Guide : Dr. Keerthi. R By : Dr. Shreedevi.

B Oral & Maxillofacial Surgery

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Contents
         

Introduction Definition Causes Indications and contraindications Classification Clinical examination Assessment Surgical procedure Post operative care Complications
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Introduction
Origin- Latin -- Impactus
"IMPINGO", "IN" and Pingo or strike.

 Heironymous cardus -Dens sensus et

sapientia et intellectus.  Dens sapientia  Dens serotinus lateness  Allen - wisdom tooth (1685)
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Impaction -Definitions
 Impacted Tooth : 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. American society of oral surgeons 1971
 Andreason:

Is defined as a cessation of the tooth eruption caused by a clinical or radiographically detectable physical barrier in the path or by an ectopic position of tooth.

 Archer:

A tooth which is completely or partially un erupted and is positioned against another tooth , bone, or soft tissue so that its further eruption is unlikely, described according to its anatomic position

 Lytle (1979):

A tooth that has failed to erupt into the oral cavity to

its functional level of occlusion, beyond the time usually expected for that tooth to erupt and is prevented by adjacent hard or soft tissue including overlying teeth or dense soft tissue

 Peterson:

A tooth is considered to be impacted when it has

failed to fully erupt in the oral cavity within its expected developmental time period and can no longer do so.

 WHO:
Impaction is any tooth that is prevented from reaching its normal position in the mouth by tissue or bone or another tooth
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Theories of impactionDurbeck
    

Phylogenic theory Mendelein theory Orthodontic theory Pathological theory Endocrine theory

Phylogenic theory: Nature tries to eliminate the disused theory: organs i.e., use makes the organ develop better, disuse causes slow regression of organ. organ. [More[More-functional masticatory force better the development of the jaw] Changing nutritional habits of modern civilized man in last 2000 years have practically eliminated needs for large powerful jaws, thus, over centuries the mandible and maxilla decreased in size leaving insufficient room for third molars. molars.
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Orthodontic theory: Jaws develop in downward and theory: forward direction. Growth of the jaw and movement of direction. teeth occurs in forward direction. Any thing that direction. interfere with such movement will cause an impaction (small jaw-decreased space). jawspace). A dense bone decreases the movement of the teeth in forward direction. direction. Causes for increased density of bone a) Acute infection, b) Local inflammation of PDL c) Malocclusion, d) trauma, e) Early loss of primary teeth arrested growth of the jaw. jaw.
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Mendelian theory: Heredity is most common theory: cause. cause. The hereditary transmission of small jaws and large teeth from parents to siblings. siblings. This may be important etiological factor in the occurrence of impaction. impaction. Pathological affecting an condensation preventing the jaws. jaws. theory: Chronic infections theory: individual may bring the of osseous tissue further growth and development of the

Endocrinal theory: Increase or decrease in theory: growth hormone secretion may affect the size of the jaws 10

Causes -Berger
Local causes
A. Obstruction of the eruption  Compact bone  Dense soft tissue  Premature loss /Retained deciduous tooth  Scar tissue  Gingival fibromatosis  Cyst formation, Odontogenic tumor  Ankylosis
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 Change in angulations of the tooth  Chronic inflammation  Reduced jaw growth  Irregularities of adjacent tooth  Arch length tooth material discrepancy  Ectopic position of tooth bud

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Systemic causes
Prenatal causes:  Heredity Post natal causes  Rickets  Anemia  Congenital syphilis  Tuberculosis  Malnutrition  Endocrinal causes- thyroid, parathyroid
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 Rare conditions: * Cleidocranial dysostosis * Oxycephaly * Osteopetrosis * Progeria

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Indications
 Pain  Infection - Pericoronitis, Abscess  Pathological resorption of 2nd , 3rd

molar  Jaw going for irradiation  Mobility of 2nd molar  Unrestorable caries
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 Facilitate orthodontic treatment  Tooth in fracture line  Retained tooth in edentulous jaw  Periodontal diseases  Prior to orthognathic surgery  Radiological evidence of pathology

cyst, tumor
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 Prophylactic removal  Prosthodontic reasons  Autogenous transplantation  Previous attempted extraction  To prevent jaw fracture  Recurrent trauma
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Mandibular Fracture
 Weak areas : angle, condyle & parasymphysis region.  Frequency of occurrence of mand. angle # is higher in

pts, with impacted lower third molars & that of condylar # is higher in pts, without it. (Lida & colleagues,2004)  Mechanism: occupy osseous space decreasing crosssectional area of bone.

 Absence of unerupted 3rd molars is significantly

associated with higher incidence of condylar #. Combination of symphysis & condyle # seen in cases without impacted lower third molars. 18 (Zhu et al , 2005)

MANDIBULAR SAGITTAL SPLIT OSTEOTOMIES

 Prior to orthognathic surgery : Patients with bony vertical

impactions and those who are scheduled for rigid fixation without maxillomandibular fixation. 1 year prior to the planned orthognathic surgery.
 Simultaneous with orthognathic surgery : Teeth where in intra-

operative removal is facilitated by the planned osteotomies and the surgical flap design does not compromise the vascular supply to adjacent dentoalveolar structures may be extracted intraoperatively.
 Following orthognathic surgery : rarely planned following SSRO
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Additional considerations
 Data suggests that asymptomatic patients

with a pocket depth around third molars greater than 5mm, have significantly increased levels of inflammatory mediators vs patients with pocket depths less than 5mm. White, R; et al. JOMS 60:1241-1245, 2002
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 Presence of periodontal disease is significantly

associated with pre-term birth. Data from 1,020 obstetric patients Results more significant if perio disease around third molars Moss, K; et al. JOMS 64:652-658, 2006
 Patients with visible third molars are more

likely to have progression of periodontal disease than patients without third molars Blakey, G; et al. JOMS 64:189-193, 2006
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Contraindications
Local contraindications:  Adequate space  Abutment tooth  Deeply placed tooth  Acute infections  Recently irradiated jaw

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Systemic contraindicationsrelative
 Uncontrolled diabetes  Uncontrolled hypertension  Cardiac diseases  Liver diseases  Steroid therapy  Blood dyscrasias
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 Fever of unexplained origin  Congestive cardiac failure  Renal failure  Pregnancy-1 & 3

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Absolute contraindications
 Acute pericoronitis  Acute necrotising ulcerative gingivitis  Haemangioma  Thyrotoxicosis
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A strong indication for removal of impacted third molar should be complemented with a strong contraindication to its retention
Mercier P, Precious D, Risk and benefits of removal of impacted third molars, IJOMS 21:17, 1992.

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Order of Frequency of Impacted Teeth

Maxillary 3rd Molar Mandibular 3rd Molar Maxillary cuspids Mandibular bicuspids Mandibular cuspids Maxillary bicuspids Maxillary central incisors Maxillary lateral incisors According to Archer
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Sequelae
 Infection  Eruption cyst  Periodontal  Orthodontic  Ankylosis  Proximal caries  Pain

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 RISK OF CYST & TUMOR

DEVELOPMENT:
Most common age : 20- 25 years. Incidence of cyst formation-2.31% al,2000) (Guven et

Incidence of dentigerous cyst- 1.6% (Keith,1973) Incidence of ameloblastoma 0.14- 2% (Shear,1978) Risk of surgical morbidity increases with age
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 Mandibular Angle Fractures (3.8 times more) (-Monty Reitzik ,J Oral Maxillofac Surg 1995:53:649)  Trismus
 Eye blindness, Iritis, Dimness of vision  Ear ringing sound, otitis  Damage to adjacent tooth

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Development of Mandibular rd Molar 3



9 yrs. tooth germ visible cusp mineralization completed - located with in ant. border of ramus facing anteriorly at the level of occlusion plane crown formation complete 50% roots formation completed - body of mandible grows at the expense of ant. border of ramus - position changes to approx. root level of 2nd molar - angulation becomes more horizontal root formation complete with wide apex 95% of 3rd molars have already erupted
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 11 yrs.

 14 yrs.  16 yrs.

 18 yrs.  24 yrs.

Mandibular third molar impaction classification

Aim :
 Describe general position of impacted

tooth.  Estimation of difficulty in removal.

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Mandibular third molar impaction classification

Winters classification [1926]
1. Mesio angular 2. Horizontal 3. Vertical 4. Disto angular 5. Lingo angular 6. Buccoangular 7. Inverted These may also occur simultaneously inina. Buccal version b. Lingual version c. Torsoversion

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WINTERS CLASSIFICATION

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Modified winters classification

 Vertical impaction +/_ 10  Mesio & disto angular +/_ 11-70  Horizontal > +/_ 70-100  Other types Buccolingual

mesioinverted, distoinverted

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Archer (1975) & Kruger (1984)

Angulation :
 Mesio angular  Horizontal  Vertical  Disto angular  Lingo angular  Buccoangular  Inverted
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Based on the nature of overlying tissue - [Peterson]

Soft tissue impaction impaction Partial bony

Bony impaction
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Pell And Gregory Classification [1933]

1.Based on the space available distal to 2nd molar

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2.Relative depth of third molar in bone

POSITION A

POSITION B

POSITION C
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3.Position of the tooth in relation to long axis of second molar

1. Mesio angular 2. Horizontal 3. Vertical 4. Disto angular 5. Lingual deflection 6. Buccal deflection 7. Inverted 8. Torsion
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4. Complications

 Abnormal root curvature  Hypercementosis  Proximity to mandibular canal  Bone density  Adipose tissue  Lack of accessibility  Inflexibility of muscles of mouth
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AAOMS & ADA CLASSIFICATION

07220 07230 07240 07241 soft tissue impaction. partial bony impaction. complete bony impaction complete bony impaction with unusual complications.

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Killey & Kay's classificationA. Angulation and position -Vertical - Mesioangular - Distoangular - Horizontal - Transverse - Buccoangular, lingoangular - Inverted - Aberrant position
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B. State of eruption- Erupted - Partially erupted - Unerupted soft tissue impaction - Complete bony impaction C. Number of roots Unfavorable impaction- Mesial curvature of

roots - Multiple roots

 Favorable impaction- Fused roots

- Distal curvature of roots

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Assessment
 Preoperative assessment:

- Clinical assessment - Radiological assessment - Psycological assessment

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Clinical assessment
 General assessment

* Age * Systemic condition * Medical risk * General examination * Drug history * Anesthesia history
 Extraoral examination

Intraoral examination * Mouth opening * Tongue size * Status of dentition * Extensibility of lips

* Swelling * Presence of Sinus * Lymphnode * Trismus

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Assessment of impacted teeth

 Status of eruption  Periodontal status  External/internal oblique ridge  Relationship with adjacent teeth  Soft tissue covering  Occlusal relationship

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Radiographic assessmentIndications
    

For orthodontic treatment plan. Rule out pathologic changes Eruption predilection For treatment plan in surgical removal Identify proximity of vital structures.

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Intra oral radiographs

 IOPA  Bite wing  Occlusal view

Indications :  Tooth in alveolus  Adequate mouth opening  Relationship with inferior alv canal
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Extra oral radiographs

 OPG  Lateral cephalometrics  Lateral oblique view of mandible

Special techniques:  CT scans ( Dodson 2005)  MRI Indications:  Trismus  Tooth in aberrant position  Associated pathology  Relationship with inf alv canal
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Radiological assessment
 Angulation, Depth , Space available  Crown size  Roots - Configuration , Length , development, Curvature, size  Bone texture & density  Nature of covering tissue  Follicular size  Accessibility  Inferior alveolar vascular bundle
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Factors that make surgery less difficult

 Mesio angular position  Class I molar relation  Class A depth  Roots 1/3-2/3 formed  Fused conical roots  Wide periodontal ligament  Large follicle  Young age  Sep from 2 nd molar, inferior alveolar canal  Soft tissue impaction
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Factors that make surgery more difficult

 Disto angular position  Class III molar relation  Class C depth  Long thin roots  Divergent curved roots  Narrow periodontal ligament  Thin follicle  Elder age  Contact with 2nd molar, inferior alveolar canal  Bony impaction
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Assessment of difficulty PEDERSON SCALE

Position of the molar
Mesioangular Horizontal Vertical Distoangular 1 2 3 4 1 2 3 Difficulty score Total
Easy Moderate Difficult 34 56 710

Relative depth
Class A Class B Class C

Relation with ramus and space available

Class 1 Class 2 Class 3 1 2 3

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Criteria of modified parent scale

 Easy I

- Extraction requiring forceps only  Easy II - Extraction requiring osteotomy  Difficult III - Extraction requiring osteotomy and coronal section  Difficult IV - Complex extraction (root section)
(Marcio Deniz ,The British asso of oral maxillofac surg 2005)

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WHARFE ASSESSMENTMac Greger

Winters classification  Horizontal 2  Mesioangular 1  Vertical 0  Distoangular 2 Height of mandible. (mm)  1-30 0  31-34 1  35-39 2

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Angle of the second Root shape and development. molar. (degrees) a. Less than1/3complete - 2  1-59 0 b. 1/3-2/3 complete - 1  60-69 1 c. More than 2/3  70-79 2 Complex - 3  80-89 3 Unfavourable curve - 2  90+ 4 Favourable curve - 1

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Follicle Normal 0 Possible enlarged (-1) Enlarged (-2) Impaction relieved (-3)

Exit path. Space - 0 Distal cusp covered- 1 Mesial cusp covered- 2 All covered - 3

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Winters assessment-WAR lines

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Winters WAR lines

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Relationship of Root to Canal

Related but not involving the canal
Separated Adjacent Superimposed


Related to changes in the roots

Darkening of root Dark and bifid root Narrowing of root Deflected root

Related with changes in the canal Interruption of lines Converging canal Diverted canal

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Relationship of Inferior Alveolar Nerve to the Roots of Third Molar

Roods Radiographic Criteria:

Darkening of root

Deflection of root

Narrowing of canal

Dark & Bifid apex

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Related with changes in canal

 Loss of lines  Converging canals  Diverted canals

Rood & Shebab criteria (Rood JP ,Shihab BA - British J OMFS 1998:28:20)

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Radiological prediction of inferior alveolar nerve injury

 According to J. P. Rood, B. A. A. Nooraldeen Shehab,

Diversion of mandibular canal Darkening of root Interruption of white lines Narrowing of roots Deflection of roots Narrowing of mandibular canal Dark and bifid root

Br Jr of Oral and Maxillofacial Surgery 1990; 28: 20-25 J Oral Maxillofac Surg 2003; 61: 417- 421 65 J Oral Maxillofac Surg 2005; 63: 3-7

RELATION SHIP TO LINGUAL NERVE

(Antony Pogrel ,J oral maxillofac Surg 1995:53:1178)

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Surgical procedure
 John tomes-1848-extn of 2nd molar-

Impaction  Steele-1895- Grinding of distal surface of 2nd molar  NOVITSKY-1890-1st to raise the flap and remove bone  Edmund kells-1918-tooth sectioning.  Winter-1926-chisel (ossisector)
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Treatment plan
 9 to 10 years prophylactic removal

- Enucleation (Henry &Morant 1936) - Germectomy (Ricketts 1972)

 10 to13 years- create adequate space for eruption by

proximal striping of primary tooth

 Just before crown is fully formed Henry -> 1/3 root

formed
 2/3 of root is developed (NIH Health consensus

development conference)
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Instrumentation
             

Mouth mirror Probe No 15 blade on a Bard Parker handle. Mosquito artery forcep Howarths nasal raspirator Retractors Chisel Mallet Bur: No 8 rose head, straight fissure Elevators Bone file Needle holder Tissue forceps Scissors

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SURGICAL PROCEDURE
         

Asepsis and isolation Anesthesia Incision and flap design Reflection of mucoperiosteal flap Bone removal Tooth sectioning Elevation & Extraction Debridement Closure Postoperative care
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Choice of anesthesia
 Apprehension level
 The patients acceptance of the procedure  The length and technical difficulty of the

procedure
 Physical status of the patient
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Indications of GA/sedation
Fear of pain during the procedure Emotionally unstable patient Anticipated lengthy procedures Removal of all four impacted molars in one sitting  Uncooperative patients  Allergy to LA  Tooth in aberrant position
   
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Advantages of LA
 Less expensive  Less bleeding  Less complications  Patient will be conscious  Medically compromised patients  Simple, short time procedures

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Incision and Muco periosteal Flap

Principles of flap  Accessibility  Vascularity  Base wider than apex  Rest on sound bone  Full thickness flap  Should not extend too far distally
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MUCOPERIOSTEAL FLAP
Incision 3 parts: Anterior, Posterior & Intermediate limb

 Not to be extended too distally Bleeding from buccal vessels & other arteries. Postoperative trismus temporalis muscle damage. Herniation of buccal fat pad. Damage to lingual nerve (lingual extension).
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Factors Governing Planning of Incision

Surgical access Healing of sutured wound dry socket Periodontal health of II molar distal pocket Suture line must rest on normal bone Partly visible crown: de-epitheliazation

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L-shaped incisionss

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Bayonet-shaped incision

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Envelope incision

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Wards incision

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FLAP DESIGN

ENVELOPE FLAP

THREE CORNERED FLAP

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MODIFIED FLAP DESIGN

SZMYD DESIGN

TRIANGULAR DESIGN

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MOORES FLAP

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Vestibular Tongue shaped Flap

 Berwick in 1986 designed a vestibular

tongue shaped flap.  Extended into the buccal shelf of the mandible.

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Comma incision

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Paragingival single flap, distal end incision Prof Kapadia`s cunicular incision

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Flap reflection
Instruments:  Howarth nasal raspirator
 Le cluse elevator  Hopkin & molt periosteal elevator  Aim- Exposure of tooth & Bone
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Flap retraction
       

Howarth nasal raspirator Thimble Austin retractor Ward killner retractor Dysons Malleable copper retractor Mac gregor periosteal elevator Fickling periosteal elevator Read periosteal elevator
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Criteria
Access Instruments Procedure Operating time Technique Bone removal Post op pain Post op edema Dry socket Bruising of face

Buccal Approach
Easy Chisel or Bur Tedious Time consuming Easy Less More High Possible

Lingual Approach
Difficult Only chisel Easy Less Difficult More Less Less Absent
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Thick buccal plate Thin lingual plate

Bone Removal
Aim:
1. To expose the crown by removing the bone overlying it. 2. To remove the bone obstructing the pathway for removal of the impacted tooth.

Types:
1. By consecutive sweeping action of bur (in layers). 2. By chisel or osteotomy cut (in sections).

How much bone has to be removed?

1. Bone should be removed till we reach below the height of contour, where we can apply the elevator. 2. Extensive bone removal can be minimized by tooth sectioning.
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Indications for use of chisel

 Young patients with elastic bone  Tooth which dose not require sectioning,

performed under G A  External oblique ridge should be below the level of bone enclosing tooth.  Internal oblique ridge should be behind the tooth.
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Methods of bone removal

 With Bur:

1.Buccal guttering technique 2.Postage stamp technique 3.Collar technique (Moore & Gillbe) 4.Lateral trepanation technique [Bowdler Henry]  With Chisel: 1.Window technique 2.Shaving technique 3.Lingual split technique 4.Distal lingual split technique
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Chisel vs Bur
Sl.No Criteria. Chisel&Mallet Bur Easy. Controlled. 1. 2. Technique Control over bone cutting Difficult Uncontrolled

3. 4. 5. 6. 7.

Patient acceptance. Healing of bone. Postoperative edema Dry socket. Postoperative Infection.

Not tolerated in L.A. Good Less Less. Less.

Well tolerated in L.A. Delayed Healing More. More. More.

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Bone Removal Techniques

Moore & Gillbes Collar Technique
 Conventional tech of using bur.  Rosehead round bur no.3 is used to create a gutter    

along the buccal side & distal aspect of tooth. A point of elevation is created with bur. Amount of bone sacrificed is less. Can be used in old patient. Convenient for patient.

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Split Bone / Lingual Split Technique

Sir William Kelsey Fry(1933)
- Quick & clean technique. - Reduces the size of blood clot by means of saucerization of socket. - Decreased risk of damage to the periodontium of the second molar. - Less risk of inferior alveolar nerve damage. - Decreased risk of socket healing problems. - Can use regional anesthesia but endotracheal anesthesia is preferred one. - Only suitable for young adults whose bone is elastic. - Inconvenience to patients due to chisel usage.
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Incision

Vertical stop cut

Horizontal cut

Distal cut

Removal of distal & buccal bone

Elevation

Removal of tooth

Closure
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Modified Lingual Split Technique for Removal of Mandibular Third Molar

(Dr. Davis 1979)

Incision

Vertical stop cut

Distal cut
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Tooth elevation

Closure
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Kamanishi modification:  Do not raise the lingual flap  Advance to the lingual side under the bone only to the extent which is necessary. Lewis modification:  Flap was made lingual to second molar instead of third.  Vertical lingual step cut just distal to second molar.  Lingual plate was hinged like an osteoplastic flap.  It is considered as combination of both lingual and buccal approach 101

Lateral Trepanation Technique

Bowdler Henry
-

Employed to remove any partially formed unerupted 3rd molar that has not breached the overlying hard & soft tissues.

- Age 9-18 yrs

-

GA/LA with sedation. Excellent PDL healing on distal surface of 2nd molar. Bone healing is excellent as there is no loss of alveolar bone around 2nd molar.

Disadvantage increased buccal swelling

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Lateral Trepanation Technique

Bowdler Henry

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Chisel technique Buccal approach

 Elevation of mucoperiosteal flap  Vertical limiting cut -5-6mm  Oblique cut -45 deg  Removal of triangular plate of bone  Point of application of elevator  Distolingual bone fractured parallel to

internal oblique ridge

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Tooth Division
Rationale of tooth sectioning is to create a space into which impacted tooth can be displaced & then removed. Tooth is sectioned in various ways depending on the type & degree of impaction.

Mesioangular Impaction

Horizontal Impaction 106

Disto Angular Impaction

Vertical Impaction

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Debridement of Wound & Closure

 Thorough debridement of the socket by Periapical

curettage.
 Smoothening of sharp bony margins by Bone file / burs.  Thorough irrigation of the socket Betadine solution +

Saline .
 Initial wound closure is achieved by placing 1stsuture

just distal to 2ndmolar, sufficient number of sutures to get a proper closure.

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Wound closure
Principle:
 Use as few sutures as possible.  Suture should penetrate the lingual flap close to

and behind the third molar and the buccal flap further distally.  Should not be excessively tight.  Suture distal to second molar - importance.  Determination of suture requirment is done in half closed mouth position.
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Post Operative Instructions

 Pressure pack 1hr  Ice application  Soft diet 1st two days  1st dose of analgesic should be taken before the anesthetic effect of

LA wears off.
 Avoid strenuous exercises for 1st 24 hrs.  Avoid gargling / spitting / smoking / drinking with straw.  Warm water saline gargling after 24 hrs + mouth wash regularly

thereafter.
 Suture removal on 7th POD.
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Complications
Intra Operative 1. During incision a. Injury to facial artery b. Injury to lingual nerve c. Hemorrhage careful history 2. During bone removal
a. Damage to second molar b. Slipping of bur into soft tissue & causing injury c. Extra oral/ mucosal burns d. Fracture of the mandible when using chisel & mallet e. Subcutaneous emphysema 3. During elevation or tooth removal

Luxation of neighbouring tooth/ fractured restoration Soft tissue injury due to slipping of elevator Injury to inferior alveolar neurovascular bundle Fracture of mandible Forcing tooth root into submandibular space or inferior alveolar nerve canal f. Breakage of instruments g. TMJ Dislocation careful history 111

a. b. c. d. e.

Nerve Injuries
 0.6-5% of all the third molar surgeries are involved

with nerve damages of which 0.2% are irreversible

 IAN: Immediate disturbance - 4-5% (1.3-7.8%)

Permanent disturbances - <1% (0-2.2%)

 Lingual N: Immediate - 0.2-22%

Permanent - 0-2%
 96% IAN injuries show spontaneous recovery within 9

months, better than lingual nerve which is about 87%.

 Beyond 2yrs recovery is unlikely.

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Treatment Flowchart for IAN Injury

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Treatment Flowchart for Lingual Nerve Injury

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Post operative           

Hemorrhage Pain Trismus Swelling Hematoma Sorethroat Pyrexia Surgical emphysema Wound dehiscence Paresthesia Alveolar ostitis Periodontal defect of the adjacent tooth
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Dry socket
Coined by Crawford(1896)  Alveolitis sicca dolorosa Empty socket  Focal osteomyelitis Painful socket  Postoperative osteitis Sloughing socket  Alveolalgia Necrotic socket  Fibrinolytic alveolitis Delayed extraction  Alveolitic osteitis Fibrinolytic osteitis  Sclerosing osteomyelitis Alveolar osteitis  Localized acute alveolar osteomyelitis  Post extraction osteomyelitic syndrome

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Dry socket-Definition
 Shafer-a focal osteomyelitis in which the

blood clot has disintegrated or been lost, with the production of a foul odour and severe pain, but no suppuration  MacGregor 1968- classically occurs after forceps extraction and the diagnosis is made by excluding the other causes of pain.
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Dry socket-Definition
 Post operative pain in and around the

alveolus which increases in severity at some moment between 2-3 days after a dental extraction accompanied by partial or total disintegration of the intra alveolar clot accompanied with a foul smell.

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Aetiology
 Alling and kerr-gross amount of peridontal

     

membrane adherent to teeth after extraction appeared to predispose development of dry socket. Lysis of formed clot Trauma Reduced blood supply- Diabetes, vasoconstrictors Generalised debilitation Dense bone Smoking

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Local factors
Birns theory of fibrinolysis

Fibrinolytic activity of alveolar bone than the bacteria. Nitzins theory Trauma reduced resistance to infection Bacterial theory
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Clinical features
 Pain

-Dull aching pain -2-3 days after extraction  Empty socket -Sensitive, gray  Foul smell  Bad taste
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Treatment
      

Mechanical debridement Zinc oxide eugenol Curettage Tetracycline Topical metronidazole Benzocaine Formula as given by AllingEugenol--46% Balsam of peru 46% Chlorobutanol 4% Benzocaine 4%
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Use of Endoscopic Approach for Ectopic Mandibular 3rd Molar

(BJOMS 2003; Oct. 41: 340-42)

Adv: Less tissue damage Good illumination Clear magnified visualization of operative field More conservative surgery with precision dissection. Disadv: Costly Needs specific equipments Good hand-eye coordination and training required
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Serriah A.Ayoub : Bjoms 2004; 42: 203-208] 203Adv:  Less stressful  Less unpleasant  No vibrations & sound  Sharp clean cut through the bone & tooth  Can be used in anxious patients Dis adv:  It is more technique sensitive.  more chances of Trismus.  Time consuming  Costly
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 Use of Erbium (Er):YAG laser [by M.AbuM.Abu-

Conclusion
 Impacted teeth are a medical deformity with variable

presentations, brought about by the dietary changes of modern civilization, or genetic predisposition. the problem of the underdeveloped jaw and resulting Class II or class III malocclusion to the extent present in modern society.

 Our recent ancestors did not experience this problem or

 Oral & Maxillofacial surgeons should be aware of the

devastation that impacted teeth can cause to the jaws and overall health of an individual and hence should undertake a rational treatment approach after performing a clear clinical and radiographic assessment of the patients mouth & reviewing the pathological ramifications resulting from impacted teeth.
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References
 Harry Archer Oral & Maxillofacial Surg. Vol I  Geoffrey Howe Minor Oral Surg.  Kelley & Kay The Impacted Wisdom tooth.  Pederson- Oral surgery  Peterson Contemporary Oral & Maxillofacial Surg.  Dental Clinics of North America  Textbook & colour atlas of tooth impaction- Andreasen.  Impacted teeth- Alling & Alling.  Textbook of oral & maxillofacial surgery-Srinivasan.  Textbook of oral & maxillofacial surgery-Nilima Malik
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Journals
 JOMS 1995; 53:1178-1181.  JOMS 2006; 64:94-99  JOMS 2005; 63:1443-1446  OOO 2001; 92:377-83  OOO 2006; 102:448-52  OOO 2006; 102:300-6  JOMS 2006; 64:1371-1376  OOO 2006; 102:154-8  JOMS 2005; 63:3-7
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