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Impactions, mandibular third molar impactions

I
n Tibetan philosophy, wisdom tooth has special significance, where only the appearances of 3rd
molars are pre ordained relationship of individual teeth to one another completed. In contrast to this
view, wisdom tooth has proved to be a precursor of problems where it leads to serious disturbance in
harmony of mastcatory apparatus, general health and is Often responsible for the host of complications. It
also influences the treatment in all dental specialties and forms a focal point of dental surgery.

DEFINITIONS:
According to WHO-
A). "Impaction is any tooth that is prevented from reaching its normal position in the mouth by tissue or
bone or another tooth,
B). A tooth that is completely or partially unerupted and is positioned against another tooth/bone/soft
tissue, so that its further eruption is unlikely, described according to its anatomical position".
C). A tooth that fails to erupt and will not eventually assume its anatomical arch relationship beyond its
chronological eruption date".

It is very important to differentiate between impacted/malposed/unerupted teeth.


Unerupted tooth- Tooth not having perforated oral mucosa.
Malposed tooth- A tooth erupted/unerupted, which is in an abnormal position in
maxilla/mandible.

THEORIES OF IMPACTION:

I). PHYLOGENIC THEORY


Anthropologist is of the opinion that increase in size of the brain case is at the expense of jaws. Pre
human forms had receded forehead and protruded jaws, which has almost become vertical in man as a
part of evolution. Also modern day life style where diet is soft & refined which eliminates the need for
powerful masticatory apparatus, thus decreasing size to maxilla and mandible. As a result of this 3rd
molars occupy an abnormal position within the jaws rendering-" it a vestigial organ, without function.

2) PATHOLOGIC THEORY
There is osteosclerosis in the region of 3r molar as a result of early infection to 1st and 2 molars, this is a
small percentage of cases as studies have shown people to have normal and vital 1st and 2nd molars but
have impacted 3rd molars.

3) MENDELIAN THEORY
As an individual gets half of genes from one parent and the other half from the other parent; he may have
small jaws from one parent and large teeth from the other parent. This may result in 3rd molar impaction.

4). ENDOCRINE THEORY


Lack of normal functioning of anterior lobe of pituitary may lead to lack of growth of mandible. This part
of pituitary is responsible for secretion of growth hormones. The presence of impacted teeth in large jaws
poses this theory wrong.

5). ORTHODONTIC THEORY


This takes into account, the developing stages of dentition. The effects of the habits like mouth breathing
on the alignment of permanent teeth and the effects of early loss of permanent 1st molars due to various
seasons on the dentitions. It also takes into account effect of retained deciduous teeth and premature loss
of deciduous teeth on impactions.

MANDIBULAR THIRD MOLAR IMPACTIONS DR. JOSEPH JOHN K. POTHANIKAT Page 1


ETIOLOGY
Berger classified etiological factors as systemic and local causes

A. Systemic factors
1. PRENATAL: HEREDITY
Shape and size of the jaws resemble of the parents & often-same tooth is impacted as their parents.
2.POSTNATAL:
Condition interfering with normal development of child can cause Impaction along with local predisposing
factors.Eg, Rickets, anaemia, TB, malnutrition, endocrine dysfunction, Congenital syphilis.
3.RARE SKELETAL DEFORMITIES:
Cleidocranial dysostosis. Achondroplasia, cleft lip&palate, Oxycephaly, Progeria (premature aging)

B. Local factors
Irregularity in position especially when it is buried under crown of adjacent tooth
Increased density of overlying surrounding bone.
Increased density of overlying mucosa due to inflammation.
Jaw size discrepancy.
Premature loss/retained deciduous dentition.
Infection in bone due to local/systemic causes
o Necrosis following infection.
o Exaotbematous diseases in children.

C. Other factors
1. Chronology
On the basis of chronological order of teeth a few teeth arc predispose) To impactions.
E.g.: mandibular & maxillary 3 molars, mandibular&maxiUary Canines, mandibular premolars.
2.Lack of space
Impaction is due discrepancy in arch size &tooth dimension. Tooth Erupting late chronologically with
insufficient space will itself present clinically As impacted. Eg-a) Mandibular 3""rnolars are impacted due to
lack of space Between 2ndmolar&anterior border of ramus of the mandible.
Canine root being longest, the crown has to cross a long distance before erupting into the oral cavity.
This is further complicated with lack of space or increased mesio-distal width and progressive
decrease in arch length due to evolution.
3. Obstructions:
During eruptions, obstructions like retained deciduous teeth, thick scar band, odontome, cyst,
odontogenic tumors, then the tooth remains unerupted even beyond its chronological age.
4. Dilacerations:
Trauma to deciduous anterior teeth transmits traumatic forces to underlying tooth bud. This leads
to shift in long axis of crown while root formation proceeds in the predetermined manner leading
to dilacerations & failure.

INCIDENCE OF IMPACTED TEETH


Depending on factors such as ago of the population, the incidence of impacted teeth was 14%, while that
of unerupted teeth was 62%. 3rd molars account for 98% of all impactions. There is no statically
difference between male &female predections.

FREQUENCY

MANDIBULAR THIRD MOLAR IMPACTIONS DR. JOSEPH JOHN K. POTHANIKAT Page 2


Frequency order is as follows: max 3rd molars, mandibular 3rd molars, maxillary canine, mandibular
premolars, mandibular canines, maxillary premolars, and supernumerary teeth.
Impactions of 16,26,36,46,31,41,32,42 are rare due to its chronological eruption date.

CLASSIFICATIONS OF IMPACTED TEETH

1. Position of the tooth in relation to long axis of 2nd molar,WINTER'S classification. (1926)
1. Vertical,
2. Horizontal,
3. Mesioangular
4. Distoangular
5. Inverted
6. Unusual position

2. Skeletal anatomic space between posterior aspect of 2nd molar & anterior border of ram us
of mandible; PELL & GREGORY (1933)
1. CLASS I There is sufficient amount of space between the ramus of mandible & distal surface of
2nd molar to accommodate mesiodjsial width of crown of 3rd molar.
2. CLASS II Space between distal surface of 2nd & ramus of the mandible is less than mesio
3. distal width crown of 3rd molar.
4. CLASS III 3rd molar is situated within the ramus of mandible.

3. Relative depth of molar in bone


1. Position A Highest portion of 3 molar is at or above the level of occlusal plane.
2. Position B- Highest point of 3rd molar is below the occlusal plane but above cervical line of 2 nd
molar.
3. Position C Highest point of 3rd molar is below cervical line of 2nd molar.

4. Mediolateral position of 3rd molar


1. BUCCAL
2. DIRECTLY POSTERIOR
3. TRANSVERSE
4. PALATAL
5. LINGUAL

5. AAOMS Classification
It is based on operation performed to remove an impacted tooth. It is not used due to whether procedure is
either understood\oy exsha do wed to Anatomical variation during surgery.

6. ADA Classification
Based on amount of hard & soft tissues covering coronal surface of impacted tooth.
1. Soft tissue impactions.
2. Partial bony impactions.
3. Complete bony impactions.
4. Complete bony impactions + surgical difficulties

7. Combined ADA & AAOMS Classification


1. 07220: Soft tissue impaction that requires incision of overlying soft tissue &removal of tooth.

MANDIBULAR THIRD MOLAR IMPACTIONS DR. JOSEPH JOHN K. POTHANIKAT Page 3


2. 07230: Partially bony impaction. Impaction that requires incision of overlying soft tissue,
elevation of flap either removal of bone sectioning of tooth its removal.
3. 07240: Complete bony impaction; Impaction that requires incision of overlying soft tissue,
elevation of flap, removal of bone &sectioning of tooth for removal.
4. 07247: Complete bony impaction + surgical difficulties; requires incision of soft (issue, elevation
of a flap, removal of bone, sectioning of tooth for removal and/or presents with unusual surgical
difficulties & circumstances.

MOLAR REGION ANATOMY


Pre operative analysis of impacted 3rd molar with respect to 2nd molar & 3 dimensional position of 3rd
molar is of utmost importance. An estimation of inferior alveolar nerve structure is seen.

MANDIBULAR 3rd MOLAR ANATOMY


Coronal portion may vary in dimension from a crown somewhat larger than that of 2nd molar to a
misshapen crown form. Usually it has a well developed buccal & lingual developmental grooves, but
may be missing due to the presence of multiple cusps irregular ridges. Radicular portion may be short in
size w.r.t. crown of molar, may be tortuous & poorly formed, which may reflect lack of anatomical
space. Roots may be grooved by inferior alveolar canal & in some cases it may be passing through the
root if root development is passed around the canal.
3rd MOLAR & 2rd MOLAR RELATIONSHIPS
Long axis of 2nd & 3rd molar :
Mesioangular, distoangular, horizontal, vertical, inverted. A distoangular may present greatest
challenge, as it requires more amount of continuous bone removal than for any other type of
impacted tooth. Usually there is close anatomical relationship of Radicular surface of 2 nd & 3rd
molars.
Level of crown of 2nd molars to 3rd molars
Crown-to-Crown relationship
Crown to Cervix relationship
Crown to Root relationship
Crown to crown relationship provides relatively easier surgical access for removal of 3 rd molar, while,
crown to cervix: or crown to root provides less surgical access, visibility due to 2 nd molar & overlying
soft/hard tissue.

Buccal / Lingual relationship of 3rd molars


If a buccal surgical approach provides greater access when 3rd molar in retromolar triangle is
buccal relative to 2nd molar. If an impacted 3rd molar is located more buccally then reasonable
amount of buccal cortical bone is removed while lingual nerve is out of the field. If it is situated
medial to retro molar triangle in the balcony of lingual cancellous-cortical bone there may be
stretching of the lingual nerve.

3RD MOLAR SKELETAL RELATIONSHIP


3rd molar position in the facial skeleton may be overlooked as a key surgical turning point (PELL &
GREGORY CLASSIFICATION), it is of much significance in predicting the surgical access of 3rd
molar. If insertion of ramus to the body of mandible eliminates the retro molar triangle, decreased surgical
access & close anatomical relationship of lingual nerve will result. If there is adequate space m the retro
molar triangle, then maximum surgical access is available for removal of 3rd molar.

RETROMOLAR TRIANGLE
It is a topographic design for a usually concave space posterior to2nd molar. It is a roughened area distal
to 2nd molar into which 3rd molar would erupt. It is bounded by anterior border of ascending ramus &

MANDIBULAR THIRD MOLAR IMPACTIONS DR. JOSEPH JOHN K. POTHANIKAT Page 4


temporal crest, where branches of mandibular nerve & vessels would emerge. It distributes over
temporalis tendon, buccinator & adjacent alveolus. Though these vessels are small, hemorrhage is seen.
Hence a distal incision is placed/carried to ramus & not towards the cheek.
Surface is mucoperiosteium attached to the most posterior aspect of superior surface of body of mandible,
posterior to 2nd molar & anteriorly to the attachment of buccinator & anterior pharynges action. This area
is inflicted with inflammation process of impacted/ malposed tooth. Any acute infection may traverse into
any plane form retro molar triangle. Greatest access through retro molar triangle is in class I impaction.
Retro molar triangle influence, on the surgical access for an impacted 3rd molar can be expressed in
saggital & transverse plane.
E.g.- Class I, crown to crown mandibular 3rd molar impaction which is also a complete bony impaction
has good access as well as enough soft tissue coverage tor accurate closure while partially bony impacted,
mesioangular in class III has surgical access also a long mucoperiostcal flap which has difficulty in
closure.

INFERIOR ALVEOLAR NERVE & VESSELS


This is a true osseous canal within the ramus and body of mandible. Neurovascular branches may be
multiple/single. Inferior alveolar canal in the radiograph is identified relatively to the impacted tooth.
Greatest surgical anatomical concern is if canal overlaps the impacted tooth. Usually the canal is inferior
to and/buccal to the impacted 3rd molar. Howe, Poyton & Pogrcl described a characteristic radiological
image of impacted 3rd molar to inferior alveolar canal. Canal may be at the same level as the 3rd molar
but not in contact so an area of overlap will appear without change in dimensions. If bilateral close
surgical anatomy of impacted 3rd molar is seen, then is wise to remove them in separate surgical
procedure to avoid bilateral post-op nerve dysfunction.

LINGUAL NERVE
It may be hidden beneath or in the mucosa, medial to the location of impacted 3rd molar near the crest in
an abnormal superior position. Studies have demonstrated that lingual nerve at times is located slightly
superiorly to the crest of the bony ridge, medial to the 3rd molar, l-2mm towards the midline in the
lingual soft tissues. It is thus vulnerable to tear. Eg- In class I, where sufficient surgical access is possible,
risk of injury to the lingual nerve is minimal, while in class II & III, the distance between 2nd molar to the
ramus of the mandible is less hence, the lingual nerve is more superiorly placed where risk of damage to
lingual nerve is increased. Thus depending on the type of impaction on patients is told before procedures
about post op lingual nerve dysfunction. Care is to be taken not to extend the incision, backwards distal to
2nd molar in the direction of medially inclined plane in the dental arch-Injecting into the lingual nerve
will lead to protracted anesthesia of anterior 2/3rd of the tongue. Ncurotemesis causes permanent
anesthesia of anterior 2/3 of the tongue on the affected side. Surgical exposure often reveals a traumatic
neuroma of the nerve.

SUBMANDIBULAR FOSSA
Cortex of the submandibular fossa is thin, thus vulnerable to acute inflammation & inadvertent
penetration of fragments of teeth into the space.

POSITION OF THE 3rd MOLAR


Tooth is situated in the distal end of the body of mandible where it meets a relatively thin ramus. A
fracture may result if excessive force is applied before adequate removal of surrounding bone. Tooth is
present in between thick buccal alveolar bone buttressed by thick external oblique ridge & narrower inner
conical plate. Occasionally, transversely/ lingualy facing 3rd molar A presence of broad outer table
prevents buccal tilting of 3 molar. In the anteroposterior plane, rare overlap of 2n molar by 3 molar almost
invariably occurs on the buccal aspect, where alveolus is broader & bolestered by thick external oblique
ridge.

MANDIBULAR THIRD MOLAR IMPACTIONS DR. JOSEPH JOHN K. POTHANIKAT Page 5


On viewing the mandible from the inferior surface, it is seen that the tooth socket lies on the prominent
ridge shelf of lingual bone, thus removing lingual cortical bone facilitates extraction. In these cases, a
buccal approach will weaken the mandible, rendering it prone to fracture.

EXTERNAL OBLIQUE RIDGE


It is a bulky prominence. In some patients it may impede extraction of 3rd molar through buccal
approach.

BLOODVESSELS
Facial artery & anterior facial vein cross inferior border of mandible just anterior to the masseter & are in
close relationship to the 2nd molar. It is possible to cause injury to the vessels if scalpel slips. It is thus
sensible to begin incision at the depth of the sulcus and direct the blade towards the teeth.

MUSCLES
Attachment of temporalis muscle extend from the coronoid process, to the root of ascending ramus,
occasionally they reach (he distal surface of 3rd molar. It always terminates as 2 limiting prongs on
borders of retro molar triangle. Consequence of this is severe post-op pain, if these fibers arc stripped.

LINGUAL POUCH
Presence of 3rd molar predominantly in the lingual region with its root or their apices in close proximity
may even perforate the lingual plate. Any attempt to elevate such roots may cause displacement of
fragments through thin lingual cortical plate, deflecting it posteriorly below myelohyoid muscle & along
the medial surface of mandible into a space called LINGUAL POUCH, after which retrieval of such
fragments is difficult A tooth in lingual version may slip into lingual soft tissue if the force is misdirected.
Sometimes the tooth along with the fractured lingual plate may be driven into the lingual soft tissues.

BONE TRAJECTORIES
It is related to mechanical stress & runs longitudinally. A buccal chisel cut is parallel to the superior of the
mandible in 3rd molar region. Care is to be taken on the account of force delivered; else an extensive
horizontal split in compact bone may result, limiting this is possible with a vertical stop distal to 2nd
molar and at right angle to free edge of the bone. Omission may lead to split in buccal cortical plate all
along till the 1st molar & denude the roots of mandibular 1st & 2nd molars. Careless application of chisel
lingually will result in fracture of lingual plate, sometimes the lingual that is about 25mm distal to 3rd
molar. Accidents have been recorded where coronoid process has been a part of fracture fragment.
Correct removal of lingual plate with chisel, may not necessitate giving a vertical stop/ limit cut distal to
2nd molar on the lingual side. In this vicinity, a thin cortex surrounding the 3 molar Iingually joins thicker
border of mandible & inner plate breaks off at that junction & doesn't extend forwards further.
Chisels may be used in younger patients where a natural line of cleavage along the grain of bone is
present In the mandible it runs vertically in ascending ramus .almost parallel to border) & horizontally in
the body of the (almost parallel to occlusal surface). In the maxilla, there is no true grain but the thin
plates is of bone are easily cut In older patients (>40 yrs) chisels are contraindicated as bone is brittle and
mandible may shatter in unpredictable planes.

PRE OPERATIVE ASSSESSMENT


CLINICAL ASSESSMENT
RADIOLOGICAL ASESSMENT

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CLINICAL ASSESSMENT
1. Mouth opening
a. GOOD (Good access)
b. Limited (Poor access)
2. Size of the mouth
a. Small (Poor)
b. Large (Good)
3. Position of the mandible
a. Retrusive (Poor)
b. Protrusive (Good)
4. Flexibility of the oral musculature.
5. Palpate the external oblique ridge,
a. if external oblique ridge is behind the tooth then access is good, else access is poor.
6. Existing pathology:
Caries in 2nd or 3rd molar
Periodontal disturbance
Absence / Presence of 1st molar
Anatomy of 2nd & 3rd. molar
Associated pathology - benign/malignant neoplasm, odontomes, cysts, ameloblastoma
Skeletal diseases - osteogenesis imperfecta, osteoporosis etc
Sclerosis of bone.

RADIOLOGICAL ASESSMENT
1. Angulation & Depth
2. No. & Shape of roots
3. Relation to canal
4. Condition of 2nd molar
5. Density of bone
6. Bone loss around the teeth
7. Existing Pathology

WHARFE'S ASSESSMENT:
It helps beginners to anticipate problems and avoid difficult impactions. In this type of assessment the
total scoring to individual cases re directly related to corresponding difficulties that one is liable to
encounter during removal of an impacted tooth. Scoring details

Horizontal 2
Distoangular 2
WINTER S CLASSITION
Mesioangular 1
Vertical 0
1-30 mm 0
HEIGHT OF MANDIBLE 31-34 mm 1
35-39 mm 2
1-50 0
60-69 1
ANGULATIONS OF 3rd MOLAR
70-79 2
80-89 3

MANDIBULAR THIRD MOLAR IMPACTIONS DR. JOSEPH JOHN K. POTHANIKAT Page 7


90+ 4
Complex 1
ROOT SHAPE Favourable 2
Unfavourable 3
Normal 0
FOLLICLE Possibly enlarged 1
Enlarged 2
Space available 0
Distal cusp covered 1
EXIT PATH
Mesial cusp covered 2
Both covered 3
TOTAL 33

CONFIGURATION OF ROOTS OF IMPACTED 3rd MOLAR:


Point of application of elevator and path of delivery of impacted tooth vary depending on configuration of
impacted tooth. Roots in radiograph are examined for
Fused / separate roots
No of roots
Straight / curved roots
If curved, curvature favorable/ not favorable indicates tooth section.
Long & slender / Short & stout roots
Convergent /divergent.
Texture & type of investing bone.

PREDICTION OF INJURY TO IDC:


HOWE & POYTON (1960) developed criteria of true relationship of root apices of impacted mandibular
3rd molar to IDC. Review reveals 4 radiologic signs in the roots of teeth & 3 changes in IDC appearance.

1. Related but not involving the canal


Separated
Adjacent
Superimposed
Root apex may be close to IDC, but intervening bone separates it. If intervening bone is less then IDC is
considered close. Neither outline of the bone is disturbed hence chances of injury to IDC are decreased.
Because of its close relationship, labial sensation impairment is a possibility.

2. Related to changes in the roots


Darkening of the root - density of the root is altered when root impinges on the canal. Position of
the root is said to be relatively radiolucent and appear dark. Darkness is due to decreased amount
of dental structures or decreased amount of cortical bone in the IDC.
Dark and bifid roots - When canal crosses the root apex a double periodontal membrane is seen at
the apex.
Narrowing of the root It denotes the presence of deep grooving or perforation of root into IDC.
Deflected root - Deviation of die root buccally / lingualIy or both when it reaches the canal.

MANDIBULAR THIRD MOLAR IMPACTIONS DR. JOSEPH JOHN K. POTHANIKAT Page 8


3. Related with changes in the canal
Interruption / loss of lines: Roof and floor of IDC are seen as radio opaque lines. Either the roof
or the floor may be disrupted in relation to the root structures indicating deep grooving of the root
& loss of dense cortical bone. It is considered a "DANGER SIGN".
Diverted canal: This is due to upward displacement of canal passing through the root During
eruption, the content is considered to he dragged upwards.
Converging / narrowing canal: When there is convergence, i.e., narrowing of diameter of the
IDC near the apex of the root giving a "HOUR GLASS APPEARANCE* indicating partial
encirclement of the canal. This is also a "DANGER SIGN".

PRE- OP RECOGNITION OF FACTORS COMPLICATING OPERATIVE


PROCEDURES:
1. State/ level of eruption: if unerupted, crown may be covered by soft tissue (soft tissue impaction),
it may be in deeper position so it is covered partly/completely by bone (bony impaction).
2. Angulations to be studied & position classified accordingly.
3. Relationship of 3rd molar to 2nd molar.
4. Distance between ascending ramus & distal surface of 2nd molar (distal tilting of 2nd molar
further decreases accessibility).
5. Appearance of roots - its no, whether straight / curved, mesially/ distaily, fused / separate,
hypercementosed.
6. Condition of tooth
a. Partly erupted- carious
b. Unerupted- may show evidence of internal resorption may be mistaken for caries
7. Inflammation / infection in periodontal tissues
8. Bone along mesial surface of tooth may be infected or destroyed by periodontal tissues, hence
may require removal of 2nd molar.
9. 2nd molar may be carious/ resorbedV may have a large restoration where elevation is risky.
Tapered roots of 2nd molar may luxate it out of the socket.
10. Size of follicular space- smaller the space most difficult the extraction.
11. Width of periodontal ligament -
a. Middle age - space is less
b. Ankyloscd tooth possible
12. Sclerosis of adjacent bone may make it difficult to remove.
13. Presence of cysts - may cause displacement of adjacent teeth / encroachment of adjacent teeth.
14. Tumors- ameloblastoma, odontome, odontogenic tumors

a. BENIGN
b. MALIGNANT
15. Skeletal diseases - Osteogenesis imperfecta, osteopetrosis...

MANAGEMENT OF IMPACTED TEETH:


Management of impacted teeth involves 2 modalities:
1. CONSERVATIVE METHODIf the impacted tooth is asymptomatic and not causing any
discomfort or alter the function of masticatory apparatus it should be left alone untreated,
particularly if the adjacent tooth is heavily filled, it is important to take a conservative approach.
2. SURGICAL METHOD is removal of impacted tooth.

MANDIBULAR THIRD MOLAR IMPACTIONS DR. JOSEPH JOHN K. POTHANIKAT Page 9


METHODS OF REMOVAL OF IMPACTED TEETH:
1. CLOSED METHOD-
a. Forceps technique
b. Elevator technique
c. Combination
2. OPEN METHOD-
a. Odontotomy
b. Odontotomy

BURS: Medium sized bur either Roschead (Ash 7-16) or fissure (Ash 7-12) are used. Cutting with fine
control can be achieved with high speed & minimal pressure. Use of irrigation with sterile saline prevents
over heating of tissues & clogging of bur. It may be used to grind bone (Roschead) / remove blocks of
bone. A gentle sweeping motion is used along the whole length of area concerned, thereby leaving a
smooth even edge. Blocks of bone are removed using fissure bur (Ash-7) to make cuts through the cortex
into the medulla around an area, which can be prized out.

CHISELS: They may be used to great advantage in young patient (<40yrs), where natural lines of
cleavage along the 'grain' of bone is present. In the mandible these run vertically in the ascending ramus
(almost parallel to posterior border) & horizontally in the body (parallel to the occlusal surface). In the
maxilla there are no grains, but the thin plate of bone makes the work easier to cut. In patient (>40yrs)
chisels are contraindicated as bone is brittle. With sharp chisels and carefully placed stop cuts, the degree
of control exercised is not inferior to that obtained by burs. Chisels may be used by hand / mallet in any
case support should be firm to avoid slipping. Chisel may be used to plane bone/ cut blocks of bone.
Chisel cuts is determined by the angle of beveled surface.
To remove blocks of bone the beveled surface is usually turned towards the bone, which is to the left.
When used to plane the bevel face is placed against the bone and driven along the required depth to shave
off wafers of bone.

Angle of holding chisel determines amount of chamfer, which the surgeon wishes to leave on this bone
edge. Outline of area with shallow cuts made with small chisel (3mm) before using broader chisel (5mm)
prevents splitting of bone along a long distance. Tooth sectioning used beveled chisels. Maximum force at
point of contact is from 5-7 lb depending on spring used. Lightest blow, which will effect reduction, is at
least 15 lbs. Blow delivery should be constant. There should be forward movement of cutting blade not
les than 1mm, which eliminates "follow through "effects.
'Ossisectors/ Hand powered chisels are alternatives to burs / chisels.

BURS: Used with sterile hand piece with coolant usually 0.9% NS
Types Diameters:
2.3mm (round)
1.6-2.6 at widest diameter (tapered)
1.6-2.6 cross cut (fissure burs)
Advantage:
1. Control over hand piece aids in control over removal of bone in that particular area.
2. Slipping is possible if chisel is used.
3. Less traumatic to patient, hence heating of wound is better with better post op complications.
4. Chisels produce efficient bone reduction and tooth sectioning
5. Burs are precise.

Disadvantage:
1. Chisel force cannot be controlled
2. Possibility of cleavage along grain over a long distance

MANDIBULAR THIRD MOLAR IMPACTIONS DR. JOSEPH JOHN K. POTHANIKAT Page 10


3. Blunt chisels requite more force placing strain on TMI or fracture of mandible.

Burs:
1. Emphysema into fascial planes / Submandibular space by forcing gases & liquid
2. Deleterious frictional heat (dull bur) m the bone resulting in undesirable inflammation / bone
necrosis & delayed healing
3. Fracture of the bur tip into the bone
4. Damage to adjacent teeth with bur.
5. Lingual plate perforation wit mandibular 3rd molars.
6. Time consuming.

POSTAGE STAMP METHOD:


Round bur (no 6) is used to drill holes in series outlining the portion of bone and may be join either fay
bur or chisels.

BUCCAL APPROACH:
More traditional, easier surgical removal on conscious patients. Post op infection likely to be superficial.
Any damage to the lingual perioslium of mandible results in more pain. Buccal cortical plate may be thick
& tedious making removal difficult, more often tooth splits from this side. In some occasions lingual bone
removal especially on distally may be associated with lingual nerve damage & increased paresthesia. It
should be avoided unless necessary.

LINGUAL APPROACH:
With ungual obliquity, the lingual plate is markedly thinner & weaker.
Advantages:
1. Fractures with case provide nerve is protected, thereby preventing major complications.
2. Breaching of buccinator muscle in buccal approach is avoided.
3. When external oblique ridge is damaged, dry socket rate increases.
Disadvantage:
1. Lingual nerve damage
2. Paresthesia in region of myclohyiod nerve supply of lower Jip.

OPERATIVE PROCEDURES
1. Preliminary considerations:
Presence of infection: Treatment of pericoronitis is essential before surgery. If maxillary 3rd molars are
impinging on infected mandibular 3rd molar then removal of maxillary 3rd molar is indicated.

2. Premeditation & preparation of the patient:

lOOmg pentobarbital sodium OraIJy/l-2/nJ IV.


Diazepam titrated IV in doses o 3-20mg to achieve "VERRIL sign", may be supplemented with
meperidine /nitrous oxide + oxygen.
Music, quiet surroundings & interesting Talks to establish a favorable atmosphere
Intraoral bacterial count decreases with use of antibacterial mouthwashes.

3. DRAPING:
STERILE TOWELS: to provide a sterile field as well as to cover the eyes to decrease psychological
trauma.

MANDIBULAR THIRD MOLAR IMPACTIONS DR. JOSEPH JOHN K. POTHANIKAT Page 11


Exposed portion of skin of face & chin washed with antiseptic solution.
Sterile over patient's chest.
ALL THES PRE OP PREPERATION DECREASE THE INCIDENCE OF DRY SOCKET.
4. Chair position: for a right-handed person, the right elbow should be opposite right shoulder.
5. Sponges: Curtain of sponge is used to isolate the area/ field in case chisel is used One end near
incision & the other on lingual prevents fragments of tooth & bone to enter throat, also eliminates time
loss associated with expectoration.

TECHNIQUE
The following steps are to be used in all 3rd molar removal
1. Incision & Flap
2. Elevation of Flap
3. Flap retraction
4. Bone Removal, Tooth Division and its removal
5. Wound cleansing
6. Suturing
7. Packing
8. Aftercare

1. INCISION & FLAP


1. L shaped
2. Bayonet Incision
3. Envelope Flap

L- shaped: it extends from a posterior limit just lateral to ascending ramus into the sulcus. It may just
avoid the distobuccal periodontium of 204 moiar or just include it, depending on proximity of 3rd molar
to 2nd molar. The incision is curved at the junction of the limbs; it may also be angled where it gives
good apposition while suturing. This incision commits the surgeon for a buccal approach because
removing a lingual flap is difficult.

BAYONET INCISION It has 3 parts


Distal
Gingival / Intermediate
Anterior
Distal part is started just lingual to external oblique reach of the ramus at about a distance of 3/4* inch
distally from lower 2 molar and is directed anterior, until it reaches the midpoint of the distal surface of
2nd molar.
Intermediate part is carried forward to a variable degree. There may be slight gingival involvement pf 2nd
molar and the result is different from L-Shaped incision. While other incisions go entirely around the
buccal margin of 2 molar to the papilla between the I* & 2nd molar or even upto the buccal fissure of 1*
molar. The anterior extent of this depends on the depth & difficulty of 3rd molar.
Anterior part of the incision extends from the gingival margin downward toward the sulcus. The incision
is angled forward as it increases the blood supply to that area, also making access better. Over extension
may lead to profuse bleeding due to venous plexus. This may be avoided by keeping die incision in
attached gingival & slight curvature of the release incision anteriorly.

ENVELOPE FLAP: This is confined to the gingival trough/ sulcus. Deeper the tooth is, more anterior
the incision can be given sometimes as far as premolar. Advantages are it's easy to suture, less post op
pain & less distortion in heating. Entire mucosa periostium are stripped from the bone to a point approx to
apical l/3rd of tooth.

MANDIBULAR THIRD MOLAR IMPACTIONS DR. JOSEPH JOHN K. POTHANIKAT Page 12


GROOVE &MOORE (1970) suggested different designs.

ELEVATION OF SOFT TISSUES:


Lateral elevation is performed using a periosteal elevator starting in anterior, passing lateral to & then
posterior to 3 molar site.2 Important maneuvers are performed
1. Sharp end of the periosteal elevator is used to reflect tissue distal to 2nd molar in an apical and
downward direction into the gingival posterior crevice,
2. Elevate the soft tissues horizontally in a sweeping motion anteroposterior to raise the retromolar
tissues in a single block with a lever type movement. Tip of the instrument should always be in
contact with bone. During reflection, periosteal layer is not to be perforated.
The flap can be undermined beyond the incisUm line, asitgi ves better access and reflection. Retraction is
easy. Raising a lingual flap after placing a distal incision in the center of the retromolar fossa gives equal
reflection buccally and lingually.

RETRACTION OF FLAP:
The main purpose is to provide access for operation and provide protection to soft tissues. Most gentle
way is to place the periosteal elevator firmly on the bone and res*, the retracted soft tissue on the opp side
of the bone. Care is to be taken that the retractor is not pulled down the surface of bone / soft tissue, else
the flap over the
EOR may be enlarged and may lead to swelling. Types of Retractor: Dyson's malleable copper retractor.
Lingual retractor, Ward's-Kilner retractor, Lack's retractor, Bowdler Henry retractor.
BONE REMOVAL, TOOTH DIVISION & ITS REMOVAL: Both are interdependent and are determined
by
Shape of tooth
Position of tooth
Shape of surrounding bone
Age of patient.
Bone removal to exposure crown will not be required in cases where the tooth is in front of the amber line
& is fully exposed. Either a bur or chisel or combination can be used if required. Bur when used with
hand piece gutter can be made around the tooth neck and a point of elevation for the elevator. The point
of elevation if on the mesial and an elevator is placed, should stand at 45 to the body of mandible
without support Lingual soft tissues should he protected if ungual spur of bone is to be removed. 2 basic
principles in removal of 3rd molars:

ODONTECTOMY: Bone is removed to permit removal of tooth in one piece.


ODONTOTOMY: tooth is sectioned and removed in parts. _
OSSISECTION: If the tooth is covered by bone sufficient amount of bone is removed to aid in
removal of the impeded tooth without heavy forces. Use of excessive force for removal may
fracture bone.
Bone removal is best using burs. MOORE & GILBE collar technique sacrifices bone similar to bone
removed with split bone chisel technique. Bur is used in sweeping motion to expose the tooth crown. A
buccal trough/ ditch / gutter is made all along die buccal surface. It should he made in the cancellous bone
of mandible. Visually it should appear red owing to the cancellous bone as opposed to white color of
cortical bone. Bone around the distolingual part of 3 molar is removed to facilitate removal
"BONE BELONGS TO THE PATIENT WHILE TOOTH BELONGS TO THE SURGEON"
Tooth is sectioned to preserve as much alveolar bone as possible. Tooth sectioning should he planned so
that removal is atraumatic. Type of impaction determines the method of sectioning based on line of
withdrawal. Generally the tooth is sectioned to with the bur and an elevator is placed. On slight
rotation of the elevator the tooth gives way along the line of sectioning,

MANDIBULAR THIRD MOLAR IMPACTIONS DR. JOSEPH JOHN K. POTHANIKAT Page 13


TOOTH DIVISION
ADVANTAGES
1. Decrease damage to the adjacent teeth. No attempt to be made to force the tooth out of its
convexity with 2nd molar else there is elevation of 2nd molar.
2. Decrease bone removal results in decreased post op swelling and pain.
3. Decreased risk of fracture of inaudible.
4. Decrease risk of lingual nerve injury because leverage forcing apex of tooth down into the canal.
5. Trismus primarily due to injury to ligaments of TMJ, a sequiae of forceful elevation of tooth.

WOUND TOILET:
Socket contains blood contaminated by variety of organisms, bone chips, slurry from burs, and lubricants
from hand piece, talcum powder from gloves, granulation tissue and follicular remnants.
Measures taken immediately after removal of 3rd molar is critical for successful healing. Cutting the
bone, which is heated if bur is used, may damage wall of the socket. Outside the socket the tissues have
been damaged and debris collection is seen at the angle of reflection.
Steps to prepare the socket:
Wedge removal: removal of triangular wedge of tissue immediately posterior to 2nd molar to
provide for surgical drainage and repair by secondary intention through production of granulation
base and gingival attachment posterior to 2nd molar. Any excess tissue is excised as a triangular
form thru an elliptical incision. Incision line on the buccal aspect is beveled in lateral direction to
remove bulk of submucosa. Tighe sealing of gingival crest margin against 2nd molar provides
tight edge to edge closure.
Debridement; Initial step is to swoothen osseous surgical margin with bur operating with saline/ bone file.
Using generous lavage of saline and suction apparatus does debridement of alveolar bone. The surgeon to
inspect the alveolus may use suction. Cnrrattage is not recommended if cystic/pathologic conttnts are
absent, as it may damage residual periodontal tissues attached to the alveolar walls. Pathologic tissues
should be removed-withcare to prevent injury to IAN If a cystic lining is to be removed in 3rd molar
region, curettage is done in areas involved only white not involved is not curetted

INTRA ALVEOLAR DRESSINGS:


It is to enhance to repair process, control pain & odema. Forms may be in the form of pastes, salves,
tablets, gelatin sponges. Following removal of 3 molar, coagulum must be vitalized by ingrowth of
fibroblasts & angioblasts preventing secondary infection. It may lead to a painful localized osteomyelitis
(dry socket).
Space occupying agents are tablets which contain active chemotherapeautic agents/antibiotic agents. As
tablets is dissolved or absorbed granulation tissue fills the alveolus.
Example-Sulphonamide tablets.
-5-10 mm of gelatin sponge soaked in Lincomycin Powdered tetracyclines for i.v use maybe3 dusted into
coagulum thus preventing establishment of microorganisms which destroy a defenceless coagulum.If
usual deft delicate, accurate removal of 3rd molar is performed then no medicament is necessary.

CLOSURE OF SOFT TISSUE FLAP.


Returning of soft tissue flap to their original position stabilizing the soft tissue flap permits repair and
preserving periodontal attachments .Retromolar triangles of class3 relation have small bony bases hence
accurate closures must be kept In mind when incisions are pfaced.2 or more sutures may be placed to
firmly stabilize the mucosal flap.Sutures are tightly placed to cause vasocompression and prevent
bleeding. Suturing may be either with non absorbable/absorbable .If a longer time span of effective
control of soft tissue is desired either 3-0 chromic gut/polyglycolic acid sutures maybe used

MANDIBULAR THIRD MOLAR IMPACTIONS DR. JOSEPH JOHN K. POTHANIKAT Page 14


.Nonabsorbable suture are black silk which is economical and permits a positive long term stable
closurcDisadvantage of giving tight sutures is postoperative swelling due to unyielding sutures. Necessity
of sutures is determined in a mouth nearly closed position.

INTRAORAL DRESSING
Important is preserving coagulum during die critical hours of repair. Gauze folded with smooth surface is
placed over the socket. Popularly used is Whitehead's varnish on gauze.

POSTOPERATIVE COMPLICATIONS.

Alveolar Osteitis (Dry Socket): Lack of blood clot in the extraction socket.

ETIOLOGY:
Trauma to bone Infection
Vasoconstriction due to L.A

PREVENTION:
0.12 percent chlorexidine 10ml preop.rinse
Paint the surgical site with 10% povidone iodine
Irrigation before closure
Tetracycline powder in the socket

TREATMENT:
Lavage the surgical site with warm normal saline. Soak iodoform gauze containing eugenol into the
socket & dressing changed every 3-4 days. Usually granulation tissue covers in a weeek. Patient can at
home irrigate with a plastic needle. . Use of either an obttmdant ( eugenol/ guiacol) or topical
anesthetic(benzocaine) is recommended.

INFECTION:
Infection is possible if no signs of remission, increased in 3-5 days. Etiolcgy:
May be prcop in origin , from preexistin conditions in periapical granuloma/ periodontal tossues, general
oral sepsis.
Failure to use an aseptic technique
Patient unable tot maintain proper oral hygiene post op

SECONDARY HAEMORRH AGE:


Usually it develops after several days as a result of infection of wound/ erosion of vessels in granulation
tissue.

TREATMENT:
socket packed with hintera oral medicament
Examine wound carefully for foreign body.
Patient on antibiotics to prevent secondary infection.

POST EXTRACTION PYOGENIC GRANULOMA:


Due to failure proper debridement, compressed loose fragement, forms sequestrum that gets infected
resulting in suppuration and or excessive proliferation of granular tissue.

MANDIBULAR THIRD MOLAR IMPACTIONS DR. JOSEPH JOHN K. POTHANIKAT Page 15


Treatment:
Open wound
Permit drainage
Remove sequestrum
Gentle curettage & irrigation

TRISMUS:
1. Common causes of pose 3rd molar extraction are
2. Inflammmtion after operative trauma results in muscle spasm-trismus
3. Infection of pterygomandibular / submassctric/prctemporal/infVatemporalspace
4. Improper LA technique-injury to medial pterygoid
5. Injury to TMJ during surgery

TREATMENT:
Intraoral & extra oral heat application to decrease inflammation and spasm (caution as a preop infection
may increase due to flare up.
Administration of analgesics for pain
Antibiotics if infection is present.

OPERATIVE COMPLICATIONS
HAEMORRHAGE:
Intra op haemorrhage during surgical procedure may result from inferior alveolar vessels. Blood loss may
be rapid/continous then patient may reach hypovolemic shock
Preop radiograph-disclose vascular anomalies, proximity to IAC radioiucency produced by AV aaerysms.
In an IAN cut the haemorrhage is prompt while if the vessels are in completely it results in intermittent
copious flow.
Control haemorrhage:
Cleanse alveolus under direct vision possibly
Crush contiguous bone into bleeding site
Severe neurovascular bundle allowing retraction and contraction of arteries
Elecrtocautery
Vascular defect procedure aagressive haemorrhage treated by packed oxidized cellulose /
microfibrilar collagen material.
Arteriovenous aneurysms may occurin any location of the mandible also in the 3rd molar region. It
presents as a radilucent lesion. Management of an aneurysm takes a predence over 3rd molar surgery.
If haemorrhage is seen when removing a root tip then temporarily pack gauze for 5-10 mm & proceed
with surgery. If bleeding recurs then in may necciate to pack the socket and suture. Removal of the root
up may be attempted later.

INJURY TO IAN:
Injudicious instrumentation
Position of the tooth
Any force that will crush bony walls of the mandibular canal will cause decompression of the nerve
leading to anesthesia or paresthesia of that area supplied by it especially in the chin & lower lip. Minor
transient nerve dys function
Post op is usually accepted by educated patient, which may last up to 6 months. If it still persists then
surgical solution may be considered like surgical decompression / neuroma resection/ microsurgical
grafting.

MANDIBULAR THIRD MOLAR IMPACTIONS DR. JOSEPH JOHN K. POTHANIKAT Page 16


TREATMENT:
If noticed at the time of surgery, examine the depth of the socket and remove spicule compressing
on the nerve.
If roots are completely covering ihe nerve men me tooth may be removed by sectioning.
Tearing/division of the nerve may be placed back in place to aid repair.

INJURY TO LINGUAL NERVE:


Fracture of the lingual cortical plate
Accidental cut with bur /chisels during odentectomy. If re approximation possible then do it and suture.

Fracture of the root: Injury may occur if the root tip is close to the mandibular
canal. Small apices 3-5mm in length can be left behind when the tooth is vital. It
is essential to remove all roots if infection is present.

Injury to 3rd molar: Complications associated are


Luxation of 3rd molar.
Trauma to alveolar crest & periodontal ligament of 2nd molar Damage to restoratin of 2nd molar.
Early removal of 3rd molar may have a beneficial effect on the periodontal health of adjacent of
the 2nd molar.

Fracture of the instrument: Search for the fracture instrument. Radiograph may be necessary. Breakage
of LA needle during IAN block is possible hence only 2/3 of the needle is inserted. Grasp with artery
forceps and remove. Fracture of the bur may be due to excessive force during drilling. Fracture of the
suture needle is possible. Metal foreign body detector may be of great assistance.

Displacement of tooth: Fracture of the thin cortex lingually may force the fragment into Submandibular
gland.

Treatment is
Indefinite observation and treatment.
Delay of 3-4 weeks to await stabilizing fibrosis.
Immediate / early removal.

SUBMANDIBULAR REGION: continuous upward external pressure displaces the tooth / fragment and
may aid visualization. Else, lingual gland is reflected till canine region and mylohyoid muscle carefully
dissected after locating the fragment, then removing it carefully.

Fracture of the alveolar process and basal bone:


Fracture is possible as a result of chronic periodontal disease/ ankylosis/ exostosis to the socket wall.
Buccal bone fracture may be retained as it is rich in blood supply due to firmly attached periostium.
Loose fracture fragments are tot be removed as they form sequestra, suppurate and delay
healing.
Fracture of the basal bone is possible with misdirected force from application of elevators. Radiograph
may be taken to confirm.

Dislocation of TMJ: is seen in patients with weak supporting muscles and lax capsule. Prevention is by
application of less force, also use mouth prop/ Willi's mouth gagprevents dislocation. Jaw if dislocated
should be reduced before the patient comes back to consciousness.

MANDIBULAR THIRD MOLAR IMPACTIONS DR. JOSEPH JOHN K. POTHANIKAT Page 17


Fracture of the mandible: Increased pressure wit helevators in impacted 3rd molars may introduce a
linear fracture without any indication. Common in
Angle region
Internal/ external oblique ridge
Thin cortex at the base of the mandible.
Fracture should be fixed wit bimmmediate reduction and full disclosure to the patient.

ODEMA: raising the lingual flap will lead to odema owing to the thin fascia.

Notes:

MANDIBULAR THIRD MOLAR IMPACTIONS DR. JOSEPH JOHN K. POTHANIKAT Page 18

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