Mandibular nerve
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The document discusses the anatomy and branches of the mandibular nerve, including its course, distribution, and supply. It describes various anesthetic techniques for blocking branches of the mandibular nerve, including the inferior alveolar nerve block, lingual nerve block, buccal nerve block, and mental nerve block. It also discusses potential local complications from anesthetic techniques such as needle breakage, prolonged anesthesia, and soft tissue injury.
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Mandibular nerve
- 2. Contents Introduction Classification of cranial nerves Derivatives of pharyngeal arches Nuclei of trigeminal nerve Muscles of mastication Origin, insertion, function, nerve supply, blood supply Course and relation Distribution & Supply
- 3. Branches (origin, course & distribution) Main trunk Nervous spinosus Nerve to medial pterygoid Anterior division Buccal nerve Masseteric nerve Deep temporal nerve Nerve to lateral pterygoid Posterior division Auriculotemporal nerve Lingual nerve Inferior alveolar nerve Otic ganglion
- 4. Anesthetic technique Nerves anesthetized, area anesthetized, indication, contraindication & technique Inferior alveolar nerve block Lingual nerve block Buccal nerve block Mental nerve block Incisive nerve block Gow gates technique Vazirani akinosi technique Supplimental injection technique Intrapulpal injection Periodontal injection Intraseptal injection
- 5. Local complications 1. Needle breakage 2. Prolonged anesthesia or paresthesia 3. Facial nerve paralysis 4. Trismus 5. Soft tissue injury 6. Hematoma 7. Pain on injection 8. Burning on injection 9. Infections 10. Edema 11. Sloughing of tissue 12. Postanesthetic intraoral lesions C o n t e n t s
- 6. Systemic complications 1. Adverse drug reactions 2. Intravascular injection 3. Drug overdose 4. Allergy Clinical implication Motor examination Reffered pain Trigeminal neuralgia Jaw jerk reflex Anatomic variation Age changes
- 7. Nerve injury Direct injury Lesion associated with anesthetic technique Effect of irrigants Effect of sealer Effect of obturating material Lesion associated with implant surgery Lesion associated with third molar removal Effect of mandibular fracture Conclusion References
- 9. 1 Mandibular nerve is largest branch of trigeminal nerve. It is nerve of first branchial arch.
- 10. Derivatives of branchial arches
- 14. Meningeal branch • ORIGIN • COURSE • SUPPLY
- 15. Nerve to medial pterygoid & lateral pterygoid • Origin • Course • Motor branches to otic ganglion
- 16. Medial pterygoid Origin • Tuberosity of maxilla • Medial surface of lateral pterygoid plate Insertion Inner surface of angle of mandible Action Elevation & protrusion NERVE SUPPLY Nerve to medial pterygoid BLOOD SUPPLY Facial & maxillary artery
- 17. Lateral pterygoid Origin • Upper head from crest of greater wing of sphenoid • Lower head from lateral surface of lateral pterygoid plate Insertion Pterygoid fovea, Ant. Margin of articular disk Action Depress & protrude the mandible NERVE SUPPLY Nerve to lateral pterygoid BLOOD SUPPLY Muscular branch of maxillary artery
- 20. Buccal nerve • Only sensory branch of anterior devision • Course through lateral pterygoid • Supply: skin, mucous membrane, buccinators, gums of premolar & molar
- 21. Masseteric nerve Origin – upper border of lateral pterygoid, front of TMJ Course – runs laterally Enters deep surface of masseter
- 22. Masseter Origin Anterior 2/3rd of lower border of zygomatic arch Insertion Ramus of mandible Action Elevates the mandible NERVE SUPPLY Masseteric nerve BLOOD SUPPLY Transverse facial artery
- 24. Deep temporal nerve Anterior & posterior part Runs between lat. Pterygoid & skull Supply - temporalis
- 25. TEMPORALIS Origin Temporal fossa & fascia Insertion Coronoid process & ant. Border of ramus Action Elevate the mandible NERVE SUPPLY Deep temporal nerve BLOOD SUPPLY Superficial temporal & deep temporal arteries
- 27. Auriculotemporal nerve 2 roots encircles middle meningeal artery. Course – runs between neck of mandible & sphenomandibular ligament Behind the mandible it ascends upwards. Auricular part – tragus, pinna, internal acoustic meatus, tympanic membrane Temporal part – skin of temple.
- 28. Lingual nerve Course – begins 1 cm below skull. 2cm below joins chorda tympani. Relations – runs downward & forward Finally it lies on Hyoglossus & genioglossus
- 29. Relation with chorda tympani
- 30. Relation with mylohyoid and superior constrictor
- 31. Relation with submandibular duct
- 32. • Runs vertically downwards , enters mandibular canal. • Branches 1. Mylohyoid branch 2. Branches to lower teeth 3. Mental nerve 4. Incisive nerve
- 34. Otic ganglion Peripheral parasympathetic ganglion Topographically – mandibular nerve Functionally – glossopharyngeal nerve Size & situation – 2-3 mm, infratemporal fossa
- 37. Sympathetic root From plexus on middle meningeal artery Contains post ganglionic fibers from superior cervical ganglion No relay Auriculotemporal nerve Parotid gland
- 38. Sensory root From Auriculotemporal nerve Other fibers are – Nerve to medial pterygoid Chorda tympani Nerve to pterygoid canal
- 41. [A] Inferior alveolar nerve block Nerve anesthetized : IA, lingual, mental, incisive. Area anesthetized : mandibular teeth till midline, buccal mucoperiosteum, ant. 1/3rd of tongue & floor of mouth. Indication : multiple extraction, buccal soft tissue anesthesia. Contraindication: acute infection, allergic, very young child. Advantage: wide area of anesthesia Disadvantage: high rate of in adequate anesthesia, self inflicted soft tissue trauma.
- 43. Technique (Malamed) Area of insertion : medial side of ramus Orientation of needle : bevel facing towards bone Position of clinician : 8 o'clock & 10 o’clock Height of injection : 6-10 mm above occlusal plane. Changes with age. Anteroposterior site of injection : 3/4th width of ramus Depth of penetration : 20-25mm. Contact the bone. Aspirate in 2 planes & deposit 1.5ml over 60 sec.
- 45. Slowly withdraw the needle till half length remain inside & deposit 0.2ml to anesthetize lingual nerve. Subjective symptoms : numbness of lower lip & tongue Objective symptoms : no response to EPT & no pain during procedure. Precautions : don’t deposit if bone is not contacted. Failure of anesthesia : deposited to far anteriorly, posteriorly, bifid canal. [B] Lingual nerve block
- 46. [C] Buccal nerve block Landmark : mandibular molar, mucobuccal fold. Operator position : 8 o’clock & 10 o’clock Penetrate 2-4 mm bevel facing downwards. If aspiration is –ve deposit 0.3ml/10sec
- 47. [D] Mental nerve block Area anesthetized : buccal mucous membrane ant to mental foramen, lower lip Technique : Locate mental foramen Insert at mucobuccal fold ant to mental foramen Target area : between apices of first & second Premolar Depth of penetration 5-6 mm If aspiration is –ve deposit 0.6ml over 20 sec Procedure for incisive nerve block is similar to Mental nerve block.
- 48. [E] Gow gates technique (1973) Nerve anesthetized Inferior alveolar Mental Incisive Lingual Mylohyoid Auriculotemporal Long buccal (in 75% of the cases)
- 49. Area anesthetized : Mandibular teeth to midline Buccal mucoperiosteum Ant 2/3rd of the tongue Floor of the mouth Skin over the zygoma Posterior portion of temporal region Contraindications Acute inflammation Young children & mentally handicapped adults Patient who is unable to open their mouth
- 50. Extra oral landmarks lower border of tragus Corner of the mouth Intraoral landmark Mesiolingual cusp of maxillary second molar Technique Ask the patient to extend his neck and to open wide Direct the needle from opposite corner of mouth at lower premolar area parallel to extra oral landmark. When maxillary third molar is present site of penetration will be distal to it. Advance the needle until condylar neck is contacted Depth of penetration – 25mm Deposit 1.8ml (original 3ml)
- 53. [F] Vazirani Akinosi closed mouth technique (1977) Synonyms : Akinosi technique Closed mouth Mandibular nerve block Tuberosity technique Indications Limited mandibular opening Inability to visualize landmarks for IANB Nerve anesthetized IAN, incisive, mental, lingual, mylohyoid
- 54. Landmark Mucogingival junction Maxillary tuberosity Coronoid notch Area of insertion Soft tissue at the medial border of mandibular ramus. Directly adjacent to maxillary tuberosity. At the height of mucogingival junction adjacent to max third molar. Target area Soft tissue on the medial border of ramus as the mandibular nerve comes out from foramen ovale.
- 55. Orientation of bevel : away from ramus Ask the patient to occlude gently Advance the needle parallel to maxillary occlusal plane Depth of penetration- 25mm Deposit 1.5- 1.8ml over 60 secs After injection make the patient upright or semiupright position.
- 59. Supplemental injection technique 1. Intrapulpal injection 2. Periodontal injection 3. Intraseptal injection 4. Mandibular infiltration
- 60. Intrapulpal injection Indication When pain control is necessary for pulp extirpation In absence of adequate anesthesia from other technique Contraindication : NONE Technique Wedge the needle firmly into the pulp chamber Bend the needle if necessary Deposit 0.2-0.3 ml
- 61. Periodontal injection Indications 1. Single tooth anesthesia 2. Rx of isolated teeth in both quadrants 3. Treatment of children 4. Where nerve block is contraindicated (hemophiliac) 5. In diagnosis of mandibular pain Contraindication 1. Inflammation 2. Presence of primary teeth Peripress
- 62. Advantages No soft tissue anesthesia Minimum dose Alternative to partially successful block Rapid onset of profound anesthesia Less traumatic Disadvantage Proper needle placement is difficult Excessive pressure may break the glass cartridge Chances of tooth extrusion
- 63. Technique Area of insertion : Long axis of the tooth to be treated on its mesial or distal root. If interproximal contacts are tight direct from the lingual or buccal surface Target area : depth of gingival sulcus Face the bevel toward the tooth Insert and deposit 0.2ml over 20 sec.
- 64. Intraseptal injection Technique Area of insertion – center of interdental papilla Stabilize the syringe & inject 0.2ml over 20 sec
- 67. Local complications 1. Needle breakage 2. Prolonged anesthesia or paresthesia 3. Facial nerve paralysis 4. Trismus 5. Soft tissue injury 6. Hematoma 7. Pain on injection 8. Burning on injection 9. Infections 10. Edema 11. Sloughing of tissue 12. Postanesthetic intraoral lesions C o n t e n t s
- 68. Systemic complications 1. Adverse drug reactions 2. Intravascular injection 3. Drug overdose 4. Allergy Clinical implication Motor examination Reffered pain Trigeminal neuralgia Jaw jerk reflex Anatomic variation Age changes
- 69. Nerve injury Direct injury Lesion associated with anesthetic technique Effect of irrigants Effect of sealer Effect of obturating material Lesion associated with implant surgery Lesion associated with third molar removal Effect of mandibular fracture Conclusion References
- 70. Needle breakage Occures at the hub Causes Intentional bending Sudden unexpected movement of patient Forceful contact with bone Management Refer to oral surgeon Locate the fragment Remove under anesthesia Prevention Don’t use short or 30 gauge needle Do not insert to its hub Do not bend
- 71. Prolong anesthesia or paresthesia Persistent anesthesia or altered sensation beyond the expected duration Causes Trauma to the nerve Contamination with alcohol Insertion of needle into foramen Hemorrhage around neural sheath Problems Self inflicted injury Hyperesthesia Management Resolve within 8weks Tincture of time
- 72. Facial nerve paralysis Cause Introduction of LA into the capsule of parotid gland Over insertion of needle Problems : unilateral paralysis of face Management Contact lenses should be removed Eye patch applied
- 73. Trismus It is prolonged tetanic spasm of the jaw muscles by which normal opening of the muscle is restricted Causes Trauma to muscles or blood vessel Contaminated solution Management Heat therapy Analgesics Muscle relaxants (diazepam)
- 74. Soft tissue injury Seen in younger children, disabled children Management Analgesics Lukewarm saline rinse for swelling Antibiotics Lubricants application
- 75. Hematoma Localized collection of extravasated blood. Cause : injection into vessels Management Direct pressure application Don’t apply heat.it worsen the situation. Cold pack
- 76. Burning on injection Cause Acidic pH of the solution Rapid injection Contamination Management Buffering the LA Slowing the speed Infection Cause Contamination of needle before injection Prevention Avoid contamination Management Antibiotic analgesic
- 77. Edema Causes Trauma during injection Infection Allergy Hemorrhage Problem Airway obstruction Management Resolve on its own If produced by infection antibiotic is given Histamine blocker
- 78. Lidocaine 4.4 mg/kg With Adrenalin 7mg/kg Drug overdose Cardivascular effect CNS effect 1.8-5 anti dysarythmic action 4.5-7 cns depression 5-10 ecg alteration 7.5-10 tonic clonic >10 cardiac arrest >10generalized cns depression
- 79. Minimal to moderate overdose levels Talkativeness, apprehension, excitability Slurred speech, euphoria, nystagmus, sweating, vomiting Disorientations, loss of response to painful stimuli elevated blood pressure, heart rate Moderate to high overdose levels Tonic clonic seizure followed by CNS depression
- 80. Allergy 1. Early phase: skin reactions Pruritus, erythema, urticaria, nausea, vomiting Inflammation of nose & mucous membrane 2. Gastrointestinal & genitourinary disturbances Abdominal cramp, diarrhea Fecal & urinary inconsistence 3. CVS symptoms Pallor, palpitation, tachycardia PRURITUS URTICARIA
- 82. Motor examination of mandibular nerve For temporalis muscle – hollowing out of temporal fossa For masseter – clenching of jaw Tensor tympani – hyperacusis Pterygoid – sidewise movement of jaw video
- 83. Referred pain Cancer of tongue Effect on lingual & Auriculotemporal nerve Pain radiate to ear & temporal fossa Rx – sectioning of lingual nerve
- 84. Jaw jerk reflex Both afferent & efferent path supplied by mandibular nerve Tapping of chin causes contraction of masseter muscle. Unilateral lesion cause depression of reflex Bilateral supranuclear lesion causes accentuated response.
- 85. Trigeminal neuralgia Synonym – TIC DOLOUREUX (Nicholas Andre,1756) ,prosoplegia. Peripheral disease affecting sensory root. Sudden attack of severe pain. Etiology : usually idiopathic, demyelination, petrous ridge compression, intracranial tumor.
- 86. Clinical features Unilateral, short, stabbing severe pain. F > M Right > left Don’t occur during sleep. TRIGGER ZONE Central portion of face Nasolabial fold Lip, periorbital area tongue
- 87. Differential diagnosis Migraine Sinusitis Dental pain Trotters syndrome
- 88. Management Medical • carbamazepine • Gabapentin • Baclofen • Sodium valporate Surgical • Glycerol injection • Microvascular decompression • Percutaneous rhizotomy • Gamma knife radiosurgery
- 90. Anatomic variations Bifid mandibular nerve Trifid mandibular nerve Accessory mandibular foramen Accessory mylohyoid nerve Retromolar foramen Contralateral innervation of anterior teeth Various shape of canal – round, tear drop & dumbbell shape
- 91. Bifid mandibular canal Prevalence = 0.5-0.9% ajith A et al ’05
- 95. Age changes Degeneration Decrease number of myelinated fiber
- 96. Nerve injury
- 97. Direct injury
- 99. 1. Lesion associated with anesthetic technique Due to direct injury with needle- lingual nerve Due to anesthetic solution- articaine Anxious patient, unexpected movement
- 100. 2.Lesion related to Endodontic procedure A. Position of tooth B. By periapical infection C. By biomechanical preparation D. By irrigating solution E. By root canal sealer F. By gutta percha
- 101. Proximity of root apex The proximity of the roots of the 2nd premolars and 1st and 2nd molars Causes paresthesia to avoid techniques of hot condensation Use of MTA sealed apex
- 102. 4 possible types of factors that can cause tissue damage and lead to develop symptoms: 1. Chemical factors because of the neurotoxic effects of sealer or irrigating solutions. 2. Mechanical trauma from over-instrumentation 3. A pressure phenomenon from the presence of core filling material or sealer within the inferior alveolar canal 4. Overheating of tissues because of incorrect warm condensation techniques (Nikolaos et al,2017)
- 103. Effect of Biomechanical Preparation & Obturation Direct damage during BMP Reversible and irreversible blockage of nerve conduction or by alteration of the nerve membrane potential Disruption of apical constriction Repair by scarring
- 104. Irrigation Hypochlorite accident When apical foramina has been destroyed Extreme pressure Binding of the needle
- 105. Root canal sealer Factors increase the risk of sealer extrusion Over-instrumentation The complexity of the anatomy of the root canal system, Excessive amount of sealer, Excessive compaction force, Hydrostatic pressure, The use of lentulo spirals, Immature canal apices or root tip resorption
- 106. Experimental studies have shown that sealers which contain both eugenol and paraformaldehyde were the most toxic could inhibit conduction of the action potential of the nerves Paraformaldehyde is a potent neurotoxin and may cause chemical destruction of the nerve axon because of its gaseous nature Brodin et al. reported that Endomethasone can irreversibly inhibit the conduction in the rat phrenic nerve.
- 107. 3. Lesion due to dental implant surgery Due to inadequate radiological & clinical diagnosis Recklessness of clinicians Length of implant
- 109. 4. Lesion related to third molar removal surgery Due to inexperienced clinician Loss of integrity of cortical bone of inferior alveolar canal. Proximity of the canal with tooth. When path of lingual nerve is in retromolar pad area
- 110. Preventive method Coronectomy Wang et al. proposed the use of orthodontic traction Tolstunov et al. proposed pericoronal osteotomy
- 111. a) Coronectomy
- 114. 5. Mandibular fractures In a study conducted by Bede et al. found that linear displacement and comminuted fractures caused more nerve lesions longer period of recovery. Recovery of nerve function in 91% of cases was obtained
- 116. Prevalence
- 117. Treatment of nerve lesion Administration of vitamin B12 Microsurgery
- 118. Conclusion Mandibular nerve is principal nerve supply of mandible. As an endodontist we should have thorough knowledge of distribution. We should be careful while performing any endodontic procedure, be it nerve block, BMP, sealer application or obturation.
- 119. References 1. Gray’s anatomy – 3rd edition 2. Chaurasias human anatomy – 5th edition 3. Handbook of local anesthesia – Malamed 1st edition 4. Manual of local anesthesia in dentistry – AP Chitre 5. Atlas of human anatomy – Netter 6. Journal of endodontics 7. Pubmed 8. www.google.co.in
Editor's Notes
- Mn has large sensory and small motor root.
- Intracranial course and Extra-cranial course. SEE THE VIDEO
- Mandibular teeth & gingiva. Skin of temporal region, auricle. Lower lip, lower part of face. Muscles of mastication. Anterior 1/3 of tongue.
- Supplies dura of middle cranial fossa.
- Gives motor root to otic ganglion that does not relay & supplies tensor vali palatine & tensor tympani
- Superficial head & deep head. Fibers runs downward & backwards.
- Fibers runs backwards & laterally for insertion
- Also supply TMJ
- Superficial & deep head from deep surface Superficial fiber runs downward n bkward at 45 Deep fibr run vertically
- Lower part – by great auricular & auricular branch of vagus nerve. Also supplies secretomotor to parotid & TMJ
- Fibers of chorda tympani which is secretomotor to submandibular & sublingual gland & gustatory to ant 2/3rd of the tongue are distributed through lingual nerve.
- Accompanied by the inf alveolar artery. Mylohyoid nerve pierces sphenomandibular ligament with mylohyoid artery , runs along the mylohyoid groove. Supplies to ant belly of digastric.
- Situation- jus below foramen ovale. Medial to mandibular nerve, lateral to tensor vali palatine. Surrounds nerve to lateral pterygoid.
- Area of injection landmark procedure
- Place figure at mucobuccal fold at first molar area. Run anteriorly till concavity or irregularity felt.
- Given by George albert Edwards gow gets from australia
- Keep pt mouth open for 1-2 mins Failure happens due to closure of mouth.
- Given by joseph akinosi. In 1960 similar method ws given by Vazirani. So the name. In 1992 wolf gave modification. Needle is bended 45 degree
- Described as Peridental injection in 1912-1923. Regained popularity in 1980 coz of manufacturer Greatest benefit- provide pulpal & soft tissue anesthesia in localized area. Malamed reported a clinical trial- shows 74% pt preffered pdl inj. Coz lack of lingual & labial soft tissue anesthesia.
- Specialized technique uses STA (single tooth anesthesia ) device C-CLAD computer controlled LA delivery
- injection in the first stage 3–6 mm distance, second stage 12 mm distance, and in the third stage 24 mm distance of needle insertion
- Nystagmas- disorder of ocular motor instability resulting in spontenious involuntary ossilation of eye
- Anphylactic or hypersensitivity rxn Cytotoxic rxn Immune complex mediated Cell mediated PREVENTION- ASK HISTORY BEFORE. USE H1 BLOCKER. GA OR ESTER LA
- Ueda et al. [12] classified IAN canal into three groups according to its morphology: round/oval, teardrop, and dumbbell shapes
- We concluded that Goto's modification of Masson-Goldner's goto stain method is the best staining method at present for the morphometric evaluation of nerve fibers'''')
- lidocaine was involved in 25%, articaine in 33% and prilocaine in 34% of cases with paresthesiae. However, the study of Hillerup et al. [8] concludes that articaine provokes a higher Neurotoxicity. Injection of local anesthetic solutions contaminated by alcohol or sterilizing solution may produce irritation resulting in edema and increased pressure, leading to paresthesia. Alcohol, especially, is neurolytic and can produce paresthesia lasting for months to years. Another factor to consider is trauma to the nerve sheath by the needle. In these cases, the patient reports the sensation of an electric shock. Hemorrhage into or around the neural sheath may increase pressure on the nerve and lead to paresthesia.22
- The proximity of the roots of the 2nd premolars and 1st and 2nd molars, should remind us of the possibility of nerve damage as a result of a little careful manipulation of endodontic filling materials. If there is a very close relationship, we should question the need to avoid techniques of hot condensation, which are potentially more extrusive and require greater control, as well as to assess the proper caliber of the apex. In these cases, the MTA sealed apex can avoid uncomfortable complications [15]. .Paresthesia resulting from periapical pathosis or various stages of root canal treatment is of great importance in the field of endodontics.
- Grossman found that repair of mechanical damage to the IAN by scarring can cause immediate but temporary paresthesia. Furthermore, excessive preparation of the root canal often results in disruption of the apical constriction,25 which in turn, is responsible for extrusion of irrigants, medicaments and obturation materials (gutta-percha and sealer) into the periapical region and subsequent chemical and mechanical nerve injury.
- NaOCl beyond the apical foramen may occur in teeth with wide apical foramina or when the apical constriction has been destroyed during root canal preparation or by resorption. In addition, extreme pressure during irrigation or binding of the irrigation needle tip in the root canal leaving no room for the irrigant to leave the root canal coronally may result in large volumes of the irrigant contacting apical tissues. If this occurs, the excellent tissue-dissolving leads to tissue necrosis.
- Commonly happens for premolar n molar Many authors believe that the extruded root canal filling material does not remain in one specific area of the antrum and acts as a foreign body. The ciliated mucosal cells tend to move it towards the natural orifice, which may then become occluded13. Stasis of secretion leads to an anaerobic condition which favors the growth of Aspergillus spores. In most cases, Aspergillus infection is caused by root canal filling materials which contain zinc oxide-eugenol (ZOE) and paraformaldehyde that are accidentally introduced into the sinus. The results are reactions of inflammation and the blocking of ciliary movement.
- contain both eugenol and paraformaldehyde, such as Endomethasone and N2 The pain can be spontaneous, intermittent, or permanent. Eating, speaking, cold, or heat may trigger its onset. The patient may also complain of a burning sensation, a feeling of ‘pins and needles’, or pressure on the teeth18. Pain can be accompanied by local inflammatory signs with the tooth painful on percussion, painful upon palpation of the buccal alveolar process or a combination of signs of mechanical trauma and inferior dental nerve inflammation with pain or numbness of the lower lip.
- in cases of severe mandibular atrophy, the use of short implants constitute a valid alternative
- Long et al. [23] carried out a systematic review of this alternative technique. They concluded that coronectomy allows, in a high percentage, the migration of the remaining roots away from the path of the nerve,.
- Wang et al. [29] and Bonetti et al. [30] propose the use of orthodontic traction for a period of 3 to 10 weeks, placing microimplants or orthodontic brackets in antagonistic maxillary molars for third molars disimpaction. Once the third molar roots are away from the canal, then they extract them, thus preventing the nerve injury [29,30.
- Tolstunov et al. proposed an alternative to coronectomy, called pericoronal ostectomy that achieves satisfactory results with only temporary neurodeficiency. This technique is performed by means of an osteotomy at the level of the clinical crown; then, we wait for a third molar eruption