MANAGEMENT OF IMPACTED TOOTH

AND COMPLICATIONS

Author – dr Saroj deo

Dept Omfs,
National medical college,
Nepal

INTRODUCTION

CAUSES OF IMPACTION

CLASSIFICATION

ASSESSMENT

MANAGEMENT OF IMPACTED TEETH

-MANDIBULAR THIRD MOLAR

- DISTOLINGUAL SPLIT TECHNIQUE

-MAXILLARY THIRD MOLAR

-MAXILLARY CANINE

-OTHER TEETH

COMPLICATIONS

CONCLUSION

REFERENCES
 Impacted tooth is 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.
Malposed tooth is tooth, unerupted / erupted which is in an abnormal position in the
maxilla/mandible
Unerupted tooth is a tooth not having perforated the oral mucosa.

Classification
Impacted, mandibular 3rd Molar
I. Winter (1926) – 1st to device classification
1. Vertical – 38%
2. Mesioangular – 43%
3. Horizontal – 3%
4. Distoangular – 6%
5. Buccoangular
6. Linguoangular
7. Inverted
8. Unusual
II. Pell & Gregory
a) Relation of the tooth to ramus of mandible & 2nd molar
Class I: - Sufficient amount of space for accommodation of mesiodistal diameter of the
crown of the 3rd molar
Class II: - The space between the ramus and distal side of 2nd molar that is less than
mesiodistal diameter of the 3rd molar.
Class III: - All/most of the 3rd molars is located within the ramus.
b) Relative depth of the third molar in the bone
Position A: - The highest portion of the tooth is on a level with/above occlusal line.
Position B: - The highest portion of the tooth is below occlusal plane, but above the
cervical line of the 2nd molar.
Position C: - The highest portion of the tooth below the cervical line of the 2nd molar
teeth in relation to the long axis of impacted 2nd molar

III. According to nature of overlying tissue

This system is used by most dental insurance companies and one by which surgeon
charges for his services.
 Soft tissue impaction
  Partial bony impaction
 Fully bony impaction.

Maxillary third molar

A. Relative depth of the impacted maxillary 3rd molar is bone.
Class A - The lowest portion of the crown of the impacted maxillary 3rd molar is on a line
with the occlussal plane of 2nd molar.
Class B - The lowest portion of the crown of impacted maxillary 3rd molar is between the
occlussal plane of 2nd molar and the cervical line.
Class C - The lowest portion of the crown of impacted maxillary 3rd molar is at/ below the
cervical line of 2nd molar.

B. The position of the long axis of the impacted maxillary 3rd molar in relation to the long
axis of the 2nd molar.
1. Vertical
2. Horizontal
3. Mesioangular
4. Distoangular
5. Inverted
6. Buccoangular
7. Linguoangular
They may occur simultaneously in
a. Buccalversion
b. Lingual version
c. Torsi version

C. Relationship of the impacted maxillary 3rdmolar to the maxillary sinus

1.Sinus approximation (SA)- No bone or a thin partition of bone between the impacted
maxillary 3rd molar and the maxillary sinus known as maxillary sinus approximation
2. No sinus approximate- 1-2mm/ more bone between the impacted maxillary 3rd molar
and the maxillary sinus known as no maxillary sinus approximation.

Maxillary canine
Archer classifies maxillary impacted cuspid s as followes:
Class 1: Impacted cuspids located in the palate.
1. Horizontal.
2. Vertical
3. Semi vertical
Class2: Impacted cuspids located in the labial or buccal surface of maxilla.
1. Horizontal.
2. Vertical
3. Semi vertical

Class 3: Impacted cuspids located in the both palatal process and labial /buccal maxillary
bone; e.g., the crown is on the palate and root is on the labial surface of maxilla.
Class 4: impacted cuspids located in the alveolar process, usually vertically between the
incisor and first bicuspid
Class 5: Impacted cuspids located in the edentulous maxilla.

Causes of Impacted teeth

• Gradual evolutionary reduction in the size of the human mandible/maxilla results in
maxilla/mandible too small to accommodate mandibular/maxillary molars.
• Nodine points out that the modern diet does not offers a decided effort in
mastication, resulting in loss of growth stimulation of jaws and modern man has
impacted teeth.
• Nodine suggests that the major basic cause of aberrant/impacted teeth in the adults
of Western Europe, Great Britain and Ireland, U.S.A and Canada are due to
artificial feeding of babies, the habits babyhood and child hood, cross breeding,
sweet food of children and youth producing disproportion.

Berger lists the following -Local causes of Impaction

1. Irregularity in the position and pressure of an adjacent tooth
2. Density of overlying / surrounding bone
3. Lack of space due to undeveloped jaw
4. Unduly long retention at primary teeth
5. Premature loss of primary teeth
6. Long continued local inflammation result to increase in density of overlying
mucous membrane
7. Acquired disease.
8. Inflammatory changes in bone
According to Berger- Systematic causes of Impaction are
 A. Prenatal causes
1. Hereditary
2. Miscegenation
B. Postnatal causes
1. Rickets
2. Anemia
3. Congenital Syphilis
4. Tuberculosis
5. Endocrine dysfunctions
6. Malnutrition
C. Rare conditions
1. Cleidocranial dysostosis
2. Oxycephaly
3. Progeria
4. Achondroplasia
5. Cleft palate

According to archer impacted teeth occur in following order of frequency.

1. Maxillary 3rd molar
2. Mandibular 3rd molar
3. Maxillary Bicuspid
4. Mandibular bicuspid
5. Mandibular cuspid
6. Maxillary bicuspid
7. Maxillary central incisor
8. Maxillary lateral incisor

Assessment of 3rd molar

Assessment of impacted tooth is done by
1. Physical evaluation
2. Radiographic evaluation
Physical evaluation -It includes inspection and palpation of
TMJ and movement of mandible
Determination of mobility characteristics of lips and cheeks
Size and contours of the tongue
Appearance of soft tissue overlying the impacted teeth
Radiographic evaluation
1. Periapical Radiographs
2. Bite wing radiography
3. Occlusal films
4. Lateral view of the mandible
5. Orthopantamograph
Using above radiographs assessment of following are considered

A. Root morphology
The number of factors considered.
a) Length of the root - Optimal time is when the roots ⅓ to ⅔ formed. When this is the
case, the ends of the roots are blunt and almost never fracture. If the full length of root
develops, the possibility of abnormal root morphology and the fractures of the root tip
during extraction increases. If the root development is insufficient less than ⅓ of the tooth,
it is difficult to remove, because it tends to roll in its crypt like a ball in a socket, which
prevents easy elevation.
b) Single/conical, separate/distinct roots are noted.
c) Curvature of roots - the surgeon should examine the tooth apex area carefully to assess
the presence of the small, abnormal and sharply hooked roots that probably fracture if the
surgeon does not give them special consideration. The direction of root curvature also
examined.
d) Total width of the roots in mesiodistal direction should be compared with the width of
the tooth at the cervical line.
e) Assess the periodontal ligament space. More the width the periodontal ligament space is
the easier the tooth is to remove.

B. Size of follicular sac

C. Density of the surrounding bone

Younger patient the bone is less dense, is more likely pliable and expands and blends
somewhat, which allows the socket to be expanded by elevators by luxation forces by itself
and easier to cut with bur.
 Patients who are older than 35 years have dense bone and thus decreased ability to
expand. In these patients surgeon must remove all interfering bone, because it is not
possible to expand the bone socket. Bone cutting is difficult and bone removal process
takes longer.

D. Contact with the 2nd molar

Taken care if 2nd molar has carious/large restoration/root canal treated.

E. Nature of overlying tissues -is considered

Soft tissue covering
Soft tissue + Bone covering
Bone
F. Inferior Alveolar Nerve and Vessels
Are usually in true osseous canal in the ramus and body of the mandible. There may be
multiple branches Inferior Alveolar Nerve, instead of single combined structure. When
Inferior Alveolar Nerve canal identified radiograhically, determine its relationship with
impacted mandibular 3rd molar. Usually canal will be inferior/buccal to the third molars,
but variations are common.
Blending of the structure radio graphically indicates that the root surround the canal and its
contents
A thinning/narrowing of canal indicates displacement of the canal by the roots of the tooth.
Distinct lines of canal and of roots indicate an overlap without encroachment.
To locate the canal, Frank suggests that a modification of tube shift method can be used to
determine whether mandibular canal is medial to, lateral to or below an impacted
mandibular 3rd molar. This method first described by Richards.
Two films in identical position used but position of the x-ray tube changed to determine
the position of impacted teeth.
To accomplish this, an x-ray angle must be shifted from 25 degree upwards and this 2nd
film compared with the film taken with the x-ray tube parallel to occlusal plane.
If mandibular canal lies lingual to impaction, it will move downward in relation to the
roots of 3rd molar. Conversely a canal on the buccal side of roots will appear to move
upward on the roots. If the canal remains in the same position, it is directly below the
roots/passes between the roots/is in a groove in the root substance apically,
lingually/buccally.

Localizing the mandibular canal in relation to lower 3rd molar impaction is valuable in
planning surgical technique to avoid trauma to nerve.
G. Lingual Nerve
The studies by Kisselbach and Chamberlain demonstrated that the lingual nerve may be
located some time slighter superior to the crest of bony ridge medial to the mandibular 3rd
molar region and only ½mm toward midline in the lingual soft tissue. At this position
lingual nerve is at risk during flap reflection. Usual location is superior and inferior to
mylohyoid muscle. The nerve may be in various locations from crest of alveolar process
to positions below mylohyoid muscle. More than one branch of the nerve may be present,
and the position of the lingual nerve, relative to the mandibular 3rd molar may vary
depending on the intersection of the body of the mandible and the ramus. The lingual nerve
is relatively more superior and more directly associated with the soft tissue immediately
adjacent to the mandible and hence greater chance of damage during surgery, in the class
III and II relationships than in the class I .

H. Relationship to Body and ramus of mandible is important surgical consideration.

This relationship described by Gregory and Pell.
Class I -There is ample room in the retro molar triangle area to accommodate the third
molar if it is in a position to erupt.
Class II- the space is not adequate for complete eruption of third molar.
Class III The ramus begins immediately posterior to 2nd molar and no space consists for
the impacted tooth to erupt.
In class II and class III relation there is reduced surgical access and close anatomic
relationship with lingual nerve exists.

I. Third molar and 2nd molar relationship

1. The long axis of the third and 2nd molar is studied to determine whether impacted tooth
is in Mesioangular/ Vertical/Distoangular/Horizontal/inverted position.
2. The level of the crown of third molar are determined whether it is crown to crown,
crown to cervix, crown to root and crown below 2nd molar.

J. Buccal to lingual position of third molar

If impacted 3rd molar is too lingually placed there may be chance of stretching of the
lingual nerve.
K.Position and depth.
This can be determined by a method described by George winter. Similar to cephalometric
radiographic tracing three lines are drawn on IOPA radiograph. Three imaginary lines are
known as WINTERS LINES.
White Line represents the occlussal plane, joining the white enamel caps of the unerupted
molars. It is extended posteriorly over the third molar region. The maximum contour of the
impacted teeth and its relationship with the white line indicates relative depth of its
locations.
Amber line represents the bone level, distal to the third molar and extended anteriorely
along the crest of the interdentally septum between the molars. It indicates amount of
alveolar bone covering the impacted teeth.
Red line is drawn perpendicular to the amber line to an imaginary point of application of
elevator. Usually cementoenamel junction of the mesial surface of the impacted teeth is
taken as the point of application of elevator. Thus red line indicates the depth at which
impacted tooth is located. It is estimated that tooth with less than 5mm long red line can
conveniently be removed with ease under local anesthesia. Increase in the length of the red
line of the every additional mm renders the removal of impacted teeth three times more
difficult. If the line is more than 9mm they can be safely removed under GA and if the
tooth is below the apices of second molar.

L. Wharfs assessment
The six factors chosen for scoring are
A) Winters classification
B) Height of the mandible
C) Angulation of the molar
D) Root shape
E) Follicle
F) Path of exit of the tooth during removal.
The scoring by this system helps the beginners to anticipate problems and to avoid
difficult impactions. Unfortunately disadvantage of this method is that it is relate d only to
radiological features alone, the details of the surgical procedures are not considered. The
total scoring is directly related corresponding difficulties in removing that impacted teeth.
Scoring details for Wharf assessment.
NOMBER RADIOGRAPHIC CATEGORY SCORE
CHARECTERISTICS
1. WINTERS Horizontal 2
CLASSIFICATION Distoangular 2
Mesioangular 1
Vertical 0
2. HEIGHT OF THE 1-30mm 0
MANDIBLE 31-34mm 1
35-39mm 2
3. ANGULATION OF 1˚-50˚ 0
THE THIRD 60˚-69˚ 1
MOLAR 70˚-79˚ 2
80˚-89˚ 3
90˚+ 4

4. ROOT SHAPE Complex 1

Favorable 2
curvature 3
Unfavorable
curvature
5. FOLLICLE Normal 0
Possibly 1
enlarged 2
Enlarged
6. PATH OF EXIT Space 0
available 1
Distal cusps 2
covered 3
Mesial cusps
covered
Both covered
TOTAL 33

MANAGEMENT OF IMPACTED TOOTH

The options of treatment plans depend on the patients presenting complaint, the history,
the physical evaluation, radiographic assessment, the diagnosis and the prognosis. The
treatment plan will fall into 4 categories.

I. OBSERVATION
II. EXPOSURE
III. TRANSPLANTATION
IV. REMOVAL OF IMPACTED TOOTH

Observation
If the impacted mandibular 3rd molar is encased in bone with no perceptible to follicle,
as may be seen in an older individual and if it has no history, signs of associated
pathology, long-term observation is appropriate.
Most impacted teeth retain an erupting potential and annual/biannual evaluation would be
needed if no indications for direct surgical management arise.
Exposure
- Is considered if there is
Probability that it may erupt into useful occlusion
But obstructed by follicle, sclerotic bone, hypertrophic soft tissue, odontoma etc.
If the 2nd molar is absent, exposure of a third molar that is blocked from eruption may be
considered.

Transplantation of mandibular 3rd molar

- Transplantation to any site in the oral cavity can be successful if basic criteria are met.
The variety of crown and root shape on the impacted 3rd molar make them candidates for
transplantation to other molar sites, bicuspid and even the cuspid locations depending upon
the anatomy of the coronal and radicular surface.

Removal
The primary reasons to remove impacted teeth are to correct associated pathology and to
intercept reasonably expected pathological process.
Indication for therapeutic removal of 3rd molar
1. Pericoronitis
2. Periodontitis
3. Caries
4.Pathologic resorption
5. Cyst formation
6. Neoplasm
7. Pain
8. Retention in an “edentulous” ridge
9. Crowding of dentition
10. Involvement in a fracture

Contraindications for removal of mandibular 3rd molar

1. Deeply embedded, assymptomatic 3rd molar that do not communicate with the mouth in
older patients.
2. When there is a some question about future status of patient.
3. Compromised medical condition.
4. Probable excessive damage to adjacent structure

Prophylactic removal of 3rd molar

According to archer there is no more justification for routine removal of all non-impacted third
molar, partially/completely formed, than there is for routine tonsillectomy,
appendicectomy/hysterectomies as routine procedures. Best time to perform prophylactic
odontectomy is when radiography shows the roots of the third molars to be half to 2/3rd formed.
If it done too early tooth bud roles in crypt during elevation. The only exception is when third
molar obstructing the path of eruption of 2nd molar. When prophylactic odontectomy considered
generally all four molar are removed. Immature impacted mandibular 3 molar are can be two types

Uncalcified crown and roots

Calcified crown with uncalcified roots.

1.Henry during 1st half of 20th century developed a technique of removal of 3rd molar at
bell stage of growth following morphodifferentiation, by enucleation/aspiration.
Preparative analysis used to differentiate 2nd and 3rd molar tooth bud. Small incision
placed to remove the uncalcified tooth using curettes/suction devices. There are few side
effects and vascular/ neural complication.

2. Fister and Gross 1980 - To approach the tooth, an incision is made along the alveolar
crest from the anterior surface of the ramus to just behind the second molar. The
enveloped flap is raised and the bone over the tooth is removed with a bur. The ensuing
opening must be large enough to accommodate the width at the crown and allow easy
removal of the tooth whether the tooth is in any position; the remaining soft part of the
tooth germ generally furnishes enough space for displacement. So that tooth can be
removed without sectioning. Purchase point/distal bone removal done according to
demand of situations. After the tooth has been extracted, the remainder of the dental
follicle must be carefully removed, since the epithelilium has potential for continued
growth and may form a cyst/tumor.

The incisions
Incisions permit the elevation and retraction of surgical soft tissue flaps to give access to
The surgical site without endangering adjacent structure in normal positions.
The incisions may be considered in following sequences from posterior to anterior.

Posterior to the 2nd molar the usual incision takes advantage at the lateral flare of the
ramus and is angled from lateral to medial as it passes forward, terminating at the
distobuccal aspect of 2nd molar (ensure avoid cutting of lingual nerve). If incision were
given directly posterior to 2nd molar, in most cases it would be a medial side of ramus of
mandible on soft tissue not on the bone may open in to pterigomandibular space and may
encounter branches of lingual nerve. The inferior portion of the incision may terminate in
any location, depending on the indication of regional anatomy and surgeon’s preference,
from the distobuccal area of 2nd molar to bicuspid area.
Occasionally, there may be no anterior component to incision, anterior to distoboccual
angle of 2nd molar, however usually the incision passes anteriorly from distobuccal aspect
of 2nd molar and may terminate at the gingival papilla between 1st and 2nd molar.
There are two options for incision that pass in the vicinity of papillae - the incisions may
include the papillae/ it may pass in the buccogingival crevice adjacent to the teeth but
below the papillae.

Additional Access can be obtained by an anterior gingival extension, a posterior

extension, and an oblique mucoperiosteal extension.
The anterior extension may be at 2nd molar/1st molar/at bicuspid depending upon required
access.
A posterior extension is made by passing the scalpel below the mucosa superior to the
periosteum. Surgical access is improved by incising unyielding periosteum.
Depending on the surgeon’s preference and anatomy an oblique extensions may be made
routinely for additional access, passing laterally toward the mandibular vestibular tissues.
If the oblique incision is used, it should begin anterior to the papilla, when applicable to
permit accurate closure. The problem is if is extended too beyond into vestibular area. It
may open it facial spaces lateral to buccinator muscle.
* For patient with paucity of normal gingival tissues lateral to second molar/hypotropic
retromolar soft tissues, the design of the flap should provide for a firm reattachment of the
soft tissue to the bony base. In such case incision, pass from the lateral aspect of
ascending ramus to the distobuccal corner of 2nd molar and then anteiorely to bicuspid
area. This flap includes normal tissue anterior and posterior to the hypo plastic tissue.
• Hypertrophic retromolar soft tissue - a beveled incision, may be used to remove
the submucosal hypertrophic tissue from the lateral flap. Therefore care should
be taken to avoid damage to lingual nerve.

Elevation of soft tissue

The lateral elevation of soft tissues is performed with a periosteal elevator, starting in the
anterior and passing lateral to and then posterior to the third molar site. The elevation of
flap arises from solid bone rather than through follicle. To protect lingual nerve two very
important maneuvers are performed.

A periosteal elevating instrument is placed in contact with the posterior surface of the
second molar and soft tissue elevated from the 2nd molar with a downward, apically
directed movement of the instrument into the gingival crevice. This elevation does not
extend medially past the distolingual curve of 2nd molar and the tip of instrument is kept
in firm contact with 2nd molar.
The second maneuver is a movement with the soft tissue-elevating instrument horizontally
across either the crest of the osseous ridge of the retromolar triangle/the crown of impacted
teeth. If it protrudes out towards lingual side, small sweeping motions anteriorly and
posteriorly, to raise retromolar tissue in a single block with a liver type movement. For
this purpose mucosal elevating instrument/curette are used. The tip should be in contact
with the bone/erupted teeth.

Retraction of soft tissues

The objective of retraction is to provide access for operation and to provide access to the
soft tissues. The gentle retraction of soft tissue is done by placing retracting instrument
resting firmly on bone, soft tissue resting on it.
Surgery on hard tissue
Operations on the bone may be performed with osteotomes/machine- powered burs/both.
Use sharp burs to cutting through the dense bone. Flush the operating site constantly with
sterile water. An adequate amount of bone is removed according to plan either to remove
tooth with sectioning/without sectioning. Usually amount of bone removed is to a level
just apical to the cervical area of the tooth.

Advantages of using bur to cut bone

According to Hall
1. 50% more effective
2. Apposition of new bone and the rate of repair enhanced when bur is used.
3. Trauma and postoperative pain reduce to 50%. Lips are less abraded.
4. Post operative swelling slightly decreased.
5. Post operative bleeding relatively same.
6. The length of time required for surgery decreases to 80%
7. Ease of operation and less fatigue.

Splitting techniques for removal of impacted teeth

It is the process of reducing the crown into small pieces that are then removed, creating a
space into which the remaining portion of the roots can be need. This is accomplished by
chisel/bur and in many cases combination of both.

Advantages as listed by Pell and Gregory

1. The field of operation may be kept small. The incisions are less extensive, leading to
less postoperative swelling.
2.Bone removal is eliminated/considerably reduced.
3.The operating time is shortened.
4. There is no damage to adjacent teeth and bone. Bone is not subjected to excess
pressure, risk of jaw fracture reduced.
5. Numbness of lips by damage to inferior-alveolar-nerve also reduced.
Disadvantages the disadvantages of Chisel splitting is
1. Teeth with shallow grooves difficult to split
2. Teeth in elderly patients difficult to split
3. Direction of split cannot be controlled.
4. Patients are disturbed by chiseling process
In above scenario, it is better to use bur to split tooth.
Removal of Impacted teeth from its bed
After impacted teeth are free (after overlying bone and bone surrounding height of contour
have been removed) Sufficient bone is removed from distal to impacted tooth to create a
space into which impacted teeth can be moved. The impacted tooth is then lifted from its
bed means of an elevator.
If tooth is not removed with moderate amount of pressure, remove the elevator; examine
reasons for resistance remove more bone. Enlarge the space created the distal side of the
third molar into which impacted tooth is to be moved. A better method is to section the
crown. Do not apply force in the attempted removal of any impacted teeth until all
resistance due to dense bone has been removed.

Lingual Split Technique

Originally describe by Ward (1956)
Developed by Fry - he reported elevating the soft tissue from the lingual aspect of
mandible in the 3rd molar region and removing lingual base of bone.
Dr. WH Davis in 1960 modified the procedure. It featured neither elevating the lingual soft
tissue/separating the lingual bone attached to the periosteum. The osteotomy also
modified by fragmentation of the bone rather than one-piece separation of plate of bone as
in the original procedure.
In 1975 Killey and Key described the procedure begins with an incision starting an buccal
sulcus - Reflection of mucoperiosteal flap- creation of anterior vertical stop - 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 it sectioned at cervical level.
Lewis (1980) suggested modification of lingual split bone technique by minimizing
periosteal reflection and buccal bone removal and by preventing fracture of lingual place.

Modified Distolingual Splitting technique by Davis (1960)

This technique usually performed under sedation. The osteotomes must remain sharp
throughout procedure, and more than one osteotome should be available for each operation
because they dull rapidly. The minimal soft tissue elevation and retraction reduces the
release of periosteum, which probably diminishes the occurrence of secondary infection in
the 2nd molar area.
Whenever possible cuff of attached gingiva is left intact on the posterior aspect of the 2nd
molar to preserve the gingiva. Vertical incision, approximately 1 cm long, is made just
posterior to the 2nd molar and sagittal soft tissue incision is made as usual. The
mucoperiosteal flap is elevated and retracted bucally. The lingual bone is released by
fragmentation and the fragments remain attached to periostium. Portion of bone not
attached to periosteum are removed. The surgical path of the osteotome is guided by the
orientation of bevel.
The periosteum is not separated from bone on the lingual side/ from osseous structure
superior to the root. Wedging of ostotomes between the impacted tooth and bone should be
avoided to minimize the risk of mandibular fracture.

Incidence of postoperative sequels

A study of 598 modified distolingual-splitting technique done - 368 patients were
evaluated.
38 occurrence of (6.4%) alveolar osteitis
15 (2.5%) - labiomental paresthesia
2 (4.3%) cases at lingual paresthesia
6 (1%) instances of infection
All complications studied were transient resolving within 5 months. There were no
statistically significant correlations were found.

Surgical Closure
1. Wedge removal -In a study done in UK states 19% surgeons done wedge removal.
This step involves the removal of a triangular wedge of soft tissue immediately posterior to
the 2nd molar to provide surgical drainage. It is expected to repair by secondary intention,
producing granulation tissue for epithelialization and gingival attachment posterior to the
2nd molar. Indications for the procedure is when we have to give post operative dressing,
which will provide access that will be comfortable for the patient as the dressing are
changed.
When there is excessive tissue prevent beveling of incision to get edge-to-edge closure,
and also to get tight sealing the gingival tissue against 2nd molar.

2. Debridement
a. Smoothen the osseous surgical margins with a bur, irrigate with sterile saline/with hand
file.
b. Debridement of alveolus performed by generous lavage of saline and suctioning. It
removes debris generated by the cutting by bur.
c. When there is no residual cyst/other pathological lesions debridement by curettage is not
indicated. Curettage of surgical site may damage the residual periodontal ligament
attached to the alveolar wall. The major portion of the cellular response to vitalize
coagulum arises from the residual, undamaged, periodontal ligament.
d. If the follicle appears to be pathological, hyper tropic/inflammatory, it should be
removed with care to avoid straining of the lingual nerve.
e. If a cyst is being removed concurrently with the 3rd molar surgery, the cystic lining is
removed with a curette, but the remaining alveolar wall not involved in the cyst formation
are not curettaged.

3. Intra alveolar Dressings

* Intra alveolar dressings enhance repair process, control pain, and reduce edema may be
considered.
* Medicament usually used on gauze strips and gelatin sponges and in form of paste, tablet
and dust.
* A study includes 100 surgeons (1) 17 placed drug on a routine basis (tetracycline,
Eugenol, lincomycin, sulfonamide tablets) (2) 43 surgeons used during if the procedure
had required unusual surgical manipulations.
* The essential function of intra alveolar dressing is the preservation of a vital coagulum
and the prevention of infection.
* Sulfonamide tablets and 5 to 10mm cube gelatin sponge soaked in linocomycin serve as
a space occupying dressing. These agents gradually absorbed/displaced as the coagulum
vitalizes and also provide local antibiosis.
* Alling also suggests in selected circumstances the follicular sac as a space-occupying
agent. It provides additional source of parent repairing cells for the coagulation. Follicular
sac adherent to lingual side may disturb the abnormally positioned lingual nerve. In this
circumstance and with no historical/present microscopic examination evidence of
tumors/cystic changes in the follicle, follicle is tucked into the alveolus as a vital space
occupying dressing.
* Antibiotics agents mixed in the original coagulum had reduced the incidence of dry
socket powdered tetracycline may be dusted to coagulum.
* Antibiotic agents combined with steroid were used during the 1970s and 1980s but the
steroid produced undesirable clinical side effects of delayed repair.
• Material and agents used in managing dry sockets may be placed in the alveolus
following the removal of an impacted third molar and subsequent trauma would
 be the same a management of dry socket, replacement of original dressing, use
of smaller dressing.

* The decision to place intraalveolar dressing is influenced by the overall management of

the impacted 3rd molar, the previous experience of the doctor and the doctor’s preference.

According to Ailling if we do deft, delicate, accurate removal of the tooth with a minimum
manipulation of tissue, he suggests no drug to be placed in addition to the normally
occurring coagulum.

4. Closure of soft tissue flap

Objectives
1. Returning of soft tissue flaps is their original anatomical position on bone.
2. Stabilizing the soft tissue flap and permit repair.
3. Resecuring the additional gingival attachments.

These objectives may be achieved by Suturing the flaps into position/depending on the
surgeons preference, by repositioning the flap and placing no sutures but relying the
maturation of the coagulum between the flap and osseous bed to stabilize the flap.
A survey of 100 surgeons reported.61% used only one suture posterior to 2nd molar .39%
used two-suture posterior to 2nd molar.2 surgeons rarely used. Alling states that it is better
to place 2/more suture to firmly stabilize the flap.

Intraoral Dressings
It is most important in preserving the coagulum during critical 1st hour of repair. It is
advisable to use folded gauze moistened with saline/water to prevent adherence to oral
mucous membrane and to prevent dislodgement of clot from surgical site. It is better to
retain the gauze to remain place for at least 1to 2 hours.

Unusual location of mandibular 3rd molar

A mandibular 3rd molar may migrate by eruptive phenomena / may be displaced by a
lesion to unusual location in the mandibular ramus. A tooth may move into the condylar
neck, to the gonial angle area of the ramus, to the base of the mandible/ into the coronoid
process. The tooth is removed by direct dissection by trans oral/extraoral approaches if
 associated with cyst or tumor. Immediate reconstruction with bone grafting procedure and
direct fixation of segments provide logical and prudent surgical solutions.

Excision of impacted mandibular molar from edentulous areas

Careful radiographic studies made to prevent fracture of mandible. The radiographs will
reveal the position, size and shape of embedded tooth and the amount of overlying bone.
The technique depends primarily or due amount of bone between the inferior border of the
mandible and the apex of tooth to be removed
2. Thickness of buccal and lingual plates
3. Shape of the crown and the number and form of roots, if more than one.

Maxillary 3rd molar

.
In removal of maxillary 3rd molar following 3 steps followed.
• Make visual, digital examination of soft tissue and teeth, hard tissue adjacent and
overlying impacted teeth.
• Study radiographs of tooth to be removed, the surrounding anatomic structure and
adjacent teeth.
• Classify the type of impaction.

Factors complicating the removal

1.Maxillary sinus approximation
2. Presence of an impacted maxillary 3rd molar
3. Fusion of 3rd molar with the root of the 2nd molar
4. Abnormal root curvature
5. Hypercementosis
6. Proximity to zygomatic process at maxilla
7. Extreme bone density in elderly patients.
8. Follicular space filled with bone
9. Difficult access to operative site
Indications and contraindications are same as mandibular 3rd molar.

Incisions
Incisions for exposing the site of impacted teeth maxillary 3rd molar should be full
thickness
The usual incision, which is described from posterior to anterior, is routinely placed over
the mid portion of the tuberosity/slightly buccal to intersect the distobuccal aspect of 2nd
molar. It passes anteriorly in to gingival crest. According to Surgeons preference
extension to 1st molar mesiobuccal surface and oblique extension /releasing incision
placed. The mucoperiosteal tissue covering the crown of impacted tooth is loosened and
reflected. Parallel portion of mucoperiosteal tissue reflected.

Removal of overlying bone

Upper 3rd molar bone is removed using chisel/ rongeurs/bur for exposing the crown of
impacted tooth. Extreme care is taken not to drive tooth to maxillary
sinus/pterigomandibular space. After overlying bone has been removed, expose the crown
of the impacted tooth; remove sufficient bone to expose the crowns height of contour.

Removal of Impacted Upper 3rd molar

Sufficient space must be obtained between the height of the contour of the impacted tooth
and the bone to permit the entrance of elevator, so that the point of elevator can be placed
beneath the crown, near gingival line, at the mesiobuccal angle.

Using appropriate elevator, using buccal plate used as fulcrum, the tooth is elevated
buccally and distally from the alveolus.

Abnormal Eruption phenomena

Maxillary 3rd molar may be carried to various location, may reside in the walls of
maxillary sinus, floor/lateral wall of nose, infraorbital area.
In such situations, removal may require transantral, transnasal/one of the several variations
of midfacial osteotomies for access and removal.

Maxillary 3rd molar may also displaced by cyst/ tumor. In such case ideal surgical plan
would be to enucleate the lesion and to remove associated teeth.

Side effects and complication

1. Hemorrhage
The PSA artery may be positioned on the lateral surface of the tuberosity. In this case it
may be lacerated by LA injection/during elevation of mucoperiosteal flap. If it is due LA
injection intact overlying tissue may balloon and stop hemorrhage by pressure against
 artery. If bleeding occurs during elevation of periosteum/flap it is initially stopped by
pressure from metal instrument followed by either crushing of contagious bone to small
vessel or by electrodessication by cautery. Hemorrhage may be fro injury to pteriogoid
plexus of veins by needle tip. No specific immediate treatment necessary.

2. Ecchymosis
The raising of Intraoral flaps may produce a normal postoperative ecchymosis, creating
subcutaneous discolorations in the facial tissue. Usually it is seen in buccal facial space,
between elderly patients ecchymosis may dissect to distant sites.

3. Trismus
May occur due to inflammation, infection and hemorrhage may secondarily affect
masticatory space and produce trismus.

4. Displacement of tooth into Maxillary sinus

A maxillary 3rd molar/ the root portion may be displaced during surgery to maxillary
sinus. If a tooth disappears from the surgical field, the team must realize that the event
though unusual is not acute emergency and is not indicative of negligent care. The
surgeon may elect to complete other planned procedure before identifying the location of
the root/tooth and planning for its management.

Localizations
It may be in one of 4 locations
1. It may pass through sinus membrane and may be in the sinus.
2. It may be between the sinus membrane and osseous wall of the sinus.
3. It may be lodged under the mucoperiosteum lateral to the alveolar process.
4. It may pass posteriorly in the infratemporal space

• Tube shift x-ray method, often with periapical films used for exact location.
• The positioned x-ray films are taken with patient’s head in an up right position, forward in
the prone position and posteriorely in the supine position.

Spontaneous removal
 * If a non-infect root is in the sinus of a patient who is historically and clinically free of
sinus inflammations there is no need to remove the root. The antral cilia should be given
opportunity to carry the root to the ostium of the antrum. If this occurs, with in 10
days/less time root will be expelled through the nose. Patients may recover the root by
sneezing/blowing the nose.

* If the root remains in the antrum, the patient should be monitored to determine whether it
would cause an inflammatory response. If the retained root is a psychological problem to
patient/if doctor considers it is better to remove prophylactically the root should be
removed. Roots that remained in the maxillary sinus for months/years are usually bound
to the normal sinus membrane by make fibrotic tissues.

Surgical Removal
An empty alveolus should never enlarged to recover a root/tooth from maxillary sinus
since it may end up in Oroantral tissue. Recovery of root may be accomplished by one of
the two approaches.
1. Opening made in the posterior lateral wall of the sinus, in the lower aspect of zygomatic
process of maxilla.
2. Through an opening in the canine fossa of anterior surface of maxilla.
If the sinus is acutely inflamed it may be necessary to make nasal-antral drainage window
following the removal of a root/tooth.

5. Displacement to the infratemporal/Pterigopalatine fossa

* Entire 3rd molar may be displaced posteriorely and superiorly to be lodged in the soft
tissues behind the maxilla and superiorly under the anterior aspect of the zygomatic arch.
• In some cases dental extraction forceps beaks placed on the occlussal one 3rd of the crown,
thereby launching the tooth in a superior direction when the beaks where squeezed
together.

* There is no immediate emergency localization by imaginary is necessary. Occlussal

radiograph, CT scan may be necessary.
* Removal is carried out under general anesthesia from transoral approach.
* Teeth displaced posterior to maxilla it is possible to be fibrosed with in 3/4 days and
have been identified and removed following sharp blunt dissection
* Some times it may be necessary to section coronoid process to obtain surgical access.
Fractured Tuberosity
It may be weakened by an alveolar extension of the maxillary sinus anterior to the
maxillary 3rd molar.
It may be Idiopathic, Secondary to loss of 1st/2nd molar
* Bulbous, ankylosed, widespread roots, tooth impacted in dense sclerotic bone may cause
fracture.
* Exerting pressure from forceps/elevators may produce fracture of tuberosity. Surgeon
will immediately sense the fracture by sound, by sudden case of movement of tooth, and
other by oozing hemorrhage.
The objective following fracture of tuberosity
1. To preserve as much as osseous tissue as possible.
2. To avoid producing OroAntralFistula.
* It fracture is small and tooth is removed, and alveolus is closed using mattress suture to
ensure repair.
* It fracture is large tooth may be replaced and stabilized with palatal splint/a buccal
orthodontic arch wire to produce bone of repair, the tooth. Removed 2/3 months later
following elevation with appropriate flaps, removal of lateral and posterior bone,
sectioning and removal of the tooth segments.

Emphysema mandibular 3rd molar is the surgical site at greater risks.

It usually results from air being forced into the connective tissue /facial spaces. It results
due to the use of air driven dental hand piece/a compressed air spray. The swelling
usually rapid in onset, giving the affected area on elastic in consistency. The air can be felt
crackling, under finger. Such air is absorbed very slowly in 1/2 week no treatment is
needed.

Periodontal defect Posterior to the 2nd molar

It may occur due to increased depth of infrabony pockets on the posterior of the 2nd molar
and in excessive soft tissue in the retromolar tissue.
Kuglelberg studied (2 years and4 years postoperatively after removal of third molar).
16.7% of cases of <25 years shown infrabony defects.40.7% of cases of >26 years shown
infrabony defects. He states that early removal of impacted 3rd molar might have
beneficial effect on the periodontal ligament health of the adjacent 2nd molar.

Post operatively excess soft tissue posterior to 2nd molar interferes with oral hygiene and
affects gingival attachment
Excessive tissue removed with a pyramid- shaped tissue mass with the base against the
2nd molar (the incision line should be divergent the mucosa. The buccal incision beveled
more than the lingual one because the mucosa covering soft tissue is more abundant and
there is no concern or encountering of highly placed lingual nerve.

Tooth segment displaced into the submandibular space.

Tooth segment displaced through very thin cortex of submandibular fossa may remain in
submandibular gland.
3 options
1. Indefinite observation and treatment as indicated if on inflammatory process should
occur.
2. Delay of removal for 3/4 weeks to await stabilizing fibrosis and then removal of
segment.
3. Immediate/early removal.

Surgical Procedure
Incision from the retro molar triangle to cuspid region with a lingual gingival crevice
incision done. The mucoperiosteum is elevated to the mylohyoid muscle. Scalpel used to
excise myelohyoid muscle fibers from bicuspid to 3rd molar region about 4mm from
margin of mandible. An assistant/surgeon provide superior support of submandibular
tissues, and the surgeon slowly separates the lobules of the submandibular gland with a
mosquito hemostat until the root is located and removed. Mylohyoid muscle incision is
closed with chromic gut suture and medial mucosal flap is closed in usual manner.

Hemorrhage
Hemorrhage following removal of mandibular impacted teeth may arise from inferior
alveolar vessels. Blood loss may be rapid patient may go for hypotension.
Preoperative radiographs used to observe
1. Proximity of the tooth to inferior alveolar canal.
2. Tributaries from inferior alveolar vessel.
3. Radiolucencies produced by AV aneurisms.
If inferior alveolar vessel is cut prompt hemorrhage ensues. If it is incompletely cut
intermittent copious hemorrhage occurs.
1.Cleansing the alveolus, suctioning, usually controls hemorrhage. Pack oxidized cellulose,
microfibirillar collagen haemostatic material into the site.
2. Crush bone into the bleeding site using sharp curette, but it may damage inferior
alveolar nerve.
3.Seperately neurovascular bundle with sharp curette, free the arteries and use
Electrocautery.

Prevention of Complication
* Attention to the basic principles of surgery, including proper preparation of patient,
evaluation, asepsis, hamostasis, use of controlled force, thorogh debridement and
meticulous management of bone and soft tissues, will reduce the severity of side effects
and the number of complications.
* To reduce complications current literature advocates removal of 3rd molar at an early
age by experienced surgeon, the unpleasant side effects and complication rates are
dramatically reduced
* The prophylactic use of antibiotic are advised unless there is a systematic condition
present that indicates their use. They may be used locally to prevent dry socket.
* Many studies suggest that the use of glucocorticosteroid in management of postoperative
pan, swelling trismus decreases pain, swelling and trismus.
* The literatures also suggest the use of long acting L.A. and NSAID s in the management
of postoperative pain.
* Efficacy of most of the opoids in the management of postoperative pain was poor.

Intra operative Management

1.TMJ
During impacted tooth surgery, the jaw should be supported so that the pressure required
to remove the tooth are not transmitted to TMJoints.A rubber bite block, placed on the
opposite side of the surgery, will stabilize mandible and decrease TMJ strain. The rare
postoperative TMJ pain can be managed by soft diets, restricted activity of mandible and
prescription if NSAIDS, orthodontic splints may be indicated.

2. Soft Tissue injuries

* Careful and controlled use of surgical instrument
* Contact of skin/mucous membrane with the shank of burs avoided.
* Creates a deep abrasion/burn. Similar injury may occurs if hand piece overheats/hot.
* Puncture wound does not require special management
* Skin abrasion allowed to repair by secondary intension.
* Minimal reflection of mucosa and periosteum reduces postoperative complications.
 * Clean incision through mucosa and periosteum and flap should be protected with a
retractor to avoid inadvertent tears/maceration.
* A study by Holland and Hindle states that complete primary closure of soft tissue distal
to 2nd molar results in more pain and swelling post operatively.
* Another study by Pedersen states that longer the surgery more pain.
3. Fracture of Maxilla and Mandible
Fracture may be maxillary tuberosity fracture to fracture of mandible. If the fractured
segment is large and still attached to periosteum of the bone, carefully separated from teeth
and left in position. It bony fragments small and appears to be ankylossed to tooth, the

periosteum should be carefully reflected from the bone and the fragments should be
removed with the tooth.
Predisposing factors
1. Injudicious force during removal of deeply impacted tooth
2. Patients with osteoporosis and other disorder of bone.
3. Mandible weakened by cysts or tumors.
4. Severely atrophic mandible
5. Infection involving bone surrounding the tooth. The patients with above conditions are
more likely to experience fracture of mandible.

• When a fracture occurred, the tooth should be removed carefully so that injury to inferior
alveolar nerve minimized. The fracture is than reduced and managed in the standard
fashion usually with intraosseous wiring or bone plating technique.

4.Root fracture
5. Oro antral communication.

Postoperative Complication
1. Post operative Hemorrhage
Hemorrhage most of the time is due to local rather than systemic factor
Thorough History taken prior to impaction surgery.
(i) Patients taking NSAIDs on chronic basis may affect platelet function prolong the BT
(ii) Patients taking anticoagulants.
(iii) Coagulopathy disorders.
When the bleeding is local an aggressive approach is usually indicated. Vital signs should
be obtained and recorded. IV infusion started. Infuse Normal Saline /Ringers lactate if
indicated. Pressure must be used.
Status, local haemostatics, crushing the bone over bleeding site are used whenever
indicated.

2.Myelspherulosis
1969 - Meclotchin and associates reported it as a fungal disease.1980 - Dunlap and Barker
described two cases. Later Lynch reported six cases.
Most cases have occurred following surgery in which the surgical site was dressed with a
tetracycline-containing petrolatum-based ointment. Spherules noted microscopically were
erythrocytes altered by the petrolatum and the brownish black color was due to
decomposition of the heamoglobin. Most lesions are assymptomatic and present as a
swelling with an associated radiolucency on x-rays, however patient may present with
pain/purulent drainage. Treatment consists of thorough curettage and irrigation of area.

3.Mylohyoid ridge Exposure

Extremely uncomfortable to the patient and frequently requires surgical management. The
exposed ridge of bone should be reduced below the level of the mucosa. The area should
be allowed to heal secondarily and no attempt should be made to close over the bony ridge.

4. Epulis Granulomatosum
Exuberant - reactive form of tissue, which totally fills the socket within, severed days. It
indicates a foreign body, usually bony sequestrum within the socket. The patient should be
anesthetized, the socket curetted and irrigated of all debris.

5. Infections
* The surgeon must be prepared to distinguish between the pain, swelling and trismus
associated with surgical trauma and those associated with infection.
* Pain due to surgery peaks in 24 hours and then tapers. If pain increases after 3 or more
days following surgery, infection/localized osteitis considered.
* Dry socket is not usually associated with increase in trismus.
* Trismus occurs in 24 hours if associated with surgical trauma, however it begins on the
3rd/4th day following surgery, on infection must be considered.
 * Swelling that increases after the 2nd/3rd day following surgery is most commonly as a
result of infection. The swelling is firm rather than soft, it is extremely tender to palpation
and the overlying skin is warm and erythematous. General systemic sign such as increase
in body temperature, chills and malaise must be considered.
* Infections after 3rd molar surgery usually limited to site, infections may involve the
buccal and temporal spaces and some times submassetric and pterigomandibular spaces
may be involved.

Management
1.Use of antibiotics.
2.Surgical drainage.
3.Supportive management.

6.Osteomyelitis
* Uncommon may occur after removal of 3rd molar.
* Chronic swelling, dull pain and trismus are clinical findings.
* Lip anesthesia may be seen.
• Radiographs reveal osteolytic process

Management
* Surgery involves debridement of necrotic bone or soft tissue from the region and
decortications of buccal cortical plate. The primary blood supply in 3rd molar region is
from lingual soft tissue and the removal of the dense buccal cortex allows for frequent
irrigation of the infected bone.
* Parenteral antibiotics are given for a period up to 6 weeks.
* Control of risk factors such as DiabetesMellitis should be done.
* Fluid administration., Application of moist heat, rest. Analgesic and antipyretic.

7. Neurological complications of surgery to impacted teeth

* Clinical evidence of nerve injury is reported in less than 0.5% to 5% of all surgeries for
impacted teeth.
* Inferior alveolar nerve is most frequently affected followed by lingual nerve.
* Mental nerve, nosopalatine nerve, ASA and PSA nerve injuries also reported.
 * More common in woman, between 2nd and 3rd decades of life.
Majority of patient’s nerve injuries related to surgery for impacted teeth are caused by
benign nerve exposure, extra neural toxic metabolic factors, and transient mild
compression by nerve stretching. Usually of type I and type II nerve injuries.
* Recovery occurs within 6 to 12 months
* These patients require physical, medical and behavioral support.
* Some times due to sustained intraneural puncture, crush compressions, tear
lacerations/mixed injuries during surgery for impacted teeth. In such cases class III, IV, V,
and VI nerve injuries may be seen and patients may present with combination of anesthetic
pain, phantom pain, and referred phenomena recoil responses to mild stimulation to
overlying tissues and constant throbbing pain exacerbated by emotional factor that
suggests autonomic and central nervous dysfunction
The challenge to surgeon is to determine the specific nature of injury.
2. Recognize and document recovery of normal neurological function or document the
emergence of a pathological syndrome.
3. Treat the informed patient early, openly and aggressively with non-surgical medical,
physical and behavioral protocol and in some cases carry out surgical decompression,
repair and lysis.

Risk Factors
* Horizontal mandibular impaction is at higher risk than vertical and lingual impactions.
* Lingual nerve is at higher risk in approximately 10% of humans; in some the nerve
normally courses at a "high" level relative to the internal oblique ridge.
* Intra bony nerve and root proximity is as obvious risk factors.
• Burs used blindly beneath posterior and lingual flap may be associated with nerve injury.

* Smoking and other tobacco habits, poor oral hygiene with foreign body entrapment
adjacent to exposed nerve/over packing of a socket may complicate benign nerve injury.
* Dry socket may interfere with the down growth of regenerating axons and contribute to
neuroma formations.
* Patient’s general metabolic states and psychiatric status.

Types and Mechanism of injury

During surgery of impacted teeth, trigeminal nerve are injured by toxic metabolic,
compressive, puncture and lacerating forces.
1. Toxic Metabolic injuries are due to hypo tonic and irritating substances such as topical
antibiotics, cleansing agents, restorative and endodontic chemicals and particularly Local
Anesthesia.
* Hydrolyzed amides and esters in LA when given in multiple injections in 3rd molar
region may cause class I and class II injuries
* Topical application of eugenol in case to treat dry socket may damage nerve.
* Exposure to toxic metabolic injuries does not usually produce epineural/internal
anatomic changes but they may produce axon necrosis leading to Class I/Class II injuries

2. Compression injuries
1. It occurs usually to Lingual and infraorbital nerve from instrument retraction on tissue
flaps. Less than 80mm Hg pressure – interferes with micro vascular perfusion and induce
epineural edema, tingling parasthesia and reversible class I injury.
400mm Hg compressive forces cause micro vascular rupture, local demylination and gap
dislocation on the nodes of Ranvier.
ii) Displaced bone fragments and root/crown fragments lodged against nerve may exert
such effects - Epineural and intraneural edema - loss of large mylinated fiber coat.
iii) Patient with compressive lesions report early sporadic pain, later more constant
burning, radiating and throbbing pain. If there are signs of progression to class III
neuroma microsurgical internal decompression may be required.

3. Puncturing Injuries
Direct injury to nerve may occur due to elevator, burs/needles/indirectly from displaced
and sharp roots/bone spicules.
When patients sustain nerve injury, if they report an intense, burning sensation that
radiates distally through nerve distribution. Usually class I reversible injury occurs. But if
there is true intrafasicular puncture it may result in more severe class III, IV and VI
injuries. Careful monitoring of symptom and reflex recovery is needed. It ever after 3
months spontaneous or triggered pain is present surgical decompression, neuroma
resection and repair indicated.

4. Laceration Injuries
 A nerve laceration may result from more severe crushing, penetration by larger
instruments, direct incisions and tears. Class V injuries may result due to formation of
amputation neuroma which will likely to interfere with normal lingual nerve recovery.
• Early exploration and microsurgical reanastamosis within 3 months produce excellent
results.
• Nerve tear result when traction exceeds the nerves elastic limit, usually seen in cases
where dilacerated roots has "hooked" the inferior alveolar nerve.
• Lingual nerve is especially vulnerable to tear lacerations when the nerve is localized at
higher-level
• Overzealous curettage and cyst enucleation may result in avulsive class V laceration.
• Incomplete laceration may result in lateral exophytic neuromas. Patients with such injuries
and neuromas typically have background aching pain and triggered sharp pain in response
to percussion of the retro molar mucosa. Such patients may need aggressive transcortical
exposure, excision of neuroma and reanastomosis correction.

Posttraumatic neuropathic syndrome

After injury 90% heal normally, however unfortunately 10% cases chronic annoying
sensory neuropathy may result. In a few cases complex intractable and debilitating pain
syndrome emerge.
Four recognizable chronic patterns are
1. Anesthesia Dolorosa.
2. Hyperpathia.
3. Allodynia.
4. Sympathalgia.

Anesthesia Dolorosa –
Pain/annoying sensation felt in an area of subjective numbness.
Hyperpathia-
* It is a delayed, surging and spreading pain, brought on by moderate mechanical pressure.
* Often seen in association with class III and IV injuries.
* It is partially/temporarily blocked by blocking the nerve proximal to the injury.
* Inferior alveolar hyperpathia occurs when we compress on mental foramen.
* Lingual nerve hyperpathia may result in compression medial to internal oblique ridge.
Allodynia-
It is a quick, intermittent pain, response to low intensity stimuli that are not normally
painful.
Regional anesthesia blocks of both the trigger point and trunk quickly and completely
eliminate Allodynia and Hyperalgesia.

Sympathalgia-It is a quick posttraumatic pain aggravated by cold stimuli, emotional

stimuli and increased sympathetic tone. Patient experience constant "throbbing, hot,
burning, nagging and pulsing" pain that does not respond to blocks of the injured
trigeminal nerve trunks.

TREATMENT OF ACUTE NERUG INJURIES

Class I and II type injuries - requires little more than supportive care and observation.
Complex class IV and V injuries dictate surgical repair.
Early treatments of class III and VI injuries are more successful in regaining pain free
neurosensory function.
Immediate treatment
When the impacted tooth is near vicinity of nerve direct observation of the nerve should be
made, preferably with the magnification. When indicated exploration begins with
debridement and lavage of at the injured area. Nerve is freed from impinging bone or
tooth fragments or foreign bodies.
When irregular/comminuted surrounding bone present, using surgical burs/rongeur nerve
is carefully decompressed.
When we see transection of cut end of nerve ideal treatment would be approximate the cut
ending with 6-0 to 10-0 nylon suture.
Even a gross adaptation of nerve will prevent nerve retraction and early fibrotic atrophy
and Secondary microsurgical repair would have better prognosis.
Post injury supportive care
* Normalize the patient’s general metabolic and central neurological status.
* Ice pack to perinerual tissues
* Minimize jaw movement for the 3 postoperative injury day. Any excessive compression
by edema, hematoma or secondary traction injuries.
* Intraoral heat therapy, oral hygiene maintenance, antibiotic therapy.
Use of corticosteroid in further prevention of nerve compression is controversial, may be
useful.
* NSAIDs, sedative narcotics can be used.
Microsurgical expose
 It is effective when carried out within 1st few days/weeks after injury, before secondary
neuroma formation /pain syndrome occurs. While doing Microsurgery certain key
principles followed.
1. The repair should be done in an optimal tissue environment of sterility and metabolic
support, with the absence of a foreign /secondary tissue irritants.
2. The repair should achieve tension free anastomosis.
3. The repair should bring anatomical alignment at fascicles whether it is accomplished by
epineural/perineural suture.
Depending upon location and type of injury the surgical approaches to the injured nerves is
determined.

TREATMENT OF CHRONIC TRAUMATIC NEUROPATHY

Multidisciplinary approach usually more effective in the long run. The surgeon should
rely on non-surgical and allied surgical colleagues help in training chronic neuropathy.

Non-surgical treatment
1. Physical therapy - encouraged engaging in regular work and play to increase vascular
perfusion with heat and movement. TENS used, nerve recovery zones should be touched
with recognizable object.
2. Medical treatments
• Sedative narcotics
• NSAIDS
• Topical capsaicin
• Anticonvalascents
• Antidepressants
iii) Behavioral therapy
It focuses on anxiety reduction, depression control and reversal of negative conditioned
behavior. Counseling should be done. A program of physical exercise and play should be
mandatory.
iv) Surgical Treatment
* Reparative surgery
* External land internal decompression
* Neuroma resection
• Direct/graft nerve reanastomosis.
Dry socket
Shafer and associates defines it as
Focal osteomyelitis in which the blood clot disintegrated or been lost, with the production
of foul odor and severe pain, but no suppuration.

Thoma explains it as
It is a condition in which the blood clot disintegrates. At 1st clot has dirt gray appearance,
and then it falls leaving a bony socket bare of granulation tissue. Suppuration absent, a foul
odor present, severe neurological pain persists for day. Symptoms starts from 2nd /3rd
days lasts for 10 to 40 days. Bare bone is extremely sensitive to touch. The socket may
not always open. It may contain necrotic granulation tissue/the orifice may be covered by
a flap of tissue so that detection is difficult. It occurs in spite of the most careful aseptic
procedure and regardless of the ability and judgment of the surgeon.

Incidence
Overall incidence of dry socket is 1% to 3.2%
AAOMFS - mean incidence of dry socket in mandibular 3rd molar area is 6.35%
More incidence of dry socket in the case of removal of mandibular 3rd molar by 9 studies
is 26.7%
Thus it is better to say dry socket occurs 10 times as frequently as compared to other site in
mandibular 3rd molar. Dry socket occurs twice as frequently when infiltration anesthesia
given which was compared with block anesthesia
Pathophysiology
Alling and Kerr studied on rhesus monkeys. They concluded that the delay of healing in
tooth extraction sockets is inversely proportional to the amount of residual periodontal
ligament remains after extraction. That is fewer periodontal membrane fragments remains
in the socket, the more likelihood of developing delayed healing/dry socket.

Theories of etiology
Dental practitioners throughout world have put their own theories about etiology of dry
socket.
Trauma
Poor blood supply
Pre-existing infections
Increased bone density
The nature of anesthesia
Fibrinolytic activity
The oral flora endemic to 3rd molar. .
1. Pre-existing pericoronits.
Incidence of dry socket is more. According to Kay its 71%. According to Meyer it is
14.1% of cases.
2. Smoking
More incidences in smokers 6.4% vs. 1.4%
3. Effects of Anesthesia
Lehmer study under LA - 3.1% developed dry socket, under GA - 2.2% developed dry
socket.
4.Poor Blood Supply-
The regional blood supply at the site of dry socket has been cited as a / contributing to
etiology. This speculation is based on the belief there is relatively greater density at bone
in the mandible than in maxilla. Very little scientific research available supports this fact.
Birn 1966 from his experimental study fond that blood supply gradually increases from
tooth to tooth towards posterior sections of dentations. It felt that blood supply greatest in
the gingival 3rd of periodontal membrane and least in middle third. He concluded that
blood supply in lower molar region is so poor, than in other regions of the jaws and
therefore above they does not suites. Dry socket hardly observed in gingival region.

5.Fibrinolysis
Birn was able to show that the pathogens at dry socket could be explained by increased
fibrinolysis actively in an around the tooth socket leading to partial/complete lysis and
destruction of blood clot. It may be due to invasion of extraction wound by enzymes
produced by bacteria or tissue kinases liberated during inflammation of wound repair.
Birn's hypothesis - sequence of event leading to dry socket
1. Inflammation of the marrow spaces (trauma/infections)
2. Subsequent release of tissue activators by injury of the cell.
3. The transformation of plasminogen to plasmin.
4. Which in turns dissolves the fibrin, thus producing loss of blood clot.
Birn also concluded that high fibrinolytic actively in dry socket and the resulting plasmin
formation came activation of prekininogen and kininogen, which are present in high
concentrations in bone marrow. The kinins thus formed give rise to the severe pain in dry
socket.
 6.Sex Predisposition-
A study by Sweet and Butler showed incident of dry socket 4.1% in the female, 0.5% is
male patients (5:1).
Incidence twice high in patients taking oral contraception. Schow found that incidence of
dry socket is 15.4% in the male, 24.5% in the female not taking contraceptive pills, 44.6%
in the female taking contraceptive pills.

PREVENTIVE MEASURES
Many serious attempts have been made to over the years to find a technique a method a
drug/a combination that would eliminate this particularly offensive post extraction
complication.
Intra alveolar topical Medications-
1937 Sinclair 1st used Sulfonamides in Dry socket Barab (1940) Guinn, Greiss, Kraston,
Davis; Rudd (1963) used it subsequently.
1942 Ostronder and Hartman questioned efficacy of sulfonamides in prevention of dry
socket.
1951 Olech used placebo and sulfonamides. No statistically significant benefit derived.
1947 - ADA disapproved these preparations
* Researches tried Penicillin; high incidence of allergy was problem. ADA
contraindicated its use locally.
* As search for prophylactic antibiotic continued tetracycline came under scrutiny.
• Study by Quinly shown there dry socket incidence when tetracycline placed 5.78%
whereas the incidence when nothing was used was 33.5%.

* 1966 Swanson studied Neomycin’s, bacitracin, and tetracycline hydrochloride local

application. His results show tetracycline outweighed (16%) and bacitracin (17.2). The
incidence of dry socket in case of tetracycline was 2.6%.
* 1981 - Davis used granules - gelatin - tetracycline compared the incidence of dry socket
2.7%.
* Ritzace attempted orally administered tranexamic acid as a prophylactic measure to
reduce Dry socket.(Antitifibrinolytic)
Dry socket developed in 22% experimental group. 23% of the placebo group. He also tried
another antifibrinolytic agent to get propylene ester of P-hydroxy benzoic acid (PEPH) in a
topical mode.
None of the patients PEPH group developed dry socket, whereas 24% receiving placebo
did. But there is higher incidence of postoperative complications such as abscess skin
rash, and hemorrhage.
* To reduce postoperative complication they studied combination of sulfonamide and
PEPH but they were unsuccessful.

Systemic Agents-
In 1961 Alty tried penicillin.8.6% in penicillin group developed Dry socket.33.7% without
penicillin group developed dry socket.1973 Helen and Nordensam - studied Lincomycin,
Penicillin and Whitehead varnish local bandage. After 3rd day incidence was 16% in
Penicillin V group.10% in lincomycin group.21% in control group. Curren and his co-
worker in his study stated that there is no justification for any systemic antibiotic use
routinely for third molar surgery.

Metonidozole-
* Rood and Murgatroyd carved out double blind study. Incidence in metronidazole group
is1%. In the placebo group is 4.2%.
* Kezies carried clinical trial using Metronidazole, Arnica montena (Homeopathic
medicine) and placebo concluded that metronidazole reduced incidence of pain and edema
and enhanced the healing process after surgery but had no effect on trismus.
* Bystedt assessed the effects of azidicillin, erythromycin, clindamycin and doxycycline
on postoperative complications after surgical removal of mandibular 3rd molar. They
concluded that systematically administered antibiotic offer only slight advantage in routine
operations of impacted 3rd molar (8% Vs 4 %).
* Treiger studied Clindamycin as a topical agent .Out of 172 mandibular 3rd molar
impactions 7 resulted in dry socket all in placebo gap.

Non-antibiotic agent-
Butler and Sweet studied sites receiving higher volume of irrigations (175ml) experienced
5.7% incidences. Whereas the sites receiving minor volume (25ml) experienced 10.7%
incidence. They concluded that simple lavage could reduce the incidence of dry socket by
58%.
* Lilly and colleagues studied use of phenol based antiseptic mouth rinse prior to
extraction of mandibular 3rd molar. They reported decreased incidence of dry socket.
* Tjernberg studied effect of 0.2% chlorhexidine gluconate mouth rinse or incidence of dry
socket. The result in test group 3.3% and in the correlation group 16.7%.
* Julies and associates carried out studied gelatin sponge soaked with oxytetracycline and
a corticosteroid was used as a socket dressing on one side, the other side of mandible. The
results indicate a incidence of 6.6% on the treated side and 28.8% incidence on the
untreated side. The study correlates when tetracycline alone used as the socket dressing.

TREATMENT
Despite the attempts to prevent dry socket none has been 100% successful. Prescribing
analgesic is one measure but itself, it is not enough. The degenerated and lost blood clot in
the tooth socket must be replaced. A protective dressing diminishes and protects against
irritants, diminishes pain, thereby decreases the need of analgesics.
* A number of agents like oil of clove, eugenol, zinc oxide, polyethylene glycol, benzoine,
glycerol, lignocaine, white heads varnish, thymol iodide and many other substances have
been used.
Requirements
1. It should not be irritating/caustic to oral tissue
2. The agent should not be complicated and simpler
3. Long effective
A common formula used is
Eugenol - 46%
Balsam of Peru - 46%
Chlorobutanol - 4%
Benzocaine - 4%
* Strip of iodoform gauze is used as the vehicle. Inspect the socket and confirm diagnosis
* Gently irrigate the socket, with warm saline; no attempt is made to curette the socket.
* Using cotton applicator/suction tip gently absorb fluids. Then the medicated strip - gauze
dressing is inserted into the socket. The dressing should not be packed forcefully, but
merely gently folded on it. While covering the exposed bone of the socket wide as much
as possible. Rare occasions LA may be necessary.
* Within 2/3 hours patient will notice significant relief and from pain. The need of strong
analgesics should be diminished.
* Patient recalled after 24 hours, frequently patients are completely comfortable, socket
irrigated and dressing changed.
* After 48 hours procedure repeated.
* Most of the cases two/three dressing will be sufficient
* Dressing should not be continued until patient is 100% free of discomfort because
dressing is foreign body and delays healing. It should be discontinued at the earliest
reasonable opportunity.
* Final measures to be taken, after dressings discontinued, are to instruct the patient in
keeping the socket clean. Patients can use disposable, plastic syringe with curved tip to
irrigate site with warm salt water.
* As the socket heals, the defect become shallower and finally it will be completely filled
and confluent with the surrounding gingiva. Once the healing socket no longer collects
debris, the irrigations may be discontinued. This stage is usually achieved in 3 to 4 weeks.

Impacted Maxillary teeth

Apart form third molars, Jacobs reported
Maxillary cuspids 41%, Maxillary 2nd bicuspid 38.8%, Mandibular 2nd bicuspid 23%
Maxillary incisors 8.6%.
.
Localization
1. Inspection done to observe-
* Bulging of the mucosa and alveolar bone.
* Tipping of adjacent teeth. The cervical aspect of an erupted tooth in maxilla bone is
denser than in apical region. Therefore pressure by an impacted tooth on the lateral aspect
of a root of an erupted tooth will tend to tip the crown of erupted tooth mesially due to
stabilizing influence of dense bone on the crest of the alveolar ridge.
*Character of resorption of overlying deciduous tooth will give a clue whether the tooth is
erupting towards palatal aspect/labial aspect. The normal resorption is equal around the
circumstance of deciduous tooth.
2.Palpation - defines the skeleton of the alveolar bone, vault of the palate, should be
compared with contra lateral side.
2. Imagery

Extra oral and intra oral radiographs used. Atleast two views are necessary for each tooth.
It is a must that the position of the tooth is defined. The location of the crown, the location
of the apex, and the relations with adjacent sinal and dental structures, periapical views,
and occlussal views are used for the purpose.
Surgical steps
An impacted maxillary tooth is managed by

1. Surgical exposure
2. Attachment to an appliance to help in eruption.
3. Removal
4. Observations
I. Incision-
The incision usually made with the No.15 blade. The various incisions are the
1.labial gingival crevice incision.
2. An alternative gingival crevice incisions involving base of the papilla.
3. The oblique/vertical extension incision
4. Fenestration incision
5. Free mucosal incision
6. Labial push back flap incision
7. Palatal flap incision
8. Palatal cruciform incision
II Elevation of soft tissues
Most gingival and palatal soft tissue flaps are raised in one block from the subperiosteal
region with sweeping motion of a subperiosteal elevator.
III Retraction of soft tissues-
Retracting instrument should be placed on bone and flap should rest on instrument. This
technique will produce minimal amount of inflammation to the flap as it rests on the
instrument.

IV Operation on Bone
It consists of
1.Removing bone impeding a normal eruption
2. Removing bone over a tooth that is destined to have an orthodontic appliance
3. Removing the bone over the tooth, which is scheduled for removal.
Usually round bur at low speed under lavage of saline and suctioning used. Sometimes on
lateral aspect of alveolar bone unibevel chisel, a periosteal elevator may be used to remove
bone.
V Operation on Teeth
The possible operations on the tooth as
a. Surgical exposure
b. Application of devices
c. Removal of the tooth
d. Surgical repositioning /auto transplantation

Ideal time surgery is <20 years old this will reduce incidence of pathologic conditions and
postoperative sequels.
Surgical exposure
For a palatally impacted teeth surgery, begin with fenestrated flap/cruciform incision,
uncovering the crown overt its greatest curvature, avoiding placing instruments on the root
and provide a trough with a bur toward the direction planned for tooth eruption and the
area may be dressed with a periodontal pack for patients comfort. Similar procedure
employed for labia/buccal impacted tooth using fenestrated flap/a push back flap.
Application of devices
Various devices used are
a. Orthodontic brackets
b. Hooks
c. Chains
d. Wires
e. Pins
f. Crowns
* Devices applied to the coronal portion of the tooth especially to the incisal/ occlussal half
are indicated to the best directional control.
* Chains/wires placed around the radicular surface may critically injure the root.
* Orthodontic brackets and hooks are ideal for providing guidance but it difficulty in
obtaining dry field encountered other options like placement of plastic crown form,
placement of pin in the crown, or often preferred option, awaiting partial eruption of
crown.
Removal of the teeth-
Removal of maxillary impacted tooth considered, when it is not feasible to move impacted
tooth into the oral cavity. It requires certain knowledge about the location of tip of crown
and tip of the root, to minimize damage to adjacent important structures.
Surgical Repositioning and Transplantation
Selected impacted teeth may require repositioning by removing overlying soft tissue and
bony impediment and the possible use of gentle movement with an elevator, or it may
involve bodily movement of the tooth laterally/medially within the alveolar process/it may
be removing the tooth from its alveolus and transplanting it to another location.
TRANS ALVEOLAR TRANSPLANTATION - includes removing alveolar bone in the
direction toward which the tooth is to be moved, taking care to avoid touching the
cementum with surgical instrument. The transplanted from stabilized with an orthodontic
appliances 2 to 3 hours and endodontic treatment is performed. The tooth being
repositioned should have an immature apical orifice. When transplanting a tooth great care
taken to protect the gelatinous apical soft tissue.

LONG TERM OBSERVATION

Sometimes due to
1. Anatomic position of impacted teeth
2. Medically compromised patients
3. Individual in 6th/7th decade of life with assymptomatic are impacted tooth, there may be
indication to permit maxillary impacted teeth to remaining position.
ABNORMAL POSITION OF MAXILLARY IMPACTED TEETH
* Maxillary cuspid may be positioned either lateral to, within /across nasal cavity/the
maxillary bones.
* Dentigerous cyst may carry maxillary tooth to unusual position.
These locations may require intranasal/intra sinal procedure.

IMPACTED MANDIBULAR TEETH

Most common mandibular teeth except 3rd molar to be impacted are the mandibular second
bicuspids, cupids, incisor, 1st and 2nd molar may be positioned on either the medial/the
lateral aspect of the dental area and in any position from vertical to inverted
Mandibular cuspid and Bicuspid
* Impacted cuspid may produce structural weakness in the parasymphyseal area of the
mandible.
* Localization of impacted cuspids is possible through inspection, palpation and periapial
and occlussal radiographic technique.
* Appropriate management should include knowledge of its location, of the potential for
damage to adjacent teeth, and of the potential involvement of mental neurovascular
structure.
The incisions used as
1. Labial gingival crevice incisions
2. A free mucosal incision
3. Lingual gingival crevice incisions
* Elevation of soft tissue and retraction of flap with by deft, delicate and accurate surgery.
* Bone removal done using bur under a lavage of saline and suctioning /with a unibeveled
chisel.
* Operation on tooth has following option
a. Surgical exposure
b. Application of device to guide the eruption
c. Removal
d. Transplantation
e. Long term observation

IMPACTED TEETH IN MANDIBULAR AND MAXILLARY FRACTURE-

The management of retained/erupted teeth in fracture line is controversial over the years.
Formerly all teeth were extracted which located in fracture line. The present concept is to
extract the tooth in the lineof fracture if
1) It I a source of infection at the site of the fracture.
2) The tooth itself is fractured.
3) The retention of the fracture may interfere with the fracture healing /fracture reduction.

Conclusion
The management of impacted teeth is the most common treatment oral and maxillofacial
surgeons do in day today practice. The tooth becomes impacted due to prevention of
eruption by adjacent teeth, excessive soft tissue etc. As a general rule, all impacted teeth
should be removed unless removal is contraindicated. Extraction should be performed as
 soon as dentist determines impacted tooth should be removed .As the age advances
removing impacted teeth becomes more difficult. If the tooth left in place until the problem
arises, there is an increased incidence of local tissue morbidity, loss of adjacent teeth and
bone, and potential injury to adjacent vital structures un necessary delay makes surgery
more difficult, complicated and hazardous, because patient may have compromising
systemic disease. Preventive dentistry dictates that impacted teeth should be as soon as
detected.

REFERENCES
• IMPACTED TEETH: TEXT BOOK BY ALLING C.C.

• CONTEMPORARY ORAL AND MAXILLOFACIAL SURGERY-

SECOND EDITION BY PETERSON

• ORAL AND MAXILLOFACIAL SURGEY-LASKIN

• ORAL AND MAXILLOFACIAL SURGEY-KREGER

• MINOR ORAL SURGERY- GEOFRY L. HOW

• TEXT BOOK OF ORAL AND MAXILLOFACIAL SURGEY- BY

SRINIVASAN

• PRINCIPLES OF ORAL AND MAXILLOFACIAL SURGEY-BY

LORRY J. PETERSON

• EXPERT THIRD MOLAR EXTRACTION-SOICHIRO

• TEXT BOOK OF ORAL AND MAXILLOFACIAL SURGERY –BY

ARCHER

• DENTAL CLINICS APRIL 1994 38; 3