TECHNICAL NOTE AND POSTOPERATIVE INSTRUCTION OF

THIRD MOLAR SURGERY

AUTHOR:
DR SAROJ PSD DEO
DEPT OF OMFS
NATIONAL MEDICAL COLLEGE
BIRGUNJ, NEPAL

The removal of impacted third molar using a bur –

Impacted teeth removed with bur in a variety of ways.

 The Moore/ Gillbe collar technique sacrifices a similar amount of bone to
that removed when split –bone chisel technique is employed.
 Other technique involves using a rose head bur to create a gutter along the
buccal side and distal surface of the tooth. A mesial point of application
created using the bur, and an elevator used to deliver the tooth.

2. The removal of the tooth impacted using tooth division.

 The removal of the bone lying bucally to the tooth done using chisel or bur.
Bone also removed from distal side of the tooth. The splitting of the
crown /root completed depending on the type of impaction using the bur /
osteotome.
 The separated crown /root delivered using elevators applied to mesial
aspect.

3. The chisel technique using buccal approach

 After exposure of the crown with suitable incision, a vertical limiting cut is
made at the distobuccal aspect of second molar using 3mm/5mm chisel
with the bevel facing posteriorely.
  Then the chisel is placed at an angle of 45˚ angle to lower edge of limiting
cut in an oblique direction. This will remove a triangular piece of buccal
plate distal to second molar.
 If necessary, bony cut enlarged to uncover the impacted tooth to desired
level. Finally distal bone is removed, so that when the tooth is elevated,
there is no obstruction at the distobuccal aspect of impacted teeth.
 The point of application created for elevator by removing a triangular piece
of bone at the junction of the vertical limiting cut and the oblique bone cut.
 The distolingual bone is fractured parellel to the external oblique ridge and
hinge it lingually if necessary.
 Using appropriate elevator the tooth is delivered out of socket.

4.Lateral trephination technique

This technique indicated for removal of unerupted third molars in the age group
of 9 to 16 years. Bowdler Henry described this technique. A modified S shaped
incision is made from the retro molar fossa across external oblique ridge. It then
curves down along the reflection of mucous membrane above the vestibule
extending up to the first molar anteriorely. Such an incision leaves behind a 5mm
cuff of attached mucosa at the distobuccal region of second molar. The
mucoperiosteal flap is elevated and held in retracted position. The buccal cortical
plate is trephined over the third molar crypt. The same bur is used to make vertical
cut anteriorely and posteriorely. A chisel or an osteotome used to remove the
buccal plate, exposing the third molar crypt completely. Elevator is applied to
deliver the tooth out of the crypt. Any follicle remains in the crypt is care fully
scooped out. Avoid injury to inferior alveolar nerve and vessels. After
smoothening the sharp bony margins and irrigating the wound the flap is sutured
back.
POSTOPERATIVE CARE
 Proper postoperative care after removal of impacted third molar is essential
to obtain successful healing of wound.
 After removal of impacted teeth patient should limit the activity for at least
remainder of the day.
 Patients should be instructed to drink plenty of fluids; a normal diet should
be started as soon as possible.
 Patient should not engage in vigorous rinsing of mouth for 8 to 12 hours
post operatively. After that they should rinse mouth 4 to 6 times daily
especially after food and brush their teeth as usual. It is better to use warm
saline water as mouth rinse.
 Slight oozing of blood from surgical site for several hours is not
uncommon. Having the patient bite firmly on a gauze piece over the wound
and applying ice pack extraorally controls it. If excessive bleeding still
persists patient should return for observation and further treatment is
necessary.
 Patient should take analgesics prescribed before the effect of local
anaesthesia wears off. Then repeat intake of analgesics at specified
intervals. Pain following removal of third molar most severe during first 4
to 8 hours of removal. Normally there will be mild to moderate pain till
third day. If severe pain persists even after third day patient should return
for observation.
 Unless steroids are used, some swelling frequently will develop after the
surgery. This reaches maximum in first 24 to 48 hours and begins to
diminish after third day. But it may take a week to resolve completely. To
help limit the swelling first 24 hours ice packs applied intermittently extra
orally. If swelling present after that moist hot packs should be used
intermittently until the swelling resolves.
 Patients advised to avoid smoking for 5 days after the surgery.
 The use of steroid during impacted teeth is controversial. Studies show that
short-term steroid limits postoperative swelling, trismus, and pain.
 The antibiotics use routinely after third molar surgery is not recommended
on healthy patients. The antibiotics are recommended if the patients
immune system is compromised / preexisting infection.