SUR GI CAL MAN AGE ME NT

OF IMPACTED
MANDI BULA R II I MOLAR S
AND
COMP LIC ATI ON S

PRESENTED BY:
DR.SATYABRATA PATNAIK
1ST YR P.G
INTRO DU CTION
FACTORS THAT MAKE REMOVAL EASIER

CLASS 1
SOFT
TISSUE POSITION A
IMPACTION

SEPRTATED ROOT 1/3RD

FROM TO
II MOLAR 2/3RD
MESIOANGULAR

LESS
FUSED CONIC
DENSE
ROOTS
BONE
WIDE
LARGE
PERIODONTAL
FOLLICE
SPACE
FACTORS THAT MAKE REMOVAL DIFFICULT

CLASS 3
COMPLETE
BONY POSITION C
IMPACTION

CONTACT LONG
WITH THIN
IIMOLAR DISTOANGULAR
ROOTS

DENSE DIVERGENT
INELASTIC CURVED
BONE ROOTS
NARROW
THIN
PERIODONTAL
FOLLICLE
SPACE
 ANATOMICAL CONSIDERATIONS

 LINGUAL NERVE
 INFERIOR ALVEOLAR NERVE
 INFERIOR ALVEOLAR VESSELS
 RETROMANDIBULAR VESSELS
 TEMPORALIS TENDON INSERTION
 PTERYGOMANDIBULAR SPACE
 FACIAL ARTERY
 SUBLINGUAL GROOVE
 RETROMOLAR TRIANGLE
 LINGUAL NERVE
• LINGUAL NERVE LIES INFERIOR & LINGUAL TO THE CREST OF
LINGUAL PLATE OF MANDIBLE WITH A MEAN POSITION OF
2.28MM(±0.9)BELOW THE CREST & 0.58MM(=/-(0.9) MEDIAL TO
CREST
- KIESSELBACH & CHAMBERLAIN

• 15% OF CASES SHOWS IT LIES SUPERIOR TO LINGUAL PLATE

• CADAVERIC STUDIES SHOWED THAT IT LIES 3.45MM MEDIAL TO
ALVEOLAR CREST & 8.32MM BELOW
• MRI STUDY DEMONSTRATED THAT THE NERVE IS LOCATED AT A
MEAN DISTANCE OF 2.53MM MEDIAL TO AND 2.75MM BELOW
ALVEOLAR CREST
 INFERIOR ALVEOLAR NERVE
• THE MANDIBULAR NERVE RUNS FROM THE TRIGEMINAL GANGLION
THROUGH THE FORAMEN OVALE DOWN TOWARDS THE MANDIBLE
• THE NERVE ENTERS THE MANDIBLE THROUGH THE MANDIBULAR
FORAMEN ON THE MEDIAL SURFACE OF THE ASCENDING
MANDIBULAR RAMUS
• AFTER PASSING THROUGH THE MANDIBULAR FORAMEN, THE
NERVE IS CALLED THE INFERIOR ALVEOLAR NERVE
• WITHIN THE MANDIBULAR CANAL, THE IAN RUNS FORWARDS IN
COMPANY WITH THE INFERIOR ALVEOLAR ARTERY AND
TOGETHER THEY ARE CALLED THE INFERIOR ALVEOLAR
NEUROVASCULAR BUNDLE.
• DIFFERENT VARIATIONS IN THE COURSE OF THE INFERIOR
ALVEOLAR NEUROVASCULAR BUNDLE ARE DESCRIBED BY THE
CLASSIFICATION BY CARTER AND KEEN (1971)
• HIGH MANDIBULAR CANALS (WITHIN 2MM OF THE APICES OF THE
FIRST AND SECOND MOLARS), 47%
• INTERMEDIATE MANDIBULAR CANALS 3%
• LOW MANDIBULAR CANALS 49%
• OTHER VARIATIONS – THESE INCLUDED DUPLICATION OR DIVISION
OF THE CANAL, APPARENT PARTIAL OR COMPLETE ABSENCE OF
THE CANAL OR LACK OF SYMMETRY.
• DUPLICATION OR DIVISION 0,9%
• BIFURCATION 0.08%
• NO CASES OF MULTIPLE CANALS IN
ORTHOGNATHIC SURGICAL CASES
HAVE BEEN REPORTED.
 INFERIOR ALVEOLAR VESSELS
• A BRANCH OF MAXILLARY ARTERY DESCENDING WITH ITS
CORRESPONDING VEIN AND NERVE AND FORMING A
NEUROVASCULAR BUNDLE
• SUPPLIES THE TEETH OF THE MANDIBLE,GINGIVAE,AND THE
• SKIN OVER THE CHIN AND LOWER LIP
• NEAR ITS ORIGIN THE INFERIOR ALVEOLAR ARTERY GIVES OFF A
LINGUAL BRANCH WHICH DESCENDS WITH THE LINGUAL NERVE
AND SUPPLIES THE MUCOUS MEMBRANE OF THE MOUTH.
• OPPOSITE THE FIRST PREMOLAR TOOTH DIVIDES INTO TWO
BRANCHES THE INCISIVE AND MENTAL
• VARIATIONS OF THE INFERIOR ALVEOLAR ARTERY ARE QUITE
RARE
• TWO REPORTS OF THE INFERIOR ALVEOLAR ARTERY ARISING
FROM THE EXTERNAL CAROTID
• MANDIBULAR REGION SHOULD BE AWARE OF SUCH A VARIATION IN
THE ARTERIAL ARCHITECTURE.
• IT HAS BEEN REPORTED THAT THE INFERIOR ALVEOLAR ARTERY
ORIGINATING FROM EXTERNAL CAROTID ARTERY 3.5CM INFERIOR
TO ITS TERMINAL BIFURCATION INTO THE MAXILLARY AND
SUPERFICIAL TEMPORAL ARTERIES
• THIS VESSEL WAS FOUND TO COURSE ANTERIORLY DEEP TO THE
RAMUS OF MANDIBLE AND SUPERFICIALLY TO THE LATERAL
PTERYGOID MUSCLE
• THIS VARIATION OF THE INFERIOR ALVEOLAR ARTERY MAY PREDIS-
POSE A PATIENT TO INCREASED MORBIDITY DURING INFERIOR
ALVEOLAR NERVE BLOCK.
 RETROMANDIBULAR VESSELS
THE RETROMANDIBULAR VEIN IS LOCATED ALONG THE
POSTERIOR EDGE OF THE MANDIBLE
BLOOD FROM THE PTERYGOID PLEXUS JOINS WITH THE
MAXILLARY VEINS JUST DEEP TO THE MANDIBLE.
THE SUPERFICIAL TEMPORAL VEIN AND MAXILLARY VEINS
COMBINE INTO THE RETROMANDIBULAR VEIN WHICH RUNS
POSTERIOR TO THE MANDIBLE.
RUNS INFERIORLY AND DRAINS INTO THE INTERNAL AND
EXTERNAL JUGULAR VEINS.
 TEMPORALIS TENDON INSERTION
THE TEMPORALIS MUSCLE IS A BROAD, THICK MUSCLE
ORIGINATES FROM THE TEMPORAL FOSSA OF THE SKULL AND THE
DEEP SURFACE OF THE TEMPORAL FASCIA.
THE FIBERS, DIVIDED INTO ANTERIOR, MIDDLE, AND POSTERIOR
DIVISIONS, JOIN TOGETHER AS THEY DESCEND, PASSING DEEP TO
THE ZYGOMATIC ARCH,
INSERT AS A TENDON INTO THE CORONOID PROCESS OF THE
MANDIBLE
 PTERYGOMANDIBULAR SPACE
 IT IS A TRIANGULAR NARROWING DOWN SPACE WHERE THE
MEDIAL PTERYGOID CONVERGE WITH THE MANDIBLE TO WHICH IT
IS ATTACHED
 THE CONTENT OF THIS SPACE ARE THE LINGUAL NERVE IN
FRONT,INFERIORALVEOLAR NERVE BEHIND AND POSTERIOR AND
LATERALLY THE INFERIOR ALVEOLAR ARTERY AND VEINS
 THE LINGUAL, INFERIOR ALVEOLAR NERVE ENTERS THIS SPACE
FROM THE ROOF OF INFRATEMPORAL FOSSA
 WHILE INSERTING THE NEEDLE INTO THIS SPACE ONE SHOULD
AVOID INJURY TO THE MEDIAL PTERYGOID MUSCLE
 TENDINITIS IS SIMPLY AN INFLAMMATION OF THE INSERTION OF
THE TEMPORALIS MUSCLE AT THE CORONOID PROCESS OF THE
MANDIBLE.
 TEMPORAL TENDINITIS INVOLVES INFLAMMATION OF THE TENDON
WITH SUBSEQUENT SYMPTOMS AND REFERRED PAIN.
 MAINLY CAUSED DUE TO PROLONGED OPENNING OF MOUTH AND
TRAUMA
 COMMONLY MANIFESTED BY PAIN AT THE ATTACHMENT OF THE
TENDON

 NORMALLY RESOLVES IN 5 TO 10 DAYS

 FACIAL ARTERY
 WHERE THE FACIAL ARTERY CROSSES THE LEVEL OF
INFERIOR VESTIBULAR FORNIX IN THE REGION OF 1ST
MANDIBULAR MOLAR
 THE ARTERY CAN BE SEVERED ACCIDENTALLY DURING
SURGICAL PROCEDURE
 HENCE DEEP INCISIONS IN 1ST MOLAR AREA
PREDISPOSE A RISK OF INJURING FACIAL ARTERY
 TO AVOID THE INCISION SHOULD BE MADE DOWNWARD
AND INWARD INSTEAD OF STRAIGHT DOWNWARD
 SUBLINGUAL GROOVE

 IT EXTENDS AS A HORSHOE SHAPED AREA UNDER THE LATERAL

EDGES AND BELOW THE TONGUE
 EXTENDS INTO THE DEPTH BETWEEN THE MYLOHYOID AND
GENIOHYOID MUSCLE
 THE GROOVE IS FILLED WITH LOOSE AND FATTY CONNECTIVE
TISSUE AND SURROUNDING STRUCTURES CONTAINED IN THE
SUBLINGUAL SPACE
 STRUCTURES ARE
SUBLINGUAL GLAND
SUBMANDIBULAR DUCT
LINGUAL & HYPOGLOSSAL NERVES
SUBLINGUAL ARTERY WITH VEINS
SOMETIMES POSTERIOR PART OF
SUBMANDIBULAR GLAND
 RETROMOLAR TRIANGLE
 A TRIANGULAR AREA NEAR THE DISTAL OF THE LAST
MOLAR
 FORMED BY THE FORK IN THE TEMPORAL CREST
LOCATED IN THE INTERNAL FACE OF MANDIBULAR
RAMUS AND DISTAL FACE OF THE LAST MOLAR
 THIS AREA BONE IS PERFORATED BY NUMEROUS HOLES
DESCRIBING THE PASSAGE OF BRANCHES OF BUCCAL
ARTERY
 HERE THE BUCCAL ARTERY ANASTOMOSE WITH THE
INFERIOR ALVEOLAR NEUROVASCULAR BUNDLE
 HENCE CREATING A COMMUNICATION BETWEEN THE
MANDIBULAR CANAL AND THE RETROMOLAR TRIANGLE
 BUCCAL APPROACH VS LINGUAL APPROACH
 BUCCAL APPROACH
ADVANTAGES
MORE TRADITIONAL
EASY TO GET THE TOOTH
WHEN PATIENT IS CONCIOUS
NO DAMAGE TO LINGUAL
PERIOSTEUM
BOTH CHISEL&BURS CAN BE
USED
DISADVANTAGES
THICK BUCCAL PLATE
MORE P.O OEDEMA
INCIDENCE OF DRY SOCKET IS
HIGHER
LINGUAL APPROACH
ADVANTAGES
EASIER THAN BUCCAL
LESS TIME CONSUMING
LESS P.O OEDEMA
DRY SOCKET INCIDENCE IS
NEGLIGIBLE
DISADVANTAGES
DIFFICULT TECHNIQUE IN
CONSIOUS PATIENT
ONLY CHISEL&MALLET TO BE
USED
CHANCE OF LINGUAL NERVE
INJURY
SLIIPING OF TOOTH INTO
LINGUAL POUCH
 SURGICAL PROCEDURE

FIVE BASIC STEPS

 ADEQUATE EXPOSURE
 ACCESS TO THE TOOTH
 SECTIONING OF THE TOOTH(OPTIONAL)
 ELEVATION FROM THE ALVEOLAR PROCESS
 DEBRIDMENT & IRRIGATION
ADEQUATE EXPOSURE
 SEVERAL DIFFERENT FLAP TECHNIQUES HAVE BEEN
DEVELOPED, AND DISCUSSED TO MINIMIZE POTENTIAL
PERIODONTAL COMPLICATIONS TO ADJACENT SECOND MOLAR
OR IMPROVE SURGICAL ACCESS.

TYPES OF INCISIONS AND FLAPS

L-SHAPED FLAP
BAYONET FLAP(WARDS INCISION)
THREE CORNERED FLAP(MODIFIED WARDS INCISION)
ENVELOPE FLAP
COMMA SHAPED INCISION/FLAP
VESTIBULAR TONGUE SHAPED FLAP
GROOVES AND MOORE FLAPS
 L-SHAPED FLAP
 THE ANTERIOR LIMB IS THE VESTIBULAR EXTENSION AT THE LEVEL
OF 2ND MOLAR
 IT CAN BE EXTENDED UPTO 1ST MOLAR
 RISK OF DAMAGING FACIAL VESSELS
 THE VERTICAL RELIEVING INCISION DIFFERENTIATE IT FROM
WARDS INCISION
 THIS RELIEVING INCISION IS GIVEN AT 45O ANGLE TO THE LONG
AXIS OF THE 2ND MOLAR AND RUNS STRAIGHT ANTERIORLY AND
DOWNWARDS
 IT TOTALLY COMMITS AN OPERATOR TO A BUCCAL APPROACH
 BAYONET FLAP
 IT HAS THREE PARTS
ANTERIOR
INTERMEDIATE OR GINGIVAL
DISTAL
 ALSO KNOWN AS WARDS INCISION
 ANTERIORLY IT EXTENDS AROUND THE GINGIVAL MARGIN OF II
MOLAR AND EVEN THE I MOLAR BEFORE TURNING INTO THE
SULCUS USUALLY ANGLED FORWARD
 OVER EXTENSION OF THE INCISION INTO THE SULCUSMAY CAUSE
BRISK OOZING OF BLOOD FROM VENOUS PLEXUS
 CAN BE AVOIDED BY MAKING THE ANTERIOR PART MORE OBLIQUE
 INTERMEDIATE IS ALONG THE GINGIVA
 DISTALLY IT IS PLACED MORE LINGUALLY OVER THE IMPACTED
TOOTH BUT LATERALLY TOWARDS THE ASCENDING RAMUS
 MORE DIFFICULT THE IMPACTION MORE LINGUALLY PLACED
 IT JOINS THE GINGIVAL MARGIN OF THE II MOLAR FROM THE
LINGUAL TO THE BUCCAL SIDE
 THREE CORNERED FLAP
 MODIFIED WARDS INCISION
 LARGER LAYER OF MUCOPERIOSTEAL FLAP
 USUALLY FOR DEEPLY IMPACTED MOLARS
 THE ANTERIOR PART SHOULD COMMENCE AT THE DISTOBUCCAL
CORNER OF 1ST MOLAR INSTEAD OF 2ND MOLAR
 EXTENDS VERTICALLY DOWNWARDS AND THEN CURVED
ANTERIORLY
 FOLLOWED BY GINGIVAL CREVICULAR INCISION ALONG THE 2ND
MOLAR
 DISTALLY IT IS SIMILAR TO WARDS INCISION
 ENVELOPE FLAP
 EXTENDS FROM MESIAL PAPILLA OF THE 1ST MOLAR
AROUND THE NECKS OF THE TEETH TO THE
DISTOBUCCAL LINE ANGLE OF THE 2ND MOLAR
 THEN EXTENDS POSTERIORLY AND LATERALLY UP TO
THE ANTERIOR BORDER OF THE MANDIBLE
 IT SHOULD NOT CONTINUE POSTRIORLY IN A STRAIGHT
LINE BECAUSE THE MANDIBLE DIVERGE LATERALLY
 EASIER TO CLOSE AND BEST HEALING
 IN 1971, SZMYD DESCRIBED THIS INCISION
 COMMA SHAPED INCISION

PROVIDES LAREG ACCESS

INDICATED IN CASE DEEP HORIZONTAL
IMPACTIONS
PERIODONTAL POCKETING DISTAL TO
2ND MOLAR IS LESS
VESTIBULAR TONGUE SHAPED FLAP
• BERWICK, IN 1966, DESIGNED A VESTIBULAR TONGUE-SHAPED
FLAP
• EXTENDED ONTO THE BUCCAL SHELF OF THE MANDIBLE
• INCISION LINE DID NOT LIE OVER THE BONY DEFECT CREATED BY
THE REMOVAL OF THE IMPACTED TOOTH
• ITS BASE AT THE DISTOLINGUAL ASPECT OF THE SECOND MOLAR
• MAGNUS ET AL WITH THE SAME AIM,
• DESCRIBED A PARAGINGIVAL FLAP IN WHICH THE ANTERIOR
RELEASING INCISION IS LOCATED 0.5 CM APICAL TO THE
GINGIVAL MARGIN OF THE SECOND AND FIRST MOLARS
 GROVES AND MOORE
 IN THE YEAR 1970 THEY DESIGNED THREE FLAPS
 RELATED TO INVOLMENT OF THE GINGIVAL MARGIN
OF 2ND MOLAR
 THE TWO FLAPS THAT DID NOT INVOLVED THE
GINGIVAL MARGIN OF THE 2ND MOLAR
 PRODUCED AN APPARENT DECREASE IN POCKETING
DISTAL TO 2ND MOLAR
ACCESS TO THE IMPACTED TOOTH
 IT IS ACHIEVED BY REMOVAL OF OVERLYING BONE
 THE BONE ON THE OCCLUSAL,BUCCAL ,DISTAL
ASPECT DOWN TO THE CERVICAL LINE OF THE
IMPACTED TOOTH SHOULD BE INITIALLY REMOVED
 AMOUNT OF REMOVAL DEPANDS ON
DEPTH OF THE TOOTH
MORPHOLOGY OF ROOT
ANGULATION OF TOOTH
BONE REMOVAL CAN
BE DONE BY
CHISELS
DRILLS
 CHISEL AND MALLET
 TRADITIONAL TECHNIQUE,
 SUPPORT OF MANDIBLE IS MANDATORY
 THE CHISEL IS KEPT PARALLEL TO THE LONG AXIS OF
BONE
 INDICATIONS
YOUNG PATIENTS
AN EXTERNAL OBLIQUE RIDGE SLIGHTLY BELOW THE
LEVEL OF BONE ENCLOSING THE 3RD MOLAR
AN EXTERNAL OBLIQUE RIDGE THAT IS SLIGHTLY
BEHIND THE 3RD MOLAR SO THAT THE DISTOLINGUAL
CORNER OF THE TOOTH SITS IN A THIN BALCONY OF
BONE
 THE CHISEL IS KEPT PARALLEL TO THE LONG AXIS OF
BONE
 A VERTICAL LIMITING CUT IS MADE AT THE DISTAL
ASPECT OF THE 2ND MOLAR WITH CHISEL BEVEL FACING
POSTERIORLY
 THE LIMITING CUT IS THEN TURNED INTO A VERTICAL
GROOVE
 THEN THE CHISEL IS PLACED AT 45O ANGLE TO THE
LOWER EDGE OF LIMITING CUT IN AN OBLIQUE
DIRECTION
 A TRINGULAR PIECE OF BUCCAL PLATE DISTAL TO 2ND
MOLAR IS THEN REMOVED
 THE DISTAL BONE IS THEN REMOVED IF REQUIRED
 THE BONY CUT CAN BE ENLARGED TO UNCOVER THE
TOOTH
 ELEVATOR IS THEN PLACED AT THE JUCTION OF
VERRTICAL LIMITING CUT AND OBLIQUE BONE CUT
 LOW SPEED ENGINE DRIVEN DRILLS
 INDICATIONS
OLD PATIENTS
AN EXTERNAL OBLIQUE RIDGE AND INTERNAL OBLIQUE RIDGE
OR BOTH ARE FAR FORMED IN RELATIONSHIP TO THE TOOTH
HENCE GUTTERING IS NECESSARY TO AVOID EXCESS
REMOVAL OF BONE

COMPLICATIONS
ACCIDENTAL DENUDEING OF ROOTS OF 2ND MOLAR
WHILE GUTTERING THE BONE THE MANDIBULAR CANAL MAY BE
OPENED AND DAMAGE TO NERVE MAY OCCUR
WHILE CUTTING DISTOLINGUAL SPUR OF BONE HIGH CHANCE OF
LINGUAL NERVE DAMAGE HENCE IT SHOULD BE MOVED LINGUAL
TO BUCCAL TO PREVENT SUDDEN SLIPPING INTO LINGUAL SIDE
 BUCCAL BONE GUTTERING
 BEGINS AT THE MESIOBUCCAL LINE ANGLE OF THE 3RD
MOLAR
 INITIAL BONE CUT IS MADE VERTICALLY DOWN TO
EXPOSE THE HEIGHT OF COVEXITY OF THE 3RD MOLAR
 THE BUR IS PASSED DISTALLY AT THIS DEPTH TO THE
DISTOBUCCAL LINE ANGLE
 THEN LINGUALLY AROUND THE DISTAL SURFACE
 IF TOOTH CANNOT BE DELIVERED THEN AGAIN BUR IS
USED TO INCREASE THE DEPTH OF OSSISECTION TO
THE LEVEL OF BIFURCATION
 INITIALLY HOLES ARE DRILLED AT A DISTANCE OF 4-
5MM FROM EACH OTHER AROUND THE BUCCAL
ASPECT (FROM THE MESIOBUCCAL LINE ANGLE TO
THE DISTOBUCCAL LINE ANGLE OF THE TOOTH)
 LARGE ROUND NO-8 BUR IS PREFFERED
 THESE HOLES ARE THEN JOINED WITH A FLAT
FISSURE BUR NO.701,702 DOWN TO THE CERVICAL
MARGIN OF TOOTH
 THIS PROVIDES ACCESS FOR ELEVATORS TO GAIN
PURCHASE POINT AND A PATHWAY FOR DELIVERY OF
TOOTH
 THE BONE CUTTING SHOULD BE DONE WITH A
CONTINOUS JET OF NORMAL SALINE
SECTIONING OF THE TOOTH
 IT ALLOWS PORTIONS OF THE TOOTH TO BE REMOVED
SEPERATELY
 DEPANDS PRIMARILY ON
ANGULATION OF THE TOOTH
UNFAVOURABLE ROOT PATTERN
TO PROTECT IMPORTANT STRUCTURES
ADVANTAGES
THE INCISION IS LESS EXTENSIVE
OPERATION FIELD CAN BE KEPT SMALL
LESS POST OPERATIVE SWELLING
LESS BONE REMOVAL
FORCEFUL ELEVATION OF TOOTH IS NOT NEEDFUL
NO DAMAGE TO ADJACENT TOOTH
RISK OF FRACTURE IS MINIMISED
DISADVANTAGES
TEETH WITH SHALLOW GROOVES DIFFICULT TO SPLIT
DIFFICULT TO CONTROL THE LINE OF SPLITING
WITH CHISEL SPLITING DAMAGE TO SOFT TISSUE MAY
BE CAUSED
PATIENT MAY FIND IT INCONVENIENT

 IT CAN BE ACHIEVED WITH

CHISELS
DRILLS
 CRITERIA TO DECIDE SECTIONING OF TOOTH
THIS CRITERIA DECIDES WHETHER THE
TOOTH IS LOCKED OR NOT
A LINE IS DRAWN FROM THE
MESIOLINGUAL CUSP TILL THE DISTAL
ROOT
THE DISTANCE IS THEN MEASURED
HALF THE DISTANCE IS TAKEN AS THE
RADIUS
AN ARC IS DRAWN
IF THE ARC TOUCHES THE 2ND MOLAR
INDICATES LOCKING OF TOOTH
SECTIONING IS MANDATORY
ELEVATION FROM THE ALVEOLAR PROCESS
 IT CAN BE DONE WITH DENTAL ELEVATORS
 IN MANDIBLE THE MOST FREQUENT ELEVATOR USED
IS STRAIGHT ELEVATOR,PAIRED CRYER
 CAREFUL APPLICATION OF FORCE SHOULD BE DONE
IN ORDER TO AVOID FRACTURE OF BUCCAL
BONE,ADJECENT TOOTH AND SOMETIME ENTIRE
MANDIBLE
 THE ELEVATORS SHOULD BE PROPERLY ENGAGED TO
THE TOOTH OR TOOTH-ROOT AND FORCE SHOULD BE
DELIVERED IN PROPER DIRECTION
DEBRIDMENT AND IRRIGATION
AFTER REMOVAL OF TOOTH
ALL PARTICULATE BONE CHIPS AND DEBRIS SHOULD BE
DEBRIDED
THOROUGH IRRIGATION WITH STERILE SALINE INCLUDING
UNDER THE REFLECTED SOFT TISSUE FLAP
A PERIAPICAL CURETTE CAN BE USED
A BONE FILE CAN BE USED TO SMOOTHEN ANY SHARP,ROUGH
EDGE OF BONE
A HEMOSTAT CAN BE USED TO REMOVE ANY REMNANT OF
DENTAL FOLLICLE
CLOSURE OF THE FLAP SHOULD BE DONE BY PRIMARY SUTURES
 REMOVAL OF MESIOANGULAR IMPACTED III MOLAR
TOOTH DIVISION IS NECESSARY
IF THE TOOTH IS BISSECTED AT NECK
ENAMEL IS VERY THIN
LOWER POSITION
DISTAL HALF OF THE CROWN IS SECTIONED OFF AT THE BUCCAL
GROOVE JUST BELOW THE CERVICAL LINE
POSITION OF ELEVATOR UNDER CEMENTO ENAMEL JUNCTION ON
MESIAL SURFACE
TOOTH IS MOVED UPWARD AND BACKWARD AS FAR AS DISTAL RIM
OF BONE WILL ALLOW
UPWARD MOVEMENT OF ROOTS
 REMOVAL OF DISTOANGULAR IMPACTED III MOLAR
 A DISTOANGULAR POSITION BRINGS THE III MOLAR WELL UNDER THE
ASCENDING RAMUS
 FREQUENTLY DISTALLY CURVED ROOTS ARE ENCOUNTERED
 AFTER SUFFICIENT BONE REMOVAL, THE CROWN IS SECTIONED
HORIZONTALLY FROM THE ROOTS JUST ABOVE THE CERVICAL LINE
 THE ENTIRE CROWN IS FIRST REMOVED
 IF ROOTS IF FUSED THEN A ELEVATOR CAN BE STRAIGHT USED TO
ELEVATE THE ROOTS INTO THE SPACE PREVIOUSLY OCCUPIED BY THE
CROWN
 IF ROOTS ARE DIVERGENT SECTIONING OF ROOTS IS NECESSARY AND
INDIVIDUAL REMOVAL
 EXTRACTION OF THIS TYPE OF IMPACTION IS DIFFICULT,BECAUSE MORE
DISTAL BONE HAS TO BE REMOVED AND THE TOOTH TENDS TO BE
ELEVATED DISTALLY AND INTO THE RAMUS PORTION OF THE MANDIBLE
 REMOVAL OF VERTICALLY IMPACTED III MOLAR
 PROCEDURE OF BONE REMOVAL AND TOOTH
SECTIONING IS SIMILAR TO MESIOANGULAR
IMPACTION
 TOOTH SECTIONED VERTICALLY
 DISTAL PART REMOVED FIRST,FOLLOWED BY THE
MESIAL HALF
 IT IS MORE DIFFICULT THAN MESIOANGULAR
IMPACTION BECAUSE THE ACCESS AROUND II
MOLAR IS LESS AND REQUIRES MORE REMOVAL
OF BONE ON THE BUCCAL AND DISTAL SIDES
 REMOVAL OF HORIZONTALLY IMPACTED III MOLAR
 REQUIRES MAXIMUM BONE REMOVAL
 BONE SHOULD BE REMOVED DOWN TO THE CERVICAL LINE TO
EXPOSE THE SUPERIOR ASPECT OF THE DISTAL ROOT AND THE
MAJORITY OF BUCCAL SURFACE OF CROWN
 SUPERIOR(DISTAL) AND INFERIOR(MESIAL) CUSP SECTIONED
 SUPERIOR CROWN IS REMOVED FIRST
 FOLLOWED BY BULK OF TOOTH AND THEN THE INFERIOR CROWN
FRAGMENT
 IF SUFFICIENT SPACE IS NOT AVAILABLE THEN A SPLIT IS MADE
NEAR THE ANATOMIC NECK OF TOOTH
 IF DIVERGENT ROOTS THEN SPITTING OF ROOTS IS NECASSERY
 AND THEN EACH ROOT IS DELIVERED INDIVIDUALLY
 REMOVAL OF BUCCOANGULAR OR LINGULAR
IMPACTED III MOLARS
 NOT SO COMMON
 TOOTH IS SECTIONED HORIZONTALLY AT THE CERVICAL REGION
 CROWN IS FIRST DELIVERED FOLLOWING ROOTS
 IN CASE OF LINGUOANGULAR IMPACTION RETRACTION OF THE
LINGUAL MUCOSA IS IMPORTANT

LINGUOANGULAR BUCCOANGULAR
AMOUNT OF BONE REMOVAL,POINT OF ELEVATION AND
OTONTOTOMIES OF IMPACTED 3RD MOLARS
 LINGUAL SPLIT-BONE TECHNIQUE
 DEVELOPED BY FRY ORIGINALLY DESCRIBED BY WARD IN 1956
 USED TO REMOVE IMPACTED 3RD MOLARS IN ALL POSITION PROVIDED
THEY ARE NOT BUCCOVERSION
 USEFUL IN REMOVING DEEPLY POSITIONED HORIZONTAL AND
DISTOANGULAR IMPACTED 3RD MOLARS
 IT INVOLVES SPLITTING THE LINGUAL CORTEX AND ELEVATING THE
TOOTH IN DISTOLINGUAL DIRECTION
 THE INCISION STARTS IN THE BUCCAL SULCUS AT ABOUT THE JUNCTION
OF MIDDLE AND POSTERIOR 3RD OF THE 2ND MOLAR AND PASSING UPWARD
TO THE GINGIVAL MARGIN AT THE DISTAL ASPECT OF THAT TOOTH
 FROM THIS POINT THE INCISION COURSE BEHIND THE 2ND MOLAR TO THE
MIDDLE OF ITS POSTERIOR SURFACE AND THEN DISTOBUCCALY UP THE
RAMUS TOWARDS THE CHEEK
 IF GREATER ACCESS IS NEEDED THE ANTERIOR ND OF THE INCISION CAN
BEGIN IMMEDIATELY DISTAL TO THE FIRST MOLAR
 AFTER THE BUCCAL FLAP IS RAISED THE LINGUOOCLUSAL TISSUE
IS ELEVATED
 A RETRACTOR IS PLACED UNDER THE LINGUAL FLAP TO PROVIDE
EXPOSURE OF THE SURGICAL SITE AND TO PROTECT THE
LINGUAL NERVE
 A VERTICAL STOP OF ABOUT 5MM IN HEIGHT IS MADE WITH A
CHISEL IN THE BUCCAL CORTEX IMMEDIATELY DISTAL TO THE 2ND
MOLAR
 A SECOND VERTICAL STOP IS MADE ABOUT 4MM DISTOBUCCAL
TO THE 3RD MOLAR
 THE TWO CUTS ARE THEN JOINED AND THE BUCCAL PLATE
COVERING THE CROWN IS REMOVED
 ANY BONE OVER THE SUPERIOR ASPECT OF CROWN IS REMOVED\
 NOW THE CHISEL IS INSERTED ON THE INSIDE OF THE LINGUAL
PLATE AT AN ANGLE OF 45 DEGREES TO THE UPPER BORDER
WITH ITS CUTTING EDGE PARALLEL TO EXTERNAL OBLIQUE LINE
WITH THE BEVEL FACING LINGUALLY
 A LIGHT TAP WITH A MALLET SPLITS OFF A PORTION OF THE
LINGUAL CORTEX WHICH IS THEN REMOVED
 ONCE LINGUAL BONE IS REMOVED,THE TOOTH CAN BE REMOVED
BY APPLICATION OF ELEVATOR FROM THE BUCCAL ASPECT
 LINGUAL SPLIT BONE TECHNIQUE BY LEWIS

 FLAP IS DESIGNED SUCH THAT BONE BODY ATTACHED

TO THE FLAP IS PRESERVED
 FLAP IS RAISED LINGUAL TO II MOLAR AND NOT THE
IIIMOLAR
 VERTICAL LINGUAL STEP CUT IS GIVEN JUST DISTAL TO
THE II MOLAR
 LINGUAL PLATE IS HINGED AS AN
OSTEOMUCOPERIOSTEAL FLAP
 LESS TISSUE TRAUMA THAN OTHER
ACCEPTED TECHNIQUE
 ASSISTS IN PRIMARY WOUND CLOSURE,
 OBLITERATION OF DEAD SPACE,
 LATERAL TREPHINATION TECHNIQUE
 PROPHYLACTIC REMOVAL OF DEVELOPING 3RD MOLAR
 AGE GROUP 10 TO 16 YRS
 BEFORE CALCIFIED CUSPS ARE UNITED
 A MODIFIED S-SHAPED INCISION IS MADE FROM RETROMOLAR
FOSSA ACROSS THE EXTERNAL OBLIQUE RIDGE
 THEN IT CURVES DOWN ALONG THE MUCOUS MEMBRANE ABOVE
THE VESTIBULE EXTENDING UPTO 1ST MOLAR
 LEAVING BEHIND 5MM CUFF OF ATTACHED MUCOSA AT THE
DISTOBUCCAL REGION OF 2ND MOLAR
 THE BUCCAL CORTICAL PLATE IS TREPHINED OVER 3RD MOLAR
 THEN VERTICAL CUTS ARE MADE ANTERIORLY AND POSTERIORLY
 THESE CUTS ARE JOINED AND BUCCAL PLATE IS FRACTURED OUT
 EXPOSING 3RD MOLAR CRYPT COMPLETELY
 ELEVATOR THEN APPLIED TO DELIVER THE TOOTH
 COMPLICATIONS
 INTRAOPERATIVE
 DURING INCISION
FACIAL OR BUCCAL VESSEL MAY BE CUT
LINGUAL NERVE INJURY
RETROMOLAR VESSELS
 DURING BONE REMOVAL
DAMAGE TO SECOND MOLAR AND ROOTS
FRACTURE OF MANDIBLE
BLEEDING
 DURING ELEVATION
CROWN FRACTURE
ROOT FRACTURE
FRACTURE OF THE JAWS
SLIPPING OF TOOTH INTO LINGUAL POUCH
DAMAGE TO NERVE
ASPIRATION OF THE TOOTH
 DURING DEBRIDEMENT
DAMAGE TO INFERIOR ALVEOLAR NERVE
 POSTOPERATIVE

 PAIN
 SWELLING/EDEMA
 HEMATOMA
 BLEEDING
 TRISMUS
 INFECTION
 DRY SOCKET
 TMJ PAIN
 PARAESTHESIA
 SENSITIVITY
 LOSS OF VITALITY
 POCKET FORMATION
 INCIDENCE OF NERVE INJURY
 LINGUAL NERVE-0-23%
 INFERIOR ALVEOLAR NERVE-0.4-8.4%

CLINICAL MANIFESTATIONS OF NERVE INJURY

ANAESTHESIA OR HYPOESTHESIA FOR MORE THAN 3
MONTHS
TONGUE , LIP & CHEEK BITING
ALTERED MASTICATION & TASTE
TRIGGERING,SIGNS(TINGLING,ELECTRIC SENSATION
OVER THE INJURED SITE THAT DOES NOT EXTEND
DISTALLY)
NO OR MINIMAL RESPONSE TO INSTRUMENTATION
ABSENCE IN THE DETECTION OF SHARP, DULL, MOVING
TACTILE STIMULI & TWO POINT DISCRIMINATION
INCREASE IN HOT OR COLD TEMPERATURE THRESHOLD
CAUSES FOR LINGUAL NERVE INJURY

• CLUMSY INSTRUMENTATION POOR FLAP DESIGN

• FRACTURE OF LINGUAL PLATE
• RAISING & RETRACTING MUCOPERIOSTEAL FLAP
• VARIATION IN LINGUAL NERVE POSITION
PREVENTION OF LINGUAL NERVE DAMAGE
 USE OF BROAD LINGUAL RETRACTOR
 BUCCAL APPROACH WITHOUT A LINGUAL RETRACTOR
SHOULD BE THE STANDARD APPROACH
 AVOIDING LINGUAL FLAP RETRACTION
 USE OF SMALL 10MM MALLEABLE RETRACTOR
 SPLITTING WITH BUR RATHER THAN USING LINGUAL
SPLIT TECHNIQUE
MANAGEMENT OF LINGUAL NERVE DAMAGE
 SURGICAL TREATMENT SHOULD BE UNDERTAKEN
AFTER 3MONTHS TO LOCATE & SUTURE THE
NERVE
 WHILE SUTURING CARE MUST BE TAKEN TO AVOID
INTERPOSITION OF NON NERVOUS TISSUE
 NONOPERATIVE TREATMENT – CORTICOSTEROID
 CHANCES OF NEUROMA.
CAUSES OF INFERIOR ALVEOLAR NERVE INJURY
 DEEPLY PLACED IMPACTED MOLAR
 MESIOANGULAR & HORIZONTAL IMPACTION
 SURGICAL TECHNIQUE USING BUR
CONDITIONS FAVOURING NERVE INJURY
INTERUPTION OF WHITE LINE OF CANAL
DEFLECTION OF ROOT
DIVERSION OF CANAL
DARK &RIGID APEX OF ROOT
NARROWING OF CANAL
NARROWING OF ROOT
 MANDIBLE FRACTURE
• RARE
• DEEPLY IMPACTED THIRD MOLAR IN OLDER
INDIVIDUAL WITH DENSE BONE
• USE OF EXCESSIVE PRESSURE WITH ELEVATORS
• SHOULD PERFORM IMMEDIATE REDUCTION AND
FIXATION OF FRACTURE.
INJURY TO ADJACENT TEETH
•DAMAGE TO FILLINGS AND ADJACENT TEETH,
• DAMAGE TO BRIDGEWORK OR TO SURROUNDING
BONE CAN OCCUR DURING THE REMOVAL OF
IMPACTED WISDOM TEETH.
 DISPLACEMENT INTO LINGUAL POUCH
 INDEX FINGER IN THE LINGUAL ASPECT
 MOBILIZE THE TOOTH TOWARDS SOCKET
 CAREFULLY ELEVATE THE TOOTH
 TMJ PAIN
• TMJ DYSFUNCTION FOLLOWING THE REMOVAL OF
WISDOM TEETH IS UNUSUAL AND USUALLY
TEMPORARY.
• IF TREATMENT IS REQUIRED, IT IS USUALLY
CONSERVATIVE IN NATURE AND INCLUDES ANTI-
INFLAMMATORY MEDICINES, PHYSICAL THERAPY AND IN
SOME CASES SHORT TERM BITE SPLINT THERAPY.
PAIN
 USUALLY REACHES MAXIMUM DURING FIRST 12 TO
24 HOURS POSTOPERATIVELY.
 NSAIDS BEFORE SURGERY MAY OR MAY NOT BE
BENEFICIAL
 MOST IMPORTANT DETERMINANT OF AMOUNT OF
POST OPERATIVE PAIN IS THE LENGTH OF
OPERATION.
 THERE IS A STRONG CORRELATION BETWEEN POST
OPERATIVE PAIN AND TRISMUS
 EDEMA
 USE OF CORTICOSTEROIDS.
 ICE – MAY BE COMFORTING BUT HAS LITTLE
EFFECT ON SIZE OF SWELLING.
 SWELLING REACHES MAXIMUM BY END OF
SECOND POST OPERATIVE DAY AND RESOLVED
BY 5TH TO 7TH DAY.
 TRISMUS
 USE OF CORTICOSTEROIDS.
 MINIMAL FLAP REFLECTION
 CAREFUL PLACEMENT OF MOUTH PROP
 LENGTH OF SURGERY
 REACHES MAXIMUM BY SECOND POST OPERATIVE DAY
AND RESOLVED BY END OF FIRST WEEK.

INFECTION
 INCIDENCE BETWEEN 2-3%
 50% ARE LOCALIZED SUBPERIOSTEAL ABSCESS
WHICH OCCUR 2-4 WEEKS AFTER
USUALLY CAUSED BECAUSE DEBRIS UNDER THE FLAP
DEBRIDEMENT AND ANTIBIOTICS.
 BLEEDING
 USE GOOD SURGICAL TECHNIQUE, MINIMIZE
TRAUMA, AVOID TEARS OF FLAPS.
 MOST EFFECTIVE MEASURE TO ACHIEVE
HEMOSTASIS IS VIA MOIST GAUZE PRESSURE OVER
WOUND.
 APPLICATION OF TOPICAL THROMBIN ON GELFOAM
INTO SOCKET AND OVERSUTURING.
 OTHER HEMOSTATICS: OXIDIZED CELLULOSE
(OXYCEL OR SURGICEL), MICROFIBRILLAR COLLAGEN
(AVITENE).
 PATIENTS WITH ACQUIRED OR CONGENITAL
COAGULOPATHY MAY NEED BLOOD PRODUCT
REPLACEMENT.
 ALVEOLAR OSTEITIS (DRY SOCKET)
• INCIDENCE BETWEEN 3% AND 25%.
• INCIDENCE APPEARS HIGHER IN SMOKERS AND
FEMALES TAKING ORAL CONTRACEPTIVES.
• PATHOGENESIS NOT ABSOLUTELY DEFINED BUT MOST
LIKELY RESULT OF LYSIS OF FULLY FORMED BLOOD CLOT
BEFORE THE CLOT IS REPLACED WITH GRANULATION
TISSUE.
• THIS FIBRINOLYSIS OCCURS DURING
THE 3RD – 4TH POST OPERATED DAY

•GOAL OF TREATMENT IS RELIEF OF PAIN

•IRRIGATION OF EXTRACTION SITE
•PLACEMENT OF EUGENOL DRESSING
•ANALGESICS
•PAIN USUALLY RESOLVES WITHIN
3-5 DAYS BUT UP TO 10 TO 14 DAYS
 AIR EMBOLISM/ SUBCUTANEOUS EMPHYSEMA
 A GAS RELATED EMBOLUS CAN BE CAUSED BY
INADVERTENT INJECTION OF A MIXTURE OF AIR AND
WATER UNDER PRESSURE
 WHICH THEN PASSES INTO THE MANDIBLE (JAW) TO
THE VEINS AND THEN TO THE LARGE VESSELS
LEADING TO THE HEART.
 LARGE AMOUNTS OF AIR CAN CAUSE SERIOUS
PROBLEMS INCLUDING CARDIAC ARREST AND DEATH,
 BY TRAVELING TO THE LARGE VEINS LEADING TO
THE HEART, AND MECHANICALLY BLOCKING THE
FLOW OF BLOOD THROUGH THE HEART.
 CORTICOSTERIODS

 INHIBITS PROSTAGLADIN SYNTHETASE

 HENCE PREVENT THE INFLAMMATORY
COMPLICATIONS OF REMOVAL OF 3RD MOLAR
 HENCE REDUCES SWELLING AND PAIN
 ABSOLUTE CONTRAINDICATED
TUBERCULOSIS
OCULAR HERPEX SIMPLEX
ACUTE PSYCHOSIS
 RELATIVE CONTRAINDICATION
EARLY PREGNANCY
 NSAID
 BLOCKS PROSTAGLANDIN SYNTHESIS
 LOKKEN IN 1980 INDICATED PARACETOMOL THOUGH
NOT A PROSTAGLANDIN SYNTETASE BLOCKER BUT CAN
BE EFFECTIVE IN REDUCING PAIN IN FIRST 24 HRS
 IT ACTS BY ACCELERATINGTHE CONVERSION OF
PROSTAGLANDIN G2
 A PRIME FACTOR IN OEDEMA AND PAIN
 CONCLUSION
 EXTRACTION OF IMPACTED THIRD MOLAR NOT ONLY
INCLUDES A PROPER TECHNIQUE WITH MAXIMUM
CONSIDERATION FOR COMPLICATIONS
 BUT ALSO THE EVALUATION OF THE PSHYCOLOGICAL
FACT OF THE PATIENT UNCERTAINITY OF THE
PROCEDURE
 THE COMBINATION OF BOTH PATIENT PSHYCOLOGY
AND SURGEON ABILITY WILL ONLY LEAD TO A
SUCCESSFUL TREATMENT
 REFERENCES
 TEXTBOOK OF OMFS BY PETERSON
 TEXTBOOK OF OMFS BY DANIEL M LASKIN
 THE IMPACTED LOWER WISDOM TOOTH BY GREGOR
 HUMAN ANATOMY BY DUTTA
 A JOURNAL ON NEUROSENSORY DISTURBANCE AFTER BILATERAL
SAGITTAL SPLIT OSTEOTOMY BY LEENA YLIKONTIOLA
 A RARE VARIATION OF THE INFERIOR ALVEOLAR ARTERY WITH
POTENTIAL CLINICAL CONSEQUENCES BYAmir Afshin Khaki 1
,R.SHANE TUBBS 2 ,MOHAMMADALI MOHAJEL SHOJA 1 ,GHAFFAR
SHOKOUHI 1 ,RAMIN MOSTOFIZADEH FARAHANI
 SIMPLIFIED SPLIT-BONE TECHNIQUE FOR REMOVAL OF IMPACTED
MANDIBULAR THIRD MOLARS IN INTERNATIONAL JOURNAL OF ORAL
AND MAXILLOFACIAL SURGERY VOLUME 24, ISSUE 5, OCTOBER 1995,