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Management of impacted mandibular third mola

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Atul Dwivedi
Hubei Polytechnic University
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CONTENTS :-

TOPIC PAGE-No

- DEFINITION 3

-REVIEW OF LITERATURE 4

-CAUSES OF IMPACTION 13

-CLASSIFICATION OF IMPACTED
MANDIBULAR MOLARS 14

-INDICATIONS FOR REMOVAL OF

IMPACTED TEETH 18

-CONTRAINDICATIONS FOR REMOVAL

OF IMPACTED TEETH 21

-RADIOLOGICAL ASSESSMENT 23

-ARMAMENTARIUM REQUIRED 30

-SURGICAL PROCEDURE FOR

EXTRACTION OF THIRD MOLAR 33

-OPERATIVE COMLICATION 48

-POSTOPERATIVE COMPLICATIONS
& TREATMENT 51

-CASE REPORTS 52

- SUMMARY 57

- BIBLIOGRAPHY 58

2
DEFINITION:-

AN IMPACTED OR EMBEDDED TOOTH:-

Fig 1:showing impacted third molar

The tooth that has failed to erupt completely or partially to its correct position in
the dental arch & its eruption potential has been lost(3)

AN UNERUPTED TOOTH :-

Is a tooth that is in the process of eruption , is likely to erupt based on clinical &
radiographic finding.(3)

MALPOSED TOOTH:-

A tooth unerupted or erupted which is in an abnormal position in the maxilla or

mandible.(3)

3
REVIEW OF LITERATURE:-

Cosme Gay Escoda et al in the year of 1983 described a modified

distolingual splitting technique for the removal of impaction of various
classes
In this technique the lingual soft tissue is not separated from the bone. In
addition the fragmented lingual bone attached to the periosteum is not
removed. This procedure is best performed with the patient under sedation or
general anesthesia.
International Journal of Oral Surgery, Oral Medicine, Oral Pathology
Volume 56, Issue 1, July 1983, Pages 2-8

Dr. R.J.Stephens et al in the year of 1983 conducted a study which

compared the result of periodontal evaluation of two mucoperiosteal flaps
used in the removing impacted mandibular third molar.
15 patients were given periodontal examination consisting of measurement
of attachment level, level of gingival margin & width of the masticatory
mucosa around the mandibular second molar at the time of 2,6 & 12 weeks
after removal of third molar.
Analysis indicated that there was no significant difference between the two
flap techniques & therefore the choice of flap technique is one of the
operator preference.
Journal of Oral & Maxillofacial Surgery, Volume 41, Issue 11
November 1983, Pages 719-724

Cosme Gay Escoda et al in the year of 1988 conducted a study for the
indication used for removal of mandibular third molar. The indication for
removal was classified as prophylactic in 27% & as orthodontic in 14%, as
carious up to 13% & due to pathologic entities like cyst, tumor & root
resorption were registered in less than 3% each. More than half of removed
third molar ( 54%) presented no symptom.
International Journal of Oral & Maxillofacial Surgery, Volume 17
Issue 3, June 1988, Pages 161-164

4
Dr. Jin Cheol Kim & Seong Gon Kim et al in the year of 1989 described
the relationship of the roots of mandibular third molar to the inferior dental
FDQDO7KHSRVLWLRQRIFDQDOLQWKHGHYHORSLQJPDQGLEOHLVGLVFXVVHGLW¶V
relationship to the mandibular third molar are classified & their diagnosis by
mean of radiographic examination is mentioned. Finally precautions to
minimize the risk of such injuries are briefly mentioned.
Journal of Oral Surgery, Oral Medicine, Oral Pathology, Volume 12,
Issue 9, September 1989, Pages 1061-1072

P.Mercier & D.Precious in the year of 1992 presented a review about risk &
benefits of removal of impacted third molar teeth is presented in 4 categories
risk of nonintervention, risk of intervention & benefit of nonintervention,
benefit of intervention. The prudent course of action for the clinician to
follow is based on rational clinical decision making using traditional method
of evaluation, to effect the optimal outcome keeping the interest of individual
patient above all else.
International Journal of Oral & Maxillofacial Surgery, Volume 21,
Issue 1, February 1992, Pages 17-27

Dr.B Kahl et al in the year of 1994 presented a study based in long term
follow up orthopantomograph of 251 adult orthodontically treated former
patient. The study showed 113 clinically asymptomatic impacted third molar
in 58 patient. Radiographic assessment revealed contact of impacted third
molar with second molars. Resorption of the mandibular second molars &
reduced bone height on the distal side of second molar as well as
pathologically widened pericoronal spaces of the mandibular third molar.
The lack of predicting factor such as age & period of impaction, extent of
space deficiency, developmental stage, level of eruption & bone condition
lead the author to recommend that former orthodontic patient be recalled at
the regular intervals for assessment of changes in the condition & position of
erupting or impacted third molar.
International Journal of Oral & Maxillofacial Surgery, Volume 23,
Issue 5, October 1994, Pages 279-285

5
Abel Garcia & Francisco Gude et al in the year of 1999 conducted a study
for the evaluation of trismus & pain after removal of impacted third molar &
investigated whether these responses were related to difficulty of surgery.
They concluded that trismus is less severe after simple extraction ( grade I )
then after surgical extraction ( grade II to IV ) however the trismus severity
after surgical extraction does not depend on difficulty of surgery. Regardless
of extraction type pain decline between days 1& 5 post surgery.
Journal of Oral Surgery, Oral Medicine ,& Oral Pathology, Volume 87,
Issue 3, March 1999,Pages305-310

Jirapan Punwutikon et al in the year of 1998 conducted a study to analyze

the occurrence of symptom in patient with unerupted mandibular third molar
& to investigate the associated pathoses.
The study shows that the most of the patient were in the third decade of life.
Partially erupted mandibular third molar had more symptom than completely
unerupted teeth. Pain & pericoronitis were the most common problem in the
patient with unerupted third molar.
Oral Surgery, Oral Medicine, Oral Radiology, Endodontic
1999 ;87:305-310

Soren Eliason, Anders Heimdahl et al in the year of 2000 conducted a

study where pathological changes related to impacted third molar, where
studied in a radiographic investigation of 2128 randomly selected patient.
The risk of pathological sequelae, because of impacted third molar is
apparently low. Prophylactic surgical removal should therefore be regarded
with some reserve particularly in view of high frequency of deep impactions
with greater risk for surgical complication.
International Journal of Oral & Maxillofacial Surgery, Volume 29,
Issue 2, April 2000, Pages 131-135

6
Orhan Guven, Ahmet et al in the year of 2000 conducted a study determine
the incidence of development of cyst & tumor around third molar. The
analysis revealed 231 cysts ( 2.31% ) & 79 tumor ( 0.79 % ) including 7
benign tumor ( 0.77 % ) & 2 malignant tumor ( 0.02 % ).The incidence of
cyst & tumor around impacted third molar was 3.10 %
International Journal of Oral & Maxillofacial Surgery, Volume 29,
Issue 2, April 2002, Pages 232-235

Jasser Maajta et al in the year of 2000 conducted a study to evaluate the

association of mandibular angle fracture with the presence & state of the
eruption of mandibular third molar. The result of this study showed that the
mandibular angle, that contain an impacted third molar is more susceptible to
fracture when exposed to an impact than an angle without a third molar.
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology,
Endodontic, 2000;89:143-146

Betaineh AB et al in the year of 2001 conducted study to evaluate the rate &
factor influencing sensory impairment of the inferior alveolar & lingual nerve
after the removal of mandibular third molar under local anesthesia. They
concluded that the elevation of lingual flap & experience of the operator are
significant factor contributing to lingual & inferior alveolar nerve
parasthesia.
American Association of Oral & Maxillofacial Surgeons, Volume 19,
Issue 5, March 2001, Pages 512-514

Wofford DT, Miller R in the year of 2001 conducted a prospective study of

dysesthesia following odontectomy of impacted mandibular third molar.
Analysis of possible etiologic factor reveals that development of dysesthesia
of inferior alveolar nerve & lingual nerve is more likely to occur with
complete bony impacted mandibular third molar when bur are used to
remove bone & when roots approximate the inferior alveolar canal.
International Journal of Oral & Maxillofacial Surgery, Volume 30,
Issue 4, August 2001, Pages 306-312

7
M.Penarrocha et al in the year of 2001 presented a study to evaluate the
association between oral hygiene before surgery & pain, inflammation,
trismus after surgical removal of 190 impacted lower third molar. They
concluded that the poor oral hygiene before the surgical removal of 190
impacted lower third molar is correlated with greater postoperative pain.
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology,
Endodontic, 2001;92:260-264

Philippe Libersa et al in the year of 2002 conducted a retrospective study,

to analyze immediate & late mandibular third molar fracture after impacted
lower third molar surgery. The result of study shows that the major incidence
of immediate & late mandible fracture occur in patient older than over 25
years. Men may be more likely to have late fracture.
American Association of Oral & Maxillofacial Surgeons 2002;60:163-
165

Nicholas A , Drage Tara et al in the year of 2002 presented a case report

based on the relation of inferior alveolar nerve injury to mandibular third
molar surgery. Perforation of the lower third molar roots by inferior alveolar
nerve is uncommon & can be difficult to determine by conventional
radiographic method.
Presented is a case of perforation that was treated by coronectomy .the
radiographic assessment of root perforation & imaging modalities used to
asses such cases are discussed,
Oral Surgery, Oral Medicine, Oral pathology, Oral pathology .Oral
Radiology Endodontic 2002;93:358-361

Inqibiorg S et al in the year of 2003 conducted a study to identify risk

indicator for extended operation time & postoperative complication after
removal of mandibular third molar. They concluded that the several
indicator were found to increase the risk of postoperative complication but a
visible inferior alveolar nerve during the operation was repeatedly found to
be the highest single risk factor.
International Journal of Oral & Maxillofacial Surgery, Volume 23
Issue 8, October 2003 Pages 224-227

8
Tay AB et al in the year of 2004 presented a study to determine the incidence
of inferior alveolar nerve parasthesia in patient with an exposed inferior
alveolar nerve bundle seen intra operatively. They concluded that sighting an
exposed intact inferior alveolar nerve bundle during third molar surgery
LQGLFDWHLW¶VLQWLPDWHUHODWLRQVKLSZLWKWKHWKLUGPRODU FDUULHVDULVNRI
parasthesia with a 70% chance of recovery by 1 year from surgery.
Journal of Oral & Maxillofacial Surgery, Volume 26, Issue 5, May
2004, Pages 592-600

Peter Marker, Arne Eckerdal et al in the year of 2005 presented a

investigation which was carried out of 57 cases of mandibular fracture, where
a completely or partially impacted third molar was present in the line of
fracture. It is concluded that closed reduction with retention of mandibular
third molar within the line of mandibular angle fracture can be carried out
with less morbidity compared with cases in which rigid fixation is used &
movement of jaw permitted immediately
Journal of Oral & Maxillofacial Surgery, Volume 39, Issue 11, March
2005, Pages 340-343

Nieves Almendros et al in the year of 2005 presented a study based on the

influences of lower third molar position on the incidence of preoperative
complication. In this study position of affected teeth, based on classification
of Pell & Gregory & Winter. They concluded that the mandibular position of
the impacted third molar may be able to be correlated to the development of
complication resulting from impaction removal. Vertical third molar in
position II A & II B of Pell & Gregory classification with partial mucosal &
bony coverage are the most susceptible to undesired outcome.
Journal of Oral & Maxillofacial Surgery, Volume 22, Issue 8,
November 2005, Pages 161-165

Miloro M et al in the year of 2006 presented a report to determine the

radiographic proximity of the mandibular third molar to inferior alveolar
nerve. They concluded that unerupted mandibular third molar teeth are closer
to inferior alveolar nerve than are erupted teeth. Mesioangular mandibular
third molar are most closely positioned to inferior alveolar nerve & this may
represent an independent risk factor for postoperative parasthesia.
Journal of Oral & Maxillofacial Surgery, January 2006, Volume 18,
Issue 1, Pages 74-82

9
Arotiva G.T et al in the year of 2006 conducted a prospective study to
investigate radiologic & clinical factor associated with increased difficulty in
removal of impacted third molar. They conclude that both clinical &
radiologic variable is important in predicting surgical difficulty in impacted
third molar extraction.
Journal of Oral & Maxillofacial Surgery, 2006 May, Volume 62, Issue
5,Pages 592-600

Atieh M.A et al in the year of 2006 presented a review to determine the

diagnostic accuracy of panoramic radiographic marker in the detection of the
relationship between the mandibular canal & root of third molar. The result
of this meta analysis suggested that the additional studies are need to
examine a more accurate, accessible & cost effective initial radiographic
technique.
Journal of Oral Surgery, Oral Medicine, Oral Pathology, Oral
Radiology, October 2006, Volume 15, Issue 5, Pages 545-549

Danda AK et al conducted a study to compare the influence of primary &

secondary closure of surgical wound on postoperative pain & swelling after
removal of impacted mandibular third molar. The result of study has shown
that the patient in the secondary closure group had a significantly lesser
amount of pain & swelling postoperatively than the primary closure group.
Journal of Oral & Maxillofacial Surgery, February 2007, Volume 19,
Issue 1, Pages 117-128

Koerner K.R et al in the year of 2007 presented an article review factor

relating to removal of impacted third molar. It covers the difficulty &
indications of procedure. Specific method may vary among dental surgeon
based on training & experience but they all should correspond to basic &
established principle of surgical technique.
Journal of Oral Maxillofacial Surgery, October 2007, Volume 65, Issue
10, Pages 1977-83

10
Boffano P et al in the year of 2007 described the article based on the surgical
extraction of deeply horizontally impacted lower third molar, the presence of
deeply horizontal impacted third molar is unusual. More over an increased
risk of caries in second lower molar is possible. Different therapeutic
approaches could be proposed for third molar impaction & malposition.
Journal of Craniofacial Surgery, October 2007, 92( 4), 377-83

Inaoka SD et al conducted a study in the year of 2008 to relate the condylar

& angle fracture with an unerupted lower third molar taking into account the
position of tooth. They concluded that the absence of impacted third molar
may increase the risk of condylar fracture & decrease the prevalence of
mandibular angle fracture.
Journal of Oral Maxillofacial Surgery, September 2008, Volume 15,
Issue 6, Pages 535-538

Fernandes MJ et al presented a report in the year of 2009 based on

incidence of symptom in previously symptom free impacted lower third
molar assessed in dental practice. These symptoms can be linked to clinical
characteristics, life style or socio demographic status. They concluded that
the predictability that an impacted lower third molar will develop symptom in
future remains unclear. Some clinical characteristics such as angulation &
patient age could be useful in predicting the likelihood of future
symptomatology.
Journal of Oral Surgery & Oral Medicine, Oral Radiology, September
2009, Volume 10, Issue 5, Pages 218-220

McGowan DA et al in the year of 2009 reported a prospective study which is

based on the rate & factor influencing sensory impairment of the inferior alveolar
& lingual nerves after the removal of impacted mandibular third molar under local
anesthesia. They concluded that the elevation of lingual flap & experience of the
operator are significant factor contributing to lingual & inferior alveolar nerve
parasthesia.
Journal of Oral Surgery, Oral Medicine & Oral Pathology, November 2009,
Volume 8, Issue 6, Pages 326-328

11
Bodina L et al in the year of 2010 presented a study to evaluate the effectiveness
of therapeutic laser in the control of post operative pain, swelling & trismus
associated with the surgical removal of impacted third molar. They concluded that
the use of therapeutic laser in the post operative management of patient having
surgical removal of impacted third molar decreases post operative pain, swelling
& trismus without statistically significant differences.
Journal of Oral Surgery, Oral Medicine & Oral pathology January 2010
7:5;37-43

Janakiraman EN et al in the year of 2010 presented a prospective analysis of

frequency & contributing factor of nerve injuries following third molar surgery.
They concluded that the various factors such as lingual retraction, surgical time
operator experience, radiologic finding contributing to the injury were correlated
& analyzed.
Journal of Craniofacial Surgery, May 2010, 21:3;784-6

Manicone P et al in the year of 2010 presented a case series based on a novel

surgical approach to impacted mandibular third molar to reduce a risk of
parasthesia. They concluded that the staged approach is the best approach which
includes the surgical removal of mesial portion of anatomic crown to create the
adequate space for third molar migration. After the migration of third molar had
taken place the extraction could be accomplished in second surgical session
minimizing neurological risk.
Journal of Oral & Maxillofacial Surgery, May 2010, 68:5;969-74

12
CAUSES OF IMPACTION

Inadequate Space In The Dental Arch For Eruption----

{a} THE PHYLOGENIC THEORY :-

To due evaluation, the human jaw size is becoming smaller & since the
third molar last to erupt. There may not be room for it to emerge in the oral
cavity.(36)

{b}MENDALIAN THEORY:-
.
Here the genetic variations play a major role. if the individual genetically
receive a small jaw from one of the parents/ or large teeth from the other
parents then the teeth can be seen impacted because of lack of space.(36)

LOCAL CAUSE OF IMPACTION

{a} Obstruction For Eruption

-- Irregularity in position & pressure of adjacent tooth.

--Density of overlying & surrounding bone.
{b} Lack of space in the dental arch
because of crowding, supernumery teeth.
{c} Ankylosis of permanent or primary teeth.
{d} Nonabsorbing of tooth bud,. Over retained deciduous teeth
{e} Ectopic position
{f} Dilaceration of root.
{g} Associated soft tissue or bony lesion.
{h} Habit involving tongue, finger, thumb, cheek, pencil.(4)

SYSTEMIC CAUSES OF IMPACTION OF TOOTH:-

(a) Prenatal causes²heredity
(b) Postnatal--- ricketts, anamia, tuberculosis, congenital syphilis, malnutrition
(c) Endocrinal disorder of thyroid. parathyroid, pituitary gland hypothyroidism,
achondroplasia etc.
(d) Hereditory linked disorder²GRZQV\QGURPHKXUOHU¶VV\QGURPH
osteoporosis, cleidocranial dysostosis, cleft palate
Here failure of overlying bone to resorb & develop an eruption pathway Absent.(4)

13
CLASSIFICATION OF IMPACTED MANDIBULAR THIRD
MOLAR:-

Maxillary & mandibular third molars are classified radiographically by

Angulation, depth & arch length or relationship to the anterior aspect of ascending
mandibular ramus.

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µ$QJXODWLRQ¶DFFRUGLQJWRWKHSRVLWLRQRILPSDFWHGWKLUGPRODU to the long axis

of the second molar.(36)
:LQWHU¶VFODVVLILFDWLRQLQVXJJHVWHG----
(1) Mesioangular
(2) Horizontal/ transverse/ inverted
(3) Vertical
(4) Distoangular
(5) Buccoangular
(6) Linguoangular

a b

c d
Fig 2 : showing ± (a) mesioangular
(b) horizontal
(c) vertical
(d) distoangular

There may be simultaneously²

(a) Buccal version
(b) Lingual version
(c) Torso version

14
µ'HSWK¶DVSHUUelationship to the occlusal surface of the adjoining
second molar of the impacted mandibular third molar
the depth can be judged. (36)

[1] Position A--- the highest position of the tooth is on a level with or
above the occlusal line
.

[2] Position B--- highest position is below the occlusal plane but above
the cervical line.

[3] Position C--- highest position of the tooth is below the cervical level
of the second molar.

a b

Fig 3:- showing (a) position A

(b) position B
(c) position C

15
>%@3(// *5(*25<¶6&/$66,),&$7,21:-

Relationship of the lower third molar to the ramus of the mandible &
second molar( based on the space available distal to the second molar)(36)

Class I--- Sufficient space available between the anterior border of the
ascending ramus & the distal side of the second molar for the
eruption of the third molar.

Class II---The space available between the anterior border of the ramus
& the distal side of the second molar is less than the
mesiodistal width of the crown of the third molar.

Class III---The third molar is totally embedded in the bone from the
ascending ramus because of absolute lack of space.

a b

Fig 4: showing (a) Class I

(b) Class II
(c) Class III

16
FREQUENCY OF IMPACTION :-

Impacted teeth seen in the following order of frequency (3)

1) Mandibular third molar

2) Maxillary third molar
3) Maxillary canine
4) Mandibular premolar
5) Maxillary premolar
6) Mandibular canine
7) Maxillary incisor
8) Maxillary lateral central incisor

** Mesioangular impaction is generally acknowledged as the least

difficult impaction to remove.
-The mesioangular impacted tooth in tilted toward second molar
in a mesial direction.
-This type of impaction is also the most the commonly seen & comprises
43% of all impacted teeth.

** In severe mesial inclination the impacted tooth is horizontal

-This type of impaction is usually concidered more difficult to remove
than the mesioangular impaction.
This is only seen in approx 3% of all mandibular impaction.

** Vertical impaction occurs with the second greatest frequency

accounts for approx 38% of all impaction.

** The distoangular impaction is the tooth with the most difficult

angulation for removal.
-This impaction is difficult to remove because the tooth has withdrawal pathway
that runs into the mandibular ramus & its removal require greater surgical
intervention.
-This accounts for only approx 6% of all impacted third molar.

** Teeth can also angled in buccal or lingual direction

occationally a tooth is angled toward the buccal aspect of mandible or
in buccal version.

17
INDICATIONS FOR REMOVAL OF IMPACTED TEETH:-

*During normal development of lower third molar begins its development in a

horizontal angulation as the tooth develops the jaw grows & angulation change
from horizontal to mesioangular to vertical.

*Failure to rotation from mesioangular to the vertical direction is the most

common cause of tooth remaining impacted.(3)

Indications are:-

[a] Prevention of periodontal diseases-

- Erupted teeth adjacent to impacted teeth are predisposed to

periodontal disease.
- The mere presence of an impacted lower third molar decrease. The
amount of bone on the distal aspect of an adjacent second molar.
- Because of most difficult tooth surface to clean is the distal aspect of last tooth
in the arch causing gingival inflammation & then apical
migration of gingival attachment , which result in the early formation
of severe periodontal disease.
- Patient with impacted lower third molar often have deep periodontal
pocket on the distal aspect of second molar.
- By removing the impacted third molar early periodontal disease can be
prevented.

[b] Prevention of dental caries:-

.
-When third molar is impacted or partially impacted the bacteria that cause
dental caries can be exposed to the distal aspect of second molar as well as
third molar.
-Even in situation in which no communication between the mouth &
The impacted third molar exists. There may be enough communication to allow
for caries production.

18
[c] Prevention of odontogenic tumor & cyst:-

-When the impacted teeth are retained with the alveolar process & associated
follicular sac is also retained, although in most patient the follicle maintain its
original size. It may undergo cystic degeneration become a dentigerous cyst or
keratocyst.
-Odontogenic cyst can also occur around impacted teeth, odontogenic tumor
can arise from the epithelium.
-The most common odontogenic tumor occur in this region is ameloblastoma.
-Occationally other odontogenic tumour may occur in cojunction with impacted
teeth.

[d] Prevention of pericoronitis:-

-Pericoronitis is an infection of the soft tissue around the crown of a partially

impacted tooth & is caused by the normal oral flora.
-Pericoronitis can arise secondary to minor trauma from a maxillary third
molar.
-Another cause of pericoronitis is entrapment of food under the operculum
. Food may be packed in the pocket between the operculam & the impacted
tooth.
-Streptococci & large variety of anaerobic bacteria cause pericoronitis.
-Pericoronitis can lead to serious fascial space infection . Because of infection
begin in the posterior mouth. It can spread rapidly in to fascial spaces of
mandibular ramus & the lateral neck.
-Prevention of pericoronitis can be achieved by removal of impacted third
Molar

[e] Prevention of root resorption:-

-Impacted tooth causes sufficient pressure on the root of an adjacent tooth to

cause root resorption.
-Removal of impacted tooth may result in salvage of the adjacent tooth by
cemental repair.

19
[f] Impacted teeth under a dental prosthesis:-

-After teeth are extracted the alveolar process slowly undergoes resorption thus
the impacted tooth become closer to surface of the bone giving the appearance
of erupting.
-The denture may compress the soft tissue on the impacted tooth. which no
longer covered with bone result is ulceration of overlying soft tissue &
initiation of odontogenic infection.
-Impacted tooth should be removed before prosthesis construction.

[g] Treatment of pain of unexplained origin:-

-Occationally patient come to the dentist complaining of pain in the retromolar

region of the mandible for no obvious reason.
-If the patient has unerupted tooth , removal of tooth sometime results in
resolution of the pain.

[h] Prevention of fracture of the jaw:-

- An impacted third molar in the mandible occupies space that is usually filled
with bone. This may weaken the mandible & render the jaw more susceptible to
fracture.
- If the jaw fracture through the area of an impacted third molar ,the third molar
is frequently removed before the fracture is reduced & inter maxillary fixation is
applied.

[i] Facilitation of orthodontic treatment:-

-In the patient who requires retraction of 1molar by orthodontic technique. The
pressure of impacted may interfere with the treatment.
-Therefore it is recommended that impacted third molar be removed before
orthodontic therapy is begin.

[j] Optimal periodontal healing:-

-One of the most important indication for removal of impacted third molar
is to preserve the periodontal health.
- It should be noted that the completely bony impacted third molar in a
patient older than age 30 should probably be left in place unless some specific
pathology develop. Removal of such asymptomatic completely impacted third
molar in older patients will clearly result in pocket depth & alveolar bone loss
which will be greater than if the tooth were left in place.

20
CONTRAINDICATIONS FOR REMOVAL OF IMPACTED
THIRD MOLAR:-

*All impacted tooth should be removed unless specific contraindication justify

leaving them in position.(3)
* When the risks are greater than the potential benefits the procedure should be
differed.
* Contraindication for removal of impacted teeth primarily involve the
3DWLHQW¶s physical status.

[1] The most frequent reason is the poor systemic condition of the patient unless
one is dealing with the treatment of malignant neoplasm, it is always possible
to adopt a temporizing approach in a patient who is a bad surgical risk.

[2] A second reason for attempting to maintain an impacted mandibular third

molar is when there is some question about the future status of second molar.
(e.g. Deep caries, a large restoration, endodontic treatment, or extensive
alveolar bone loss).
In such cases it is assumed that if the second molar has to
be extracted at some time. The third molar will either move in to a more
functional position or at least serve as a bridge abutment.

[3] The most common contraindication for removal of impacted teeth in advanced
age. As the patient ages the bone become highly calcified therefore less
flexible & less likely to bend under the force of extraction.
The result is that more bone must be removed to displace the tooth from its
socket.
As the patient ages they respond less favourably & with more post operative
sequelae.

21
[4] Compromised medical status

Similar to extremes of ages compromised medical status may contraindicates

the removal of an impacted tooth.
If the impacted tooth is asymptomatic its surgical removal must be viewed as
elective.
IIWKHSDWLHQW¶VFDUGLRYDVFXODURUUHVSLUDWRU\IXnction or host defenses for
combinating infection are compromised or the patient has a serious acquired or
congenital coagulopathy.
The surgeon must consider leaving the tooth in alveolar process.

[5]Probable excessive damage to adjacent structure---

- If the impacted tooth lies in an area in which its removal may seriously
jeopardize adjacent nerves, teeth or previously constructed bridge. It may be
prudent to leave the tooth in place.
- For younger patient who may suffer the sequelae of impacted teeth it may be
wise to remove the tooth while taking special measure to prevent damage to
adjacent structure.
- In older patient with no sign of impending comlication & for whom the
- probability of such complication is low the impacted tooth should not be
removed.

22
RADIOLOGICAL ASSESSMENT:-

[1] Technique ----

-A standard periapical radiograph of the mandibular third molar region is

mandatory.
-The patient is seated in the dental chair with the mandibular occlusal plane
parellel to ground floor in the mouth open position.
-Intraoral film is inserted & retained in the lingual vestibule resting on the lingual
surface of the molar.
- Ideally anterior edge of the film should correspond to the mesial surface of the
first molar & superior edge should be marginally above the occlusal plane of the
mandibular tooth.
- The x ray cone is placed in such a way that the central rays pass through the
distal cusp of second molar tooth at right angle to the x ray film.(37)

[2] Type of impaction:-

It include:-
A) Angulation of impacted third molar in relation to the long axis of second
molar.
B) Type of impaction in relation to horizontal & vertical planes.
C) The position & depth with in mandible is also imported.

[3] Position & depth:-

)LJVKRZLQJ:LQWHU¶VOLQHV

They can be determined by a method originally described by µ*HRUJH:LQWHU¶

Similar to cepholometric radiograph a tracing of the intraoral periapical
radiographis taken.

23
Three imaginDU\OLQHVDUHGUDZQNQRZQDV³:LQWHUOLQHV´(as shown in fig 6)
** White line --- represents the occlusal plane the line is drawn touching
the occlusal surface of first molar & second molar & is extended
over the third molar region.
-It indicate the difference in the occlusal level of second & third molar .
-In vertical impaction occlusal surface of the impacted tooth is parellel to white
line.
- In mesioangular impaction occlusal plane of third molar meets the white line in
front of the third molar.
- The maximum contour of the impacted tooth & its relationship to the white line
will indicate the relative depth of its location.

** Amber line--- Represents the bone level.

this line is drawn from the crest of the interdental septum
between the molar or to the ascending ramus.
-This line donate the alveolar bone covering the impacted tooth & the portion of
tooth not covered by the bone.
- When the mucoperiosteal flap is reflected the position of impacted tooth above
the amber line will be visible while the rest of the portion of the impacted tooth
is embedded in the bone.
- This will indicate the extent of bone to be removed for the extraction of the
impacted tooth.

**Red line---is drawn perpendicular from the amber line to an imaginary

point of application of the elevator.
-It indicates the amount of bone that will have to removed before elevation. i.e
depth of tooth in bone & the difficulty encountered in removing the tooth.
-Usually CE junction on the mesial surface of the impacted tooth is taken as point
of application of the elevator.
-Thus the red line indicate the depth at which the impacted is located
- Only in distoangular impaction CE junction on the distal surface is taken as the
point of application of the elevator.

** It is estimated that any impacted tooth with less than 5mm long red line can
conveniently be removed with ease under local anesthesia.
-Increase in length of the red line of every additional mm render the removal of
the impacted tooth three times more difficult.
-Depending on the difficulties they are best revolved under the endotracheal
anesthesia.
-If the red line is more than 9 mm & if the impacted tooth is below the level of
the apices of the second molar. Careful planning is necessary as to whether second
molar will have adequate bony support or whether extensive removal of the bone
may render the mandibular second molar weak.

24
** buccoversion linguoversion can be identified by the relative radioopacity of
the impacted tooth in relation to second molar tooth.(37)

[4] Crown of impacted tooth:-

-Shape of crown of impacted lower third molar is seldom a major cause of

difficulty during its removal
- Teeth with large square crown & prominent cusp are more difficult to remove
than the teeth with small conical crown& flat cusp.
- Crown & cusp shape of special importance when the line of withdrawal of third
molar is completely obstructed by the presence of a part of second molar a
conditiRQLVNQRZQDVµWRRWKLPSDFWLRQ¶.
- When the tooth impaction is present the cusp of third molar is superimposed
upon the distal surface of second molar in the standard intra oral radiograph..
- In these condition the application of force to the mesial surface of the impacted
tooth will either cause damage to the supporting structure of the second molar
or even displace the tooth from its socket.
- This complication can be avoided by sectioning the impacted tooth with either a
bur or an osteotome(37)

[5] Configuration of the root of the impacted third molar(37)

The point of application of elevator & the path of delivary of impacted tooth very
greatly depending on the configuration of the root of impacted tooth to be
removed

Radiograph carefully examined with the reference to the following

(i) fused or separate roots
(ii) number of root
(iii) straight or curved root
(iv) if curved is curvature favourable or unfavourable
(v) long & slender or short root
(vi) convergent or divergent
unfavourable curvature indicate the need for tooth division technique.

Root of the second molar²if the second molar is smaller in relation to the
impacted tooth or if the roots of second molar are fused & conical.
-Operator must be careful not to luxate the second molar during the elevation.
-Similarly absence of first molar leaves the second molar unsupported.
-During elevation inadvertment luxation or dislogdement of second molar should
be avoided.

25
[6] Bone Texture:-

-This varies with individual age, sex & systemic constitution.

-Bone is cancellous & elastic in younger age group while it tend to become dence
& sclerosed as the age advances.
-It is fortunate that some indication of texture of the bone can be gained by noting
the size of cancellous spaces & density of bone enclosing them in the standard
film.
-If the spaces is large & bone structure fine, the bone is usually elastic.
-While if the space are small & bone shadow is dence, the bone is sclerotic.(37)

[7] Relationship with inferior alveolar canal:_

If the root apices are close related to inferior alveolar canal,the patient should
be sufficiently warned about the possible postoperative impairment of labial
sensation.
When in doubt it is better to employ tooth division technique to minimize the
possible nerve damage.

**Prediction of injury to the inferior alveolar nerve

Even tooth is not related injudicious elevation of mesioangular impaction may
result in root apex impinging on the inferior alveolar canal.

³+RZH 3R\WRQ´GHYHORSHGWKHFULWHULDWRGLDJQRVHWKHWUXHrelationship of the

root apices of the impacted lower third molar to the inferior alveolar canal.

** Relationship of root to the canal

[i] Related but not involving the canal

(a) separated
(b) adjacent
(c) superimposed

[ii] Related to the change in the root

(a) Darkening of the root
(b) Dark & bifid root
(c) Narrowing of the root
(d) Deflected root

[iii] Related to change in the canal

(a) Interuption (loss) of line
(b) Converging canal
(c) Diverted canal

26
[a] Related to change in the root

[i] Darkening of the root

7KURXJKRXWWKHOHQJWKRIWKHURRWLW¶VGHQVLW\LVWKHVDPH
It is not disturbed when the image of root apex & canal is superimposed.
The density of root is altered when the root impinges on the canal, in such
condition position of the root is said to be relatively radiolucent & appears dark.

[ii] Dark & bifid root

When the canal crosses the root apex. It can be identified by double periodontal
membrane shadow of bifid root.

[iii] Narrowing of the root

If there is a any narrowing of the root where the canal crosses. It denotes the
pressure of deep grooving or perforation of the root or involvement of the greater
diameter of root by the canal in some form.

[iv] Deflected root

This is seen as a deviation of root buccally, lingually or both. When it reaches the
canal it may even be deflected to mesial or distal aspect.

[b] Related to change in the canal :-

[i] Interruption or loss of white radio opaque line.

The dense root & the floor of canal are seen as two white radio opaque line in the
radiograph.
Either of them or both may be disrupted in relation to the root structure.
This is considered to indicate deep grooving of the root & loss of the dense
cortical wall of canal which is considered to be danger sign.

[ii] Converging canal

When the canal crRVVHVDURRWDSH[WKHUHLVUHGXFWLRQLQLW¶VGLDPHWHU
This narrowing or converging appearance of canal is due to the displacement of
WKHURRI IORRURIDFDQDOWRZDUGVHDFKRWKHUUHVXOWLQJLQDQµKRXUJODVV¶
appearance.
This appearance indicates partial encirclement of the canal.
This is also as danger sign.

27
[iii] Diverted canal
7KHFDQDODSSHDUVGLYHUWHGZKHQLWLVFKDQJHVLW¶VGLUHFWLRQ
This is due to an upward displacement of canal passing through the root.

** studies have revealed that any darkening of root, diversion of canal &
interruption of white lines are found to be significantly related to the inferior
alveolar nerve injury as compared to other sign.(37)

[8] Existing pathology :-

[a] Dental caries in second & third molars.

[b] Periodontal disturbance.
[c] Presence or absence of first molar.
[d] Any fusion of crown between second & third molar.
[e] Conical & fused root of second & third molar.
[f] Any associated dental pathology like odontome.

Presence of any existing pathology like cyst & tumor may predispose to
pathological fracture of the mandible.(37)

28
[9] Scoring Details For Wharf Assessment :- (37)

category score
winter classification horizontal 2
distoangular 2
mesioangular 1
vertical 0
height of mandible 1-30 mm 0
31-34 mm 1
35-39 mm 2

root shape -complex 1

-favorable
curvature 2
-unfavorable
curvature 3

Follicle - normal 0
-possibly
enlarged 1
- enlarged 2
path of exit space available 0
distal cusp covered 1
mesial cusp also
covered 2
both covered 3
angulation of third molar 1-50 0
60-69 1
70-79 2
80-89 3
> 90 4

In this type of assesment the total scoring to individual cases are directly related to
corresponding difficulties that one is liable to encounter during the removal of any
impacted teeth.

29
ARMAMENTARIUM REQUIRED :-

Fig 5: showing ± Armamentarium of third molar

surgery

The practice of third molar surgery requires a variety of instruments which may be
divided into following broad categories.(4)

[1] Extractor
These are main instruments used to physically remove teeth & tooth fragments
from their bony alveolar socket.
[a] dental forcep
[b] dental elevator

[2] Nonextractor
These are accessory instrument which are used to facilitate the exodontia
procedure in 3 ways
(a) Access to the tooth & maintenance of surgical field , clear of fluid & debris
(b) Removal of surrounding tissue
(c) Repair of surgical wound

Dental forcep
American style lower forceps may be useful for some erupted
lower third molar but often these instrument do not allow sufficient leverage force
required to remove the third molar

Dental elevator
They are used for
(a) To luxate the teeth
(b) To expand the bone socket
(c) to remove broken or surgically sectioned dental
fragment from their bony crypt or socket

30
Dental elevator are²
(a) Straight elevator
(b) Cryers elevator no 30
(c) Cryers elevator no 311
(d) Coupland bone chisel no 1
(e) Coupland bone chisel no 2
(f) Coupland bone chisel no 3
(g) Apical elevator

Instrument for access & maintaining a clear surgical field

(1) Mouth prop or gag²placed in the molar teeth to hold the mouth open.
(2) Cheek retractor
(3) Tongue retractor or depressure
(4) Flap retractor

To maintain a clear surgical field instrument requires

(1) Suction ± aspiration of pooled blood leaked from the surgical wound.
(2) Fine hemostat forcep ( mosquito forcep)
(3) Pressure pack

Instrument for removal of tissue

(1) Scalpel- scalpel handles with disposable blade no 15.
(2) Periosteal elevator used to raise or bluntly dissect a mucoperiosteal flap of
the bone
(3) Dissection scissor

For bone surgery

(1) Chisel & mallet.
(2) Osteotome² bevelled on both side.
this instrument is often used to split bone.
(3) Bone forcep² such as the rongeur used to trim bony projection.
(4) Powered handpiece & bur²surgical burs are often stainless steel or
tungsten-carbide either round or fissured.
sometimes fast cutting jet burs may be
used. Coolant sterile irrigation fluid must
always be used with powered handpiece to
avoid overheating.

31
Instruments for wound toilet & repair

[1] Tissue forcep² for picking out loose tissue debris.

[2] Curette ²used in scraping or scooping fashion to clear up fragments
of soft tissue.
[3] Irrigation syringe²filled with sterile isotonic irrigation fluid such
as saline.
[4] Suture set²used to repair the wound through primary closure of
surgical defect.
[a] Needle holder.
[b] Toothed tissue forcep--- for picking up & stabilizing the tissue to be
sutured.
[c] Suture material--- 3-0 black silk is used.
[d] Suture cutting scissor.

32
SURGICAL/ OPERATIVE PROCEDURE :-

steps are²
[1] ASEPSIS & ISOLATION
[2] LOCAL ANESTHESIA/ SEDATION + LA/ GENERAL ANESTHESIA
[3] INCISION²FLAP DESIGN
[4] REFLECTION OF MUCOPERIOSTEAL FLAP
[5] REMOVAL OF OVERLYING BONE
[6] SECTIONING OF THE TOOTH
[7] DEBRIDEMENT OF WOUND & WOUND CLOSURE

[1] Asepsis & isolation:-

Isolation of surgical site
** scrubbing + painting of skin & oral mucosa
Scrubbing solution used first on skin only.
Solution contains centrimide + absolute alcohol or centrimide + povidone +
iodine.
Or centrimide + absolute alcohol + chlorhexidine.

Cleaning solution-- used on skin only to remove residual soap solution.

normal saline.
alcohol

Painting solution²act topically to inhibit further growth of microbe.

povidone- iodine 5% for skin, 1% for oral mucosa.
chlorhexidine gluconate- 7.5 % for skin, 0.2 % for
rinsing oral cavity.

Drape the patient with sterile drape to cover upper part of face to isolate the oral
cavity. (36)

[2] Local anesthesia/ sedation + local anesthesia/ general anesthesia

For mandibular molar pterygomandibular nerve block.

Good infiltration is must to provide, haemostasis & to define the tissue plane
Saline adrenaline in concentration of 1:400000
Plane saline ( in case of hypertensive patients)
L.A solution with adrenaline.(36)

33
[3] Incision ( flap design) :--

--An impacted tooth buried under the tissue can be elevated only after gaining
adequate access & eliminating the impediment.
--Many types of incision have been advocated.
--Practically all of them have a posterior & anterior limb with or without
an intermediate limb.
--Incision should not be extended to far distally to avoid-
(a) bleeding from buccal vessels & anastomosing branches of lingual & facial
arteries.
(b) post operative trismus due to damage of temporalis muscle.

Distal incision made along the occlusal plane towards the lingual direction carries
the risk of iatrogenic injury to the lingual nerve.

Different types of flaps are:-

[i] L Shaped flap:-

Fig 6 :- showing L shape flap

--This is most commonly practiced design.

--incision distal to the second molar is angled laterally from the lateral margin of
the distolingual cusp of second molar.
--The total length of distal incision is around 2 c.m.
-- Anterior limb is vestibular extension at the level of second molar.
-- If wider exposure is desired it can extend anteriorly upto first molar
but it carries the risk of damaging the facial vessels. If it is extended
beyond the vestibular depth.

34
--Both the limb of incision joint at the distobuccal region of the second molar
tooth. During the elevation of flap severing of the distal attached gingiva at the
junction of both limb can iatrogenically result in gingival recession post
operatively.
-- It can be avoided if the incision is made such a way that it avoids the damage to
distal epithelial attachment of second molar by rendering the junction of both the
limb as a smooth one sweep curve.
-- This will also avoid the extension towards the vestibule by extending the
anterior limb curved anteriorly above the vestibular level.
-- Mesial limb start at mid point of the buccal free marginal gingiva of second or
first molar. This is to avoid splitting the interdental papilla.
-- Another modification has been suggested by shifting the distal incision away
from the distobuccal aspect of second molar.
-- In this type the intermediate limb is vertical towards the junction of both the
limb.(38)

[ii] Envelop flap:-

Fig :- 7 showing Envelop flap

--In this flap the distal limb is similar to the l shape flap. The difference lies in the
anterior limb.
--It confines itself along the free gingival margin.
--,W¶VDQWHUior extension is directly proportional to the depth at which impacted
tooth is present,
. Hence deeper the tooth longer the anterior extension.
--Envelop flap is preferred technique. It is easier to close & heals better than three
cornered flap.
--It is preferred incision for removal of an impacted mandibular third molar.
--It extends from mesial papilla of mandibular first molar around the neck of tooth
to the distobuccal line angle of the second molar & then posteriorly to &
laterally upto anterior border of mandible.
--The flap is laterally reflected to approx the external oblique ridge with a
periosteal elevator. (38)

35
[iii] Bayonet shaped flap:-

Fig 8 :- showing Bayonet shaped

flap

--It has three part mesial, distal, or intermediate or gingival limb.

-- The incision for this type of flap is similar to L shape flap.
-- The junction between the two limb is the intermediate gingival incision
-- In this type more difficult is the tooth more likely that the distal incision is
placed more lingually.
-- If the mesial incision is placed or angled forward. It increases the access.
-- It also provide better blood supply to flap by the providing broader base.(38)

[iv] Triangular flap

Fig :-9 showing Triangular flap

This is the flap that keep well away from the gingival attachment of the adjacent
teeth & sweep down & forward from the distobuccal aspect of second molar in
to the mucobuccal fold enabling good access without potential periodontal
problem.

36
[4] Removal of overlying bone

Once the soft tissue elevated & retracted. So adequate amount of bone should be
removed to enable the elevation.
But extensive bone removal can be minimized by sectioning the tooth.

Two way of bone removal

(a) High speed , high torque handpiece & bur technique
(b) Chisel & mallet technique

Bur technique:_

--Either no 7/8 round bur or straight no 703 fissure bur is used.

--Either of these bur used for bone removal or sectioning of a tooth.
Bur should be always used along with copious saline irrigation to avoid thermal
trauma to the bone .

First step

Bur is used in sweeping motion around the occlusal, buccal, & distal aspect of
mandibular third molar crown to expose it to have its orientation.

Second step

--Once the crown has been located, the buccal surface of tooth is exposed with the
bur to cervical level of crown contour & buccal trough or gutter is created.
--The buccal trough should be made in the cancellous bone.
--It is important that the adequate amount of trough is created to remove any bony
obstruction for exposure delivery of tooth especially around the distal aspect of
crown.
--The distolingual portion of tooth should be exposed without cutting through the
lingual bony plate to prevent the damage of lingual nerve.(36)

37
Chisel & mallet technique

First step

Placement of vertical stop cut which is made by placing a 3mm or 5mm chisel
vertically at the distal aspect of the second molar with the bevel facing posteriorly
( 5 to 6mm).

Its aim to prevent the force transmission anterior to direction of bone removal.

Second step

--At the base of vertical stop cut the chisel is placed at the angle of 45 degree with
the bevel facing upward & occlusally. Oblique cut is made till the distal most
point of third molar.
-- This will result in the removal of triangular piece of buccal plate distal to second
molar.
--Finally distal bone is removed so that tooth is elevated .
--There should be no obstruction at the distobuccal aspect.

38
Variation in bone removal(36)

Lingual split technique:-

--This technique ZDVHYROYHG LQWURGXFHGE\µ.elsey FU\¶ ODWHUSRSXODUL]ed

E\µ7. WDUG¶
--This method is useful to remove any impacted third molar placed lingually.

a b c

d e f

Fig 10 :- showing lingual split bone technique

a) Outline of incision
b) Reflection of a mucoperiosteal flap & creation of an vertical stop.
c) Removal of the buccal plate to expose the crown.
d) Placement of a chisel to section the lingual cortex.
e) Elevation of the third molar.
f) Wound sutured

39
Steps are :-

--Vertical stop cut is made by placing the chisel with bevel facing posteriorly
distal to the second molar.

--With the chisel bevel downward a horizontal cut is made backward from the
lower end of vertical stop cut.

--The buccal bone plate is removed.

--The distobuccal bone is then fractured inward by placing the cutting edge of
chisel.

-- The chisel is held at the angle of 45 to the bone surface.

-- Finally small wedge of bone which then remaining distal to the tooth & between
the buccal & lingual cut is excised & removed.

-- A sharp straight elevator then applied & the minimum force is then used to
elevate the tooth.

--As the tooth upward & backward & lingual plate get fractured & facilitate the
delivery of tooth.

--After the tooth is removed the lingual plate is grasped with the hemostat & freed
from the soft tissue & removed.

--Smoothening of the edge is done with the bone file wound irrigate & sutured.(37)

40
LATERAL TREPHINATION TECHNIQUE

a b c

d e f
Fig 11:- showing lateral trephination technique
a) Black line indicates the line of incision.
b)Mucopeiosteal flap elevated to expose the bone.
c)Bur holes are made in accordance with the position
of underlying impacted tooth & buccal plate is
removedusing chisel & mallet.
d)Impacted tooth is seen after removal of buccal plate of bone
e)Tooth removed using appropriate elevator.
f)Wound closure

This procedure was first described by µ%RZGOHU-Henry.

--Procedure is indicated for removing an unerupted third molar in the age group of
9-16 year.
--This modified S shape incision is made from the retromolar fossa across the
external oblique ridge.
--It then curve down along the reflection of the mucous membrane above the
vestibule extending upto the first molar anteriorly.
--The mucoperiosteal flap is elevated & held in the retracted position.
-- The buccal cortical plate is trephined over the third molar crypt.
--Vertical cuts are made anteriorly & posteriorly.
-- A chisel is applied in the vertical direction over the bur hole.
-- Then the buccal plate is fractured out exposing the third molar crypt completely
-- Elevator is applied to deliver the tooth out of the crypt.
-- After the smoothening the sharp bony margin & irrigating the wound flap is
suture in position.(37)

41
[5] SECTIONING THE TOOTH
{A} Odontectomy for the vertically impacted mandibular third molar

Fig 12:- showing sectioning of the

Vertically placed third molar

-- Vertically impacted third molar frequently located beneath the ascending ramus
extends over the distal part of the occlusal surface for verying distances.

-- The incision is carried along the alveolar crest to the distal aspect of the second
molar then either in the gingival crevice to the medial aspect of the first molar
cutting horizontally across the papilla or obliquely in to the vestibule
.
-- The incision should penetrate the entire periosteum
-- It is necessary to remove considerable osseous structure to uncover the
occlusal & buccal surface
.
-- If the tooth has straight it can be elevated in vertical direction therefore it is
only necessary either to create a space little longer than the perimeter of the
crown
.
-- If the roots are curved distally however it is necessary either to remove the distal
part of the crown to create enough space for turning the tooth.

--When roots are curved mesially , so mesial part of the crown should be excised
to permit Application of an elevator between the distal surface & alveolar bone
to tilt the tooth forward.

--Frequently after removal of occlusal buccal distal bone is removed. The distal
half of the crown is sectioned & removed . The tooth is elevated by the applying
an elevator at the mesial aspect of the cervical line of the tooth

--It is more difficult than a mesioangular removal because access around the
mandibular second molar is difficult to obtain & requires the removal of
substantially more bone in the buccal & distal sides.(35)

42
{B} Odontectomy for mesioangularly impacted third molar:--

Fig 13:- showing sectioning of mesioangular

Impacted third molar

--In mesioangular impaction the third molar may or may not be locked beneath
crown of second molar.
--If correctly angulated generally will show whether the tooth can be removed by
elevation without bisection or whether this procedure would injure the second
molar.
--The incision is same as for other unerupted molars consist of an envelop flap for
high positioned teeth & an angulated flap for low positioned teeth.
--After flap reflection bone is removed until the distal buccal & occlusal surfaces
of tooth are exposed.
--If the tooth has non fused roots & is in close proximity to second molar. It is
geQHUDOO\VSOLWDORQJLW¶VORQJD[LVZLWKDEXFFDOEHYHOFKLVHOLQVHUWHGLQWKH
buccal groove directing the force as parellel to long axis as possible.
--The distal half of tooth is then removed with an elevator placed between the split
sections using the buccal plate as a fulcrum.
--This creates sufficient space for elevation of remaining half.
--If it does not split properly with bi bevel chisel a bur should be used to section
the root before removal.
--When the root are fused longitudinal sectioning is not possible & such condition
the bur is used to divide the tooth horizontally at the CE junction.
--The cut can be made completely through the tooth or groove may be extend half
way & crown split off by inserting an elevator & rotating it.
--The crown is removed by inserting a straight elevator under the medial aspect.
--An apex elevator placed between the roots & the buccal plate is used to luxate
them into the space created by removal of crown.(35)

43
{C} odontectomy for horizontally impacted mandibular third molar

Fig 14:- showing sectioning of horizontally

impacted third molar

--Most third molar in horizontal position require sectioning even they are in a high
occlusal positioning.

--Their removal is greatly facilitated if they are bisected at the neck just below the
enamel or where enamel is very thin.

-- When they are in a low position division of the tooth is always necessary.

--The incision is made in usual manner except for deeply embedded teeth in such
situation an oblique extension of the anterior end of the incision in the vestibule
provide better access & prevent tearing of gingival.

--The tooth then divided horizontally from a superior or a buccal approach.

--After the tooth has been sectioned the crown is removed with an elevator.

-- The cut surface of remaining part of tooth is carefully examined

.
-- It may be possible to disengage the roots by mean of an apex elevator inserted
on the buccal aspect or into small hole drilled in the remaining portion of tooth.

-- But if the roots are firm or extremely curved it may be necessary to devide
them with the bur & remove separately. (35)

44
{D}Odontectomy for distoangularly impacted third molar

Fig 15:- showing sectioning of

distoangularly Impacted third molar

-A distoangular position generally brings the third molar well under the ascending
ramus .

- Because of this distal curvature of the roots, it is not possible to make an

excavation in the ramus large enough for tooth to be turned.

-Incision in the same as that made for other impaction & enough bone is remove
over the occlusal & buccal surfaces to expose most of the crown.

-Ihe crown is then remove by horizontal odontotomy & roots are luxated by
leverage applied in a vertical direction at mesial as well as buccal surface of that
tooth purchase point is put a distoangular into remaining root portion of the tooth
& root are delivered by cryer elevator with wheel & axle type of motion.(35)

{E}Odontectomy for buccoangularly & linguoangularly impacted

mandibular third molar:-

-Buccoangular & linguoangular impaction are not common . The condition

should be diagnosed from radiograph taken in both a lateral & coronal view.

- Both types of teeth are best removed after they have been divided at the
junction of the roots& the crown
.
- The crown is easily removed after they have been divided at the junction of root
& the crown.

- The crown is easily removed from buccoangularly impacted teeth

.
- In linguoangularly impacted teeth retraction of the lingual mucosa is
important.(35)

45
{F} Odontectomy for mandibular third molar in inverted position:--

--Third molar is an inverted position are difficult to remove unless an odontectomy

is performed.

-- When a cyst develop around the crown of tooth may be removed in a one piece
.
-- In cases in which sectioning of tooth is indicated the procedure is not unlike that
described for deep horizontal impaction
.
-- In some cases however the roots are removed first by exposing them more
extensively. After the roots have been taken out there is more room to remove
the crown.(35)

46
DEBRIDEMENT OF WOUND & WOUND CLOSURE :-

--Once the impacted tooth is removed from the alveolar process the surgeon must
direct attention to debriding the wound of all particulate bone chips & debries.

--The surgeon should irrigate the wound with sterile saline taking special care to
irrigate the wound thoroughly under the reflected soft tissue flap.

--The periapical curette is used to mechanically debride both the superior aspects
of the socket & inferior edge of the reflected soft tissue to remove any
particulate material that might have accumulate during surgery.

--The bone file is used to smooth any sharp rough edge of bone.

--The surgeon should check for adequate haemostasis.

--Specific bleeding point should be controlled if they exist.

--The brisk generalized ooze is seen after the suture are placed, the surgeon should
apply firm pressure with a small moistened gauze pack.

--Postoperative bleeding occur relatively frequent after third molar extraction

therefore adequate hemostasis at the time of operation is important.

--Usually the closure of the incision should be a primary closure.

--Initial suture should be placed through the attached tissue on the posterior aspect
of the second molar.

--Additional sutures are placed posteriorly from that portion & anteriorly through
the papilla on the mesial side of second molar.

--Usually 3- 4 sutures are necessary to close an envelop incision. If the releasing

incision was used attention must be directed to closing that portion of the
incision as well.(36)

47
OPERATIVE COMPLICATION :-
[1] Hemorrhage

--Accidental injury of the inferior alveolar artery is most common cause of

massive hemorrhage.
--It is likely to occur if the tooth encroaches on the mandibular canal or if canal
passes between the root of tooth.
--If the tooth has already been removed packing the socket with an absorbable
material( gelatin, sponge, oxidized cellulose) & suturing the flap over the socket
usually will control the bleeding.
--Temporary packing a gauze sponge in to the socket & applying firm pressure for
5 to 10 min usually result in hemostasis & surgery can then proceed.
--If bleeding recur, it may be necessary to pack the socket & suture the wound as
would be done if the tooth had been extracted & attempt removal of the root tip
1 or 2 weeks later.(4)

[2] Injury of the inferior alveolar nerve

--In most cases inferior alveolar nerve injury is caused by injudious

instrumentation or elevation.
--Elevator should not be forced beneath the tooth if it lies close to mandibular
canal.
--A good radiograph will indicate the safest place for elevation. any force that will
crush the bony wall of the mandibular canal will cause compression of the nerve
. this is followed by anesthesia or parasthesia of the area supplied by it.
--It is particularly felt in lower lip & chin. some patients also complain of a
changed sensation in mandibular teeth supplied by nerve.
--If the accidental injury is noticed at the time of surgery the operator should
examine the depth of the socket & carefully remove any spicule of the bone that
may be pressing on the nerve.
--The inferior alveolar nerve is also may be partly or completely torn during
odontectomy because the roots of third molar have completely surrounded it.
--In such cases if recognized preoperatively the nerve should be free by resecting
one root before attempting elevation of the root
--If the nerve is torn or must be divided every effort should be made to reposition
it in the mandibular canal so that the ends are closely approximated.(35)
--As long as the nerve is lies in the canal without being obstructed there is a good
chance for regeneration & repair.

48
[3] Injury of the lingual nerve

--it can occur either when there is fracture of lingual cortex of mandible or when
the nerve is accidentally cut with the bur or chisel during odontectomy.
-- if the situation is recognized at the time of surgery the nerve ends should be
reapproximated & sutured.(35)

[4] Injury of the second molar

--Injury of the second molar may result when a third molar is in close contact with
it.
--Tooth division eliminate the worst injury i.e luxation of the second molar when
lever action is used to force the third molar .
--If partial luxation of the second molar occurs the blood supply may be
interrupted at the apices with resultant necrosis of the pulp. Endodontic therapy
will then be needed.
--Improper instrumentation also may cause trauma to the alveolar crest &
periodontal ligament of the second molar.
--If the crown of the second molar is carious, restoration should be delayed until
after removal of the third molar to avoid this complication.(35)

[5] Displacement of mandibular third molar

--Displacement of impacted third molar most often result from misdirected force
from a chisel used to section the tooth fracturing the lingual plate.
--The tooth will be dislodged either into submandibular or pterygomandibular
space.
--Removal is similar to that for a displaced root.(35)

[6] Fracture of the alveolar process

--Fracture of the lingual plate of mandible may occur when tooth is forced is that
direction by elevator technique or by a misdirected blow from a chisel during
odontotomy.
--If the piece is completely detached from the gingiva. It should be removed.(35)

49
[7] Fracture of mandible

--Mandibular fracture is a regrettable accident that fortunately rarely happens. It

may be due to injudious use of elevator or chisel.
--But most often it occurs the jaw should be immobilized by maxillomandibular
fixation using either arch bar or ivy loops.

[8] Breakage of instrument

Occasionally burs break while dividing a tooth or cutting bone the fragment
can be removed by drilling a groove around it to facilitate its being grasped
with a small hemostat.(35)

50
POSTOPERATIVE COMPLICATIONS & THEIR TREATMENT
Certain amount of swelling & pain is to expected after odontectomy & needs no
further treatment than just described.(35)
Most serious complication however are secondary hemorrhage, infection of
wound & surrounding fascial spaces & alveolar osteitis.

[1] Secondary hemorrhage

In a normal patient hemorrhage occurring 3 to 5 days after surgery is usually

due to infection although it also can be due to mechanical disruption of clot.(35)

[2] Infection

When swelling does not show sign of remission increases on appear after 3 to
5 days the cause is generally infection.
infection may be preoperative in origin,
arising from preexisting condition in the periapical or periodontal tissue or
from general sepsis
The wound also can become infected because of failure to use aseptic surgical
technique.(35)

[3] Alveolar osteitis

It is one of the most common & disagreeable complication of surgery for

impacted third molar

[4] Post extraction pyogenic granuloma

- Failure to properly debride the wound or remove bone compressed during

luxation of tooth can lead to formation of a sequestrum that ultimately
becomes infected & result in suppuration tissue.
- Usually the detected bone fragments can be visualized radiographically.
- Treatment consist of opening the wound margin to permit drainage removing
the sequestrum by gentle curettage & irrigating the socket.
- Generally antibiotic therapy or packing of the socket is not indicated.(35)

51
CASE REPORTS:-

CASE NO 1:-

Fig 1:-Intraoral view showing Fig 2:- Radiographic view showing

impacted lower left third molar horizontal impacted lower left third molar

Fig 3 :- Removal of overlying bone Fig 4:- Third molar removed

Fig 5:- Wound closure Fig :- Extracted tooth

52
CASE NO 2

Fig 1:- Intraoral view showing impacted Fig 2:- Radiographic view showing
Lower left third molar horizontal impacted lower left third molar

Fig 3:- Incision given Fig 4 Removal of overlying bone

Fig 5 Extraction socket Fig 6 Wound closure

Fig 7 extracted tooth

53
CASE NO 3

Fig 1:- Intraoral view showing Fig 2:- Radiograph showing vertically
Impacted lower left third molar impacted lower left third molar

Fig 3:- Incision given Fig 4:-Removal of overlying bone

Fig 5:- Tooth sectioning Fig 6:- Extraction socket

54
Fig 7:- Wound closure Fig 8:- Extracted tooth

CASE NO 4

Fig 1:- Intraoral view showing right Fig 2:- Radiographic view showing
Lower third molar mesioangular impacted third molar

Fig 3:- Extraction socket Fig 4 :- Wound closure

Fig 5:- Extracted tooth

55
CASE NO 5

Fig 1:- Intraoral view showing Fig 2:- Radiographic view showing disto
Impacted lower left third molar -angular impacted third molar

Fig 3:- Incision given Fig 4:- Removal of overlying bone

Fig 5:- Extraction socket Fig 6 :- Extracted tooth

56
SUMMARY & CONCLUSION

Impaction of lower third molar are not recently known entity. Treatment by
surgical extraction is followed for a long time .
Though there are various technique of surgeries which have been followed &
modified gradually in order to reduce morbidity & number of complications
arising during or after the procedure.
Assessment of impacted third molar clinically as well as radiographically helps to
define an appropriate treatment plan, follow of which does not cause difficulty
during the surgical procedure.
Removal of impacted third molar had very few indications for their extraction
which gradually have widen to the point of prophylactic removal for various
obvious reasons.
Thus we would conclude by stating that having a thorough knowledge of various
aspects of third molar surgeries is an essential requirement for complete training of
a dental surgeon.

57
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