MANDIBULAR THIRD MOLARS

Presented by
Dr Bhanu Praseedha
 CONTENTS
• Introduction
• Terminologies
• Definition
• Incidence
• Theories
• Development of third molars
• Frequency of impaction
• Causes of impactions
• Indications and contraindications
• Surgical anatomy
• Classification
• Pre operative assessment
• Radiographic interpretation
• Indices of difficulty in removing mandibular third removal
• Armamentarium
• Surgical procedure
• Sequence of procedure
• Incisions
• Techniques
• Surgical closure
• Post operative complications
 INTRODUCTION

• The third molar has been the most widely discussed tooth in the dental literature, and the
debatable question “….. to extract or not to extract” seems set to run into the next century.
- Faiez N. Hattab, JOMS, 57: 389-391 (1999).

• Got their name “Wisdom teeth” from the age during which they erupt: 17 to 25. This is the age at
which men and women become adults, and, presumably wiser.
 TERMINOLOGIES

• Unerupted tooth-is a tooth that is in the process of eruption and

is likely to erupt based on clinical and radiographic findings.

• Malposed tooth-a tooth , erupted or unerupted which is in

abnormal position in maxilla or mandible
DEFINITION

PRIMARY SECONDARY
IMPACTION
RETENTION RETENTION
• Cessation of the • If no physical • Cessation of
eruption of a barrier can be eruption of a
tooth caused by identified as an tooth after
a clinically or explanation for emergence
radiographically the cessation of without a
detectable eruption of a physical barrier
physical barrier normally placed in the path of
in the eruption and developed eruption or as a
path or due to tooth germ result of an
an abnormal before abnormal
position of the emergence. position.
tooth.
DEFINITION

• Origin- Latin -- impactus

• Cessation of eruption of teeth cause by physical barrier or ectopic eruption

• American society of oral surgeons 1971-impacted tooth is defined as the tooth

which has already passed chronological age of eruption and failed to come to
oral cavity inspite of normal eruptive forces due to some mechanical
obstruction.
 DEFINITION

• According to WHO – An impacted tooth is any tooth that is prevented from reaching its normal
position in the mouth by tissue, bone or another tooth.

• According to ARCHER – 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.

• According to ANDERSON-An impacted tooth is a tooth which is prevented from completely

erupting into a normal functional position due to lack of space, obstruction by another tooth or an
abnormal eruption path
 DEFINITION

• According to PETERSON -A tooth is considered impacted when it has failed to fully erupt into the oral cavity
within its expected time period and can no longer reasonably be expected to do so.

• According to J. MICHAEL MCCOY- An impacted tooth is one that either fails to erupt into its natural
position or one that is hindered from such eruption by adjacent teeth, dense bone, or an overgrowth of soft
tissue.
FREQUENCY OF IMPACTION

• mandibular third molars

• maxillary third molars
• maxillary cuspids
• mandibular bicuspids
• mandibular cuspids
• maxillary bicuspids
• maxillary central incisor
• maxillary lateral incisor
• supernumerary teeth mainly mesiodens
 INCIDENCE

Mandibular 3rd molar exhibit the highest rate of impaction.. According to different authors:-
• RICHARDSON-50%
• RICKETTS-35%
• BJORK-25%
• HELLMAN-9.5%
TWO HYPOTHESIS
Nature and Nurture Hypothesis

• John hunter (1771)- stated that as the successive teeth erupt the jaws grow to make room for
them. If the jaws are not big enough then there will not be room for all teeth, and last to erupt
will become misplaced.

• Darwin (1881)-he had previously noted that the posterior dental portion of the jaws always
shortened in more civilized races of man and Darwin attributed this to “civilized mans habitually
feeding on soft cooked food”
 THEORIES OF IMPACTION
Orthodontic theory :
 Jaws develop in downward and
forward direction. Growth of the jaw and
movement of teeth occurs in forward
direction , so any thing that interfere with
such moment will cause an impaction
(small jaw-decreased space).
A dense bone decreases the movement
of the teeth in forward direction.
Phylogenic theory:
Nature tries to eliminate the disused organs
i.e., used makes the organ develop better,
disuse causes slow regression of organ.
[More-functional masticatory force – better
the development of the jaw]
Due to changing nutritional habits of our
civilization have practically eliminated needs
for large powerful jaws, thus, over centuries
the mandible and maxilla decreased in size
leaving insufficient room for third molars.
Mendelian theory:
Heredity is most common cause.
The hereditary transmission of small
jaws and large teeth from parents to
siblings. This may be important
etiological factor in the occurrence
of impaction.

Endocrinal theory
Increase or decrease in
growth hormone secretion
may affect the size of the
jaws.
Pathological theory:
The Skeletal theory
Chronic infections affecting an
Several studies have demonstrated that when
individual may bring the
there is inadequate bony length, there is a higher
condensation of osseous tissue
proportion of impacted teeth.
further preventing the growth and
development of the jaws
DEVELOPMENT OF THIRD MOLARS

• 7-8 yrs: initiation of tooth bud formation

• 9 yrs: tooth germ visible in the radiograph
• 11 yrs: completion of cusp mineralisation
• 14 yrs: crown development completed
• 16 yrs: approx. 50% root developed
• 18 yrs: root development completed
• 20- 24 yrs: 95% of lower third molars erupt
SURGICALANATOMY OF MANDIBULAR 3RD MOLAR
LINGUAL PLATE

• The Lingual Plate is the side of the lower jaw

tooth socket nearest the tongue.
• In the region of the lower 3rd molar the Lingual
plate can often be very thin.
 MUSCLES
• Vestibule is formed by the attachment of buccinator buccally and mylohyoid lingually.
• Along the anterior border of the ramus - tendinous insertion of temporalis
• Excessive stripping of these muscle will cause hematoma, pain and trismus.
 Neurovascular Bundle
• The neurovascular bundle contains the inferior alveolar artery, vein and nerve enclosed in a fascial
sheath.
• The radiographic evaluation of the relationship of the mandibular canal and roots of the third molar
forms an important part of the preoperative assessment.
 Retromolar Foramina and Their Canals
• They are anatomic variants in the mandible located
distally to the last molar.
• The RMF is located posteriorly to the last molar in
the retromolar trigone, which is bounded
• The nerve that runs through the RMC might arise from
the early accessory branches of the inferior alveolar
nerve (IAN) or long buccal nerve. This area is commonly
invaded during mandibular third molar surgery,
autologous bone harvesting, and sagittal split osteotomy.
• The most common variation of the RMC is a branch of
the mandibular canal below the third molar. The nerve
travels in a posterosuperior direction and opens in the
retromolar fossa those posterior to the third molar
• Most prevalent types of retromolar triangles,according to Suazo et al.,2007

• A. Tapering form 9.16% B. Drop form 10.83%; • C. Triangular form 80%.

 ARTERIES
• Inferior alveolar artery
• Lingual artery
• Facial artery & facial vein run
in close approximation with
lower 1st molar near the
anterior border of masseter.
• Hemorrhage can occur during
surgical removal of impacted
tooth if distal incision is not
taken laterally towards cheek.
INFERIOR ALVEOLAR NERVE
 LINGUAL NERVE

• Lingual nerve lies inferior and medial to the crest of the lingual plate of mandible with a mean
position of 2.28mm(+/-0.9) below the crest & 0.58mm(+/-0.9) medial to crest - KIESSELBACH&
CHAMBERLAIN
• In 17% of cases it lies superior to the lingual plate
 BIFID & TRIFID MANDIBULAR CANALS
Most commonly occurs in females
During embryonic development, three separate canals fused to form a single canal . Failure of this fusion
results in bifid or trifid canals
–Chavez lomeli
CLASSIFICATION SYSTEMS OF
IMPACTED MANDIBULAR THIRD
MOLARS
 BASED ON NATURE OF OVER LYING TISSUE

• According to contemporary oral and maxillofacial surgery-Peterson The three types of impactions
are:
(1) Soft tissue impaction
(2) Partial bony impaction
(3) Full bony impaction
GEORGE WINTER’S CLASSIFICATION(1926)

• Based on the relationship of the long axis of the impacted tooth in relation to the long axis of

the 2nd molar

Mesioangular – Most common type(43%) because mandibular third molars follow an mesial
inclination while eruption, least difficult to remove but most damaging
Vertical - 2nd most common type(38%)
Horizontal - 3%
Distoangular - Most difficult to remove (6%)
These may occur simultaneously in:
Buccal version
SIGNIFICANCE - Each type of impaction has
Lingual version some definite path of withdrawal of
Torsoversion the teeth.
PELL & GREGORY’S CLASSIFICATION
1. Relation of the tooth to the ascending ramus of the mandible and to the distal surface
of the 2nd molar
Shows the anterio posterior relationship of the tooth to the arch and the amount of
resistance offered by the bone of the ascending ramus that may influence the tooth
removal
CLASS I
CLASS II – Most common
CLASS III

2. Relative depth of the third molar in bone

Shows the superior inferior relationship of the tooth in relation to the occlusal plane.
POSITION A
POSITION B – Most common
POSITION C
COMBINED ADA & AAOMS CLASSIFICATION OF
PROCEDURAL TERMINOLOGY
Based on clinical and radiographic interpretation of the tissue overlying the
impacted teeth
• 07220-Soft tissue impaction
• 07230-Partial bony impaction
• 07240-Complete bony impaction
• 07241-Complete bony impaction with unusual surgical complications
 ACCORDING TO SUPERIO-INFERIOR POSITION OF 3RD
MOLAR

• Crown to crown

• Crown to cervix

• Crown to root
 KILLEY & KAY’S CLASSIFICATION

a) Based on angulation and position:

(Same as Winter’s classification)

b) Based on the state of eruption: - Completely erupted

- Partially erupted
- Unerupted

c) Based on roots: 1) Number of roots - Fused roots

- Two roots
- Multiple roots

2) Root pattern - Surgically favorable

- Surgically unfavorable
 G.R.OGDEN METHOD

• Compare the distance between the roots of 2nd & 3rd molars with that of 1st & 2nd
RECENT ADVANCES IN CLASSIFICATION

• Quek et al. (2003) classification of impaction

• Operative Classification (2010)
QUEK ET AL. (2003) CLASSIFICATION OF IMPACTION

• Vertical impaction (10° to -10°)

• Mesioangular impaction (11° to 79°)
• Horizontal impaction (80° to 100°)
• Distoangular impaction ( -11° to -79°)
• Others (111° to -80°)
 OPERATIVE CLASSIFICATION OF IMPACTED MOLARS (2010)
The mandibular third molar is classified according to its position relative to the mandibular canal using a
standard panoramic x-ray.
• There are 3 major types of third molar positions.
 CAUSES OF IMPACTION

Archer has classified into local and systemic causes

systemic causes Local causes

• Prenatal causes -Hereditary • Inadequate space in the dental

• Postnatal causes – Rickets, anaemia,
tuberculosis, congenital syphilis, arch for eruption
malnutrition • Inclination
• Endocrinal disorders – Hypothyroidism,
hypopituitarism, achondroplasia • Obstruction of tooth eruption
• Hereditary linked disorders – Down • Over retained deciduous teeth
syndrome, Hurlers syndrome , Osteopetrosis,
Cleft palate.(Due to failure of overlying bone • Ankylosis of primary or
to resorb and to develop an eruption permanent teeth
pathway)
• Dilaceration of roots(trauma)
• Ectopic position of tooth bud
• Non absorbing alveolar bone
 BERGER
LOCAL CAUSES
• Irregularity in the position and presence of
an adjacent tooth.
• Density of the overlying or surrounding
bone.
• Long – continued chronic inflammation
with resultant increase in density of the
overlying mucous membrane.
• Lack of space due to underdeveloped jaws.
• Unduly long retention of the primary
teeth.
• Premature loss of the primary teeth.
• Acquired diseases, such as necrosis due to
infection or abscesses and inflammatory
changes in the bone due to
exanthematous diseases in children.
SYSTEMIC CAUSES
• Prenatal :Heredity
• Miscegenation
• Postnatal Causes: Rickets
• Anemia
• Congenital Syphilis
• Tuberculosis
• Endocrine Dysfunctions
• Malnutrition
• Rare Causes : Clediocranial Dysostosis
• Oxychephaly
• Progeria
• Achondroplasia
• Osteopetrosis
• Cleft Palate
Indications

PAIN
• Inflammation
• Food lodgement
• Trauma to adjacent mucosa
• Pressure on adjacent tooth
• Rule out MPDS & TMDs
 PERICORONITIS
• Greek word- peri- around, Corona –crown ,itis-inflammation
It refers to the inflammation of soft tissue in relation to the crown of
an incompletely erupted tooth including gingiva and dental follicle.
• HISTORY-
• 1844-GUNNEL –PAINFUL AFFECTION
• END OF 19TH CENTURY-FOLLICULITIS (as the tooth breaches the
follicle)
• 20th century- term PERICORONITIS
• Also called as OPERCULITIS
• INCIDENCE-
• AGE GROUP- 20 – 29years
67%-VERTICAL CASES
12%-MESIOANGULAR CASES
14%-DISTOANGULAR CASES
7%-OTHER POSITIONS
Bilateral pericoronitis is rare- may be in Infectious mononucleosis
Streptococcus Viridans is the most common facultative isolate.

The predictivity of mandibular third molar position as a risk indicator for pericoronitis Kemal Yamalık &
Süleyman Bozkaya Clin Oral Invest (2008) 12:9–14
 COMPLICATIONS

• Pericoronal abscess.

• Spread posteriorly into the oropharyngeal area and medially to the base of the tongue, making
swallowing difficult.

• Peritonsillar abscess formations, cellulitis, Ludwig’s Angina are infrequent but potential sequel of acute
pericoronitis.
 UNRESTORABLE DENTAL CARIES

• Inability to effectively clean the area

• Inaccessibility
 PATHOLOGIES/ PREVENTION OF CYSTS AND TUMORS RISK
OF CYST & TUMOR DEVELOPMENT:
•Most common age : 20- 25 years.
•Incidence of cyst formation- 2.31% (Guven et al,2000)
•Incidence of dentigerous cyst- 1.6% (Keith,1973)
•Incidence of ameloblastoma – 0.14- 2% (Shear,1978)
•Risk of surgical morbidity increases with age.
ORTHODONTIC CONSIDERATION

• Crowding of mandibular incisors

• Obstruction of orthodontic treatment
• Interference with orthognathic surgery
PROPHYLACTIC INDICATION

• Prophylactic removal of a non-erupted tooth is by definition a surgical intervention to prevent

future disease.
• This practice is often referred to as “removal of asymptomatic third molars”. It is important to
define this subject more precisely.
 PROPHYLACTIC INDICATIONS
For medically needful
• Prior to radiation therapy for head and neck malignancies;
• Prior to organ transplantation;
• Chemotherapy;
• Bisphosphonate therapy.
For surgical reasons-
• The presence of a third molar in a fracture line.
• Prior to orthognathic surgery.
• When a third molar may be considered for autogenous transplantation, usually to a first molar
region.
• When the third molar region is involved in tumor
• Resection or jaw reconstruction surgery.
NICE(NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE) GUIDELINES ON
EXTRACTION OF WISDOM TEETH(2000)

• The practice of prophylactic removal of pathology-free impacted third molars should be discontinued .

• Surgical removal of impacted third molars should be limited to patients with evidence of pathology

• The evidence suggests that a first episode of pericoronitis, unless particularly severe, should not be
considered an indication for surgery. Second or subsequent episodes should be considered the
appropriate indication for surgery.
 CONTRAINDICATIONS
Absolute contraindications

• Extreme of age • Acute pericoronitis

• Acute necrotising ulcerative gingivitis
• Compromised medical status • Haemangioma
• Probable excessive damage to adjacent • Haemophilia
structure (un favorable risk /benefit • leukaemia
ratio) • Thyrotoxicosis
• Third molars needed as abutments
• Recently irradiated jaw
• Tooth in tumour.
 PRE- OPERATIVE ASSESSMENT

• CLINICAL ASSESSMENT
• General assessment
• Age/ sex
• Systemic condition
• Drug history
• Anesthesia history
• General physical examination
ASSESSMENT OF IMPACTED TEETH

• Status of eruption
• Periodontal status
• External and internal oblique ridge
• Relationship with adjacent teeth
• Soft tissue covering
• Occlusal relationship with opposing tooth
 RADIOGRAPHS
• INTRA ORAL RADIOGRAPHS
• IOPA
• Occlusal
• EXTRAORAL RADIOGRAPHS
• OPG
• Lateral cephalometric
• DIGITAL IMAGING
• CT
• CBCT
LOCALIZATION TECHNIQUES:
-Buccal object rule (SLOB)
- Magnification
-CBCT(3D)
 RADIOGRAPHIC INTERPRETATION

• Assessment of lower third molar

• Angulation
• The crown
• The roots
• Relationship of apices with inf alveolar canal
• Depth of tooth in alveolar bone
• Buccal / lingual obliquity

• Assessment of lower second molar

• Assessment of surrounding bone
 RADIOGRAPHIC INTERPRETATION
1.Type of impaction
2.Access - External oblique ridge
oblique & post . to third molars – good access
vertical & ant. to third molar – poor access
3. Position & depth (WAR lines)
4. Existing pathology
-Dental caries in II and III molars
-Periodontal problems
-Presence or absence of I molar
-Fused roots of II and III molars
-Any associated pathologies like cysts , odontomes.
5.Assessing the buccal / lingual obliquity
Crown – sharp & well defined
Lingual obliquity -difficult
Root apices - sharp & well defined

6.Shape of the crown

Large square crown – difficult

7.Root pattern
8. Path of withdrawal 9. Size of the follicular sac

FLAP DESIGN
AMOUNT OF BONE
REMOVAL
TOOTH ELEVATION &
SECTIONING
NATURAL
PATH OF
WITHDRAW
AL

10. Texture of investing bone

RELATIONSHIP WITH INFERIOR ALVEOLAR CANAL
POSITION OF ROOT TO INFERIOR ALVEOLAR CANAL
INDICES OF DIFFICULTY IN
REMOVING OF 3RD MOLARS
The modified Parant scale 

was implemented to predict post-operative

difficulties.
RECENT ADVANCE IN GRADE OF DIFFICULTY
 WAR (WINTER’S) LINES

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

The red line when extended to the inferior

edge of the radiograph should meet at 90

Red line <5mm: extraction - easy, there after every 1mm increase in depth increases
the difficulty three folds (Geoffrey Howe)& if it is >9mm then plan the surgery under
GA or LA with sedation
 The ‘‘Red Line’’ Conundrum: A Concept
Beyond Its Expiry Date?

Change of angulation of the film causes the ‘‘red-line’’ to change in length

significantly. The red-line in B is shorter by ( 30 % )than in A with a 15 change
in angulation of the film.

The ‘‘Red Line’’ Conundrum: A Concept Beyond Its Expiry Date? Sanjeev Kumar •
Mahendra P. Reddy • Lokesh Chandra • Alok Bhatnagar : JMOS 02 aug 2013
WHARFE’s ASSESSMENT by McGregor (1985)
1.WINTERS CLASSIFICTION Horizontal 2
Distoangular 3
Mesioangular 1
Vertical 0
1-30mm 0
2.HEIGHT OF MANDIBLE 31-34mm 1
35-39mm 2
1° - 50° 0
3.ANGULATION OF THIRD MOLAR 60° - 69° 1
70° -79° 2
80° - 89° 3
90°+ 4
Complex 1
4.ROOT SHAPE Favourable curvature 2
Unfavourable curvature 3
Normal 0
Possibly enlarged 1
5.FOLLICLE Enlarged 2
Space available 0
Distal cusp covered 1
6.PATH OF EXIT Mesial cusp covered 2
Both cusp covered 3
RELATIONSHIP OF INFERIOR ALVEOLAR NERVE TO
THE ROOTS OF THE THIRD MOLAR.

Darkening of root Deflection of root Narrowing of root Dark & Bifid apex

Rood JP , Shehbab BA-BJOMS 1998:28:20

Interruption of white Narrowing of canal Diversion of canal
line of canal
Rood JP , Shehbab BA-BJOMS 1998:28:20
Factors that Make Surgery Less Difficult
• Mesio-angular impaction
• Class 1 ramus
• Class A depth
• Roots 1/3 – 2/3 formed (present in the younger patient)
• Fused conical roots
• Wide periodontal ligament (present in the younger patient)
• Elastic bone (present in the younger patient)
• Separated from 2nd molar
• Separated from IDN
• Soft tissue impaction
Factors that Make Surgery More Difficult
• Disto-angular impaction
• Class 3 ramus
• Class C depth
• Long thin roots (present in the older patient)
• Divergent curved roots
• Narrow periodontal ligament (present in the older patient)
• Dense, inelastic bone (present in the older patient)
• Contact with 2nd molar
• Close to IDN
• Complete bony impaction
Patient factors predicting increased difficulty of third molar removal
• Obesity
• Dense bone
• Large tongue
• Strong gag reflex
• Position of the inferior alvelolar canal
• Advanced age
• Superiorly positioned maxillary third molar
• Fractious patient
• Apical root of lower third molar in cortical bone
• Atrophic mandible
• Limited surgical access

Third Molar Removal: An Overview of Indications,Imaging, Evaluation, and Assessment

of Risk Robert D. Marciani, DMD
ARMAMENTARIUM
 Handling The Instruments

• The scalpel is held with thumb, middle and ring

finger while the index finger is placed on the upper
edge to help guide the scalpel.

• The scalpel should never be used in a "stabbing"

motion especially while raising a flap.
 SURGICAL PROCEDURE

• The surgical procedure for the extraction of impacted teeth includes the following steps:
1. Asepsis and isolation
2. Local anesthesia/ general anesthesia
3. Incision-flap design
4. Reflection of mucoperiosteal flap
5. Bone removal
6. Sectioning (division) of tooth
7. Elevation and tooth removal
8. Debridement and smoothening of bone
9. Closure-suturing
 ISOLATION AND ASEPSIS

SCRUBBING
• Cetrimide+ absolute alcohol
• Cetrimide + povidine iodine
• Cetrimide+ abs. Alcohol+ chlorhexidine
CLEANING
• Normal saline
• Alcohol- spirit
PAINTING
• Povidone iodine (5% skin, 1% oral mucosa)
• Chlorhexidine (7.5% skin, 0.2% oral cavity)
 ANESTHESIA
• Choice of anesthesia
• Apprehension level
• The patient’s acceptance of the procedure
• The length and technical difficulty of the procedure
• Patient’s preference and risk to benefit ratio
Indications for general anesthesia
• 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
 DIFFERENT TYPES OF INCISION AND FLAP DESIGN
• SHORT ENVELOPE
• LONG ENVELOPE
• L-SHAPED INCISON
• BAYONET SHAPED INCISION
• TRIANGULAR FLAP
• WARDS INCISION
• MODIFIED WARDS INCISION
• GROOVE AND MOORE INCISION
• S SHAPED INCISION
• COMMA SHAPED INCISION
• SZMYD FLAP
• MODIFIED SZMYD
• BERWICKS TONGUE FLAP
 ENVELOPE FLAP
Incision is made horizontally along the crest of the ridge or in
the buccal gingival crevice.
• Has no vertical incision.
• Indicated for mesioangular/soft tissue impactions

Advantages
.Provides the broadest base and fully covers the resultant bony cavity .1

.There is little danger of violating any major anatomical landmarks.2

During the procedure, the envelop flap can be extended as needed; if .3

still greater access is required
STANDARD INCISION(WARD’S INCISION,1968)

Ward’s incision Modified ward’s incision

 PARTS OF INCISION

• The incision having 3 parts-

LIMB A: The anterior incision started from buccal sulcus approx. at the junction of posterior and
middle third of 2nd molar, passes upwards extended up to the distobuccal angle of the 2nd molar at
the gingival margin approx 6mm.
LIMB B:It was carried along the gingival crevice of third molar extending up to the middle of
exposed distal surface of the tooth
LIMB C: Started from a point where intermediate gingival incision ended and was carried laterally.
This arm should be approx 19mm long.
Total length of incision should be approx 25.4mm.or 1inch
• LIMB C - not to be extended too distally
• In case of unerupted tooth ,intermediate incision is not needed.
• The limb A is extended upto the middle of the distal surface of the 2nd molar.
 L – SHAPED FLAP
Suits only for buccal approach
2nd molar paramarginal Flap with vestibular extension
Vertical relieving incision is given at 45˚ angle to the long axis of
the 2nd molar and runs straight anteriorly and downwards.

BAYONET – SHAPED FLAP

• Distal limb
• Mesial limb
• Intermediate gingival incision
 COMMA INCISION

Designed by Nageshwar

Indications:
• Total soft tissue impaction
Advantages
• No part of wound lies on resultant bone defect
• Less postoperative pain and swelling
 S SHAPED INCISION

Incision was made from the retromolar fossa across the external oblique ridge curving down
through the attached mucoperiosteum to run along the reflection of the mucous membrane to
the anterior border of the first permanent molar
For lateral trephination
 SZMYD FLAP MODIFIED SZMYD FLAP
• Envelope flap with the incision beginning just •A vertical incision line from the distofacial
medial to the external oblique ridge and extending line angle of the second molar apically to
to the middle of the distal aspect of the second the mucogingival line approximately 2 to 3
molar mm

• sulcular incision
 VESTIBULAR TONGUE SHAPED FLAP(Berwick,1966)

• Extend onto the buccal shelf of the mandible

• Incision line did not lie over the bony defect created by the
removal of the impacted teeth

• Its base at the distolingual aspect of the second molar to spare

pdl of adjacent tooth.
 GROOVE & MOORE

• A collar of tissue was preserved around the 2nd molar hence decreasing the pocket
formation

• A lingual extension of the incision allowed for exposure of the lingual aspect as well
 MUCOPERIOSTEAL FLAP

• A surgical flap may be defined as a piece of tissue which has been detached from its underlying
support but which remains partially connected with its original site and receives nourishment from
this attachment.
 Principles of flap design

• Incisions should avoid anatomical structures, such as major nerves or blood

vessels.
• Incisions far enough away from the surgical area-The wound margins should rests
on sound bone
• The base of the flap should be wider than the apex to ensure adequate blood
supply.
• A firm pressure upon a sharp scalpel should be used so that both the mucosa
and periosteal layers of the gingiva are incised down to bone.
• Incisions are made in one operation, as extensions. Cut the soft tissues at right angles to the
surface of underlying bone.
• The Flap should be made large enough to provide for visibility, accessibility and adequate room
for instrumentation.
• The vertical releasing (relaxing) incision should be avoided if the horizontal incision will provide
adequate access.
• Schow(1974) –Extending flap design beyond EOR increases the chances of dry socket formation.
REFLECTION OF MUCOPERIOSTEAL FLAP

• Periosteal elevator or Minnesota or Austin retractors

• Howarth retractor
• Austin retractor
• Ward kilner retractor
• Dyson’s Malleable copper retractor
• Fickling periosteal elevator
• Read periosteal elevator
 BONE REMOVAL

• BUR TECHNIQUE
Postage stamp technique
Moore and Gillbe’s technique
Guttering technique
Bowdler Henry’s( Lateral trephination(1969))
• CHIESEL AND MALLET
Window technique
Lingual split technique
Shaving technique
Distal lingual split technique
 POSTAGE STAMP TECHNIQUE

• In this technique a row of small holes is made(at 2-3mm equidistance) with a small bur and then
joined together either with bur or chisel cuts.
 MOORE & GILLBE’S COLLAR TECHNIQUE
• Conventional technique 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 (mesial purchase point) is
created with bur.
• Amount of bone sacrificed is less.
• Can be used in old patient.
• Convenient for patient.
 BUCCAL GUTTERING TECHNIQUE

• Once the soft tissue is elevated and retracted, the surgeon must make a judgment concerning the
amount of bone to be removed.
• Bone must be removed in an atraumatic, aseptic, and non heat producing technique, with as little
bone removed and damaged as possible.
• The amount of bone that must be removed varies with the depth of impaction, the morphology
of roots, and the angulation of tooth.
• The speed of micromotor should be 12000- 20000 rpm.
• Ideal length of the bur used is 7mm & diameter of 1.5mm. (#702-diameter-
1.6mm length-4.5mm) (#703-diameter- 2.1mm length-4.8mm)
 REMOVAL OF OVERLYING BONE

• A large round bur ( No. 8 ) is desirable, because it is an end cutting bur and can be effectively used
for drilling with a pushing motion.
• The tip of a fissure bur ( No. 703 ) does not cut well, but the edge rapidly removes bone and
quickly sections teeth when used in lateral direction.
• The bone on the occlusal aspect of the tooth is removed first to expose the crown of the tooth.
• Then the cortical bone on the buccal aspect of the tooth is removed down to cervical line.
• Exposure of the crown of the tooth using a round bur.
• The surgeons should apply a handpiece load of approximately 300g and an irrigation rate of
15mL/min to 24mL/min.
• For tooth sectioning – 300-550g
• Pressure applied for normal restorative dentistry-100-150g

(Sharon et al Oral SUR oral Med Oral Pathol Oral Radiol Endod 1999)
LATERAL TREPHENATION TECHNIQUE

• Bowlder Henry
• Employed to remove any partially formed unerupted 3rd molar that has not breached the
overlying hard & soft tissues.
• Age 9-18 years
• 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
 LINGUAL-SPLITTECHNIQUE

• Described by Sir William Kelsey Fry (1933).

• Later popularized by Terence G ward(1956) Specially for lingually placed tooth.
• Modified by Dr. Davis & Lewis in 1960
SURGICAL BASIS OF LINGUAL SPLIT TECHNIQUE
Whenever tooth is extracted

Lingual cortical plate is resorbed

• Procedure :
• Ward’s or Modified Ward’s incision
• Reflection of mucoperiosteal flap
• Removal of buccal plate expose the crown
chisel is used and section the lingual cortex by
planning 45˚angle to upper border and cutting
edge parallel to external oblique ridge
• 3rd molar elevated from mesial aspect.
• If it is firm crown is sectioned at cervical
MODIFIED LINGUAL SPLIT TECHNIQUE FOR REMOVAL OF MANDIBULAR
THIRD MOLAR (DR. DAVIS 1979)

• Not to separate the mucoperiosteum from lingual area of bone

• 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
 TOOTH DIVISION TECHNIQUE
• Kelsey Fry
• To reduce the removal of large amount of bone
• Avoid damage to adjacent structures
• Decreases dead space
• Allows portions of tooth to be removed separately with elevators
• Direction depends primarily on angulation of impacted tooth
• With a bur, tooth is sectioned 3/4th toward lingual aspect
 BUCCAL VS. LINGUAL APPROACH
criteria buccal lingual
Access Easy in conscious patient Difficult in conscious
patient
Instruments Chisel and mallet or bur Only Chisel and mallet
Procedure Tedious Easy

Operating time Time consuming Less time

Technique Tech. easy Tech.difficult

Bone removal Thick buccal plate Thin lingual plate

Post op pain Less More-due to damage to

lingual periosteum

Post op edema More Less

Dry socket Incidence high – due to Negligible-socket

damage to ext. oblique eliminated
ridge
CRITERIA FOR SECTIONING OF TOOTH
• A line is drawn from the mesiolingual cusp
till the distal root of the impacted third
molar.
• Half the distance measured is taken as the
radius and an arc is drawn.
• If the arc touches the 2nd molar indicates
locking of tooth.
• Then sectioning is mandatory.
• Mesio distal diameter of crown and
mesiodistal width of roots are more than the
space for exit of the tooth.
 SECTIONING OF TOOTH

• Reduces the amount of bone removal required prior to elevation of tooth.

• Reducing the risk of damage to the adjacent tooth.
• Once sufficient amount of bone removed, the surgeon should access the need to section the
tooth.
• The direction in which the impacted tooth should be divided depends primarily on the angulation
of the impacted tooth & root curvature.
• The sectioning can be performed with a bur or chisel.
• The bur is used by most surgeons, but if a chisel is used it must be sharp.
• When the bur is used, the tooth is sectioned three- fourth of the way towards the lingual aspect.
• A straight elevator is inserted into the slot made by the bur and rotated to split the tooth.
• Sectioning of the crown of an impacted tooth, in the buccolingual
direction, which extends as far as the intraradicular bone.
 MESIOANGULAR IMPACTION

C . A small straight
B. The distal aspect of the
A. buccal and distal bone are elevator is inserted into
crown is then sectioned from
removed to expose crown of the purchase point on
tooth. Occasionally it is
tooth to its cervical line. mesial aspect of 3rd
necessary to section the entire
molar, & the tooth is
tooth into two portions rather
delivered with a
than to section the distal
rotational motion of elevator.
portion of crown only
 VERTICAL IMPACTION

A. When removing a B. The posterior aspect of C. A small straight no.

vertical impaction, the
bone on the occlusal,
buccal, and distal aspects
of the crown is removed,
and the tooth is sectioned
Into mesial and distal portions.
the crown is elevated first
with a Cryer elevator
inserted into a small
purchase point in the
distal portion of the tooth.
301 elevator is then used
to lift the mesial aspect
of the tooth with a rotary
and levering motion.
HORIZONTAL IMPACTION
A. Removal of distal and buccal underlying bone

B. The crown is sectioned from the roots of the tooth

and is delivered from socket.

C, The roots are delivered together or independently

with a Cryer elevator used with a rotational motion.
Separation of root into 2 parts - occasionally
the purchase point is made in the root to allow the
Cryer elevator to engage it.

D, The mesial root of the tooth is elevated in similar

fashion
DISTOANGULAR IMPACTION
A. Removal of mesial & distal bone. It is
important to remember that more distal bone
must be taken off than for a vertical or
mesioangular impaction.

B. The crown of the tooth is sectioned off with a

bur and is delivered with straight elevator.

C. The purchase point is put into the remaining

root portion of the tooth, and the roots are
delivered by a Cryer elevator with a wheel and
axle motion. If the roots diverge, it may be
necessary in some cases to split them into
independent portions.
 SMOOTHENING & DEBRIDEMENT OF SOCKET

• Attention must be given to debriding the wound of all particulate bone chips and debris.
• Wound should be irrigated with sterile saline, taking special care to irrigate thoroughly under the
reflected soft tissue flap.
• Remove any remaining dental follicle and epithelium.
• The bone file is used to smooth any sharp, rough edges of bone.
• A final irrigation and a thorough inspection should be performed before the wound is closed.
CLOSURE OF SOFT TISSUE FLAP

• Return soft tissue flap to the original position

• Stabilize the flap to permit repair
• Resecure periodontal/ gingival attachments
 COMPLICATIONS

• Intra Operative
1. During incision
a. Injury to facial artery
b. Injury to lingual nerve
c. Hemorrhage
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
a. Luxation of neighbouring tooth/ fractured restoration
b. Soft tissue injury due to slipping of elevator
c. Injury to inferior alveolar neurovascular bundle
d. Fracture of mandible
e. Forcing tooth root into submandibular space or inferior alveolar nerve canal
f. Breakage of instruments
 POST OPERATIVE COMPLICATIONS
• Immediate
Hemorrhage
Pain
Edema
Drug reaction
• Delayed
Alveolitis
Infection
Trismus
 HAEMORRHAGE

• The overall complication rate associated with the removal of third molars is 7% to 10%, and the
risk of hemorrhage is 0.2% to 1.4%.
• Hemorrhage from the mandibular molars is more common than bleeding from the maxillary
molars (80% and 20%, respectively) because the floor of the mouth is highly vascular.
• Furthermore, the distolingual aspect of the mandibular third molar region is the most highly
vascularized site, and this should be taken into consideration when all third molars are to be
removed.
• This area may encompass an accessory artery emanating from the lingual aspect of the mandible,
and bleeding may be profuse if this vessel is cut.
STYPTICS AND LOCAL AGENTS
 PAIN

• Pain usually begins after the anesthesia from the procedure wears off and reaches peak levels 6
to 12 hours postoperatively.
• It is usually moderate and of short duration for the first 24-48 hours .
• Pathophysiology of pain may be explained by facts that following tissue injury or inflammation,
there is a sequential release of mediators from mast cells, the vasculature and other cells.
• Histamine and serotonin appear first, followed shortly after by bradykinin and later
prostaglandins.
• The longer duration of the surgery leads a longer tissue injury. In this way more mediators are
released and therefore could be a reflection of the severity of pain, swelling and trismus.
 SWELLING/OEDEMA

• The swelling or surgical edema usually reaches a maximum level in 2 to 3 days postoperatively
and should subside by 4 days and resolve by 7 days.
• Mucoperiosteal flap designs may play also an important role in postoperative surgical edema
development, thus those flaps which ensure a secondary healing, because of wound drainage, lead
to lower incidence of swelling
 TRISMUS

• Trismus or difficulty opening the mouth, is often the result of surgical trauma and is secondary to
masticatory muscle inflammation following lower third molar surgery. The patient may feel jaw
stiffness with difficulty to brush, talk, or eat normally.
• If the mouth stays open for too long, trismus may be expected. So, its development is correlated
with operation time. In most cases, the trismus is temporary.
• Preoperative use of steroids may be helpful in reduction of trismus.
DEFINITION-

• DRY SOCKET- Postoperative pain in and around the extraction site, which increases in severity at
any time between 1 and 3 days after the extraction accompanied by a partially or totally
disintegrated blood clot within the alveolar socket with or without halitosis.”

• I.R. Blum: Contemporary views on dry socket (alveolar osteitis): a clinical appraisalof
standardization, aetiopatho genesis and management: a critical review. Int. J. Oral Maxillofac.
Surg. 2002; 31: 309 3–17
• First described by CRAWFORD-1896
• SYNONYMS
• Alveolar osteitis(AO) ,Alveolitis ,Localized
osteitis ,Alveolitis sicca dolorosa ,Localized
alveolar osteitis , Fibrinolytic alveolitis
,Septic socket ,Necrotic socket , Alveolalgia
ETIOLOGY

• Multifactorial in origin Suggested factors include

• Oral micro organisms(Treponema denticola)
• Difficulty and trauma during surgery
• Roots or bone fragments remaining in the wound
• Excessive irrigation or curettage of the alveolus after extraction
• Physical dislodgement of the clot
• Local blood perfusion and anaesthesia
• Oral contraceptives-estrogens, like pyrogens, will activate the fibrinolytic system indirectly
• Smoking
 NERVE INJURIES

• Incidence
• > 20% in the first 24 hours postoperatively.
• 0.3% to 5.3 % after six months.
• Inferior alveolar nerve- Immediate disturbance-4-5% (1.3-7.8%) Permanent disturbances -<1% (0-2.2%)
 The nerve damage depends of several factors such as type of anesthetic, state of eruption, depth of
impaction, patient age, experience of the surgeon and type of lingual flap retraction.
• Clinical symptoms of lingual nerve damage
 Pain , drooling, tongue biting
 Burning sensation of the tongue, burns on the tongue from hot food and drinks
 Change in speech pattern and change in taste perception of foods and drinks
• Neurosensory dysfunctions associated with nerve injuries includes anesthesia or numbness (loss
of sensation, because of damage to a nerve or receptor)

• Paresthesia (abnormal touch sensation, such as burning, prickling or formication, often in the
absence of an external stimulus), dysesthesia or hypoesthesia.

• Nerves can be damaged by traumatic, compressive or toxic injuries, which usually result in
neuropraxia; however traumatic anatomic breakdown of the nerve may occur leading to
axonotmesis or neurotmesis.

Axonotmesis and neurotmesis can lead to subsequent paresthesia which may almost never resolve.
 CORONECTOMY

• A method of removing the crown of a tooth but leaving the roots untouched, which may be
intimately related with the inferior alveolar nerve, so that the possibility of nerve injury is
reduced.
• First proposed in 1984 by Ecuyer and Debien .
• Also known as intentional partial odontoectomy, partial root removal and deliberate vital root
retention
• BASIS FOR CORONECTOMY :It is common practice for broken fragments of the root of vital teeth
to be left in place and most heal uneventfully.
• Renton et al.and Leung et al. (randomised clinical trial), Hatano et al. (case control study) and and
O‟Riordan (retrospective study) provided evidence that coronectomy decreases the risk of IDNI
when compared to traditional extraction of Mandibular Third molars.
 MANDIBLE FRACTURE

• Alveolar Process Fracture

• the lingual plate, alveolar plate, buccal cortical plate, palatal cortical plate, and labial cortical plate(s) may
fracture during procedure.
REFERENCES

• Oral and maxillofacial surgery – LASKIN volume

• Oral and maxillofacial surgery - FONSECA volume I
• Killey and Kay's outline of oral surgery
• Principles of oral & maxillofacial surgery-Peterson
• Textbook of oral & maxillofacial surgery-Neelima Anil Malik
• Textbook and color atlas of tooth impactions-JENS O ANDERSON
Thank you