELD CAN BE KEPT SMALL
LESS POST OPERATIVE SWELLING
LESS BONE REMOVAL
FORCEFUL ELEVATION OF TOOTH IS NOT NEEDFUL
NO DAMAGE TO ADJACENT TOOTH
RISK OF FRACTURE IS MINIMISED

DISADVANTAGES
IT CAN BE ACHIEVED WITH
CHISELS
DRILLS
TEETH WITH SHALLOW GROOVES DIFFICULT TO SPLIT
DIFFICULT TO CONTROL THE LINE OF SPLITING
WITH CHISEL SPLITING DAMAGE TO SOFT TISSUE MAY BE CAUSED
PATIENT MAY FIND IT INCONVENIENT

REMOVAL OF MESIOANGULAR IMPACTED III MOLAR
TOOTH DIVISION IS NECESSARY
IF THE TOOTH IS BISSECTED AT NECK
ENAMEL IS VERY THIN
LOWER POSITION
Distal half of the crown is sectioned off at the
buccal groove just below the cervical line
Position of elevator under cemento enamel
junction on mesial surface
Tooth is moved upward and backward as far as
distal rim of bone will allow
Upward movement of roots

REMOVAL OF DISTOANGULAR IMPACTED III MOLAR
 Distoangular position brings the iii molar well under
the ascending ramus
 frequently distally curved roots are encountered
 after sufficient bone removal, the crown is sectioned
horizontally from the roots just above the cervical line
 the entire crown is first removed
 if roots if fused then a elevator can be straight used to
elevate the roots into the space previously occupied by
the crown
 if roots are divergent sectioning of roots is necessary
and individual removal
 extraction of this type of impaction is difficult,because
more distal bone has to be removed and the tooth
tends to be elevated distally and into the ramus
portion of the mandible

REMOVAL OF VERTICALLY IMPACTED III MOLAR
 procedure of bone removal and tooth
sectioning is similar to mesioangular
impaction
 tooth sectioned vertically
 distal part removed first,followed by the
mesial half
 it is more difficult than mesioangular
impaction because the access around 2nd
molar is less and requires more removal of
bone on the buccal and distal sides

REMOVAL OF HORIZONTALLY IMPACTED III MOLAR
 requires maximum bone removal
 bone should be removed down to the cervical line to
expose the superior aspect of the distal root and the
majority of buccal surface of crown
 superior(distal) and inferior(mesial) cusp sectioned
 superior crown is removed first
 followed by bulk of tooth and then the inferior crown
fragment
 if sufficient space is not available then a split is made near
the anatomic neck of tooth
 if divergent roots then spitting of roots is necassery
and then each root is delivered individually

REMOVAL OF BUCCOANGULAR OR LINGULAR
IMPACTED III MOLARS
 NOT SO COMMON
 TOOTH IS SECTIONED HORIZONTALLY AT THE CERVICAL REGION
 CROWN IS FIRST DELIVERED FOLLOWING ROOTS
 IN CASE OF LINGUOANGULAR IMPACTION RETRACTION OF THE LINGUAL MUCOSA IS
IMPORTANT
LINGUOANGULAR BUCCOANGULAR

ELEVATION FROM THE ALVEOLAR PROCESS
 IT CAN BE DONE WITH DENTAL ELEVATORS
 IN MANDIBLE THE MOST FREQUENT ELEVATOR USED IS STRAIGHT ELEVATOR,PAIRED
CRYER
 CAREFUL APPLICATION OF FORCE SHOULD BE DONE IN ORDER TO AVOID FRACTURE
OF BUCCAL BONE,ADJECENT TOOTH AND SOMETIME ENTIRE MANDIBLE
 THE ELEVATORS SHOULD BE PROPERLY ENGAGED TO THE TOOTH OR TOOTH-ROOT
AND FORCE SHOULD BE DELIVERED IN PROPER DIRECTION

DEBRIDMENT AND IRRIGATION
AFTER REMOVAL OF TOOTH
ALL PARTICULATE BONE CHIPS AND DEBRIS SHOULD BE DEBRIDED
THOROUGH IRRIGATION WITH STERILE SALINE INCLUDING UNDER THE REFLECTED SOFT TISSUE
FLAP
A PERIAPICAL CURETTE CAN BE USED
A BONE FILE CAN BE USED TO SMOOTHEN ANY SHARP,ROUGH EDGE OF BONE
A HEMOSTAT CAN BE USED TO REMOVE ANY REMNANT OF DENTAL FOLLICLE
CLOSURE OF THE FLAP SHOULD BE DONE BY PRIMARY SUTURES

LINGUAL SPLIT-BONE TECHNIQUE
 DEVELOPED BY -- FRY &DESCRIBED BY -- WARD IN 1956
 USED TO REMOVE IMPACTED 3RD MOLARS IN ALL POSITION PROVIDED THEY ARE NOT BUCCOVERSION
 USEFUL IN REMOVING DEEPLY POSITIONED HORIZONTAL AND DISTOANGULAR IMPACTED 3RD MOLARS
 IT INVOLVES SPLITTING THE LINGUAL CORTEX AND ELEVATING THE TOOTH IN DISTOLINGUAL DIRECTION
 THE INCISION STARTS IN THE BUCCAL SULCUS AT ABOUT THE JUNCTION OF MIDDLE AND POSTERIOR 3RD OF THE 2ND
MOLAR AND PASSING UPWARD TO THE GINGIVAL MARGIN AT THE DISTAL ASPECT OF THAT TOOTH
 FROM THIS POINT THE INCISION COURSE BEHIND THE 2ND MOLAR TO THE MIDDLE OF ITS POSTERIOR SURFACE AND
THEN DISTOBUCCALY UP THE RAMUS TOWARDS THE CHEEK
 IF GREATER ACCESS IS NEEDED THE ANTERIOR ND OF THE INCISION CAN BEGIN IMMEDIATELY DISTAL TO THE FIRST
MOLAR

Vertical stop cut
Split of Disto
lingual bone
Elevation
Horizontal cut
Removal of distal
& buccal bone
Removal of disto
lingual bone
Incision
Closure

LINGUAL SPLIT BONE TECHNIQUE BY LEWIS
 FLAP IS DESIGNED SUCH THAT BONE BODY ATTACHED TO THE FLAP IS
PRESERVED
 FLAP IS RAISED LINGUAL TO II MOLAR AND NOT THE IIIMOLAR
 VERTICAL LINGUAL STEP CUT IS GIVEN JUST DISTAL TO THE II MOLAR
 LINGUAL PLATE IS HINGED AS AN OSTEOMUCOPERIOSTEAL FLAP
 LESS TISSUE TRAUMA THAN OTHER
ACCEPTED TECHNIQUE
 ASSISTS IN PRIMARY WOUND CLOSURE,
 OBLITERATION OF DEAD SPACE,

Sagittal split ramus osteotomy
 Conventionally used for orthognathic surgery.
 Amin 1995, Toffanin 2003, and Jones 2004 have
advocated this technique for remiving impaction
in indicated cases.
 Advantages
 Good access
 Conserve bony structure
 Allows nerve to be seen and avoided
 Disadvantages
 Occlusion at risk (risk)
 Unfavourable split either proximally or distally
 Indication:
 Deeply impacted in close proximity with IAN

Buccal corticotomy
 Alternative approach to deeply seated
impacted third molar
 Advocated by Tay in 2007
 Trapezoid mucoperiosteal flap raised
 Rectangular bony window made and
removed
 Mesial and distal cut extended till inferior
border.
 Tooth removed.

LATERAL TREPHINATION TECHNIQUE
 prophylactic removal of developing 3rd molar
 age group 10 to 16 yrs
 before calcified cusps are united
 a modified s-shaped incision is made from
retromolar fossa across the external oblique ridge
 then it curves down along the mucous membrane
above the vestibule extending upto 1st molar
 leaving behind 5mm cuff of attached mucosa at the
distobuccal region of 2nd molar
 the buccal cortical plate is trephined over 3rd molar
 then vertical cuts are made anteriorly and
posteriorly
 these cuts are joined and buccal plate is fractured
out
 exposing 3rd molar crypt completely
 elevator then applied to deliver the tooth

BUCCAL APPROACH VS LINGUAL APPROACH
 BUCCAL APPROACH
ADVANTAGES
MORE TRADITIONAL
EASY TO GET THE TOOTH
WHEN PATIENT IS CONCIOUS
NO DAMAGE TO LINGUAL PERIOSTEUM
BOTH CHISEL&BURS CAN BE USED
DISADVANTAGES
THICK BUCCAL PLATE
MORE P.O OEDEMA
INCIDENCE OF DRY SOCKET IS HIGHER
LINGUAL APPROACH
ADVANTAGES
EASIER THAN BUCCAL
LESS TIME CONSUMING
LESS P.O OEDEMA
DRY SOCKET INCIDENCE IS NEGLIGIBLE
DISADVANTAGES
DIFFICULT TECHNIQUE IN CONSIOUS PATIENT
ONLY CHISEL&MALLET TO BE USED
CHANCE OF LINGUAL NERVE INJURY
SLIIPING OF TOOTH INTO LINGUAL POUCH

COMPLICATIONS INTRAOPERATIVE
 DURING INCISION
facial or buccal vessel may be cut
lingual nerve injury
retromolar vessels
 DURING BONE REMOVAL
damage to second molar and roots
fracture of mandible
bleeding
 DURING ELEVATION
crown fracture
root fracture
fracture of the jaws
slipping of tooth into lingual pouch
damage to nerve
aspiration of the tooth
 DURING DEBRIDEMENT
damage to inferior alveolar nerve

POSTOPERATIVE
 PAIN
 SWELLING/EDEMA
 HEMATOMA
 BLEEDING
 TRISMUS
 INFECTION
 DRY SOCKET
 TMJ PAIN
 PARAESTHESIA
 SENSITIVITY
 LOSS OF VITALITY
 POCKET FORMATION

INCIDENCE OF NERVE INJURY
 LINGUAL NERVE-0-23%
 INFERIOR ALVEOLAR NERVE-0.4-8.4%
CLINICAL MANIFESTATIONS OF NERVE INJURY
anaesthesia or hypoesthesia for more than 3 months
tongue , lip & cheek biting
altered mastication & taste
triggering,signs(tingling,electric sensation over the injured site that does not extend distally)
no or minimal response to instrumentation
absence in the detection of sharp, dull, moving tactile stimuli & two point discrimination
increase in hot or cold temperature threshold

CAUSES FOR LINGUAL NERVE INJURY
 CLUMSY INSTRUMENTATION POOR FLAP DESIGN
 FRACTURE OF LINGUAL PLATE
 RAISING & RETRACTING MUCOPERIOSTEAL FLAP
 VARIATION IN LINGUAL NERVE POSITION

PREVENTION OF LINGUAL NERVE DAMAGE
 USE OF BROAD LINGUAL RETRACTOR
 BUCCAL APPROACH WITHOUT A LINGUAL RETRACTOR SHOULD BE THE STANDARD
APPROACH
 AVOIDING LINGUAL FLAP RETRACTION
 USE OF SMALL 10MM MALLEABLE RETRACTOR
 SPLITTING WITH BUR RATHER THAN USING LINGUAL SPLIT TECHNIQUE

MANAGEMENT OF LINGUAL NERVE DAMAGE
 SURGICAL TREATMENT SHOULD BE UNDERTAKEN AFTER 3MONTHS TO
LOCATE & SUTURE THE NERVE
 WHILE SUTURING CARE MUST BE TAKEN TO AVOID INTERPOSITION OF
NON NERVOUS TISSUE
 NONOPERATIVE TREATMENT – CORTICOSTEROID
 CHANCES OF NEUROMA.

CAUSES OF INFERIOR ALVEOLAR NERVE INJURY
 DEEPLY PLACED IMPACTED MOLAR
 MESIOANGULAR & HORIZONTAL IMPACTION
 SURGICAL TECHNIQUE USING BUR
CONDITIONS FAVOURING NERVE INJURY
INTERUPTION OF WHITE LINE OF CANAL
DEFLECTION OF ROOT
DIVERSION OF CANAL
DARK &RIGID APEX OF ROOT
NARROWING OF CANAL
NARROWING OF ROOT

 MANDIBLE FRACTURE
• RARE
• DEEPLY IMPACTED THIRD MOLAR IN OLDER
INDIVIDUAL WITH DENSE BONE
• USE OF EXCESSIVE PRESSURE WITH ELEVATORS
• SHOULD PERFORM IMMEDIATE REDUCTION AND
FIXATION OF FRACTURE.
INJURY TO ADJACENT TEETH
•DAMAGE TO FILLINGS AND ADJACENT TEETH,
• DAMAGE TO BRIDGEWORK OR TO SURROUNDING BONE CAN OCCUR
DURING THE REMOVAL OF IMPACTED WISDOM TEETH.

DISPLACEMENT INTO LINGUAL POUCH
INDEX FINGER IN THE LINGUAL ASPECT
MOBILIZE THE TOOTH TOWARDS SOCKET
CAREFULLY ELEVATE THE TOOTH

 TMJ PAIN
 TMJ DYSFUNCTION FOLLOWING THE REMOVAL OF WISDOM TEETH IS
UNUSUAL AND USUALLY TEMPORARY.
 IF TREATMENT IS REQUIRED, IT IS USUALLY CONSERVATIVE IN NATURE AND
INCLUDES ANTI-INFLAMMATORY MEDICINES, PHYSICAL THERAPY AND IN
SOME CASES SHORT TERM BITE SPLINT THERAPY.

PAIN
 USUALLY REACHES MAXIMUM DURING FIRST 12 TO
24 HOURS POSTOPERATIVELY.
 NSAIDS BEFORE SURGERY MAY OR MAY NOT BE
BENEFICIAL
 MOST IMPORTANT DETERMINANT OF AMOUNT OF
POST OPERATIVE PAIN IS THE LENGTH OF OPERATION.
 THERE IS A STRONG CORRELATION BETWEEN POST OPERATIVE PAIN AND TRISMUS

 EDEMA
 USE OF CORTICOSTEROIDS.
 ICE – MAY BE COMFORTING BUT HAS LITTLE EFFECT ON SIZE OF
SWELLING.
 SWELLING REACHES MAXIMUM BY END OF SECOND POST OPERATIVE
DAY AND RESOLVED BY 5TH TO 7TH DAY.

 TRISMUS
 USE OF CORTICOSTEROIDS.
 MINIMAL FLAP REFLECTION
 CAREFUL PLACEMENT OF MOUTH PROP
 LENGTH OF SURGERY
 REACHES MAXIMUM BY SECOND POST
OPERATIVE DAY AND RESOLVED BY END OF FIRST
WEEK.
INFECTION
 INCIDENCE BETWEEN 2-3%
 50% ARE LOCALIZED SUBPERIOSTEAL ABSCESS
WHICH OCCUR 2-4 WEEKS AFTER
USUALLY CAUSED BECAUSE DEBRIS UNDER THE FLAP
DEBRIDEMENT AND ANTIBIOTICS.

 BLEEDING
 use good surgical technique, minimize trauma, avoid tears of flaps.
 most effective measure to achieve hemostasis is via moist gauze pressure over wound.
 application of topical thrombin on gelfoam into socket and oversuturing.
 other hemostatics: oxidized cellulose (oxycel or surgicel), microfibrillar collagen
(avitene).
 patients with acquired or congenital coagulopathy may need blood product
replacement.

 ALVEOLAR OSTEITIS (DRY SOCKET)
• INCIDENCE BETWEEN 3% AND 25%.
• INCIDENCE APPEARS HIGHER IN SMOKERS AND
FEMALES TAKING ORAL CONTRACEPTIVES.
• PATHOGENESIS NOT ABSOLUTELY DEFINED BUT MOST
LIKELY RESULT OF LYSIS OF FULLY FORMED BLOOD CLOT
BEFORE THE CLOT IS REPLACED WITH GRANULATION
TISSUE.
• THIS FIBRINOLYSIS OCCURS DURING
THE 3RD – 4TH POST OPERATED DAY
•GOAL OF TREATMENT IS RELIEF OF PAIN
•IRRIGATION OF EXTRACTION SITE
•PLACEMENT OF EUGENOL DRESSING
•ANALGESICS
•PAIN USUALLY RESOLVES WITHIN
3-5 DAYS BUT UP TO 10 TO 14 DAYS

AIR EMBOLISM/ SUBCUTANEOUS EMPHYSEMA
 A GAS RELATED EMBOLUS CAN BE CAUSED BY INADVERTENT INJECTION OF A
MIXTURE OF AIR AND WATER UNDER PRESSURE
 WHICH THEN PASSES INTO THE MANDIBLE (JAW) TO THE VEINS AND THEN TO THE
LARGE VESSELS LEADING TO THE HEART.
 LARGE AMOUNTS OF AIR CAN CAUSE SERIOUS PROBLEMS INCLUDING CARDIAC
ARREST AND DEATH,
 BY TRAVELING TO THE LARGE VEINS LEADING TO THE HEART, AND MECHANICALLY
BLOCKING THE FLOW OF BLOOD THROUGH THE HEART.

CORTICOSTERIODS
 INHIBITS PROSTAGLADIN SYNTHETASE
 HENCE PREVENT THE INFLAMMATORY COMPLICATIONS OF REMOVAL OF 3RD MOLAR
 HENCE REDUCES SWELLING AND PAIN
 ABSOLUTE CONTRAINDICATED
TUBERCULOSIS
OCULAR HERPEX SIMPLEX
ACUTE PSYCHOSIS
 RELATIVE CONTRAINDICATION
EARLY PREGNANCY

NSAID
 BLOCKS PROSTAGLANDIN SYNTHESIS
 LOKKEN IN 1980 INDICATED PARACETOMOL THOUGH NOT A PROSTAGLANDIN
SYNTETASE BLOCKER BUT CAN BE EFFECTIVE IN REDUCING PAIN IN FIRST 24
HRS
 IT ACTS BY ACCELERATING THE CONVERSION OF PROSTAGLANDIN G2
 A PRIME FACTOR IN OEDEMA AND PAIN

CONCLUSION
 EXTRACTION OF IMPACTED THIRD MOLAR NOT ONLY INCLUDES A
PROPER TECHNIQUE WITH MAXIMUM CONSIDERATION FOR
COMPLICATIONS
 BUT ALSO THE EVALUATION OF THE PSHYCOLOGICAL FACT OF THE
PATIENT UNCERTAINITY OF THE PROCEDURE
 THE COMBINATION OF BOTH PATIENT PSHYCOLOGY AND SURGEON
ABILITY WILL ONLY LEAD TO A SUCCESSFUL TREATMENT

Management of impacted3rd molar

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