This is a presentation of management of impacted third molars from the point of view of an Maxillo-Facial Surgeon

1. IMPACTIONS
PRESENTED BY
DR Rayan
MODERATOR
DR M E Sham

2. CONTENT• History
• Definitions
• Theories of impaction
• Etiology
• Indications & Contraindications for removal
• Classification
• Pre-op assessment
• Surgical techniques perioperative care
• Prophylactic Odontectotmy & Coronectomy
• Impacted maxillary third molars
• Impacted maxillary and mandibular canine
• Surgical side-effects and complications
• References

3. History
• The term impaction is of latin origin coming from the term
‘impactus’.
• Dr George B Winter has played a major role in the development of
third molar surgery.
• Winter published a treatise after many years of research, which
appeared in ‘Dental Items of Interest’ under the title of “Exodontia”
in 1913.
• In the year 1926 a much enlarged second edition was printed and
the title was changed to ‘The Impacted Mandibular Third Molar’

4. DEFINITIONS
Impacted Tooth:
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.(American society of oral surgeons 1971)
A cessation of the tooth eruption caused by a clinical or
radiographically detectable physical barrier in the path or by an
ectopic position of tooth.(Andreason 1997)

5. “ A tooth that has failed to erupt into the oral cavity to its
functional level of occlusion, beyond the time usually expected
for that tooth to erupt and is prevented by adjacent hard or soft
tissue including overlying teeth or dense soft tissue”.(Lytle
1979)
“A tooth is considered to be impacted when it has failed to
fully erupt in the oral cavity within its expected developmental
time period and can no longer do so.” (Peterson)
“ Impaction is any tooth that is prevented from reaching its
normal position in the mouth by tissue or bone or another
tooth”. (WHO)

6. Malposed tooth: A tooth, unerupted or erupted, which is in an abnormal
position in the maxilla or mandible.
Unerupted tooth: A tooth not having perforated the oral mucosa. Early loss
of deciduous teeth may cause arrested development of teeth.
Embedded tooth: This term is synonymous with the term impacted tooth.
Embedded teeth are teeth with no obvious physical obstruction in their path;
they remain unerupted usually because of a lack of eruptive force
Partial impaction: A tooth that is incompletely erupted is a partial eruption.
The tooth may be seen clinically but is frequently malposed and always
covered with soft tissue to some extent.
Complete bony impaction: The tooth is completely contained within the
bone.

7. Partial bony impaction: The tooth is partially covered with the bone.
Potential impaction: An unerupted tooth that still retains the potential for eruption,
but which will most likely not erupt into normal position & function because of
obstruction, unless surgical intervention occurs – is referred to as potential
impaction.
Ectopic/ displaced teeth: a tooth is ectopic if malposed due to congenital factors or
displaced by the presence of pathology.
Ankylosed teeth: when the cementum of the teeth is fused to the bone and there is
no periodontal soft tissue in between, a tooth is considered to be ankylosed.

8. Orthodontic theory
Pathological theory
Endocrine theory
Mendelian theory
Phylogenic theory
THEORIES OF IMPACTION

9. ETIOLOGY
Local causes
– Irregularity in the position and presence of an adjacent tooth.
– Density of the overlying or surrounding bone.
– Chronic inflammation with resultant increase in density of the
overlying mucous membrane.
– Lack of space due to underdeveloped jaws.
– Long retention of the primary teeth.
– Premature loss of the primary teeth.
Berger A. As cited by Archer, WH, Oral and Maxillofacial Surgery. Vol 1 Ed.5Philadelphai,WB, Saunders Co., 1975

10. • Ankylosis of the primary or the permanent tooth
• Non absorbing alveolar bone
• Ectopic position of the tooth
• Dilaceration of the roots
• Habits involving tongue,finger,thumb,cheek.

11. • Systemic causes :
•Prenatal causes
– Heredity
•Postnatal causes
– Rickets
– Endocrine dysfunctions
– Malnutrition
•Rare conditions
– Cleidocranial dysostosis
– Oxycephaly
– Achondroplasia
– Cleft palate

12. ORDER OF FREQUENCY OF IMPACTED TEETH
Maxillary lateral incisors
Maxillary central incisors
Maxillary bicuspids
Mandibular cuspids
Mandibular bicuspids
Maxillary cuspids
Maxillary 3rd Molars
Mandibular 3rd Molars

13. According to AAOMS, 1989, indications for removal of
impacted teeth are :
 Pericoronitis
 Non restorable dental caries.
 Cyst formation.
 Interference with orthodontic treatment.
 Presence of impacted tooth in the line of fracture.
 Pre-irradiation.
 Periodontitis
 Pathological Resorption
 In edentulous ridge

14. Contraindications for removal of Impacted Teeth
 Possible Damage to Adjacent Structures
 Compromised Physical Status
 Prosthetic consideration
 Availability of adequate space
 Questionable future status of the second molar

15. • According to Larry J. Peterson the general contraindications
for removal of impacted teeth can be grouped into 3 primary
areas :
• Patient factors
– Extremes of age
– Poor health.
– Surgical damage to adjacent structures.
•Local factors
– Radiotherapy
– Teeth in close proximity to tumour
– ANUG
•Systemic factors
– Uncontrolled diabetes
– Pregnancy
– Underlying bleeding disorders
– Patients on anticoagulants,etc .

16. IMPACTED MANDIBULAR 3rd MOLARS

17. PRE-OP ASSESSMENT
• Chief complaint
• History of presenting illness
• Medical history
• Dental history
• Personal history
• General physical examination
• Maxillofacial examination
• TMJ examination

18. Hard tissue examination
• Number of teeth
• Occlusion
• Carious teeth
• Restored teeth
• Prosthesis
• External & internal oblique ridge
• Status of concerened 8
• Status of 7
• Status of opposing 8

19. Soft tissue examination
• Periodontal involvement
• Status of buccal mucosa
• Tongue
• Salivation and hydration

20. • RADIOGRAPHIC EVALUATION
1. To study the relation with adjoining tooth.
2. To study the configuration of the roots & status of the
crown.
3. To know the buccoversion or linguoversion of impacted
tooth.
4. Shadow of the external oblique ridge.
• If vertical & anterior to the Impacted tooth – Poor access.
• If oblique & posterior to the Impacted tooth—Good
access.

21. • Localization Of Impacted Teeth:
• Three different methods are useful in determining the
exact location of an impacted tooth with the periapical x-
ray:
• The conventional method directing the central ray of the
x-ray beam at 90° to the film surface;
• The use of the periapical x-ray film to record an
occlusal view as described by Donovan.
• The tube shift concept as described by Clark

22. • PERIAPICAL X-RAYS
FRANK’S TUBE SHIFT TECHNIQUE
22 radiographs
directed at 90
degree to each
other

23. RADIOLOGICAL ASSESSMENT OF AN
IMPACTED MANDIBULAR THIRD MOLAR
1.Type of impaction
2.Access.
3.Existing pathology.
4.WHARFE assessment.
5.Position –WAR lines.
6.Crown of impacted tooth.
7.Root of impacted tooth.
8.Relationship with inferior alveolar canal

24. WHARFE’S ASSESSMENT
1. Winter's classification
Horizontal 2
Distoangular 2
Mesioangular 1
Vertical 0
2. Height of mandible
1-30mm 0
31-34mm 1
35-39mm 2

25. 3.Angulation of 2nd molar
1- 59° 0
60 -69° 1
70 -79° 2
80 -89° 3
90° & above 4
4. Root shape- Root development
Favourable curve 1
Unfavourable curve 2
Complex 3

26. 5.Follicle
Normal 0
Possibly enlarged -1(NEGATIVE)
Enlarged -2(NEGATIVE)
Impaction relieved -3(NEGATIVE)
6. Path of exit
Space available 0
Distal cusp covered 1
Mesial cusp covered 2
Both covered 3

27. WINTER’S LINES OR WAR LINES.
• WHITE LINE
• It corresponds to the occlusal plane.
• It indicates the difference in occlusal level of second & third molars.

28. AMBER LINE.
• Crest of the interdental septum
• This line denotes the alveolar bone covering the
impacted tooth & the portion of the tooth not covered
by the bone.

29. RED LINE
• It indicates the amount of bone that will have to be
removed before elevation i.e. the depth of tooth in
bone & the difficulty encountered in removing the
tooth.
• Length more than 5mm - extraction is difficult
• Every additional millimeter renders the removal of
the Impacted tooth 3 times more difficult.

31. RELATIONSHIP WITH INFERIOR ALVEOLAR
CANAL
I. Root Related But Not Involving The Canal
• Root and canal separate – more intervening bone.
• Root and canal adjacent -less intervening bone.
• Superimposed –no intervening bone.
II. Related To Change In Root
• Dark and bifid root – canal crosses root.
• Root narrow – canal involves more of root.
• Deflection of root – canal passing through root apex.
Rood, B. A, Shehab NA; The radiological prediction of inferior alveolar nerve injury during
third molar surgery; BJOMS Journal of Oral and Maxillofacial Surgery (1990) 28,204

32. III. Related With The Changes In The Canal
• Interrupted “tram” lines - danger sign
• Converging “tram” lines - hour glass appearance.
• Diverted “tram” lines- upward displacement of canal passing
through the root.

33. Darkening of root Deflection of root Narrowing of root Dark & Bifid apex

34. Interruption of white Narrowing of canal Diversion of canal
line of canal

35. Arc of rotation is drawn with the centre of circle at distal root tip and periphery at
mesial cusp tip

36. CLASSIFICATIONS

37. Winters classification [1926]
1. Mesio angular
2. Horizontal
3. Vertical
4. Disto angular
5. Lingo angular
6. Buccoangular
7. Inverted

38. Classification suggested by Pell &Gregory(1933)
A. Availability of space between 2nd molar and ramus of
the mandible (horizontal plane):
Class I-There is sufficient space between the ramus of the
mandible & the distal side of the second molar for the
accommodation of the mesiodistal diameter of the crown of the
third molar.
Br J Oral Maxillofac Surg 2000; 83:585-587

39. Class II
The space between the ramus of the mandible & the
distal side of the second molar is less than the
mesiodistal diameter of the crown of the third molar.

40. Class III
Complete or most of the third molar is located within
the ramus.

41. • B. Relative depth of the 3rd molar in bone (vertical
plane):
Position A
The highest portion of the tooth is on a level with or above the occlusal
plane.
Position B
The highest portion of the tooth is below the occlusal plane, but above the
cervical line of the second molar.
Position C
The highest portion of the tooth is below the cervical line of the second
molar.

42. • C. Long axis of the impacted tooth in relation to the long axis of
the 2nd molar :
1. Vertical.
2. Horizontal.
3. Inverted.
4. Mesioangular.
5. Distoangular.
6. Buccoangular.
7. Linguoangular.

43. Archer (1975) & Kruger (1984)
Angulation :
 Mesio angular
 Horizontal
 Vertical
 Disto angular
 Lingo angular
 Buccoangular
 Inverted

44. Based on the nature of overlying
tissue - [Peterson]
Soft tissue impaction Partial bony
impaction
Bony impaction

45. Killey & Kay's classification-
A. Angulation and position
Vertical
Mesioangular
Distoangular
Horizontal
Transverse
Buccoangular,
Lingoangular
Inverted
Aberrant position

46. B. State of eruption-
- Erupted
- Partially erupted
- Unerupted – soft tissue impaction -
Complete bony impaction
C. Number of roots-
• Unfavorable impaction- Mesial curvature of roots
- Multiple roots
• Favorable impaction- Fused roots
- Distal curvature of roots

47. G.R. Ogden Method:
A simple method of determining the type of impaction involves
comparing the distance between the roots of 3rd and 2nd molars,
with the distance between the roots of the 2nd and 1st molars.

48. • a>b : mesioangular
• a=b: vertical
• a<b: distoangular

49. SUPERIOR-INFERIOR POSITION OF THE 3RD MOLAR:
• Crown to crown
• Crown to cervix
• Crown to root

50. ADA code on procedures and nomenclature:
• The American Dental Association (ADA) Code describes the
amount of soft and hard tissues over the coronal surface of an
impacted tooth.
• These are described as:
 Soft tissue impactions,
 Partial bony impactions,
 Completely bony impactions
 Completely bony impactions with unusual surgical complications.

51. Combined ADA and AAOMS classifications :
The AAOMS published the ADA coding with explanations from the
AAOMS procedural terminology, in parentheses, as follows:
• 07220 : Removal of impacted tooth – (overlying) soft tissue
(Impaction that requires incision of overlying soft tissue and the
removal of the tooth).
• 07230 : Removal of impacted tooth – partially bony impacted
(Impaction that requires incision of overlying soft tissue, elevation of
a flap, and either removal of bone and tooth or sectioning and
removal of tooth.
• 07240 : Removal of impacted tooth – completely bony (Impaction
that requires incision of overlying soft tissue, elevation of a flap,
removal of bone, and sectioning of tooth for removal).
• 07241 : Removal of impacted tooth – completely bony, with unusual
surgical complications (Impaction that requires incision of overlying
soft tissue, elevation of a flap, removal of bone, sectioning of the
tooth for removal, and/or presents unusual difficulties and
circumstances.

52. PEDERSON SCALE OF DIFFICULTY INDEX FOR
REMOVAL OF IMPACTED LOWER 3RD MOLARS
• Class I – 1
• Class II – 2
• Class III- 3
• Mesioangular - 1
• Horizontal – 2
• Vertical - 3
• Distoangular - 4
Pederson GW. Oral Surgery. Philadelphia: WB Saunders, 1988. The removal of
impacted third molars –principles and procedures. Dent Clin North Am 1994; 38: 261

53. Position A - 1
 Position B - 2
 Position C - 3
INTERPRETATION:
• Relatively difficult: 3-4
• Moderately difficult: 5-7
• Very Difficult : 7-10

54. •According to Pogrel •According to Holzle and Wolfe
SURGICAL ANATOMY

55. • Third molar is situated in the distal end of the body of the mandible.
• It is embedded between a thick buccal bone and thin lingual cortical plate

56. IMPORTANT CONSIDERATIONS
• On average, the buccal aspect of the canal is 4.9 mm from the buccal
cortical margin of the mandible. The superior aspect of the IAN canal is
17.4 mm inferior from the alveolar crest
• The mean distance from root of the erupted mandibular third molar teeth to
the inferior alveolar canal is 0.88 mm.
• The lingual nerve lies 0.5 mm lingual to the lingual cortex and 2mm apical
to the alveolar crest in the third molar region.
Levine M H, Goddard A L , Dodson TB, Journal of Oral and Maxillofacial Surgery
Volume 65, Issue 3, March 2007, 470-474
Relationship of lingual nerve to mandibular third molar region. Journal of oral and
maxillofacial surgery 53:1178-1181, 1995

57. • Distance from superior border of the canal to the most apical
aspect of the tooth
 Mesioangular (0.97 mm),
 Vertical (0.61 mm),
 Distoangular (0.31 mm),
 Horizontal (0.24 mm).
• Inferior alveolar vein lies superior to the nerve and the artery
appears to be solitary and lies on the lingual side of the nerve,
slightly above the horizontal position.
Radiographic proximity of the mandibular third molar to the inferior alveolar canal;Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2005;100:545-9
The Anatomic Structure of the InferiorAlveolar Neurovascular Bundle in the Third Molar
Region;J Oral Maxillofac Surg 67:2452-2454, 2009

58. Lingual Nerve
• Lingual nerve lies on the medial aspect of third molar.
• Lingual nerve may course submucosally in contact with periosteum
covering the lingual wall of the third molar socket
• Studies done by Keisselbach (1984) Pogrel (1995) Holzle(2001) conclude
that
o Lingual nerve was found to be at the crest of the lingual plate in 4.6 to
17.7% of cases
o Direct contact of lingual nerve with lingual plate was seen in 22.3% - 62%
o Horizontal distance from lingual nerve to lingual plate was 0 to 7mm (avg
0.6mm)
o Vertical distance from the lingual nerve to the crest of the lingual plate
ranged from 2mm above to 14mm below (average 2.3mm)

59. Pogrel MA, Goldman KE. Lingual flap retraction for third molar removal. J Oral Maxillofac Surg. 2004;62:1125–30
Hölzle FW, Wolff KD. Anatomic position of the lingual nerve in the mandibular third molar region with special consideration of an
atrophied mandibular crest: an anatomical study. Int J Oral Maxillofac Surg. 2001 Aug;30(4):333-8.

60. Mylohyoid nerve
• Mylohyoid nerve leaves the
inferior alveolar nerve just
before the latter enters the
mandibular foramen
• It then penetrates the
sphenomandibular ligament
and proceeds in the
mylohyoid groove
• The nerve maybe damaged
during lingual approach .
Long buccal nerve
• It emerges through the
buccinators and passes anteriorly
on its outer surface
• Rarely injury to the nerve can
occur when the posterior part of
incision is placed too laterally
• If injured results in sensory deficit
in buccal mucosa adjacent to
lower molar teeth

61. Musculature
Buccinator
• Musculature of the cheek
• During extraction deeply impacted third molars attachment may get
severed resulting in marked pain and edema
Temporalis
• During buccal approach the outer tendon maybe sectioned to enable
reflection of flap
• This will facilitate adequate bone removal bucally and distally
Medial pterygoid
• Not directly involved in 3rd molar surgery
• While using a lingual approach post op edema may result in trismus due
secondary involvement

62. Prophylactic Odontectomy
• It is the removal of the third molars before its complete
development.
• Done by lateral trephination technique
• Described by Bowdler henry in 1969
• Best time to perform it is when the radiograph of the tooth shows
the roots of the third molar to be half to two third formed.
• If prophylactic odontectomy is done, generally all the four 3rd
molars are removed.
Advantages
• Good bone healing
• Alveolar height is maintained
• No pocket formation distal to 2nd molar

63. Timing :
1 6-9 yrs: by enucleation
before the beginning of
mineralization or before
the calcified cusp have
united.
2 10-16 yrs: by lateral
trephination when only
the crown is formed.

64. • Coronectomy is a surgical procedure, first proposed in 1984 by
Ecuyer and Debien, designed to avoid the risk of iatrogenic
neuro-logical injury to the inferior alveolar nerve (IAN) by
removal of the anatomical crown only, leaving root fragments
Contraindications
1. Teeth with an active infection or pathology
2. Teeth in which the roots are mobile
3. Horizontally impacted teeth that are along the IAN canal in
such a position where sectioning could result in injury
LT Nicole Yates ;Guidelines for Surgical Coronectomies; Clinical Update Naval
Postgraduate Dental School

65. Incision -Triangular full thickness mucoperiosteal
flap is reflected
Exposure - Expose tooth to the level of the
cemental enamel junction (CEJ) using a fissure bur
in a high speed hand piece.
Decoronation-Sectioning of the tooth roughly three-
quarters through the tooth in the buccal lingual
dimension, 1-2mm below the CEJ is completed
with a fissure bur
Finishing of the Root Surface-A round bur is used
to reduce the surface of the root to 2-3mm below
the level of the surrounding alveolar bone, and
remove any retained enamel.
Debridement of the socket-Any exposed surface of
the mandibular second molar should be curetted and
the entire surgical site should be copiously irrigated
with saline to remove debris

66. M. Anthony Pogrel, Coronectomy: A Technique to Protect the Inferior Alveolar
Nerve; J Oral Maxillofac Surg 62:1447-1452, 2004

67. Complications of Coronectomy
• Mobalized root fragment
• Heamorrage
• Damage to adjacent tooth
• Alveolar osteitis
• Migration or eruption of roots

68. GENERAL STEPS IN SURGERY
1. Thorough case history
2. Radiological assessment.
3. Patient preparation with aseptic technique
4. Anaesthesia.
5. Incision and reflection of mucoperiosteal flap.
6. Removal of bone.
7. Removal of tooth.
8. Wound debridement.
9. Wound closure.

69. ARMAMENTARIUM
Disposable hole towel Towel clip Rampley sponge holder
Fraser suction tip Mckesson mouth props Mouth mirror and probe

70. Retractors
Austin retractor Minnesota retractor Seldin retractor
Henahan retractor Kilner cheek retractor

71. Bone cutting instruments
Straight handpiece No 702 straight fissure bur No 6 round bur
French’s pattern chiesel Osteotome Weiss pattern mallet

72. Elevators
Straight Cryer elevator Milller elevator
Potts elevator Warwick james Heid Brink apex elevator

73. ARMAMENTARIUM
Miller 52 pattern bone file London college pliers Rongeur forceps(ash’s no 3)
Weider’s tongue retractor Lucas curette

74. ARMAMENTARIUM
(Suturing instruments)
Adson forceps Stillies forceps Gillies rat tooth forceps Spencer wells
hemostat
Mayo hegar(6 inch)NH Kilners NH Lane’s suture needle 4 ½ inch SCS

75. SURGICAL TECHNIQUE
• GENERAL PRINCIPLES FOR SURGICAL TECHNIQUE OF
IMPACTION REMOVAL
• Reflect mucoperiosteal flap to obtain good visual access.
• Remove buccal bone with high speed surgical drill using
round or cross-cut bur.
• Expose crown of impaction upto CEJ and make room to
allow for elevator placement.
• Attempt to gently evaluate for motility with elevator.
• Section crown with handpiece. Care should be taken to
protect the lingual soft tissue and depth of surgical cut
should not be too much.

76. » Straight elevator should be used to separate crown
from tooth.
» Deliver roots with root tip elevators.
» Inspect bony crypt for loose debris and any bleeding
problems and smooth bone margins with bone file.
» Carefully remove follicular soft tissue and tease it out
from surrounding mucosa.
» Copious irrigation of socket and beneath soft tissue

77. » Reapproximate soft tissue flap and close with 3-0 or 4-0
chromic or black silk sutures.
» Consider intraoral injection of steroids if extensive bone
surgery has been performed.
» Evaluate for post surgical bleeding prior to flap closure.

78. INCISIONS
ENVELOPE FLAP
• It begins on the ascending
ramus following the
centre of 3rd molar shelf to
distobuccal surface of
second molar
• Then extends as a sulcular
incision to the
mesiobuccal corner of the
2nd molar

79. WARDS INCISION
• Begins 6.4 mm in the buccal sulcus
• At the junction of middle and posterior
Junction of 2nd molar
• Passed upward to distobuccal angle of
2nd molar
• Cervically behind tooth to midline of
its posterior surface
• Finally penetrates to mucosa of cheek,
2-3mm
• Total average 25.4mm
MODIFIED WARDS
INCISION
Anterior incision is commenced at
the distobuccal corner of the
mandibular 1st molar instead of 2nd
molar

80. L- SHAPED INCISION
Incision is a few mm away from the marginal
gingiva.
Helps in an intact marginal attachment distal to
2nd molar

81. BAYONET - SHAPED INCISION

82. COMMA INCISION

83. • 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.

85. Vestibular Tongue shaped Flap
• Berwick in 1986 designed a vestibular tongue
shaped flap.
• Extended into the buccal shelf of the mandible.

86. SZMYD DESIGN THREE CORNERED FLAP

87. Principles of flap
• Accessibility
• Vascularity
• Base wider than apex
• Rest on sound bone
• Full thickness flap
• Should not extend too far distally
FLAPS

88. REFLECTION OF FLAP
•Reflection of the flap begins at the
papilla. The end of the no. 9 periosteal
elevator is used .
• Once the flap reflection is started,
the broad end of the periosteal elevator
is inserted at the middle corner of the
flap, and the dissection is carried out
with a pushing stroke, posteriorly and
apically.

89. BONE REMOVAL
Aim:
To expose the crown by
removing the bone overlying it.
To remove the bone obstructing
the pathway for removal of the
impacted tooth.
To prepare a fulcrum for
support of an elevator.
Types:
 By consecutive sweeping
action of bur (in layers).
 By chisel or osteotomy cut
(in sections).

90. • Bone should be removed till we reach below the height of
contour, or its greatest circumference where we can apply
the elevator.
• Extensive bone removal can be minimized by tooth
sectioning.
• The amber line determines the amount of bone covering the
impacted tooth which has to be removed for applying
elevator to remove the tooth.
• When the entire crown lies above and in front of the amber
line, there is no necessity to remove the bone. In other
cases, bone can be removed with the help of chisel or burs.
How much bone has to be removed?

91. BUR TECHNIQUE
•The crown of the impacted tooth should be
exposed (CEJ) by removal of surrounding
bone:
• Mesially – to create a point of
application.
• Buccally – cutting a trough or gutter
around the tooth to the root furcation.
• Distolingually – lingual plate should
not be breached to protect the lingual
nerve.

92. CHISEL TECHNIQUE

93. The limiting cut is completed by shifting the chisel anteriorly
with the bevel resting on the bone, thereby making a deep
vertical groove.
Its approximate height is 5-6 mm. Then the chisel is placed at an
angle of 45° at the lower edge of the limiting cut in an oblique
direction.
This will result in the removal of a triangular piece of buccal
plate distal to the II molar. If necessary, bony cut can be
enlarged to uncover the impacted tooth to the desired level.
Distal bone must be removed so that when the tooth is elevated,
there is no obstruction at the distobuccal aspect.

94. IRRIGATION
•The various solutions which can be used as irrigants are:
– Saline
– Sterile water
– Ringer’s lactate
– 1% Povidone iodine

95. SECTIONING OF THE TOOTH
• “Bone belongs to the patient and the tooth belongs to the surgeon.”
•Pell and Gregory stated the following advantages of splitting technique:
• Amount of bone to be removed is reduced. The time of operation is
reduced.
• The field of operation is small and therefore damage to adjacent teeth and
bone is reduced.
• Risk of jaw fracture is reduced.
• Risk of damage to the inferior alveolar nerve is reduced
•Disadvantages :
• In elderly patients, splitting of the tooth is possible due to the sclerosis of
the tooth structure.
• Sometimes due to the presence of shallow grooves on the tooth structure,
splitting is difficult.

96. Mesioangular impactionSectioning of the tooth based on the type of impaction:

97. Horizontal impaction

98. Vertical impaction

99. Distoangular impaction

100. WOUND TOILET
•It is important to irrigate the surgical site, with particular
attention paid to the space directly underneath the buccal flap
where loose debris may accumulate and cause a buccal space
infection.
•Adequate haemostasis is also important prior to wound
closure to minimize the risk of persistent postoperative
oozing and haematoma formation.

101. CLOSURE
•The most important suture is the one
placed immediately behind the second
molar, ensuring there is accurate
apposition of wound edges .
•It is also useful to place a suture across
the distal incision where the soft tissue
thickness and potential bleeding source is
greatest.
•Primary closure of the wound should not
be attempted unless – atleast 5mm of a
band of buccal attached mucoperiosteum is
present.

102. TECHNIQUES FOR REMOVAL OF
DIFFERENT TYPES OF MANDIBULAR 3rd
MOLAR IMPACTIONS

103. Lateral Trepanation Technique

104. ADVANTAGE
• Partially formed unerupted 3rd molar can be removed.
• Can be preformed under general or regional anesthesia with
sedation.
• Bone healing is goodand there is no loss of alveolar bone
around the 2nd molar.
DISADVANTAGE
• Virtually every patient has some post operative buccal
swelling for 2-3 days after surgery

105. Vertical stop
cut
Distal cut
Elevation
Horizontal cut
Removal of distal
& buccal bone
Removal of
tooth
Incision
Closure
Lingual Split Bone Technique
(Kelsey Fry , T. Ward)

106. Advantages:
• Faster tooth removal.
• Less risk of inferior alveolar nerve damage.
• Reduces the size of residual blood clot by means of saucerization of the socket
• Decreased risk of damage to the periodontium of the second molar.
• Decreased risk of socket healing problems.
Drawbacks:
• Risk of damage to the lingual nerve. The incidence of lingual nerve and inferior
alveolar nerve damage has been reported as 1-6.6%.
• Increased risk of postoperative infection
• Patient discomfort due to the use of a chisel and mallet for lingual bone
removal or fracturing.
• Only suitable for young patients with elastic bone.
Lingual Split Bone Technique

107. Lewis technique: Lewis (1980) modified the lingual split-bone technique by
minimizing periosteal reflection and buccal bone removal and by
preserving the fractured lingual plate.
Davis's technique mentions not to separate the mucoperiosteum from
lingual area of bone. The bone was released in segments to allow tactile
control of osteotome to prevent penetration of the osteotome into soft tissue.

108. MODIFIED LINGUAL SPLIT TECHNIQUE FOR
REMOVAL OF MANDIBULAR THIRD MOLAR
(Dr.DAVIS 1979)
DISTAL CUTVERTICAL STOP CUTINCISION

109. CLOSURETOOTH ELEVATION

110. Sagittal Split Ramus Osteotomy
• First advocated by Amin (1995) and Toffanin (2003)
• Indication – 3rd molars are placed deeply or in intimate relation with
inferior alveolar nerve
Drawbacks of using conventional technique
• Extensive bone removal
• Limited visibility
• Nerve damage
• Fracture of mandible
Advantages of sagittal split ramus osteotomy
• Preserves bone
• Avoids chances of nerve injury

111. Disavantages of saggital
split osteotomy
• Unfavourable splits
• Derrangements of occlusion
Amin M, Haria S, Bounds G. Surgical access to an impacted lower third molar by sagittal
splitting of the mandible: A case report. Dent Update 1995;22:206-208

112. Buccal corticotomy
• First reported by Tay (2007)
• Indications 3rd molars are placed deeply or in intimate relation with
inferior alveolar nerve
Surgical technique
• Trapazoidal mucoperiosteal flap is raised
• Using bur, rectangular window is made.
• Imapcted molar is exposed, sectioned and extracted
• The buccal cortical place is fixed using plats and screws
• Closure is done
Tay Andrews BG. Buccal corticotomy for removal of deeply impacted mandibular
molars. Br J Oral Maxillofac Surg 2007;45:83-84

114. MOORE/GILLBE COLLAR
TECHNIQUE
– A mucoperiosted flap of standard
design is elevated exposing the
underlying bone.
– A rose-head bur (no.3) is used to
create a ‘gutter’ along the buccal side
and distal surface of the tooth.
– The lingual soft tissue is protected
with a periosteal elevator during the
removal of the distolingual spur of
bone

115. – A mesial point of application is created with the
bur, and a straight elevator is used to deliver the
tooth.
– After delivery of the tooth has been effected, the
sharp bone edges are smoothed with a vulcanite
bur, and the cavity is irrigated.
– The wound is closed with sutures

116. CHISEL VS BUR

117. BUCCAL VS LINGUAL APPROACH
Criteria Buccal Lingual
Access Relatively easy in the conscious
patient
Relatively difficult
Instruments Chisel and mallet or bur Only chisel and mallet
Procedure Tedious Easy
Operating time Time consuming Less time consuming
Technique Easy to perform, hence
traditionally popular
Technically difficult, hence not
popular
Bone removal Thick buccal plate Thin lingual plate
Postoperative pain Less More due to the damage of
lingual periosteum
Postoperative
edema
More Less
Dry socket Incidence is high due to the
damage of external oblique ridge
Incidence is negligible since
socket is eliminated.

118. CLASSIFICATION OF IMPACTED
MAXILLARY MOLARS

119. CLASSIFICATION OF MAXILLARY THIRD MOLAR
– Archer’s (1975)
• On anatomic basis similar to mandibular 3rd molar
– Pell & Gregory
• Based on relative depth in relation to 2nd molar
– Based On Relation Of Max 3rd Molar To Max Sinus
Floor
• Sinus approximation- no bone / thin partition present
• No sinus approximation – 2mm or more bone is present

120. Techniques For Maxillary Third Molar
Impactions

121. • Flap design: Envelope flap is most commonly
used.
• Armamentarium are same as used for
mandibular impactions except forceps and
elevators.
• Millers and Potts elevators are commonly used
because of their curved blades.

123. • Fracture of the maxillary tuberosity is most
commonly associated with manipulation of the
mesioangular impactions.
• Displacement of the tooth in the infratemporal
fossa occurs most frequently with the
distoangular impactions.

124. CLASSIFICATION OF MAXILLARY AND
MANDIBULAR CANINE IMPACTION

125. Etiology
• The origin of impaction is unclear but most likely is
multifactorial.
• Because the maxillary canine has the longest path of eruption
in the permanent dentition, alteration in position of the
central and lateral incisor may be a factor.
• Arch length discrepancy and space deficiency may result in
the canine becoming labially impacted.

126. MAXILLARY CANINE
– LABIAL POSITION
• Crown in intimate relationship with incisors
• Crown well above apices of incisors
– PALATAL POSITION
• Crown near surface in close relation to roots of incisors
• Crown deeply embedded in close relation to apices of incisors
– INTERMEDIATE POSITION
• Crown between lateral incisor & 1st premolar root
• Crown above lateral incisor & 1st premolar with crown labially
placed and root palatally placed or vice versa
– UNUSUAL POSITION
• In nasal or antral wall
• In infraorbital region
FIELD & ACKERMAN (1935)

127. • CLASS I : PALATALLY PLACED MAXILLARY CANINE A)
HORIZONTAL B) VERTICAL C) SEMIVERTICAL
• CLASS II: LABIALLY OR BUCCALLY PLACED MAXILLARY CANINE
A) HORIZONTAL B) VERTICAL C) SEMIVERTICAL
• CLASS III: INVOLVING BOTH BUCCALAND PALATAL BONE
• CLASS IV: IMPACTED IN THE ALVEOLAR PROCESS BETWEEN THE
INCISORS AND FIRST PREMOLAR
• CLASS V: IMPACTED IN EDENTULOUS MAXILLA

128. • CLASSIFICATION FOR IMPACTED
MANDIBULAR CANINE
Labial : vertical, oblique , horizontal
Aberrant : at inferior border or On the opposite side

129. Treatment options
• No treatment with periodic radiographic
evaluation.
• Interceptive removal of primary canine.

130. • Surgical removal and prosthetic replacement.
Surgical extraction of the impacted canine is
indicated when there is poor position for
orthodontic alignment, there is early evidence of
resorption of adjacent teeth, the patient is too old
for exposure, and the degree of displacement does
not allow for surgical reposition or
transplantation.

131. Surgical exposure
Surgical exposure is the conventional treatment
for impacted canines.
• open surgical exposure.
• surgical exposure with packing and delayed
bonding of the orthodontic bracket.
• surgical exposure and bonding of orthodontic
bracket intraoperatively.

132. SURGICAL SIDE-EFFECTS AND
COMPLICATIONS
Perioperative Complications.:
• Fracture of the crown of the adjacent tooth or luxation of the
adjacent tooth
• Soft tissue injuries
• Fracture of the alveolar process
• Fracture of the mandible
• Broken instrument in tissues
• Dislocation of the temporomandibular joint
• Subcutaneous emphysema
• Hemorrhage
• Displacement of the root or root tip into soft tissues
• Nerve injury

133. Postoperative Complications:
• Trismus
• Hematoma
• Ecchymosis
• Edema
• Post extraction granuloma
• Dry socket
• Infection of wound

134. CONCLUSION
• Surgical removal of an impacted mandibular third molar is
one of the most frequently performed minor oral surgical
procedures and demands sound understanding of surgical
principles to perform it as atraumatically as possible.

135. REFERENCES
Peterson’s Principles of oral and maxillofacial surgery, 2nd edition, vol. 1.
Textbook of oral and maxillofacial surgery, vol. 2, Laskin.
Textbook of oral and maxillofacial surgery-Kruger
Nageshwar;Comma incision for impacted Mandibular third molars. J Oral
MaxillofacSurg 2002; 60:1506-1509.
Alling CC, Helfrick JE, Alling RD: Impacted Teeth (ed 1). Philadelphia, PA,
Saunders, 1993, pp 167-170
Dolanmaz D,Esen A,Isik K,Candirli C. Effect of 2 flap designs on post-
operative pain and swelling after impacted third molar surgery .Oral
Surg Oral Med Oral Pathol Oral Radiol 2013;116:244–6.

136. • Sandhu A, Sandhu S, Kaur T. Comparison of two different flap designs in
the surgical removal of bilateral impacted mandibular third molars. Int J
Oral MaxillofacSurg 2010; 39:1091–6.
• Jakse N,BankaogluV,Wimmer G,Eskici A, PertlC;Primary wound healing
after lower third molar surgery: evaluation of 2 different flap designs. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 2002; 93:7–12.
• Pogrel MA1, Renaut A, Schmidt B, Ammar A; The relationship of the
lingual nerve to the mandibular third molar region: an anatomic
study.;JOMS 1995;53:1178-1181.
• A.J. Gibbons, C.E. Moss;Lingual Nerve Damage After Mandibular Third
Molar Surgery: A Randomized Clinical Trial; JOMS 2005;63:1443-1446
• Sedaghatfar M, August MA, Dodson TB. Panoramic radiographic findings
as predictors of inferior alveolar nerve exposure following third molar
extraction. J Oral Maxillofac Surg. 2005;63:3–7

137. • Chapokas A R; The impacted maxillary canine: a proposed classification
for surgical exposure; Oral Surg Oral Med Oral Pathol Oral Radiol
2012;113:222-228