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Mandibular impacted third molar removal
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.
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Mandibular impacted third molar removal
- 1. Mandibular impacted 3rd molarremoval Dr. Anushan Madhushanka..BDS, MD/OMFS, MFDRCSI Senior registrar in OMF surgery North ColomboTeaching hospital, Sri Lanka
- 2. What is animpaction? • 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
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- 4. Indication for removal (NICEguidelines) 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 difficultyassessment ? • 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 • Mouthopening • 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 assessmentcont.. Radiographic assessment • Use - IOPA, Lateral Oblique, OPG, CBCT • Standard – IOPA / OPG
- 10. Radiographic assessment • IOPA/OPGassessment 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
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- 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 • TypeA - Easy • Type B - Difficult • Type C – Very Difficult
- 14. Winters Lines • Redline < 5mm – Easy, can do under LA • Red line > 5mm – Difficult, need GA • Increasing 1mm make difficulty 3 folds
- 15. Proximity to IDnerve Look for – Tramp line course Radio density changes in root Root disfiguration These increase risk of ID nerve damage
- 16. Crown & Rootconfiguration • Large bulbous crown – diificult • Divergent root – difficult • Multiple roots - difficult
- 17. Associated pathology Large pericoronalspace - Easy Associated cystic cavity - Easy
- 18. Surgical Procedure Preparations • Ptpreparation – mental preparation INFORMED WRITTEN CONSENT Antiseptic mouth wash • Sterility – through out the procedure • Chair, Light, Suction & Instruments • Assistants – Need two
- 19. Local anaesthesia • Topicalanaesthesia – lidocain spray/ gel • ID nerve & Lingual nerve block • Buccal infiltration • Intraligamentary ? • Intrapulpal ? • Pre emptive analgesia ????
- 20. Incision Envelop flap/One sidedflap Two sided flap three sided flap - prefered
- 21. Flap elevation • Useperiosteal elevator • Work under the periosteum • Raise mucoperiosteal flap ( No mucosal flaps) • Raise little lingual flap & protect lingual Nv
- 22. Bone removal • Removebuccal & 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
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- 24. Tooth removal • Usedental 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 doif there is a, • Persistent swelling • Persistent bleeding • Massive haematoma • Nerve injuries Refer to OMFU • Bone/tooth fracture • Persistant trismus • Anaesthesia/Paraesthesia • TMJ pain
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