The document provides an overview of mandibular impacted 3rd molar removal, including indications for removal, factors to assess difficulty, the surgical procedure, potential complications, and post-operative care. Key areas of assessment that influence difficulty include depth of impaction, angulation, proximity to important structures like the inferior dental nerve. Thorough pre-operative evaluation and careful technique during removal can help reduce risks of complications.

1. Mandibular impacted 3rd
molar removal
Dr. Anushan Madhushanka..BDS, MD/OMFS, MFDRCSI
Senior registrar in OMF surgery
North ColomboTeaching hospital, Sri Lanka

2. What is an impaction?
• A tooth that failed to erupt during its
development
• Eruption time 18-20 yrs
• Maximum time 24 yrs
• After 25yrs no eruption, remain same site
• Eruption unlikely if mesioangulated
No space distal to 2nd molar

3. Relevant anatomy

4. Indication for removal
(NICE guidelines)
Episodes of pericoronitis > 2times
Gross caries
Untreatable pulpitis
Associated pathology- cyst , tumour, CA
Jaw surgeries – Osteotomies
Orthodontist requirement
*** No prophylactic removal if asymptomatic

5. Difficulty assessment
Why difficulty assessment ?
• To determine GA/LA
• For Preparation of pt
• To minimise the complication
What is the difficulty here?
Physical & mental stress to surgeon & Pt
Time
Preservation of vital structures

6. General assessment
• PMH/allergies
• Past dental treatment
• Age
• Body frame
• Male / female
• Occupation

7. Local assessment
• Mouth opening
• Tongue size
• Thickness of alveolar bone
• Condition of the 2nd molar – large restorations
Caries
• Pre OP sensation of lower lip & tongue****

8. 3rd molar assessment
*****Clinical & Radiographic
Clinical Assessment
• Depth of impaction
• Angulation
• Space available distal to 2nd molar

9. 3rd molar assessment cont..
Radiographic assessment
• Use - IOPA, Lateral Oblique, OPG, CBCT
• Standard – IOPA / OPG

10. Radiographic assessment
• IOPA/OPG assessment
1. Depth of impaction
2. Angulations
3. Ramus relation
4. Winters Lines
5. ID Nerve relationship
6. Crown & root configuration
7. Bone quality
8. Any pariapical pathology

11. Depth of impaction

12. Angulation
1. Mesialy - Easy
2. Distaly – Very difficult
3. Vertical – Moderately difficult
4. Horizontal - Moderately difficult
5. Buccoversion
6. Linguoversion
7. Inverted

13. Ramus relation
• Type A - Easy
• Type B - Difficult
• Type C – Very Difficult

14. Winters Lines
• Red line < 5mm – Easy, can do under LA
• Red line > 5mm – Difficult, need GA
• Increasing 1mm make difficulty 3 folds

15. Proximity to ID nerve
Look for – Tramp line course
Radio density changes in root
Root disfiguration
These increase risk of ID nerve damage

16. Crown & Root configuration
• Large bulbous crown – diificult
• Divergent root – difficult
• Multiple roots - difficult

17. Associated pathology
Large pericoronal space - Easy
Associated cystic cavity - Easy

18. Surgical Procedure
Preparations
• Pt preparation – mental preparation
INFORMED WRITTEN CONSENT
Antiseptic mouth wash
• Sterility – through out the procedure
• Chair, Light, Suction & Instruments
• Assistants – Need two

19. Local anaesthesia
• Topical anaesthesia – lidocain spray/ gel
• ID nerve & Lingual nerve block
• Buccal infiltration
• Intraligamentary ?
• Intrapulpal ?
• Pre emptive analgesia ????

20. Incision
Envelop flap/One sided flap
Two sided flap
three sided flap - prefered

21. Flap elevation
• Use periosteal elevator
• Work under the periosteum
• Raise mucoperiosteal flap ( No mucosal flaps)
• Raise little lingual flap & protect lingual Nv

22. Bone removal
• Remove buccal & distal bone
• Expose crown & uppur 1/3 of root
• Need straight/ contra angle micromotor
• Use 1mm TC bur. Steel bur often breaks.
• Need good irrigation with N.S

23. Tooth sectioning

24. Tooth removal
• Use dental elevators
• Minimum force
• No forcep delivery – might damage ID nerve
• Can make drill hole to get point of application

25. Wound conditioning
• Irrigation – Use 20cc syringe with 16/18G
cannula + 0.9% N.S
• Removal of sharp edges & debris
• Insert surgicel / gelfoam – optional
• Close the wound

26. Suturing & Dressing
• Can use absorbable/non absorbable material
• Size- 3/0 with round bodied needle
• 2-3 sutures – 1st – mesial end
2nd – distal end
3rd – inbetween - optional
• No vertical incision suturing – used as drain
port
• Keep antibiotc gauze pack with pressure

27. Post OP instructions
• Strict resting - 24 hrs
• Keep pack – 10 min
• No hot drinks or hot meals for 24hrs
• No gargling of mouth for 24hrs
• No smoking/alcohol for 3 days
• No insertion of foreign objects
• Take soft diet
• Keep ice pack in jaw
• Use 0.2% chlorhexidine MW/bd

28. Post op drugs
*** Studies show No need of antibiotcs.
• Augmentin - 625mg/bd – 5 days
• Celecoxib - 200- 400mg/bd – 3days
• Panadine - 1000mg/qds – 3days
• Dexamethazone - 2mg/bd – 24 hours
• Ranitidine – 150mg/bd – 3 days
• Diazepam - 5mg/noct on that day

29. Potential Complications & Their
Management
Intra OP
• Bleeding – pack for 10 min
DO NOT FEAR. IT WILL ARREST
• Loss of tooth piece/tooth – look into socket,
suction apparatus, tissue spaces
Aspirated ? – Need CXR & referal
• Bone fracture
• Nerve injury Refer to OMF unit

30. Immediate Post op (24rs to 48hrs)
• Pain****- Main problem, give good anlgesia
• Bleeding – mild oozing will settle
• Swelling – will settle
• Haematoma – if large, refer to OMF unit
• Self inficted trauma – warn the pt

31. Intermediate post op (after 2-3 days)
• Swelling
• Mild pain
• Trismus – facilitate jaw opening
• Infection – give antibiotics & do I & D
• Dry socket – frequent irrigation & ZOE pack
• Lower lip/Tongue – Anaesthesia, Paraesthesia
Do sensory mapping
Observe improvement

32. What to do if there is a,
• Persistent swelling
• Persistent bleeding
• Massive haematoma
• Nerve injuries Refer to OMFU
• Bone/tooth fracture
• Persistant trismus
• Anaesthesia/Paraesthesia
• TMJ pain

33. Thank You
Any Questions ?