This document summarizes the surgical procedures and considerations for extracting impacted third molars. It describes the different types of impactions - mesioangular, vertical, horizontal, and distoangular - and the techniques for removing each, such as sectioning the tooth and removing bone. Potential complications are outlined, including bleeding, swelling, trismus, pain, infection, root fracture, and alveolar osteitis. Methods to prevent and treat complications are provided, such as the use of antibiotics, steroids, irrigation, and dressings. Surgical success depends on factors like impaction depth and the surgeon's experience.

1. Oral Surgery
L3 Impacted 3rd
Molar Cont--- Dr Amera Alkaisi
1. Mesioangular impaction
The mesioangular impaction is usually the least difficult to remove.
 The distal half of the crown is sectioned off from the buccal groove to
just below the cervical line on the distal aspect of the tooth. This
portion of the tooth is delivered, and the remainder of the tooth is
removed with a small straight elevator placed at a purchase point on
the mesial aspect of the cervical line
 Prepare a purchase point in the tooth with the drill and use a Cryer
elevator in the purchase point to deliver the tooth (Petorson)
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2.  The bone covering the tooth is removed using a round bur, until the
entire crown is exposed.
 Using a fissure bur, sufficient bone is removed using the guttering
technique, on the buccal and mainly the distal aspect of the tooth.
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3.  If the tooth is single-rooted, to facilitate its removal, the mesial
portion of the tooth is removed first, while the remaining portion is
then luxated.
 If the tooth has two roots, the roots may be separated and each root
may be extracted in the easiest direction, depending on its curvature.
More specifically, a deep vertical groove is made on the crown of the
tooth using a fissure bur, approximately as far as the intra radicular
bone.
 Sectioning is achieved using a straight elevator, which, after being
placed in the groove already created, is rotated and separates the
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4. roots. This separation of the tooth allows for limited bone removal,
thus causing less trauma and faster completion of the surgical
procedure.
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5. Bone removed buccaly & distally. The cut is increase to level of the
bifurcation & the chisel used to section the distal half of the crown of the
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6. third molar or to section vertically through its bifurcation. The distal crown
segment or the distal crown segment & attached root are removed as a
single unit. The mesial portion is tightly wedged under the second molar.
The bur can be used to cut a deep groove in mesial root beginning in the
pulp camper so an elevator can split the crown from the root then they
removed separately.
2. Vertical impaction: The vertical impaction is one of the more
difficult ones to remove, especially if it is deeply impacted. The
procedure for bone removal and sectioning is similar to that for the
mesioangular impaction in that occlusal, buccal, and judicious distal
bone is removed first Bone removal usually by splitting technique using
chisel & malate or by bur technique which preferable in patient locally
anaesthetized. Point of application created mesially or buccaly then by
straight elevator the tooth is delivered. Or the distal half of the crown is
sectioned and removed, and the tooth is elevated by applying a small
straight elevator at the mesial aspect of the cervical line. The option of
preparing a purchase point in the tooth is also frequently used, as for the
mesioangular impaction(Peterson)
3.Horizontal impaction
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7. The tooth may be superficial or deep in the bone and frequently its crown is close
to the distal aspect of the second molar. The horizontal impaction usually
requires the removal of more bone than the mesioangular impaction. Tooth
neck is exposed by bur technique and the crown separated from the root &
removed with a Cryer elevator. The roots are then displaced into the socket
that was previously occupied by the crown and delivered into the mouth.
Occasionally, they may need to be sectioned into separate portions and
delivered independently. A groove is then created vertically to the long axis
of the tooth using a fissure bur, at the cervical line of the tooth, to separate
the crown from the root The groove created by the bur should not be deep
since the mandibular canal is often found in close proximity to the tooth
and there is a risk of injuring or severing the inferior alveolar nerve. The
straight elevator is used, after being placed in the groove created earlier, to
separate the crown from the root with a rotational movement. The crown is
removed using movement upwards, and the root is then easily removed.
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11. 4. Distoangular
The most difficult tooth to remove, since it is located beneath the anterior
border of the ramus with a fair amount of bone above its crown while its
roots are inclined somewhat near the distal root of the second molar.
Therefore, it is impossible to remove the tooth in one piece, unless a large
amount of bone is removed. After the distobuccal bone & buccal bone are
removed, the crown is usually sectioned from the roots just above the
cervical line and delivered with a Cryer elevator. A purchase point is then
prepared in the tooth, and the roots are delivered. together or sectioned and
delivered independently with a Cryer elevator (Prterson) or the distal
portion of the tooth is sectioned or the tooth is divided through its
bifurcation, or sectioning the tooth in half or section of crown from root,
followed by separation of the mesial root distal root & removed separately
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13. Extraction of Impacted Third Molar in Edentulous Patient
The surgical extraction of the third molar in edentulous patients is much easier and
faster compared to dentulous patients. The second molar, the major problems faced in
surgery of impacted mandibular third molars in dentulous patients which often hinders
manipulations during the operation. is often missing; therefore, tooth sectioning is not
necessary. Same principles are used.
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14. Post extraction socket care (Socket toilet)
• Débriding the wound of all particular bone chips and other debris. The best
method is to mechanically débride the socket and the area under the flap with a
periapical curette
• A bone file should be used to smooth any rough sharp edges of the bone.
• A mosquito hemostat is usually used carefully to remove any remnant of the
dental follicle which is usually on the distal aspect of the second molar as well
as bone fragments that may be present in the socket are removed.
• The socket and wound should be thoroughly irrigated with saline or sterile
water (30 to 50 mL is optimal).Within certain limitations, the more irrigation
that is used, the less likely the patient is to have a dry socket, delayed healing, or
other complications
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15. Suturing
After bleeding controlled the flap is sutured. The incision should usually be
closed by primary intention. The flap is returned to its original position
• Envelop flap requires a suture between buccal & lingual flaps distal to
the second molar, the initial suture placed at the posterior aspect of
the second molar continue to the posterior end of the incision
• when the flap is extended to the papilla between the first & second
molar both this & the sulcus incision need suturing to retain the flap
in place (interdental papillae).
After 7 days the suture is removed.
Medications
1. Systemic Antibiotics
Perioperative Systemic Antibiotics: prophylactic antibiotics are
necessary in some surgical procedures. Surgery for the removal of impacted
third molars clearly fits into the category of clean-contaminated surgery.
The incidence of postoperative infections in a clean surgery is related more
to operator technique than to the use of prophylactic antibiotic however,
infection probably is a rare occurrence following third molar surgery. This
means that it is unusual to see pain, swelling, and a production of purulence
that requires incision and drainage or antibiotic therapy. The incidence of
such infections is very low for most surgeons expect to have an infection
rate in the range of 1 to 5% for all third molar procedures. it is unnecessary
to use prophylactic antibiotics in third molar surgery to prevent
postoperative infection in the normal healthy . A more subtle type of wound
healing problem that occurs after the surgical removal of the impacted
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16. mandibular third molar is alveolar ostitis or dry socket. This disturbance in
wound healing is most likely caused by :
• The combination of saliva and anaerobic bacteria.
Techniques that reduce bacterial contamination of the socket
 The use of prophylactic antibiotics in third molar surgery, reduce
the incidence of dry socket.
 Copious irrigation
 Preoperative rinses with chlorhexidine
 Placement of antibiotics in the extraction socket, are also effective.
Although systemic antibiotics are effective in the reduction of postoperative
dry socket, they are no more effective than are local measures. The increase
of antibiotic-related complications, such as allergy, resistant bacteria,
gastrointestinal side effects, and secondary infections, is not outweighed by
the benefits. Therefore, the use of perioperative systemic antibiotic
administration does not seem to be valid.
Perioperative Steroids
The use of corticosteroids to minimize swelling, trismus, and pain. The
method of usage, is extremely variable, and the most effective therapeutic
regimen has yet to be clearly delineated.
• An initial intravenous dose of steroid at the time of surgery has a
major clinical impact on swelling and trismus in the early postoper-
ative period.
• If the initial intravenous dose is not followed up with additional doses
of steroids, this early advantage disappears by the second or third
postoperative day.
• Maximum control of swelling requires that additional steroids be
given for 1 or 2 days following surgery. The two most widely used
steroids are dexamethasone and methylprednisolone.
Common dosages of dexamethasone are 4 to 12 mg IV at the time of
surgery. Additional oral dosages of 4 to 8 mg bid on the day of surgery and
for two days afterward result in the maximum relief of swelling, trismus,
and pain. Methylprednisolone is most commonly given 125 mg IV at the
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17. time of surgery followed by significantly lower doses, usually 40 mg PO tid
or qid, later on the day of surgery and for two days after surgery.
High-dose short-term steroid use is associated with minimal side effects. It
is contraindicated in the patient with gastric ulcer disease, active infection,
and certain types of psychosis. The administration of perioperative steroids
may increase the incidence of alveolar osteitis after third molar surgery, but
the data are lacking as to the precise degree of increase.
Determinant of the incidence of complications of third molar surgery
• The depth of impaction, that is, whether it is a complete bony
impaction. The removal of complete bony impactions is likewise
associated with increased postoperative pain and morbidity and an
increase in the incidence of inferior alveolar nerve anesthesia.
• The age of the patient. Removal of impacted teeth in the older
patient is associated with a higher incidence of postoperative
complications, especially alveolar osteitis, infections, mandible
fracture, and inferior alveolar nerve anesthesia.
• The relative experience and training of the surgeon. The less
experienced surgeon will have a significantly higher incidence of
complications than the trained experienced surgeon
Complications:
o Bleeding: can be minimized by using a good surgical technique and by
avoiding the tearing of flaps or excessive trauma to the overlying soft tissue.
The most effective way to achieve hemostasis following surgery is to apply a
moist gauze pack directly over the site of the surgery with adequate pressure.
application of topical thrombin on a small piece of absorbable gelatin sponge
into the extraction socket. The socket can also be packed with oxidized cellulose
o Swelling: Postsurgical edema or swelling is an expected sequel of third
molar surgery. The parenteral administration of corticosteroids is frequently
employed to help minimize the swelling that occurs. The application of ice
packs to the face may make the patient feel more comfortable but has no
effect on the magnitude of edema. The swelling usually reaches its peak by
the end of the second postoperative day and is usually resolved by the fifth to
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18. seventh day. This can be reduced by the use of the 10 mg of dexamethasone
for 2 days
o Trismus: is a normal and expected outcome following third molar
surgery. Patients who are administered steroids for the control of
edema also tend to have less trismus. Like edema, jaw stiffness
usually reaches its peak on the second day and resolves by the end of
the first week
o Pain: it is normal consequence of surgery. The more extensive the
surgery the more discomfort. The postsurgical pain begins when the
effects of the local anesthesia subside and reaches its maximum
intensity during the first 12 hours postoperatively. The most common
analgesics are combinations of acetylsalicylic acid or acetaminophen
with codeine, and the non steroidal anti inflammatory analgesics.
Analgesics should be given before the effect of the local anesthesia
subsides. The administration of nonsteroidal analgesics before surgery
may be beneficial in aiding in the control of postoperative pain. The
most important determinant of the amount of postoperative pain that
occurs is the length of the operation.
o Infection: Infection after removal of mandibular third molars is
almost always a minor complication. About 50% of infections are
localized subperiosteal abscess-type infections, which occur 2 to 4
weeks after a previously uneventful postoperative course. These are
usually attributed to debris that is left under the mucoperiosteal flap
and are easily treated by surgical débridement and drainage
o Fracture of a portion of the root One of the most frequent problems
encountered in removing third molars is the fracture of a portion of the
root, which may be difficult to retrieve. In these situations the root
fragment may be displaced into the submandibular space, the inferior
alveolar canal, or the maxillary sinus.
 Uninfected roots left within the alveolar bone have been shown to
remain in place without postoperative complications. The pulpal
tissues undergo fibrosis, and the root becomes totally
incorporated within the alveolar bone.
 Aggressive and destructive attempts to remove portions of roots
that are in precarious positions seem to be unwarranted and may
cause more damage than benefit. Radiographic follow-up may
be all that is required
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19. o Aveolar Osteitis
The incidence of alveolar osteitis or dry socket following the removal of
impacted mandibular third molars varies between 3 and 25%.The
pathogenesis of alveolar osteitis has not been clearly defined, but the
condition is most likely the result of lysis of a fully formed blood clot before
the clot is replaced with granulation tissue. This fibrinolysis occurs during the
third and fourth days and results in symptoms of pain and malodor after the
third day or so following extraction. The source of the fibrinolytic agents may
be tissue, saliva, or bacteria.The role of bacteria in this process can be
confirmed empirically based on the fact that systemic and topical antibiotic
prophylaxis reduces the incidence of dry socket by approximately 50 to 75%.
The periodontal ligament may also play a role in the development of alveolar
osteitis.
The incidence of dry socket seems to be higher in patients
 who smoke
 in female patients who take oral contraceptives.
Its occurrence can be reduced by several techniques, most of which are aimed
at reducing the bacterial contamination of the surgical site.
• Presurgical irrigation with antimicrobial agents such as chlorhexidine
reduces the incidence of dry socket by up to 50%.
• Copious irrigation of the surgical site with large volumes of saline is
also effective in reducing dry socket.
• Topical placement of small amounts of antibiotics such as tetracycline
or lincomycin may also decrease the incidence of alveolar osteitis.
Treatment
The goal of treatment of dry socket is to relieve the patient’s pain during the
delayed healing process. This is usually accomplished by irrigation of the
involved socket, gentle mechanical débridement, and placement of an
obtundent dressing, which usually contains eugenol. The dressing may need to
be changed on a daily basis for several days and then less frequently after that.
The pain syndrome usually resolves within 3 to 5 days, although it may take
as long as 10 to 14 days in some patients. There is some evidence that topical
antibiotics such as metronidazole may hasten resolution of the dry socket.
In summary, alveolar osteitis is a disturbance in healing that occurs after the
formation of a mature blood clot but before the blood clot is replaced with
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20. granulation tissue. The primary etiology appears to be one of excess
fibrinolysis, with bacteria playing an important but yet ill-defined role.
Antimicrobial agents delivered by perioperative mouth rinses, topical-
ly placed in the socket, or administered systemically all help to reduce the
incidence of dry socket. Mechanical débridement and copious saline irrigation
of the surgical wound also are effective in reducing the incidence of dry
socket. A rational approach may be to provide preoperative chlorhexidine
rinses for approximately 1 week before surgery, irrigate the wound thoroughly
with normal saline at the conclusion of surgery, place a small square of gelatin
sponge saturated with tetracycline in the socket, and continue chlorhexidine
rinses for 1 additional week. This combination approach should substantially
reduce the incidence of dry socket.
o Nerve Disturbances: Surgical removal of mandibular third molars places
both the lingual and inferior alveolar branches of the third division of the
trigeminal nerve at risk for injury.
 The incidence of injury to the inferior alveolar and lingual nerves
following third molar surgery is about 3%, Only a small proportion of
these anesthesia and paresthesia problems remain permanent
 The lingual nerve is most often injured during soft tissue flap reflection
 Inferior alveolar nerve is injured when the roots of the teeth are
manipulated and elevated from the socket. Mostly occur in complete
bony impaction of mandibular third molars. The angulation
classifications most commonly involved are usually mesioangular and
vertical impaction. In some cases, nerve proximity to the root is indicated
by an apparent narrowing of the inferior alveolar canal as it crosses the
root or severe root dilaceration adjacent to the canal. diversion of the
path of the canal by the tooth, darkening of the apical end of the root
indicating that it is included within the canal, and interruption of the
radiopaque white line of the canal.
o Periodontal pocketing down the distal aspect of the second molar
is late complication. If the third molar is partially impacted and is
partially exposed in the mouth, it should be removed as soon as
possible. The reason for this is that there is already a deep and
potentially destructive periodontal lesion that is difficult for
the patient to maintain hygienically. Even if the patient is
asymptomatic, the impacted tooth should be removed as soon as
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21. possible to allow the best periodontal healing after surgery as
possible. In these situations the periodontal healing is
compromised because of the fact that there was already a
destructive lesion caused by the presence of the partially
impacted third molar
o Fracture of the mandible. Rarely occur.
L4 O.Surgery Dr Amera Alkaisi
Maxillary third molars
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22. Surgical technique
Incision: The most commonly used incision used for the maxillary third
molar is also an envelope incision. It extends posteriorly from the
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23. distobuccal line angle of the second molar and anteriorly to the first molar.
A releasing incision is rarely necessary for the maxillary third molar.An
incision is made diagonally across the tuberosity from its distopalatal aspect
to distobuccal corner of the second molar & on in almost the same line up
into buccal sulcus. If we need more bone removal the incision is extended
around the upper second molar to its mesial aspect & mesial papilla
included before its taken into the sulcus.
Bone removal
For maxillary teeth, bone removal is done primarily on the lateral aspect of
the tooth down to the cervical line to expose the entire clinical crown.
Frequently, the bone on the buccal aspect is thin enough that it can be
removed with a periosteal elevator or a chisel using manual digital pressure.
 Maxillary verticle impaction: -The thin bone overlying the
buccal surface of the tooth is removed. Bur is introduced back of
the distal surface to create space for backward movement. A thin
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24. bladed instrument (straight elevator ) is introduced between teeth,
if we can’t introduce the instrument a hole is drilled into the buccal
surface of the impaction to allow purchase by sharp elevator to
move the tooth downward & backward. A straight Warwick
James elevator used & placed mesial to the neck of third molar.
1. Maxillary mesioangular: Bone removal around the impacted tooth
small currate to be sure if there is space between third molar & second
molar acurved Warwick James elevator can be used to remove the tooth.
2. Maxillary distoangular: Buccal & alveolar bone is removed. The
area distal to the impaction is carefully exposed. The tooth is elevated from
the purchase on mesial side. The tooth can be pushed into antrum or into
the tissue back of tuberocity.
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25. Complications:
 Excessive bleeding from the sulcus incision.
 Haematoma formation with periorbital edema.
 Oro-antral fistula arise after elevation, but it heals if wound is
suture.
 Displacement of wisdom tooth into antrum will require removal
through a Caldwell-Luc antrostomy.
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26.  Occasionally the tooth displaced into infratemporal fossa lateral to
ptrygoid plates.
 Fracture of the tuberosity espicially when the tooth roots are
hypercementosed.
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