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Article history:
Paper received 5 January 2013
Accepted 10 May 2013
Purpose: Conventional surgical extraction of impacted mandibular third molars (M3M) requires a lateral
ap reection in conjunction with lateral bone removal for outward mobilization of the tooth. The aim of
this report is to outline a novel inward fragmentation technique (IFT) in conjunction with an occlusal
miniap approach to reduce the amount of bone removal to a minimum.
Patients and methods: Seventeen consecutive patients (7 men and 10 women; mean age 24.4 years, range
18e36 years) required the extraction of 21-impacted M3M with a close relationship to the inferior
alveolar nerve (IAN).
Occlusal miniaps were used and only occlusal bone removal was performed to expose the M3M
under endoscopic vision. A central space-making cavity was created followed by inward fragmentation
and mobilization of the crown and subsequent root removal through the space created.
Results: 20 of 21 sites healed uneventfully, one late infection was observed, no permanent neurosensory
lesion occurred. The mean preoperative buccal bone height was 15.5 (11e18) mm and the postoperative
buccal bone height 14.7 (11e17) mm. On the 2nd day, the mean swelling level was 1.38 (0e2) on a 4
point scale, the pain level was 2.30 (0e5) on a 10 cm VAS, mean pain duration was 2.04 days.
Conclusion: An inward fragmentation technique allows preservation of >90% of the buccal bone height
adjacent to mandibular third molars and may reduce postoperative morbidity without raising the risk of
IAN lesions.
2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.
Keywords:
Mandibular third molars
Endoscopes
Microsurgical removal
Occlusal approach
1. Introduction
Third molars are present in 90% of the population, with 33%
having at least one impacted third molar (Scherstn et al., 1989)
thus extraction is a relatively common procedure. Extraction involves the manipulation of both soft and hard tissues, so the patient
usually experiences pain, oedema, and trismus in the immediate
postoperative period. Conventional surgical extraction of impacted
mandibular third molars (M3M) requires lateral bone removal
(Thoma, 1969) to allow an outwardly directed mobilization of the
tooth. In cases of deep impaction this technique may be associated
* Corresponding author. Department of Maxillofacial Surgery, University of Gttingen, Robert-Koch-Str. 40, 37099 Gttingen, Germany.
E-mail address: wengelke@med.uni-goettingen.de (W. Engelke).
1010-5182/$ e see front matter 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jcms.2013.05.003
214
Fig. 2. Schematic diagram of endoscopic odontosection, third molar removal by support endoscopic assistance. Preoperative position of the molar and its close relation
with the inferior alveolar nerve. A, sulcular incision. B, Crestal exposure of the third
molar. SE e Support endoscopy.
Fig. 4. A, Crown reduction under direct vision using large a diamond bur. SE e Support
endoscopy, DRB e Diamond round bur. B, Removal of the mesial part of the crown.
E e Elevator.
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Fig. 5. A, Mobilization of the distal root with a round bur under direct vision.
SE e Support endoscopy, SRB e Straight round bur. B. Distal root removed with
elevator. E e Elevator.
Fig. 6. A, Final control of the alveolus under endoscopic vision for root remnants and
determination of the bone level using a periodontal probe. SE e Support endoscopy,
PP e Periodontal probe. B, Closure with 2 interrupted sutures for primary healing.
handpiece and sterile saline irrigation, the pulp was opened widely
towards the level of the furcation in order to obtain a space for
inward fragmentation of the crown. At the same time an overview
of the internal tooth anatomy and the furcation area was obtained
(Fig. 3B).
Crown removal was performed by inward fragmentation. The
use of large diamond round burs in the furcation area is essential to
ensure complete separation of the roots before inward
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Fig. 7. Evaluation of the buccal bone height (BH), as distance of the apical point (A) of
the alveolus and the buccal bone contour (BC) along the longitudinal axis (LA) of the
inferior third molar.
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Fig. 8. Cone-beam computed tomographic cross-sectional slice of the third molar area. A, In presurgical slices the close proximity of the roots and the inferior alveolar canal are
clearly visible. B, In postsurgical slices the third molar was completely removed by the endoscopic occlusal approach, resulting in maintenance of the buccal wall.
Table 1
Bone height measurement. T-test evaluation of POBH vs. IOBH revealed signicant
difference (p < 0.01).
n 21
POBH (mm)
IOBH (mm)
Mean
Min.
Max.
Std. dev.
15.5
11.5
18
1.47
14.7
12.0
17.0
1.42
Table 2
Postoperative symptoms in 17 patients.
n 21
Mean
Median
Min.
Max.
1.38
1
0
2
2.30
2
0
4
2.04
2
0
7
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Table 3
Correlation of postoperative symptoms in 17 patients.
Symptom
Swelling
Swelling
Swelling
Swelling
Swelling
a
level
level
level
level
level
2nd
2nd
2nd
2nd
2nd
day
day
day
day
day
Associated variable
0.013a
0.14
0.012a
0.04a
0.668
may be speculated that the use of support sheathes as, demonstrated in our report, may also facilitate the observation of details of
the ramus and the Le Fort 1 osteotomies and simultaneously may
serve as a tissue-separating tool. IFT technique furthermore may be
applied in some other alveolar bone sites (Hrzeler et al., 2010; AlHarbi, 2010), providing a tool for atraumatic extraction in critical
anterior maxillary sites.
We observed an increase of postoperative symptoms dependent
on the time of surgery. The mean duration of surgery in our report
may be relatively long compared to previous studies (Renton et al.,
2001; Bello et al., 2011; Chye et al., 1993), but can be explained by
the selection of complex cases. Additional time needed for
sectioning and inward fragmentation instead of outward mobilisation may be taken as a disadvantage for simple access sites, but
plays a minor role in complex and deeply impacted molars.
4.1. Complex cases
As Kim et al. (2011) stated, the degree of surgical difculty increases as the depth of the impacted tooth increases and its section
becomes more difcult. Using magnifying tools, this difculty can
be overcome. 3D e imaging of the case example (Fig. 8) shows
clearly that, independently of the degree of impaction, lateral bone
removal can be avoided. The technique describe here has signicantly facilitated the removal M3M. The removal of the crown from
an occlusal perspective opens the view to the remaining roots and
facilitates the identication as well as the mobilization of root
fragments with a minimum of bone loss. Support endoscopy (SE)
has been proven to be a valuable tool when using microelevators
under monitor control instead of conventional application without
direct vision, in particular when working at close distance to the
mandibular canal. In combination with 3D imaging based on preoperative cone beam examination, the depth and location of root
tips can be identied by direct probing under magnication. According to the experience of both centres, the occlusal approach is
of particular value in cases of deeply impacted molars in close
contact with the mandibular canal (see Fig. 8). If required, surgeons
with less experience may extend the bone removal from the
occlusal to the lateral aspect of the mandible in order to get access
for burs mounted in a straight handpiece. Nevertheless the amount
of bone removal always can be kept below a critical size with
respect to fracture risk.
4.2. Incidence of nerve lesions
One of the main complications related to M3M removal is temporary or permanent disturbance of the sensory function of the IAN.
Incidence varies between 1.3% and 5.3% (Renton et al., 2005). There is a
signicant risk if the root tip is projected onto the mandibular canal.
According to Ortiz and San Pedro (2009) the incidence of overprojection is 55.66% and the adjacent position 25.6%. Gen and
Vasconcellos (2008) reported 23% overprojection and 33% adjacent
position respectively. These gures outline the importance related to
the problem, when minimally invasive surgery is applied. Tolstunov
et al. (2011) described a technique to reduce damage of the IAN in
cases of high-risk patients using pericoronary osteotomy with secondary removal after spontaneous eruption. Of 14 patients, 3 had a
temporary neurosensory dysfunction. Landi et al. (2010) also reported
a two-stage technique to assist the eruption. Wang et al. (2012)
however suggested an orthodontic approach to reduce the risk of
IAN lesion. It appears obvious, that these approaches only are applicable in cases with favourable anatomical conditions to allow further
eruption of the M3M after primary surgery or during orthodontic
treatment, which in individual cases cannot be predicted. The IFT with
an occlusal miniap as described here does not show an increased risk
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