1. The method of gaining
mucoperiosteal flap dates
back to year 1849, when
John Tomes first described
the technique to remove
impacted third molar
After placing an
incision with a sharp
15 no. blade, a
mucoperiosteal flap is
raised for appropriate
Mark the incision
with marking ink
making a rough
2. Envelope flap
It starts on the ascending ramus following the centre of the 3rd
molar shelf to the distobuccal surface of 2nd molar and then
extends as a sulcular incision to the mesiobuccal corner of the
Indicated for mesioangular/soft tissue impactions
Also known as 2nd molar sulcus incision
The incision extending to the mesiobuccal surface of 1st molar is a
2nd & 1st molar sulcus incision. Its best for linguoangular
impactions as it provides better visibility.
Three cornered/triangular/bayonet flap
Envelope incision + anterior vertical releasing incision
Most commonly used.
3. Incision begins 6.4mm in the buccal
sulcus at the junction of middle &
posterior third of 2nd molar.
Passed upwards to the distobuccal
angle of 2nd molar
Cervically behind tooth to midline
of its posterior surface.
Taken back and laterally to prevent
vessel injury in retromolar area.
In final continuation it penetrates
the mucosa of cheek.
This is k/a tailing of incision (2-
Total length 25.4mm
Modifications of three-cornered flap
(Terrence Ward’s incision)
4. Minor modification in terrance ward’s incision
Its for partially erupted teeth which includes the
posterior limb is extended to cervical area of partially
erupted tooth before continuing it backwards and
5. Anterior incision is commenced at the distobuccal corner
of the crown of mandibular 1st molar instead of 2nd
6. Incision is a few mm away from the marginal gingiva.
Also called as “PARAMARGINAL FLAP”
Helps in an intact marginal attachment distal to 2nd
7. A small ‘V’ shaped incision, made with one point at
distobuccal line angle of the second molar. One vertical
limb followed the external
oblique ridge, and the other avoided the gingival
sulcus and extended down to the mucogingival
junction, doen’t involve papilla of mandibular 2nd
8. Used when lingual approach is used for
removal of third molars. Incision starts at
ascending ramus aiming at the distobuccal
corner of second molar as sulcular incision and
then continued ligually to the first molar.
A sulcular incision is made along the buccal
aspect of second molar.
9. Starting from a point at the depth of
stretched vestibular reflection
posterior to the distal aspect of the
preceding second molar, the
incision is made in an anterior
direction. The incision is made to a
point below the second molar, from
where it is smoothly curved up to
meet the gingival crest at the
distobuccal line angle of the second
molar. The incision is continued as
a crevicular incision around the
distal aspect of the 2nd molar.
allows reflection of a distolingually
based flap adequately exposing the
entire 3rd molar area.
10. Sharp point of periosteal elevator is used to elevate a
mucoperiosteal flap beginning at the point of incision at the
level of second molar and down the releasing incision.
The flatter end of periosteal elevator is then used to elevate
the periosteum posteriorly to the ascending ramus of the
11. It is done to
• Expose the crown by
removing the bone overlying
• To remove the bone
obstructing the pathway for
removal of the tooth.
• To create a fulcrum for
engagement of an elevator
Techniques of bone removal
• With help of bur
• -postage stamp method
• -Moore Gilbee’s Collar
• Chisel and mallet technique
12. No. 7 or 8 round bur can be used in the range of 5000-
Use of bur should always be done with copious saline
irrigation to prevent thermal injury.
Bone should be removed from
The occlusal surface of the tooth.
A channel is formed in the bone lateral and posterior to the
impacted third molar to the cervical level of the crown contour.
Adequate amount of trough should be created to remove any
bony obstruction for exposure and delivery of the tooth.
Careful bone removal should be done around the distal and
distolingual aspect of the tooth without damaging the lingual
nerve which lies in the vicinity of the lingual plate adjacent to the
13. Adequate cutting of bone on buccal aspect of
tooth is done in the shape of postage stamp &
adequate space for application of elevator is
14. First step is placement of vertical stop cut with a 3mm/5mm chisel
vertically at the distal aspect of second molar with the bevel facing
Second step is placement of the chisel at the base of vertical stop at an
angle of 45 ̊ with bevel facing occlusally and oblique cut is made till
distal aspect of third molar.
Then 2nd vericle cut is placed at the point where entire buccal aspect of
third molar is ending (apprx 4mm).
This results in removal of buccal plate distal to the second molar.
15. Additional piece of bone can be removed at the junction of
vertical and oblique cut for making a purchase point.
Final step is removal of the distal bone so that during elevation
there is no bony obstruction.
16. First developed by
Sir William Kelsey
Fry (1933) but
Terrence Wards in
which are placed
during the entire
A slight increase in
the incidence of
the use of this
Vertical stop cut is made by placing the chisel with the
bevel facing posteriorly, distal to 2nd molar buccaly.
2nd stop is made apprx 4mm distobuccal to 3rd molar crown
18. •With a chisel bevel upwards a horizontal cut is made backwards from a
point just above the lower end of the vertical stop cut.
•This enables the buccal plate to be removed.
•Distolingual bone plate is then fractured inwards by placing the cutting
edge of the chisel along the red line in the figure, with the chisel held at an
angle of 45 ̊ to the bone surface and pointing in the direction of lower
second premolar of the opposite side.
19. - Keeping the cutting edge of the chisel parallel to the external oblique
ridge, a few light taps with the mallet are made to separate the lingual plate
from the rest of the alveloar bone and hinge it inwards on the soft tissues
attached to it.
- Keeping the chisel parallel to the internal oblique ridge may result in
extension of lingual split to the coronoid process.
20. •A straight elevator is then applied on the mesial surface of
tooth to displace the tooth upwards and the lingual plate is
then lifted from the wound.
•Bone edges are smoothened, lingual plate is removed, wound
is irrigated and closure is done
21. Lewis (1980) has modified the lingual split bone
technique by incorporating following features:
- Minimal periosteal reflection
- Preserving fractured lingual plate
- Less buccal bone removal
Leading to less lingual nerve damage, decreased
periodontal pocket formation and better wound
Hochwald, Kamanishi & Davis (1983) modified it by
splitting distolingual bone in segments to allow
better tactile control of osteotome to prevent its
penetration into soft tissues.
22. This procedure can be
employed to remove any
partially formed unerupted
third molar.It has been
employed to remove such
teeth from patients from 9 to
18 years of age.
It can be performed under
GA or regional anaesthesia
Good technique for
preservation of pre-
operative periodontal status
of 2nd molar.
Lateral trepanation technique of Bowdler Henry
23. •The operation is performed as follows—
•Extended S-shaped incision is made from the retromolar fossa,
across the external oblique ridge to the first molar.
•The soft tissues are readily elevated from the surface and
retracted from the surface of bone and held away with Bowdler
24. A round bur is used to trephine the position of the crypt of a
third molar. When the anteriorposterior length of the crypt
has been determined, the bur is used to make a vertical cut
through the external plate at its anterior margin.
A second cut through the outer cortex is made at the posterior
end of the crypt at an angle of 450.
A chisel applied in a vertical direction is used to out fracture
the buccal plate, which is then delivered with a curved
haemostat thus exposing the crown of the third molar lying in
25. A warwick james elevator is applied to the occlusal surface of the
tooth and used to deliver it.
Any follicular remnants are removed.
The wound is irrigated and is sutured.
26. Given by C - J Yeh in 1995
An incision is placed on the buccal side of anterior border of
ramus towards distal aspect of second molar and along the
buccogingival sulcus to its mid point and reflect the flap.
Remove buccal bone to expose height of contour.
Create an osteoperiosteal flap by making a cut with chisel
superiorly, distally & lingually to expose crown & root.
Make a horizontal bone cut with chisel over the edge of
previously placed incision in Pdl space & then proceed
lingually & distally
Separate rest of lingual plate by paralleling chisel with long
axis of tooth.
Deliver the tooth in distolingual direction
27. Coronectomy is the removal of crown of the tooth, leaving the
roots “in situ” when applied to third molars or any unerupted
posterior tooth in the mandible, It is a measure adopted to avoid
damage to inferior alveolar nerve
The crown of the tooth is completely transacted with the help of a
bur at an angle of 45° and the roots are reduced 3mm below the
crest of buccal and lingual cortical plates. The exposed vital roots
need not to be treated endodontically as bone formation occurs
around these roots and osteocementum usually extends to cover
the roots. If after coronectomy the roots migrate towards the
alveolar crest or infection of roots occur then a second surgery is
always possible for the removal of these roots.
horizontally impacted teeth, teeth with active infection, mobile
teeth, non vital teeth, teeth with periapical pathology , patients
having pre-existing inferior alveolar nerve and lingual nerve
disturbance and patients with compromised immune system.
28. After bone removal an elevator may be applied on mesial
surface of the tooth and the tooth is removed along the path of
Lower border of mandible should be supported all the time.
If there is hindrance in the path of removal then tooth
sectioning should be opted for.
Unfavourable root morphology
To prevent injury to adjacent anatomical structures
To avoid removal of large amount of bone
ADVANTAGES OF TOOTH SECTIONING
Reduces the amount of bone removal
Reduces the risk of jaw fracture
Less post-operative trismus
Avoidance of damage to anatomical structures.
30. •Sectioning done in superoinferior direction preventing
31. •Removal of the
•Removal of the
roots together or
sectioning of roots
and then removal
of individual roots.