Mang of Impacted Teeth

For Personal Use Only
Library of School of Dentistry, TUMS

A
Practical Guide to the
Management of Impacted Teeth
A
Practical Guide to the
Management of Impacted Teeth
K George Varghese MDS DSS (Vienna)

Vice Principal
Professor and Head
Department of Oral and Maxillofacial Surgery

Government Dental College, Kottayam
Kerala, India
Foreword
Kishore Nayak
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A Practical Guide to the Management of Impacted Teeth

© 2010, Jaypee Brothers Medical Publishers (P) Ltd.
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by
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the publisher.
This book has been published in good faith that the material provided by contributors is original. Every effort is made to ensure
accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error (s). In case of any
dispute, all legal matters are to be settled under Delhi jurisdiction only.
First Edition: 2010
ISBN 978-81-8448-878-4
Typeset at JPBMP typesetting unit

Printed at Ajanta Offset
This book is dedicated to
the loving memory my parents
and my esteemed teachers
who have made me what I am today,
to my students who gave me the impetus for learning

and to my colleagues who provided me with support

with
Love and Respect
Contributors
SECTION 1: Dr K George Varghese MDS, DSS (Vienna), Vice Principal and Professor, Department of Oral and
Maxillofacial Surgery, Government Dental College, Kottayam, Kerala, India.
SECTION 2: Chapters 16, 18, 21, 22, 23, 24, 25
Dr K George Varghese
Chapter 17: Dr LS Sreela MDS, Head of the Department of Oral Medicine and Radiology, Government Dental
College, Kottayam, Kerala, India.
Chapter 19: Dr George Philip MDS, FDSRCS (UK), FFDRCS (Ire), Assistant Professor, Department of Oral and
Maxillofacial Surgery, Government Dental College, Kottayam, Kerala, India.
Chapter 20: Dr Elbe Peter MDS, Assistant Professor, Department of Orthodontics, Government Dental College,
Kottayam, Kerala, India.
Foreword
I am delighted to write the foreword for this wonderful book written by Dr George Varghese. Oral and Maxillofacial
Surgery has progressed to a multi-faceted specialty with scope of work ranging from minor oral surgery to major
facial ablative and reconstructive procedures. What is frequently overlooked is the fact that dento-alveolar surgery
constitutes the bulk of the work for practitioners the world over. In the light of this fact, this book certainly fills a
void that many recent publications have failed to do and provides marvelous attention to detail to an area of our
profession that many of us take for granted.
The first five chapters of the book devote attention to not just the etiology and indications but provide a wonderful
description of the development and applied anatomy of the third molar in truly descriptive yet delightful way! The
routine and sometimes seemingly mundane details of instrumentation and surgical procedures have been dealt
with “clinical” precision with the added sections on drug therapy and complications make it extremely comprehensive.
The concluding chapter in Section 1 on recent advances provides a thought provoking conclusion to the saga of the
impacted tooth which will certainly prove stimulating to the reader who will then certainly want to think beyond
the book.
The second section of the book delves into the intricacies of the impacted canine in every way possible. It makes
a wonderful case and distinction between the modalities of management rather than focus of just description of
surgical removals. That is what makes a refreshing change in approach in this textbook. The concluding chapters on
autotransplantation, surgical repositioning and supernumerary teeth make the textbook an absolutely all-inclusive
one.
Who should be reading this book? Almost certainly all students of dentistry both post and undergraduate, will
benefit immensely from the text. It will also serve as a great refresher to all practitioners in the field of dentistry and
oral surgery who will want to read this in order to provide a broad update to this important part of their practices.
Kishore Nayak
MDS FDS RCS (Eng), FFD RCS (Irel), FDS RCPS (Glas)
Consultant Maxillofacial Surgeon, Bangalore, India
Past President, Association of Oral & Maxillofacial Surgeons of India (AOMSI)
President-Elect, International Association of Oral & Maxillofacial Surgeons (IAOMS)
Preface
The steady growth of various dental specialties witnessed in the last century is continuing unabated in this century
also. This is evidenced by the development of newer subspecialties in dentistry like cosmetic dentistry and
implantology. However, oral surgery and dentoalveolar surgery that is considered as one of the oldest branches of
dentistry has not lost its relevance today. Rather it still remains the core of general dental practice.
Impacted teeth and their management is one of the difficulties that general dental practitioners face in the practice
of oral surgery. Though one covers the theoretical aspects on the management of impacted teeth during the under-
graduate studies, the applied part very often comes only in the actual clinical practice. Naturally doubts may arise
regarding the management of different problems. This book is intended as the name suggests to be a practical guide
on the management of different problems related to impacted tooth that the practitioner faces in the day today
practice.
Our first book titled A Handbook on the Management of Impacted Teeth published in 2002 was well received by the
dental fraternity so much so that now the book is out of print. Since then there has been numerous requests from our
colleagues, students and general dental practitioners for a more detailed one highlighting the practical aspects of the
topic. Hope this book will reach up to your expectations.
This book has been divided into two sections. The first section illustrates the management of impacted third
molar and the second section deals with the management of impacted canine. In addition section two has chapters
on the management of impacted premolars and supernumerary teeth. Special emphasis has been given for the
localization of impacted teeth and its relationship to adjoining structures using modern imaging modalities. Similarly
instruments required for the surgical removal is also included as a separate chapter.
Though this book is intended for the general dental practitioners and the undergraduate students this will be a
handy guide for the postgraduates too.
There may be errors of omission and commission. Any comments and suggestions for improvement are welcome.
Praying for your blessings, wholehearted support and cooperation.
K George Varghese
Acknowledgments
At the outset we thank the God Almighty, Who has made our dream of writing this book a reality. Nothing is
possible without His blessings.
I acknowledge with great respect my postgraduate teacher Dr PI John, former Professor and Head of the
Department of Oral and Maxillofacial Surgery, Government Dental College, Thiruvananthapuram for teaching the
basics of maxillofacial surgery and who inducted me into the specialty.
I am indebted to Dr VK Kuriakose (late) whom I consider as my mentor. Under his guidance I started my career
as a maxillofacial surgeon.
My deep appreciation to the contributors viz. Dr LS Sreela, Dr George Philip and Dr Elbe Peter whose untiring
efforts have made this possible.
I express my gratitude to Sri Thankappan, Artist, Medical College Kottayam for the neat and timely completion
of the drawings for the book.
My special thanks to my wife Alice, my daughter Rose and my son Mathew for their constant support and
encouragement to accomplish this endeavor.

I am also grateful to M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, who encouraged me to write
this book and for publishing it. I am extremely thankful to Shri Jitendar P Vij (CMD), Mr Tarun Duneja (Director-
Publishing) for taking the initiative to publish the book well in time. I owe a great deal to Shri Jose Sebastian, Branch
Manager and Shri Jagadeesh S, Marketing Manager, Kochi for the excellent liaison between the publisher and myself
as well as for their help and friendship.
Contents
SECTION 1: MANAGEMENT OF IMPACTED THIRD MOLAR

1. Introduction .................................................................................................................................................................... 3
2. Why Teeth Get Impacted? .......................................................................................................................................... 10
3. Why Do We Remove Impacted Teeth? .................................................................................................................... 16
4. Development of Mandibular Third Molar ............................................................................................................... 26
5. Surgical Anatomy ........................................................................................................................................................ 29
6. Preoperative Planning................................................................................................................................................. 40
7. Instrument Tray Set-up ............................................................................................................................................... 62
8. Operative Procedure ................................................................................................................................................... 71
9. Other Methods for Removal of Impacted Lower Third Molar ............................................................................. 88

10. Surgical Removal of Impacted Maxillary Third Molar ........................................................................................ 101
11. Postoperative Care and Instructions ....................................................................................................................... 114

12. Drug Therapy ............................................................................................................................................................. 117
13. Complications of Impaction Surgery ...................................................................................................................... 123
14. Ectopic Teeth and Unusual Cases ........................................................................................................................... 153
15. Recent Advances and the Future of Third Molars ................................................................................................ 157
SECTION 2: MANAGEMENT OF IMPACTED CANINE

16. Introduction ................................................................................................................................................................ 163
17. Localization of Impacted Canine ............................................................................................................................. 169
18. Modalities of Management of Impacted Canine ................................................................................................... 182
19. Surgical Exposure of Impacted Maxillary Canine ................................................................................................ 185
20. Orthodontic Eruption of Impacted Canine ............................................................................................................ 199
21. Surgical Removal of Palatally Impacted Maxillary Canine ................................................................................. 211
22. Removal of Labially Positioned Impacted Maxillary Canine ............................................................................. 221
23. Management of Impacted Mandibular Canine ..................................................................................................... 230
24. Surgical Repositioning/Autotransplantation ......................................................................................................... 238
25. Unerupted and Impacted Supernumerary Teeth ................................................................................................. 241
Index ............................................................................................................................................................................. 245

Section 1
Management of Impacted Third Molar

Chapter 1 Introduction
Chapter 2 Why Teeth Get Impacted?
Chapter 3 Why do We Remove Impacted Teeth?

Chapter 4 Development of Mandibular Third Molar
Chapter 5 Surgical Anatomy
Chapter 6 Preoperative Planning
Chapter 7 Instrument Tray Setup
Chapter 8 Operative Procedure
Chapter 9 Other Methods for Removal of Impacted Lower Third Molar
Chapter 10 Surgical Removal of Impacted Maxillary Third Molar
Chapter 11 Postoperative Care and Instructions
Chapter 12 Drug Therapy
Chapter 13 Complications of Impaction Surgery
Chapter 14 Ectopic Teeth and Unusual Cases
Chapter 15 Recent Advances and the Future of Third Molars
1 Introduction
Although the scope of oral and maxillofacial surgery has Third Molar'. It was the most extensive treatise on the
expanded in many directions recently, the mainstay of subject profusely illustrated.
practice remains dentoalveolar surgery. The atraumatic The term impaction is of Latin origin coming from
removal of impacted teeth is one of the most commonly the term 'impactus'. Its general usage is one which
performed surgical procedures in the specialty of oral and designates an organ or structure which because of an
maxillofacial surgery. A thorough theoretical knowledge abnormal mechanical condition has been prevented from
and adequate clinical training is essential to perform the assuming its normal position.
surgery successfully. A study by Berge (1995) has shown Webster defines an impaction as the wedging of one
that there is a four fold increase in the incidence of part into another. The medical dictionaries applying the
complications when the surgery was performed by the word to dentistry mention the lodging of a tooth between
general practitioner as compared that performed by the the jaw bone and another tooth.
oral surgeon. This difference in complication rates may Rounds (1962) 2 gave an explicit definition of
be explained by inadequate surgical training and lack of impaction as the condition in which a tooth is embedded
experience of the former. However, another study by Boer in the alveolus so that its further eruption is prevented.
M P et al (1995)1 has shown no statistically significant Archer (1975)3 defines impacted tooth as one which
difference in the mean complication rate when the surgery is completely or partially unerupted and is positioned
was performed by staff members and the rate when against another tooth or bone or soft tissue so that its
surgery was performed by residents. further eruption is unlikely.
It was Dr George B Winter who more than anyone The definition given by Lytle (1979)4 is closely related
else helped to rationalize the technique of removal of to that of Archer. Impacted tooth is one that has failed to
impacted mandibular third molar. Winter's treatise was erupt into normal functional position beyond the time
the result of intensive research which extended over the usually expected for such appearance. Eruption is
years. The first publication of his findings appeared in prevented by adjacent hard or soft tissue including tooth,
'Dental Items of Interest' under the title of 'Exodontia', a bone or dense soft tissue.
term which he himself has coined. In 1913, he published Andreasen et al (1997) 5 defines impaction as a
a large volume on the subject under that name. A revised cessation of the eruption of a tooth caused by a clinically
and much enlarged second edition was printed in 1926 or radiographically detectable physical barrier in the
and the title was changed to 'The Impacted Mandibular eruption path or by an ectopic position of the tooth.
4 A Practical Guide to the Management of Impacted Teeth
TOOTH ERUPTION mechanisms/theory explaining eruption and the

anatomical structures resisting eruption.
Teeth develop with in the alveolar bone. After the crown
formation is complete, the root begins to form and active
eruption moves the tooth towards its functional position Terminology
inside the mouth. Tooth eruption is thus defined as the
• An unerupted tooth is a tooth lying within the jaws,
movement of a tooth from its site of development within
entirely covered by soft tissue and partially or
the alveolar bone to its functional position in the oral
completely covered by bone. It is in the process of
cavity. During the eruption process, movement of the
eruption and is likely to erupt based on clinical and
tooth occurs in all three dimensions and at the same time
radiographic findings.
there is an increase in its size and that of the alveolar
• A partially erupted tooth is a tooth that has failed to
bone. Even though eruption of tooth is a continuous
erupt fully into a normal position. The term implies
process, it can be arbitrarily divided into the following
that the tooth is partly visible or in communication
six stages (Fig. 1.1):
with the oral cavity.
1. Pre-eruptive stage
2. Intra-osseous stage/Alveolar bone stage • A malposed tooth is a tooth which is in an abnormal
3. Mucosal penetration/Mucosal stage position in the maxilla or in the mandible.
4. Pre-occlusal stage • An impacted tooth is a tooth which is prevented from
5. Occlusal stage completely erupting into a normal functional position.

6. Maturation stage. This may be due to lack of space, obstruction by
It can be noticed that even after achieving occlusion, another tooth, or an abnormal eruption path.
a slow but continuous eruption occurs through out the • Primary retention occurs in syndromes where
lifetime. The normal eruption of the tooth can be osteoclastic resorption is deficient such as cleidocranial
interfered at any of the stages from one to four and an dysplasia and osteopetrosis.
impaction will result. • Secondary retention relates to a cessation of eruption
Although a number of theories had been put forth of a tooth after emergence, without a physical barrier
by various authors to explain the eruption of tooth, none in its path or ectopic position of the tooth. Clinically it
of these theories alone can explain the journey the tooth appears as an in eruption subsequent to emergence.
makes in its lifetime. However, root elongation, alveolar • Clinical emergence is the condition when the tooth
bone remodeling and periodontal ligament formation has pierced the mucosa.
explain tooth eruption most convincingly. Table 1.1 shows • Alveolar emergence is the piercing of the alveolar bone
the various eruption stages, the possible related eruption seen in a radiographic image.
Fig. 1.1: Schematic diagram showing different stages of eruption of tooth

Introduction 5
Table 1.1: Eruption stages, eruption mechanism and structures resisting eruption
Eruption stage Eruption mechanism/ Structures resisting

theory eruption
1 Pre-eruptive stage - -
2 Intra-osseous stage Vascular hydrostatic Bone
pressure Primary
Root formation predecessors
Bone formation (deciduous tooth)
3 Mucosal stage Vascular hydrostatic pressure Mucosa
Root formation
Bone formation
4 Pre-occlusal stage Vascular hydrostatic pressure Periodontal ligament
Root formation Mastication
Bone formation
5 Occlusal stage Root elongation Periodontal ligament
Bone formation Mastication
Occlusion
6 Maturation stage Root elongation Periodontal ligament
Bone formation Mastication

Occlusion
Obstruction of the Eruption Pathway collision is probably explained by the fact that
neither of the follicles can resorb the other, and
This can be considered under the following headings:
therefore the eruption of the involved teeth does
1. Lack of eruption space (crowding)
not occur. The treatment of the condition is the
2. Follicular collision
removal of one of the colliding tooth germs. The
3. Obstruction by physical/mechanical barriers such
decision is easy when one of the tooth germ is a
as scar tissue, fibromatosis, compact bone,
supernumerary, where as when both are
unattached mucosa, odontogenic cyst and tumors.
The diagnosis of the nature of obstruction to eruption permanent, the decision is often difficult.
pathway is by clinical and radiographic examination. 3. Obstruction by physical barriers: The eruption
Once the etiology is established, the treatment principle pathway may become obstructed by various
is to eliminate the cause and there by permitting the tooth obstacles such as odontogenic cysts or tumors,
to erupt normally. odontomes, eruption sequestra, compact bone,
1. Lack of eruption space (Crowding): In this situation supernumerary tooth, fibrous scar tissue, giant cell
an orthodontic evaluation is performed to assess fibromatosis, or unattached mucosa. The treatment
whether expansion can be tried to increase the space in general is the surgical removal of the obstructing
to accommodate the impacted tooth or whether the structure and to permit the eruption of tooth if
extraction of the impacted tooth or adjacent tooth possible. However, in conditions when the
is the treatment of choice. impacted tooth is associated with an odontogenic
2. Follicle collision: This is classically seen in the cyst or tumor it may have to be sacrificed along with
maxillary anterior region when a single super- the removal of the pathologic lesion.
numerary tooth can prevent the eruption of one or The modern concept of skillful and effective surgery
more permanent incisors. Another example is the of impacted tooth has not been one of spontaneous
collision between the second and the third molar generation. Instead, it is one of gradual evolution
tooth germs. The reason why impaction occurs in extending from the first surgical endeavor of prehistoric
times with its crude elements to the highly refined Archer observed impacted teeth occurring in the
techniques and precautionary measures that are accepted following order of frequency: maxillary third molars,
as ordinary requisites of today. The development of mandibular third molars, maxillary cuspids, mandibular
anesthesia, radiography, high speed rotary instruments bicuspids, mandibular cuspids, maxillary bicuspids,
and antibiotics provided the necessary tools to perform maxillary central incisors, and maxillary lateral incisors.
the surgery paying homage to the old saying, "tute cite et Bruce et al (1980)7 after analyzing 990 impacted
jucunde" i.e. safely, quickly, and pleasantly. mandibular third molars found that the incidence of
While some of the impacted teeth can be extracted vertical impaction is 29.8%, mesioangular impaction 38%,
easily by the use of an elevator, others require a more distoangular impaction 11.8% and horizontal impaction
difficult surgical exercise. Provided that the tooth is 20.4%. Horizontal and full bony impaction was found to
removed skillfully and the end result is acceptable to the be higher in the older age group than in the younger age
patient and the operator, then the method adopted can group.
be considered satisfactory. In a study of 425 Greek patients by Kamberos S
The most commonly impacted teeth are the (2002)8 with impacted teeth (202 male and 223 female)
mandibular and maxillary third molars and the maxillary aged between 18 and 75 years old it was found that out
canines. Rarely other teeth also get impacted like the of the 940 impacted teeth, 499 (53.08%) were found in
premolars; both maxillary and mandibular premolars and females and 441 (46,92%) in males. 406 (43.19%) impacted
also the second molars (Fig. 1.2).
teeth were found in the maxilla and 534 (56.81%) in the

mandible. 51 of the impacted teeth were in the anterior
part of the jaws (44 in the maxilla and 7 in the mandible)

whereas in the posterior area 889 cases of impacted teeth
were found (362 in maxilla, 527 in the mandible). The
majority of impacted posterior teeth were third molars.
Mandibular third molars were found to be the most
frequent impaction (54.04%), followed by the maxillary
third molars (37.55%) and canines (4.57%).
In a study of Hong Kong Chinese population by Chu
et al (2003)9 the records of 7486 patients were examined.
It was found that a total of 2115 (28.3%) patients presented
with at least one impacted tooth. Among the 3853
Fig.1.2: Radiograph showing impacted left mandibular second molar impacted teeth, mandibular third molars were the most
(black arrow) and left maxillary second premolar tooth (yellow arrow).
common (82.5%), followed by maxillary third molars
All other teeth have erupted and all the four-third molars are developing.
(15.6%), and maxillary canines (0.8%). The highest
incidence of impaction of 55.1% was found in 20-29 age
Incidence of Impaction
group.
Review of literature shows there is considerable variation
in prevalence of impacted tooth. This ranged from as low Management of Impacted Tooth
as 6.9% (Shah et al, 1978) to as high as 37.8% (Hugoson
and Kugelberg,1998) Even though surgical removal of impacted tooth is
Mead (1930)6 reported from a collection of dental considered as the standard method of management, the
radiographs of 6389 cases of which 1462 were full mouth following other methods also should be considered
radiographs of office patients and rest were radiographs depending upon the case:
of skulls obtained from Smithsonian Institution. Out of 1. Conservative method: Leaving the tooth alone with
the total of 581 impacted teeth, 461 (80%) teeth were third frequent follow up clinically and radiographically.
molars - 248 in the mandible and 213 in the maxilla. For example a deeply situated asymptomatic third
Among office patients 276 (18.8 %) had at least one molar may be left as such especially in an older age
impacted tooth. group patient.
Introduction 7
2. Operculectomy: Partially erupted mandibular third patients were surgically exposed and then
molar which has adequate space to erupt and when orthodontically guided to erupt. After the tooth has
its further eruption is prevented by thick overlying erupted, it was removed and periodontal
mucoperiosteum, operculectomy can be performed. parameters were measured on the second molar.
If the tooth still fails to erupt fully and remains as The authors concluded that this non-surgical
such with the crown in communication with oral removal of impacted mandibular third molars
cavity, it has to be considered for removal. avoided damage to the inferior alveolar nerve as
3. Autogenous transplantation: Occasional use of the well as prevented iatrogenic periodontal sequelae
third molar tooth when it is sound is used for (pocket formation) of the second molars.
autogenous transplantation; usually to a first molar 5. Eruption activating procedures: These may be tried
socket site. The low incidence of success with the for developing teeth when indicated. Table 1.2
procedure means it is not widely used except in shows the summary of eruption activating
special circumstances. procedures for developing permanent molars.
4. Orthodontic guidance: This is more useful in cases
of maxillary canine and to some extent in Table 1.2: Eruption activating procedures
for developing molars
mandibular canine when the tooth can be guided
into functional position in the arch. Orthodontic Eruption stage Intervention
guidance can also be considered in selected cases
1 Intraosseous stage a. Mucosa + bone removal

of impacted premolars and to a lesser extent to
b. Mucosa + bone + follicle
impacted mandibular molars (Figs 1.3A and B)
removal
Chechi et al (1996)10 reported a case of combined c. Surgical repositioning
surgical orthodontic approach for successfully d. Space augmentation
erupting an impacted lower third molar tooth e. Removal of obstacles
showing close relationship to inferior alveolar canal preventing eruption
and its subsequent removal. The authors claimed 2 Mucosal stage a. Mucosa removal
that the procedure avoided injury to inferior b. Space augmentation
alveolar canal.
3 Preocclusal stage a. Orthodontics
Similar studies were conducted by Hirsch et al b. Space augmentation
(2003).11 Impacted mandibular third molars in 18
Figs1.3 A and B: Steps in combined surgical orthodontic eruption of impacted mandibular third molar: (A) Periapical X-ray showing orthodontic
bracket attached to impacted molar tooth after surgically exposing the crown, (B) Periapical X-ray showing orthodontically assisted eruption
of tooth.
Burden on Health Care Delivery patients present in middle age and beyond with acute
problems arising from their third molars; at this time not
The surgical removal of impacted teeth is one of the four
only their bone but also their cardiovascular system is
surgical operations included in both top 10 day case and
brittle. Their reduced power of recovery are such that
inpatient NHS procedures in England. Shepherd et al
what is an unpleasant experience in the late teens and
(1994)12 quoting the Department of Health, UK reported
early twenties can become a major surgical problem with
that in the 1989-90 period more than twice as many people
hazards of mandibular fracture, nerve damage, and
(60,000) were admitted for the surgical removal of teeth
as were treated as day cases (28, 000). In addition, 67,000 anesthetic and medical complications.
people had their third molars removed by dental There is no reliable research evidence to support the
practitioners in the general dental service and 22,000 had prophylactic removal of disease-free impacted third
their third molars removed in the private sector. Third molars. Available evidence suggests that retention may
molar surgery has been estimated to cost the NHS in be more effective and cost-effective than prophylactic
England up to £30 million per year and approximately removal, at least in the short to medium term. However,
£20 million is spent annually in the private sector. In the the concept of prophylactic surgery need not be totally
hospital service, patients waiting for third molar removal abandoned. Each case necessitates careful thought and
account for up to 90% of patients on waiting lists in oral discussion with the patient, who should be well informed
and maxillofacial surgery. Shepherd et al (1994)12 pointed because our patients will grow older and the full
out that considering the enormity of expenses involved consequences of some of our decisions are still to come.
in the surgical removal of impacted tooth, the wholesale
removal of unerupted teeth prophylactically seems as Summary

inappropriate as the wholesale removal of tonsils and
adenoids. Currently in developed countries like UK in Third molars or wisdom teeth generally erupt between
terms of health gain, the scales are loaded against the ages of 18 and 24 years. However, sometimes they
intervention even in the presence of mild pericoronitis. fail to erupt because they are either absent or impacted.
An impacted third molar tooth that fails to attain a
Controversies on Prophylactic Removal functional position can cause infection, unrestorable
of Third Molars caries, periodontal disease, cysts, or tumors. The impacted
third molar tooth can be managed conservatively, or
Longitudinal studies show that the prevalence of disease alternatively, removed by surgical extraction, a common
associated with third molars peaks at ages 18-25 and that oral surgical procedure, which can be carried out by
impacted third molars that are free of disease in middle- general dental practitioners or by oral surgeons. Other
aged people can be safely left in situ because disease rarely procedures include operculectomy, which can be
develops and is usually minor when it does. A substantial considered in carefully selected cases with the proviso
number of impacted third molars erupt, given the chance. that subsequent removal of the tooth may be required.
Malpositioned third molars are often valued by Surgical exposure or surgical reimplantation/
restorative dentists in the construction of bridges, transplantation may be appropriate treatment in selected
dentures, and over-dentures for older people.
cases.
Points in favor of prophylactic removal are that
surgery becomes increasingly difficult with advancing
age. Before the mid-twenties, an impacted tooth once REFERENCES
mobilized during surgery, can be easily dislodged from
1. Boer MP, Raghoebar GM, Stegenga B, Schoen PJ, Boering
the socket. After this age a greater effort is required to G Complications after mandibular third molar extraction.
disrupt the attachment. From middle age onwards the Quintessence Int 1995; 26(11):779-84.
bone of the jaw becomes progressively harder and more 2. Rounds C.E. Principles of Exodontia, edn.2, St. Louis, C.V.
brittle so that in elderly people the greater part of the Mosby Co. 1962.
socket may have to be removed before the tooth will move 3. Archer William H. Oral and Maxillofacial Surgery, Vol. I,
without fracture. More over, significant number of ed. 5, Philadelphia, WB Saunders Co. 1975.
Introduction 9
4. Lytle JJ. Indications and contraindications for removal of 9. Chu FCS, Li TKL, Lui VKB, Newsome PRH, Chow RLK,
impacted tooth. Dent Clin of North Amer 1979; 23 (3): Cheung LK. Prevalence of impacted teeth and associated
333-46. pathologies—a radiographic study of the Hong Kong
5. Andreasen JO, Petersen JK, Laskin DM. Textbook and Chinese population. Hong Kong Med J 2003; 9:158-63.
Color Atlas of Tooth Impactions, edn.1, Copenhagen, 10. Checchi L, Bonetti Alessandri G, and Pelliccioni GA.
Munksgaard 1997. Removing high-risk impacted mandibular third molars: a
6. Mead SV. Incidence of impacted teeth. Int Jl Orthodontia surgical-orthodontic approach J Am Dent Assoc 1996;
1930; 16: 885-90.
127(8):1214-17.
7. Bruce AA, Frederickson GC, Small GS. Age of the patient
11. Hirsch A, Shteiman S, Boyan BD, Schwartz Z. Use of
and morbidity associated with mandibular third molar
Orthodontic Treatment as an Aid to Third Molar Extraction:
surgery. Jl Amer Dent Assoc 1980; 100 (2): 240-45.
8. Kamberos S, Mamalis A, Gisakis I, Kalyvas D. The A Method for Prevention of Mandibular Nerve Injury and
Frequency of Impacted Teeth in Greek Population. Clinical- Improved Periodontal Status. Journal of Periodontology.
Statistical-Radiographic Study of 940 Cases of Impacted 2003; 74 (6):887-92.
Teeth. Hellenic Arch Oral Maxillofac Surg 2002; 3(1): 12. Shepherd JP, Brickley M. Editorial - Surgical removal of
49-58. third molars BMJ 1994; 309:620-21.
2 Why Teeth Get Impacted?
The third molars or the wisdom teeth normally erupt last, primitive which requires lot of mastication. Nodine
between 18 and 25 years of age. Since they erupt at about suggests that the major cause of aberrant or impacted
the time when the youth goes off into the world to become teeth in the adults of Western Europe, United Kingdom,
'wise' the name 'wisdom teeth' was used to describe them. United States and Canada are artificial feeding of babies,
A number of theories has been put forth to explain intake of soft diet like biscuits, toffees and intermarriage
the phenomenon of impaction. The most commonly between different races.
accepted ones are the following: Berger (1930)2 lists the following local causes of
1. Discrepancy between the arch length and the tooth impaction:
size. 1. Irregularity in the position and pressure of an
2. Differential growth of the mesial and distal roots. adjacent tooth.
3. Retarded maturation of the third molar—dental 2. The density of the overlying or surrounding bone.
development of the tooth lags behind the skeletal 3. Long continued chronic inflammation with
growth and maturation. resultant increase in density of the overlying
4. Incidence of extraction of permanent molars is mucous membrane.
reduced in the mixed dentition period, thus 4. Lack of space due to under developed jaws.
providing less room for eruption of third molars. 5. Unduly long retention of the primary tooth.
This is very relevant in the present day due to 6. Premature loss of primary tooth.
increased awareness of the population and dental 7. Acquired diseases such as necrosis due to infection
treatment started early in childhood. or abscess
5. Evolution theory. Impaction may also be found where no local
6. Lack of development of jaw bones due to predisposing conditions are present.
consumption of more refined food which causes According to Berger the following are the systemic
lack of functional stimulation to the growth of jaw causes of impaction:
bone. A Prenatal causes: Hereditary and miscegenation
This theory is strengthened by the facts brought out B Post natal causes: Rickets, anemia, congenital syphilis,
by Nodine (1943)1. He noticed that Eskimos of the north, tuberculosis, endocrine dysfunction, malnutrition.
Australian Aborigines of the south and Indians of Mexico C Rare conditions: Cleidocranial dysostosis, oxycephaly,
did not have impacted teeth. Their food was found to be progeria, achondroplasia, and cleft palate.
Why Teeth Get Impacted? 11
EVOLUTION THEORY civilized races of man. … They do not cut through the gums
till about the seventeenth year, and I have been assured
Evolutionists have taught that humans evolved from ape- that they are much more liable to decay, and are earlier
like ancestors that possessed larger jaws and teeth than lost than the other teeth; but this is denied by some eminent
us. The evolution has produced 'an increase in brain size dentists. They are also much more liable to vary, both in
at the expense of jaw size (MacGregor,1985).3 In the structure and in the period of their development, than the
process of evolution the jaw has become smaller, allowing other teeth. In the Melanin races, on the other hand, the
less room for the third molars to erupt and causing wisdom-teeth are usually furnished with three separate
numerous dental problems. Our better understanding of fangs, and are generally sound; they also differ from the
the complex teeth-jaw relationship has revealed this other molars in size, less than in the Caucasian races.
explanation is far too simplistic. Research now indicates Professor Schaaffhausen accounts for this difference
that the reasons for most third molar problems today are between the races by "the posterior dental portion of the
not due to evolutionary changes but other reasons. These jaw being always shortened"... I am informed by Mr Brace
reasons include a change from a coarse abrasive diet to a that it is becoming quite a common practice in the United
soft western diet, lack of proper dental care, and genetic States to remove some of the molar teeth of children, as
factors possibly including mutations. It was a common the jaw does not grow large enough for the perfect
practice in the past to routinely remove wisdom teeth. development of the normal number.'
Recent research has concluded that this practice is unwise.
The third molars are often labelled vestigial (of use

Antagonistic View to Evolution Theory
in the past but not today) and used as evidence to support
human evolution from a hypothetical less evolved The conclusion that a smaller jaw cannot contain the large
primate ancestor. The vestigial organ view was expressed teeth we inherited from our ancestors, and consequently
by Durbeck (1943).4 “It is a well-known fact that nature tries wisdom teeth are not needed, has recently been
to eliminate that which is not used … Likewise, civilization, challenged on several fronts. Macho and Moggi-Cecchi
which has eliminated the human need for large, powerful jaws, (1992)8 concluded that compared to other primates the
has decreased the size of our maxillae and mandibles. As a direct third molars are the smallest in Homo sapiens. Further,
result, in a surprisingly large number of adults, the lower third if the third molars are forced to develop in a more
molar occupies an abnormal position and may be considered a restricted space they tend to be smaller than anterior teeth
vestigial organ without purpose and function. This has been and in humans this reduction often leads to agenesis of
termed the phylogenic theory. It implies that, because the third molars.9 Corruccini (1991)10 observed that dental
throughout the history of man the jaws decreased in size from crowding in whites seems to be more related to smaller
a lack of function, some present-day adults do not have room alveolar space than to smaller jaws overall or to larger
for a full complement of teeth, and the third molar, being the teeth. Furthermore, in an extensive study of aberrant
last to erupt, is denied room to accommodate itself.” maxillary third molars, Taylor (1982)11 found a lack of
The loss of an organ in evolution purely as a result of evidence for a genetic trend towards elimination of the
disuse, also called Lamarckian Evolution, has now been third molar from human dentition as assumed by many
thoroughly disproved. The belief that wisdom teeth are evolutionists. It is now widely acknowledged today that
vestigial organs that lack a function in the body is less these teeth are not rudimentary or vestigial: they aid in
common today. chewing our food as do all of our other 28 teeth. The
The putative problem is that humans today have outdated vestigial organ conclusion, though, has
smaller jaws but just as many teeth as their evolutionary influenced the extraction of billions of teeth, the removal
antecedents (Sakai, 1981).5 The result is the common of many which may have been unnecessary according to
assumption that most humans do not have enough room current research (Leonard, 1992).12
in their mouth for wisdom teeth which lack a function and Wisdom teeth extraction was for many years one of
only cause us much health trouble (Schissel, 1970).6 This the more common surgical interventions in the Western
view was evidently first widely propounded by Darwin world (Ganss, 1993).13 Leff (1993)14 and others claim that
(1896),7 who concluded: '... the posterior molar or wisdom- a significant percent of third molars that are extracted
teeth were tending to become rudimentary in the more could be saved. This observation is supported by the fact
that extraction rates are influenced by local beliefs and vary widely in all races. Studies by Chung( 1970)26 and
for this reason vary considerably (Singh, 1996).15 In Neiswander (1975)27 found significant differences in
America some estimate 20% of all young people with mandibles existed in the population they studied which
otherwise healthy teeth develop impacted wisdom teeth was evidently due to a dominant gene which produced
requiring medical attention, yet in the past some estimate different risks of malocclusion. In another study of race,
nine out of ten American teenagers who have dental Barrett ( 1957)28 did not find a single case of an impacted
insurance lost their wisdom teeth.16 One report concluded third molar in his sample of 69 adult Yeundumu
the cost of this operation may exceed that of most routine Aborigines. Yeundumu generally have large maxillary
medical or dental procedures. (Tulloch et al, 1987)17 sinus but they also usually have large teeth. A problem
Many dentists once routinely advised extraction of may result when either intergroup or intragroup marriage
all wisdom teeth, regardless of whether they were causing produces a child with large teeth and a small maxillary
problems-some even routinely removed wisdom teeth sinus which causes crowding, or a large maxillary sinus
during adolescence if it only appeared that they might and small teeth which results in excessive tooth spacing.
later become impacted18,19 Barrett notes the diet of the Yeundumu is now less
The research now argues that since the appearance abrasive and softer, consequently wisdom teeth and other
of wisdom teeth is part of normal development, third tooth problem may be more likely in the newer
molars that cause problems should be dealt with in the generations. Curtis (1935)29 found that both predynastic
same way as any other problem teeth (Tulloch et al, Egyptians and Nubians rarely had wisdom teeth
1990).20 Leff21 concludes that, if other viable options exist problems, but they often existed in persons living in later
aside from extraction there is 'an excellent chance they'll periods of history. He concluded that the maxillary sinus
never be a problem.' This conclusion is a major reversal of the populations he compared were similar and
of the previous perception held by many dentists for attributed the impactions he found to diet and also to
decades, namely that wisdom teeth are essentially useless disuse causing atrophy of the jaws which resulted in a
trouble-makers-'little time bombs'. low level of teeth attrition. Dahlberg (1963)30 in a study
of American Indians found that mongoloid peoples have
a higher percentage of agenesis of third molars than other
ROLE OF GENETICS
groups and few persons in primitive societies had
Jaw and maxillary shelf size are individual genetic traits wisdom teeth problems. As Dahlberg notes, third molars
that vary according to a normal curve as do all human were 'very useful in primitive societies' to chew their
dimensions. Some individuals inherit very small coarse diet.31
maxillary sinus, and those toward the smaller end of the
normal curve may sometimes experience wisdom teeth Role of Diet
problems. An example is when a petite woman marries a
large man and the children inherit a jaw structure that The two most commonly cited explanations for third
cannot completely accommodate their teeth.22, 23 These molar problems, i.e. natural selection and mutation effect;
cases, though, are relatively few and are not the both have been challenged by many researchers including
norm(Barrett, 1957).24 Wisdom teeth problems are more Calcagno and Gibson (1988).32 The fact that impacted
common among European whites compared to Orientals teeth are rarely seen in animals and nontechnologic
and blacks. This conclusion is supported by research on human societies indicates that some change in humans
dental problems and race that concluded that racial that occurred in their recent past is responsible.33, 34 Many
differences exist’. It is tempting to suppose that researchers have concluded that the dietary shift to soft,
interbreeding would exacerbate malocclusion and processed foods has caused a decrease in masticatory
increase the number of impactions.25 This may be true demands (the disuse theory) resulting changes in the
partly because certain jaw shapes and sizes are associated teeth-jaw relationship which could lead to malocclusion
with third molar impaction and jaw shapes are an and wisdom teeth.35 According to Singh et al (1996)36 the
inherited trait. However, this is only one factor. The major earlier human diet tended to be highly abrasive 'which
factors, the size of the jaw, maxillary sinus and teeth, all caused attrition of teeth,' resulting in the total arch length
(the widths of all the teeth added together) to become amount of particulate matter or grit in the diet is a
less. Especially 'the processed foods has caused secondary factor in inter proximal wear, although it
consequential reduction in masticatory functional accounts for most of the occlusal wear. Advanced
demand' producing a higher rate of impacted wisdom population that consume a diet composed largely of
teeth. cooked meat and vegetables, as well as processed foods,
Begg (1954),37 in a study of 'stone age men' concluded do not require the large chewing forces that lead to lateral
that human teeth continually migrate in two directions movement of the teeth and inter proximal wear. The low
throughout life, horizontally and vertically. Begg sampled incidence of crowding in primitive population seemingly
skulls of Australian Aborigines who had died before the results from the high degree of inter proximal attrition
westernization of Australia by the British and who had and not from a more harmonious concordance of tooth
consumed a diet he judged 'late paleolithic,' (for this and jaw size.39
reason he used the term stone age to describe their diet). Goose (1963)40 found from measurements of jaw sizes
He concluded that the coarse, hard gritty, fibrous and and teeth, that a decrease occurred in the palate coronal
unprocessed diet causes inter proximal and occlusal dimensions between the middle ages and the seventeenth
attrition which 'permits all the lower teeth to move century. He concluded that this change was unlikely to
gradually forward relative to the upper. The result of teeth be due to racial changes or hybridization since no
wear produces mesial drift because the space required to evidence exists of racial mixing during recent British
accommodate the teeth in each jaw gradually becomes history. Conversely, profound changes in diet have
less, allowing a proper fit of the third molar teeth. This occurred since medieval times which can account for the
wear does not occur with the modern diet, and differences found. Studies in numerous other populations
consequently Begg argues many westerners often don't also indicate that diet and other environmental factors
have enough room in their mouth for wisdom teeth, and are of major importance in tooth variation problems (Mac
therefore crowding of permanent canines and incisors is Gregor,1985),3 ( Kallay,1963).41
more likely to occur today. In short, when the chewing workload is reduced, the
Several other research studies on primitive skulls mandible and jaw muscles atrophy, and when chewing
have concluded a clear association between civilization workload is increased, the muscles strengthen and the
and dental attrition, and lack of dental attrition was jaw develops. Other dental problems such as
strongly related to teeth crowding and wisdom teeth malocclusion are also 'widely believed to be a disease of
impaction.38 In a summary of the research on diet and civilization' (Mills, 1963).42
dental crowding, Lombardi (1992)39 concluded, "Dental
crowding is endemic among technologically advanced SUMMARY
populations and uncommon in primitive groups. The
significant elements in the development of most dental Several factors have been found to be important in
crowding are mesial migration and the lack of inter causing third molar problems and malocclusion. The
proximal attrition. Mesial migration of the posterior teeth most important factor is probably diet. But the influence
provides the functional replacement for the tooth surface of other factors including mutations needs to be examined
lost to attrition because of the rigors of a primitive diet. more fully to understand why wisdom teeth are more
In modern man there is little attrition of the teeth because often a problem today. The once common belief that
of a soft, processed diet; this can result in dental crowding wisdom teeth problems are related to putative
and impaction of the third molars." evolutionary modifications has now been discredited.
In short, this theory concludes that the inter proximal Mac Gregor concluded following an extensive study that
wear is highly correlated with the chewing force required the 'increase of brain size at the expense of jaw size'
by the diet. A diet consisting largely of tough foods, such evolutionary view is invalid. The evidence derived from
as nuts, seeds, fibrous vegetables, and partially cooked paleontology, anthropology, and other studies indicates
meat, requires high chewing forces that cause lateral very convincingly that a reduction in jaw size has
movement of the teeth relative to each other. This rubbing occurred due to civilization. The main associated factor
of adjacent teeth is the cause of inter proximal wear. The appears to be the virtual absence of inter proximal
attrition, but initial tooth size may have some effect. Jaw 14. Leff M. Hold on to your wisdom teeth. Consumer Reports
size and dental attrition are related and they have both on Health 1993; 5(8):84-85.
decreased with modern diet. Jaws were thought to be 15. Singh H, Lee K, Ayoub AF. Management of asymptomatic
reduced in size in the course of evolution but close impacted wisdom teeth: a multicentre comparison. British
examination reveals that within the species Homo Journal of Oral and Maxillofacial Surgery 1996; 34:389-93.
16. MacGregor AJ, Ref. 3.
sapiens, this may not have occurred. What was thought
17. Tulloch JF, Antczak A, Wilkes J. The application of decision
to be a good example of evolution in progress has been
analysis to evaluate the need for extraction of asymptomatic
shown to be better explained otherwise.
third molars. Journal of Oral Maxillofacial Surgery 1987;
Hence, it can be concluded that the problems
5:855-63.
associated with wisdom teeth in modern society are not 18. Leff M, Ref. 14, p. 84.
due to evolution or mutation effect but largely to changes 19. Singh H, Lee K, Ayoub AF. Ref. 15.
in diet, namely to softer, less abrasive processed foods 20. Tulloch JF, Antczak A, Ung N. Evaluation of the costs and
which do not give the teeth the workout which they relative effectiveness of alternative strategies for the
require to ensure proper relationship in the jaw. removal of mandibular third molars. International Journal
of Technology Assessment in Health Care 1990; 6:505-15.
21. Leff M, Ref.14.
REFERENCES
22. Mills JRE. Occlusion and malocclusion of the teeth of the
primates. In: Dental Anthropology, Brothwell, DR (Ed.),
1. Nodine AM. Aberrant teeth, their history, causes and

treatment. Dent. Items of interest 1943; 65: 895-910. Pergaman Press, Oxford, UK, 1963.
2. Berger A. As cited by Archer, WH, Oral and Maxillofacial 23. Durbeck WE. Ref. 4. pp. 4-5.
Surgery. Vol. I, Ed.5 Philadelphai, WB, Saunders Co., 1975. 24. Barrett MJ. Dental observations on Australian Aborigines:
3. MacGregor AJ. The Impacted Lower Wisdom Tooth, tooth eruption sequence. Australian Dental Journal 1957;
Oxford University Press, New York, 1985; p. 3. 2:217-27.
4. Durbeck WE. The Impacted lower Third Molar, Dental Pub. 25. MacGregor AJ. Ref. 3, p. 12.
Inc., Brooklyn, New York, 1943. 26. Chung CS et al. Genetic and epidemiological studies of
5. Sakai T. Human evolution and wisdom teeth. Dental oral characteristics in Hawaii's schoolchildren, II.
Outlook, 1981; 58(4):615-23. Malocclusion. American Journal of Human Genetics 1970;
6. Schissel MJ. Dentistry and Its Victims, St. Martin's Press, 23:471-95.
New York, 1970; pp. 50, 170. 27. Chung CS, Neiswander JD. Genetic and epidemiological
7. Darwin C. The Descent of Man and Selection in Relation studies of oral characteristics in Hawaii's schoolchildren,
to Sex. D. Appleton and Company, New York, 1896; p. 20. V. Sibling correlations in occlusion traits. Journal of Dental
8. Macho GA and Moggi-Cecchi, J. Reduction of maxillary Research 1975; 54(2):324-29.
molars in Homo sapiens; a different perspective. American 28. Barrett MJ. Dental observations on Australian Aborigines:
Journal of Physical Anthropology 1992; 87(2):151-59. tooth eruption sequence. Australian Dental Journal 1957;
9. Macho and Moggi-Cecchi, Ref. 8, p. 156. 2:217-27.
10. Corruccini R. Anthropological aspects of orofacial and 29. Curtis HF. 1935. The relationship of attrition and the
occlusal variations and anomalies. In: Advances in Dental impacted mandibular third molar as found in the ancient
Anthropology, Chapter 17. Kelley, MA and Larson, CS Egyptians. Transactions of the American Dental Society of
(eds), Wiley-Liss, New York, 1991; p. 308. Europe, 1997.
11. Taylor MS. Aberrant maxillary third molars; morphology 30. Dahlberg A. Analysis of the American Indian dentition.
and developmental relations. In: Kurtèn (ed.), 1982; pp. In: Dental Anthropology, Brothwell, DR (Ed.), Pergaman
64-74. Press, Oxford, UK, 1963.
12. Leonard MS. Removing third molars: a review for the 31. Dahlberg A. Ref. 30, p. 171.
general practitioner. Journal of the American Dental 32. Calcagno JM, Gibson KR. Human dental reduction: natural
Association 1992; 123(2):77-82. selection or the probable mutation effect. American Journal
13. Ganss C, Hochban W, Kielbassa AM, Umstadt HE. of Physical Anthropology 1988; 77:505-17.
Prognosis of third molar eruption. Oral Surgery, Oral 33. MacGregor AJ. Ref. 3, p. 3.
Medicine, Oral Pathology 1993; 76(6):688-93. 34. Corruccini R. Ref. 10, p. 295.
35. Macho and Moggi-Cecchi. Ref. 8, p. 158. 40. Goose DH. Dental measurement: an assessment of its value
36. Singh H, Lee K, Ayoub AF, Ref. 15, p. 391. in anthropological studies. In: Dental Anthropology,
37. Begg PR. Stone Age man's dentition. American Journal of DR Brothwell (Ed.), Pergamon Press Oxford, UK, 1963;
Orthodontics 1954; 40:298-312, 373-383 and 462-75. 179-90.
38. MacGregor AJ, Ref. 3. 41. Kallay J. A radiographic study of the Neanderthal teeth
39. Lombardi AV. The adaptive value of dental crowding: a from Krapina. In: Dental Anthropology, DR Brothwell
consideration of the biological basis of malocclusion. (Ed.), Pergaman Press, Oxford, UK, 1963.
American Journal of Orthodontics 1992; 81:38-42. 42. Mills JRE Ref. 22, p. 46.
3
Why Do We Remove
Impacted Teeth?
It is likely that prehistoric people did not have the clinical studies the following indications for removal have
infections which we have associated today with impacted been identified.
and partially impacted third molars. Although caries and 1. Pericoronitis and Pericoronal abscess: This is the most
periodontal disease were prevalent, evidence suggests common cause for extraction of mandibular third molars
that dental pathology was relatively low. Towards the (25 to 30%). Pericoronitis is commonly found to be
end of the 17th century, people experienced an increase associated with distoangular and vertical impaction. If
in the prevalence of dental disease, most likely as a result improperly treated, infection may extent posteriorly
of shift in lifestyle and diet. resulting in sub masseteric abscess.
From that time until the advent of modern dentistry In certain cases chronic pericoronal abscess may point
at the beginning of the 20th century, there was a dramatic extra orally leading to difficulty in diagnosis regarding
acceleration in the rate of dental disease associated not the focus of origin of infection (Figs 3.1 A to C)
only with third molars but also with every other tooth. The aim of a study conducted by Halverson et al
Today, despite advances in preventive dentistry, the (1992)1 was to obtain a predictive clinical profile of the
location of third molars in the dental arches often make impacted mandibular third molar at greatest risk for
them difficult to care for, and their frequent impaction pericoronitis. It was noted that 81% involved vertically
exposes patients to degenerative conditions infrequently oriented while mesioangularly impacted accounted for
associated with any other tooth. only 11.2% of pericoronitis cases. The remaining cases
As a general principle, teeth should not be removed comprised distoangular and horizontally impacted
without due cause. This applies to unerupted/ impacted mandibular third molar (3.4% and 3.8% respectively). It
third molars as much as it does to any other teeth. All was concluded that the risk for pericoronitis appears to
forms of surgery, whether under local anesthesia or increase with greater vertical orientation and higher the
general anesthesia, carry some risk of complications and eruption.
there is an inevitable morbidity associated with surgical 2. Dental Caries: Incidence of caries of the 2nd molar or
removal of teeth even in the best of hands. Apart from 3rd molar is about 15%. This high incidence is attributed
this, there is a question of cost involved. Therefore, there to difficulty to perform oral hygiene measures in the third
has to be a distinct reason for the removal of third molar molar area (Figs 3.2 and 3.3).
tooth. Shugars and co-investigators (2004) noted a definite
Even though not all unerupted/impacted teeth cause association between dental caries incidence in
problems, all have that potential. Based on extensive asymptomatic third molars and caries in restorations in
Why Do We Remove Impacted Teeth? 17
second and first molars. One third of the study population

had caries in the third molar. Almost all the patients who
had caries in the third molar also had caries in the first or
second molar. The absence of caries in the first or second
molar was associated with caries-free third molar. Hence,
removal of third molars may be a prudent option to avoid
caries of other molar teeth
Partially erupted impacted tooth with extensive
caries can cause traumatic ulcer of buccal mucosa (Fig.3.4)
or tongue.
3. Periodontal diseases: Blakey et al (2002) reported that
the prevalence of increased periodontal probing depths
(PD) in the third molar region is higher than that is
expected in asymptomatic third molars. They noted that
in a sample of 329 patients 25% cases had at least one
Figs 3.1 A to C: (A) Chronic pericoronal abscess in relation to impacted
third molar pointing extra orally (black arrow), (B) Intraoral view showing
PD –> 5 mm in the third molar region. Increased
impacted 48 (green arrow), (C) Periapical X-ray showing horizontally periodontal probing depths and attachment loss leads to
increased periodontal pathogen colonization and
impacted tooth with the root closely related to mandibular canal

increased levels of inflammatory mediators. Various other
studies have shown that chronic oral inflammation
associated with periodontal disease has been implicated

in increasing the risk of cardiovascular disease and renal
insufficiency, restricted fetal growth and preterm births.
Endothelial cell activation is the common cause for these
clinical conditions.
Recurrent food impaction between the partially
erupted third molar results in periodontal inflammation
and subsequent bone loss. This weakens the support of
Fig.3.2: Horizontally impacted 38 with dental caries
Fig.3.3: Secondary caries beneath the restorations Fig. 3.4: Ulceration of buccal mucosa due to sharp
in 37 and 38 (yellow arrows) margins of carious 38.
the second molar and later on leads to pulpo periodontal

involvement. Where there is periodontal disease and
pocketing between the third molar and the second molar,
there is some evidence to suggest that if removal of the
third molar is delayed beyond the age of 30 years then
the condition may become irreversible. Removal of the
third molar will result in repair of the injured
periodontium and therefore early removal of the
impacted third molar is beneficial. Untreated horizontal
and mesio-angular impactions are particularly prone to
Figs 3.6 A to C: (A) Crowding of mandibular incisors which is suspec-
cause bone loss distal to the second molar (Fig.3. 5) ted to have originated secondary to impaction of 38 and 48 (B and C)
develop in many cases and this also happens to be the

most common age group for developing wisdom teeth
to erupt or become impacted; hence the association.
The hypothesis that the mesial pressure from the
third molars is transferred through the contact points
resulting in the narrow contacts of the lower incisors

is slipping. Recent studies have examined the strength
of this hypothesis and the following statements can

be made:
— The presence or absence of third molars, whether
impacted or erupted, does not influence the
amount of post-retention relapse following
orthodontic treatment (Kaplan, 1974).
— There is no difference in mandibular incisor
Fig.3.5: Horizontal impaction of 48 causing bone loss crowding between people who have third molars
(yellow arrow) distal to 47 impacted, erupted normally, congenitally absent
or extracted early (Ades et al, 1990).
Late removal of such impacted teeth has not been — Direct measurement of proximal contact pressure
shown to improve the periodontal status of the adjacent before and after third molar extraction reveals no
second molar, but early extraction of the impacted mesial pressure from impacted third molars
wisdom tooth reduces periodontal damage. (Southard at al, 1991).
4. Orthodontic reasons: — A critical review of the literature reveals a weak
a. Crowding of incisors: Third molars can produce an association between third molars and incisor
anterior component of force leading to crowding of crowding. Therefore, it is impossible to exclude
mandibular incisors. Hence removal of third molars third molars as a minor factor in the development
have been recommended during or after orthodontic of late incisor crowding (Vasir and Robinson,
treatment (Figs 3.6 A to C ). 1991).
However, there has been much contention On this basis, it can be concluded that although there
regarding the role of wisdom teeth in post-treatment are many valid reasons for third molar extraction, there
change (commonly called relapse) after orthodontic is no reason to believe that extraction of third molars
treatment. Many still believe that they create pressure will alleviate or prevent crowding of incisors.
on the front teeth as they develop and erupt causing Therefore, routine prophylactic removal cannot be
crowding of the lower anteriors. Much of the reasoning justified solely for reasons of orthodontic stability.
for this is that during the late teens to mid to late b. To facilitate orthodontic treatment: Since current trends
twenties, lower incisor crowding can be seen to in orthodontics have shifted towards non-extraction
therapy, molar distalization mechanics and treatment 6. Odontogenic cysts and tumors: Follicular sac of the
modalities have become increasingly popular impacted tooth can give rise to tumors and cysts
especially in the management of Class II malocclusion. (Figs 3.8 to 3.14). This is one of the most important reasons
The use of headgear for molar distalization was for the removal of asymptomatic third molars.
followed by easier to use non-compliance intraoral
appliances. In those cases where distalization of second
molars is considered, extraction of impacted / erupted
maxillary third molar tooth is indicated to facilitate
the distal movement of maxillary molars.
5. To facilitate orthognathic surgery: In the presurgical
preparation for orthognathic surgery, removal of third
molars at the planned osteotomy sites should be
considered. Bilateral sagittal split osteotomies (BSSO) can
be better performed when third molars are not present
at the site of osteotomy. Third molars (both erupted and
unerupted should be removed preferably one year before
the planned osteotomy to ensure the formation of
adequate bone (Figs 3.7 A to D).
Fig. 3.8: OPG showing impacted 37 and 38 (yellow circle) associated

Rigid fixation of the osteotomized segments is with odontogenic tumor involving left ramus and angle of mandible
facilitated when there is adequate sound bone to secure
plates and screws. Erupted maxillary third molars that

are out of occlusion after a mandibular advancement
should be considered before orthognathic surgery.
However, maxillary third molars that are developing or
are superiorly positioned are more easily removed at the
time of Le Fort I osteotomy.
Fig. 3.9: OPG showing impacted 37 associated with extensive

dentigerous cyst of mandible involving the left ramus, angle and
body crossing the symphysis
Figs 3.7 A to D: (A) Intra-oral photo of an 18-year-old young man with

class III incisor relationship and mandibular excess who is being
prepared to undergo surgical mandibular setback by bilateral sagittal
split osteotomy (BSSO), (B) Cephalogram of the patient showing all
features of mandibular excess. (C) OPG of the same patient showing
impacted 38 and 48 with the apex incompletely developed (yellow
arrows) which makes its surgical removal easy, (D) Extracted 48 showing Fig. 3.10: OPG showing impacted 37 and 38 associated
the incompletely developed roots (yellow arrows) with dentigerous cyst involving the mandible
Figs 3.13 A and B: Carcinoma associated with impacted 38. (A) Intraoral
photograph of a 76-year-old man with recurrent pain and swelling in the
Fig. 3.11: OPG showing odontomes associated with bilaterally impacted left retromolar region, (B) Lateral oblique view of mandible showing
mandibular third molars (black oval). Note the bulbous crown of second impacted 38 in the ramus with surrounding radiolucent area. Incision
molars (yellow arrows) biopsy was taken from soft tissues in the retromolar region. The biopsy
report came as poorly differentiated epidermoid carcinoma. The case
was surgically treated with hemimandibulectomy and block dissection.
In spite of this, the patient succumbed to the disease later
Fig. 3.12: OPG showing multiple impacted teeth (yellow arrows) and
multiple jaw cysts in a 17-year-old patient
Olson et al (2000)2 reported an unusual odontogenic

carcinoma, which occurred in a dentigerous cyst
associated with an impacted third molar in a 66-year-old Figs 3.14 A to E: (A) A 46-year-old man with recurrent swelling left side
male patient. The impacted tooth and the lesion were of face, (B) Lateral oblique view of mandible showing impacted 38 in
the ramus with surrounding radiolucent area, (C) PA view of mandible
excised based on evidence of radiographic change and showing bilaterally impacted mandibular third molars (white and yellow
clinical findings. arrows). A provisional diagnosis of dentigerous cyst of mandible was
Rarely epidermoid carcinoma has been reported made. Surgical removal of impacted 38 along with surrounding soft tissue
was done under general anesthesia. Specimen was sent for
associated with impacted mandibular third molar tooth histopathological examination. (D) Postoperative radiograph showing
(Figs 3.13 A and B and 3.14 A to E). irregular bony margin. The biopsy report came as poorly differentiated
7. Management of unexplained pain: Removal of epidermoid carcinoma. (E) Postoperative photo after wide excision
and hemimandibulectomy. However, the patient succumbed to the
impacted teeth very often relieves the patient of disease later
unexplained pain. It is still obscure how this pain relief
occurs. However, the patient should be informed of the
pros and cons. third molar should cause pain. Much more commonly,
The situation with regard to facial pain of an atypical atypical facial pain is associated with temporomandibular
nature is a difficult one and removal of a completely joint dysfunction and this possibility must be eliminated.
buried tooth should only be considered as a last resort Signs of muscle spasm are normally present in
and only when the patient points to that area as the source dysfunctional situations. Confusion can arise when there
of pain. In some cases, this relieves the pain but there is is concomitant muscle pain associated with a clenching
no guarantee. It is not known why a completely buried habit and local third molar pain.
Sometimes it may be during a routine radiographic

examination to identify any focus of facial pain that the
presence of an impacted tooth is identified (Fig.3.15)
Fig. 3.15: OPG of a 67-year-old lady who was wearing denture for 9
years complained of headache and facial pain. Since no oral focus could
be identified, an OPG was taken to rule out any bony pathology. OPG
revealed an impacted 28 (yellow dotted line) which was not clinically
visible in oral cavity.

8. Resorption of root of adjacent tooth: Once the root

resorption of second molar is identified, removal of third Fig. 3.16: Radiograph showing fracture of mandible in the right angle
(yellow arrows). The presence of impacted 48 has caused an area of
molar should not be delayed to avoid further damage to weakness which predisposed the area to fracture.
the former.
9. Teeth under dental prosthesis: Risk versus benefit
ratio is assessed in each case before planning surgical
procedure. Teeth that are more superficial should be
considered for removal before fabricating prosthesis.
Rarely, an unerupted third molar may lie in an atrophic
mandible and a careful choice needs to be made whether
it is better to remove the tooth or leave it in situ. There is
no clear evidence as to what is best to do and a degree of
common sense must therefore prevail. This situation
needs to be carefully evaluated. In very elderly patients Figs 3.17 A and B: (A) Infection in relation to fracture of the right angle
of the mandible (black long arrow). Note the presence of impacted 48.
the third molar might be left but in a middle-aged patient Even though there is another fracture in the left parasymphysis region
where there is a risk of spontaneous fracture or where (black short arrow), it has not lead to infection. (B) Extra oral pus
minor trauma might cause a fracture then prophylactic discharge (yellow arrow) from the infected fracture in the right angle
removal is appropriate.
10. Prevention of jaw fracture: Prophylactic removal of mandibular third molar and fractures of mandibular
impacted third molars should be considered for those condyle.
engaged in contact games. An impacted third molar 11. Deep fascial space infection: Pericoronitis associated
presents an area of lowered resistance to fracture with impacted tooth has the potential for developing into
(Fig. 3.16). deep fascial space infection (Figs 3.18 A and B). Litonjua
Moreover presence of impacted tooth in the line of (1996)3 found that among the patients who reported for
fracture may cause increased complications in the management of impacted mandibular third molars, 11%
treatment of fracture (Figs 3.17 A and B). presented with deep fascial space infection of which 72%
Recent studies by Zhu et al (2005) have shown a were secondary to pericoronitis. Vertical impaction (68%)
definite relationship between the presence of unerupted was associated with highest incidence of pericoronitis.
Since pericoronitis is the commonest indication for

surgical removal of impacted third molar it is appropriate
to discuss the condition in a more detailed manner.
Pericoronitis
Pericoronitis is the inflammation of the soft tissues

associated with the crown of a partially erupted tooth
Figs 3.18 A and B: Deep fascial space infection associated with and is seen most commonly in relation to the mandibular
impacted 48 in a 28-year-old man. (A) Note the swelling in the
submandibular region spreading to neck. (B) Intraoral view showing
third molar. The common symptoms and signs are pain,
impacted 48. Surprisingly the associated trismus was minimal bad taste, inflammation, and pus expressible from
beneath the pericoronal tissue. The condition is
aggravated by trauma from an opposing tooth.
Osaki et al (1995)4 conducted a study on the clinical
Pericoronitis is the commonest cited reason for removal
characteristics of infections caused by impacted third
of wisdom teeth; though its presence does not necessarily
molars in elderly persons over 60 years of age.
mean that the associated tooth requires removal.
Pericoronitis was the most frequent infectious condition
Unless the cause is removed pericoronitis may
associated with impacted third molars in this elderly
present as a recurrent condition requiring multiple

population. A significant percentage of the infectious
episodes of treatment. In severe episodes, an acute
conditions that arose in these patients may be due to the pericoronal abscess may develop which may remain
combination of physiologic alveolar bone resorption and localized or spread to involve one or more of the adjacent
denture irritation. This combination of factors may expose deep fascial spaces and may be associated with systemic
teeth that were not previously accessible to the oral as well as local signs and symptoms.
environment, thus increasing their risk of infection.
12. Impacted teeth as potential source of infection (e.g.
prior to administration of radiotherapy): Teeth at risk Identification of Risk Factors
of infection which could result in osteoradionecrosis or 1. Presence of unerupted/partially erupted tooth/
endocarditis should be removed. Cardiac patients with teeth in communication with the oral cavity. Vertical
valvular disease or those who have undergone valve and distoangular mandibular third molars are most
replacement have evidence of molar periodontal defects commonly affected.
and inflammatory mediators in their crevicular fluid; 2. Pathological periodontal pocketing adjacent to
should have asymptomatic third molars removed. unerupted/partially erupted teeth.
Although the risks of these conditions developing 3. Opposing tooth/teeth in relation to pericoronal
endocarditis may be small, their serious nature precludes tissues surrounding unerupted/partially erupted
the retention of a potentially infected third molar. A tooth/teeth.
partially erupted third molar tooth would come into this 4. Previous history of pericoronitis.
category, whereas a completely unerupted tooth which 5. Poor oral hygiene.
is never likely to erupt would not. In borderline situations, 6. Respiratory tract infections.
removal should be undertaken if symptoms are likely in
the future. Other medical procedures such as organ
Diagnostic Criteria
transplantation, chemotherapy, or the insertion of
alloplastic implants should be considered in a similar • Presence of unerupted/partially erupted tooth/teeth
way. in communication with the oral cavity.
13. For autogenous transplantation to a first molar • Cardinal signs/symptoms of inflammation associated
socket: Although this was very popular in the past, the with the pericoronal tissues.
procedure has fell into disrepute due to unpredictable • Local pain/discomfort.
results. However, it is worth trying when indicated. • Swelling.
• Erythema. The following should be considered after resolution of

• Associated signs/symptoms (variable expression): the acute phase
— Pus expressible from beneath the pericoronal A Local soft tissue surgery: Operculectomy. This involves
tissues. the surgical removal of the overlying soft tissue using
— Restricted mouth opening. surgical blade or using electrocautery under local
— Abnormal taste. anesthesia. Most authors favor the latter, since it will
— Halitosis. also aid in hemostasis. Before operculectomy is
— Cervical lymphadenopathy. planned it is mandatory to have a good periapical
— Presence of associated disease - pericoronal/ radiograph of the area to note the angulation of the
cervical abscess. tooth and to verify that there is adequate space for the
tooth to erupt (Pell and Gregory Class I) once the
— Systemic signs and symptoms.
overlying soft tissue is removed surgically. If on the
— Evidence of trauma by opposing tooth/teeth.
other hand the space is inadequate between the second
molar and the anterior border of ramus of mandible
Treatment (Pell and Gregory Class II and III), it is futile to attempt
operculectomy, since there is the possibility of
The following should be considered in the acute phase:
regrowth of the soft tissue during the healing phase
1. Irrigation of pericoronal space: Irrigation of the causing recurrence of pericoronitis. More over, a
pericoronal space mechanically removes any debris vertically impacted tooth in Postion A has a better
that may have collected within the space. The chance to erupt normally than a distoangular one.
irrigant should be sterile. Irrigants that may be used Additionally age of the patient also should be
include; water for injection, normal saline, considered when operculectomy is contemplated.
chlorhexidine and local anesthetic solutions. The schematic diagram showing the various steps
2. Use of local agents to cauterize the soft tissues: of operculectomy is shown in Figs 3.19 A to D. It may
Caustic agents to cauterize the local tissues, if used, be noted that, in most cases operculectomy may have
should be applied with caution and appropriate care to be combined with a sulcus deepening procedure in
taken to avoid injury to adjacent tissues. the area because of the inadequate height of the
3. Removal of opposing tooth/teeth: This is done if attached gingiva and the shallow sulcus. Because of
traumatic occlusion with pericoronal tissues is the necessity of all these procedures, operculectomy
present.
4. Use of appropriate analgesia: Pericoronitis is an
inflammatory condition and NSAIDs should be
considered the analgesic of choice unless contra-
indicated.
5. Use of appropriate antibiotics in the presence of
severe local disease or if systemic symptoms are
identified: The use and choice of antibiotics is
controversial. The bacterial flora is a complex
mixture of gram-positive and gram-negative
organisms and consideration should therefore be
given to the use of broad spectrum or combinations
of antibiotics depending upon the clinical situation.
6. Advice regarding oral hygiene: Meticulous oral
hygiene is to be maintained. Frequent use of warm
saline gargle will hasten the resolution of the Figs 3.19A to D: Schematic diagram of operculectomy using
electrocautery - (A) Note the operculum covering erupting 38, (B)
condition. Occlusal view, (C) Use of electrocautery tip to excise the operculum,
7. Use of 0.12% chlorhexidine mouthwash is advisable. (D) Postoperative appearance.
has fell into disrepute recently and most authors favor preferred option for teeth if there is insufficient anatomic
surgical removal of impacted lower third molar space to accommodate normal eruption. It is clear that
following a second instance of pericoronitis. timely removal of such impacted third molar teeth at an
B. Removal of involved tooth: As stated above most authors early age is a valid and scientifically sound treatment
favor this to operculectomy especially when factors rationale based on medical necessity. Current textbooks
contributing to normal eruption mentioned above are on oral and maxillofacial surgery also document the
not there. scientific basis for the treatment of asymptomatic
impacted teeth. For example, Peterson’s Contemporary
Oral and Maxillofacial Surgery states, “if impacted teeth
Contraindications for Removal of Impacted
are left in the alveolar process, it is highly probable that
Tooth
one or more of a number of problems will result.” Clinical
1. Poor systemic condition of the patient: Patients with decision-making in the management of pathology
uncontrolled or poorly controlled systemic disease associated with impacted teeth depends on the
are unsuitable candidates for surgical removal of anticipated natural course. The parameters state that in
impacted third molars. This is because order to limit known risks and complications associated
complications can occur either intra operatively or with the removal of impacted teeth, it is medically
post operatively in such patients. Hence, a proper appropriate and surgically prudent to remove such teeth
prior to complete root development. This is supported
history, physical examination and laboratory

investigations are mandatory in all the cases to rule by the National Institutes of Health Consensus
out systemic diseases. Development Conference: Removal of Third Molars,
2. Advanced age: As age advances the bone becomes which found that "third molars should be removed in
sclerosed, there is decreased healing response, the younger age patient because there is less transitory
greater bony defect following surgery, the surgical or permanent morbidity," and less anesthetic risk.
procedure is more difficult, more likely hood of Treatment at an older age carries with it an increase
fracture to occur, the surgical insult is less tolerated in the incidence and severity of perioperative and
and the recuperation period is prolonged. postoperative problems, a longer and more severe period
3. Damage to adjacent structures: Removal of deeply of postoperative recovery, greater anesthetic risk and
impacted third molars is likely to damage the greater and more costly interference in daily activities
inferior alveolar neurovascular structure resulting and responsibilities.
in permanent anesthesia. While making a treatment decision, the risks and
4. Questionable nature regarding the future status of benefits of removal of impacted teeth must be weighed
second molar: Extraction of a badly decayed and against the risks of retention and the cost and availability
unrestorable second molar will permit the third of professional clinical monitoring for an individual
molar to assume a more functional position or at patient. The final decision should be based on valid
least serve as a bridge abutment. Such cases have scientific and clinical information.
to be meticulously evaluated and final decision
taken after consultation with the prosthodontist and SUMMARY
endodontist.
5. Deeply impacted third molars in patients with no The removal of third molars is not indicated if they are
history or evidence of pertinent local or systemic asymptomatic and free of any pathology as long as good
pathology should not be removed. oral hygiene is maintained. The possible outcomes of
surgery may be worse than that of non-treatment; the
Removal of Asymptomatic Impacted Third risk of an impacted third molar developing pathology
Molars being small compared to the risks of surgical intervention.
Conservative treatment has also been found to be more
Besides the obvious indications for removal of impacted cost-effective. Late anterior crowding related to impacted
teeth such as overt pathology, removal is also the third molars cannot be accurately predicted and hence
the removal of third molars to prevent crowding may be • Orthodontic consideration: may be indicated prior to
unjustified. Conservative treatment is also advised for orthognathic surgery
medically compromised patients when the risk to the • Prosthetic consideration: removal of partially erupted or
patient's overall health outweighs the benefits of surgery. unerupted third molar close to the alveolar surface
should be considered prior to denture construction or
Indications for Surgical Management implant placement
• Other pathology: third molars in relation to other
The surgical removal of impacted third molars is
indicated in some situations. The decision to remove the pathology e.g. cysts, fractures, tumors may require
impacted third molar must be made with due removal.
consideration to the patient's overall health status and
the potential risk of complications. Preoperative REFERENCES
assessment should be carried out and informed consent
obtained prior to surgery. The following are the 1. Halverson BA, Anderson WH. The mandibular third molar
indications for removal: position as a predictive criteria for risk for pericoronitis: a
retrospective study. Mil Med 1992;157(3):142-5.
• Infection: removal of any symptomatic wisdom tooth
2. Olson JW, Miller RL, Kushner GM, Vest TM. Odontogenic
should be considered, especially where there have
carcinoma occurring in a dentigerous cyst: case report and
been one or more episodes of infection such as
clinical management. J Periodontol 2000;71(8):1365-70.
pericoronitis, cellulitis, abscess formation; or 3. Litonjua LS. Pericoronitis, deep fascial space infections, and
untreatable pulpal/periapical pathology the impacted third molar. J Philipp Dent Assoc
• Caries: removal should be considered when there is 1996;47(4):43-7.

caries in the third molar and the tooth is unlikely to be 4. Osaki T, Nomura Y, Hirota J, Yoneda K. Infections in
usefully restored, or when there is caries in the adjacent elderly patients associated with impacted third molars.
second molar tooth which cannot be satisfactorily Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;
treated without the removal of the third molar 79(2):137-41.
4
Development of Mandibular
Third Molar
A biological review of the events that result in the Alterations in the pattern of jaw growth, as well as
development of third molars sheds light on why these changes in the migration of dental lamina, occur due to
teeth may develop frequently with morphological evolutionary forces and environmental factors such as
malformation, malposition and possibly even agenesis. trauma and disease. Environmental factors and
Third molars are the only teeth that develop entirely after teratogens have been shown to affect tooth development
birth. All other teeth begin development in utero or, as with devastating effects on tooth size, shape and position.
in the case of permanent second molars, are entering into It is not surprising, therefore, that aberrations in normal
the tooth bud stage of development near birth. The third molar pattern frequently occur.
initiation of the development of third molars does not The following is the milestone with regard to
begin until ectodermal dental lamina, migrating distally development and eruption of mandibular third molar:
in the growing child's mouth, spatially relates to and
Tooth germ visible 9 yrs
interacts with jaw mesenchyme, which is derived from
Cusp mineralization 11 yrs
the embryonic cranial neural crest. In the case of third
Crown formation 14 yrs
molars, the interaction of these two tissues is initiated
Roots formed (apex open) 18 yrs
following birth after significant jaw growth at around
Eruption 18-24 yrs
5 years of age. If these two tissues never interact, no tooth
will form. Since no subsequent similar interaction occurs A number of longitudinal studies have been
between these two distinct tissue types after third molar performed that have clearly defined the development and
tooth bud initiation, no other teeth develop at a later age. eruption pattern of the mandibular third molar.
Development for all mammalian teeth is very similar after Bjork (1956)1 found that there are three factors which
tooth bud initiation. are significant in the development of mandible and which
Initiation of third molars occurs macroscopically at are related to the amount of space for the third molar:
or near the surface of the developing jaw bone. During 1. A predominantly vertical direction of condylar
the five years from birth to the initiation of third molars, growth, resulting in little resorption of the anterior
genetic factors and environmental factors influence jaw border of the ramus.
growth and dental lamina migration, which ultimately 2. Insufficient mandibular growth in length in
may affect the timing of the interaction and final proportion to the amount of tooth structure.
positioning of the two tissues necessary for the initiation 3. A backwardly directed trend of eruption of
of tooth bud development. For normal tooth pattern to dentition will diminish the length of the arch.
occur with regard to size, shape and position, the two At the time of development the tooth germ it is
tissues must be in the right place at the right time. located at the anterior border of the ramus with the
Development of Mandibular Third Molar 27
occlusal surface facing anteriorly. As the body of the the neighbouring second molar; (5) showed sufficient
mandible grows in length at the expense of the resorption space between the ramus and the second molar. In
of the anterior border, the developing third molar contrast, the teeth that remained impacted at the age of
occupies a position at the root level of the second molar 26 years showed such initial features as: (1) incomplete
by 16 to 18 years (Figs 4.1 A and B). At this time it root formation; (2) embedding in bone; (3) mesio-
undergoes a rotational movement. The angulation of the angularity; (4) situated at the cervical level of the
crown slowly changes from horizontal to mesioangular neighbouring second molar. It was concluded that a
and later to vertical. This rotational movement is of great panoramic tomogram taken at age 20 years revealed
importance because those third molars that do not follow radiographic features on which an estimation of future
this sequence get impacted even when sufficient eruption of mandibular third molars could be based.
retromolar space existed. In the mandible, the mean change in inclination was
Hattab(1997)2 noted that a significant proportion of 19 degrees and the percentage of teeth with changed
mesially impacted mandibular third molar had changed angulation was 76%. In the maxilla, only 23% of the teeth
their angulation and became fully erupted by the time changed their inclination. The state of impaction (soft
the individual reached 24 years of age. Positional changes tissue, partially in bone, completely in bone) had changed
and eruption of impacted mandibular third molar are for 44% of the teeth (Venta I et al, 2001)4
unpredictable phenomena. Nance et al (2006)5 following a study in 237 patients
Studies by Venta I et al (1991)3 showed that the lower concluded that if impacted third molars are angled
third molars that did erupt after the age of 20 years were mesial/ horizontal, it is unlikely that these teeth will
initially: (1) root formation complete; (2) impacted in soft erupt. Mesial/ horizontal impacted third molars often
tissue; (3) vertical; (4) placed at the same occlusal level as have PD _> 4 mm and infrabony defects between the
second and third molar. Retaining these teeth after 30
years of age greatly reduced the chance of the periodontal
status improving with third molar removal. The prudent
decision for treatment of mesial/ horizontal impacted
third molars seems to be removal. Conversely, if third
molars are impacted vertical/distal, a period of follow -
up might be prudent to see if the third molars will erupt
to the occlusal plane. It was noted that one-third of
vertical/distal impacted third molars erupted to the
occlusal plane. However, removal of these teeth should
be considered if PD _> 4 mm in the third molar region
exists or develop during follow up.
Predicting the Eruption/Impaction

of Mandibular Third Molars
Predictions of future eruption or impaction of lower third
molars could be made using a transparent device
developed by Venta I et al (1997).6 Termed as 'Third Molar
Eruption Predictor' (US patent 5,816,814; not
commercially available) could be superimposed on a
panoramic tomogram taken of a patient at age 20 years.
The device was developed from data on 40 lower third
molars initially retained at age 20 years; one half of these
Figs 4.1 A and B: Showing the progressive remodeling of ramus for remained impacted, and the other half of them erupted
creating space for the eruption of molars. However in certain instances,
this growth ceases before sufficient space has been created for eruption by age 26 years. Tracings were made from panoramic
of third molar, which becomes impacted. tomograms taken at age 20 years. The critical point for
prediction in the overlay was the intersection of a REFERENCES

horizontal reference line and the anterior border of the
ascending ramus. To estimate this critical separation line, 1. Bjork A. Mandibular growth and third molar impactions.
Bayes' Decision Theory was used. The sum of false Acta Odontol Scand 1956; 14: 231.
negatives and false positives was least at a distance of 2. Hattab FN. Positional changes and eruption of impacted
14.5 mm from the distal surface of the second molar. mandibular third molars in young adults. A radiographic
Mesial from this point, the probability of impaction was 4-year follow-up study.Oral Surg Oral Med Oral Pathol
76%; distal from this point, the probability of eruption Oral Radiol Endod 1997;84(6):604-8.
was 72%. Tested against 35 initially unerupted lower third 3. Venta I, Murtomaa H, Turtola L, Meurman J,
molars, the predictions made by the device and the actual Ylipaavalniemi P. Assessing the eruption of lower third
clinical findings were in conformity in relation to 97% of molars on the basis of radiographic features Br J Oral
the test teeth. It could thus be concluded that the method Maxillofac Surg 1991;29(4):259-62.
was simple to use and may prove a good addition for 4. Venta I, Turtola L,Ylipaavalniemi P. Radiographic follow-
predicting lower third molar development. up of impacted third molars from age 20 to 32 years. Int J
The 'Third Molar Eruption Predictor' though initially Oral Maxillofac Surg 2001;30(1):54-57.
developed for use on panoramic tomogram can also be 5. Nance PE, White RP, Offenbacher S, Philips C, Blakey GH,
used on periapical radiographs after calibration of the Haug RH. Change in third molar angulation and position
device. The device could be calibrated using the method in young adults and follow-up periodontal pathology. J
of simple proportions and Bayes' Decision Theory. It was Oral Maxillofac Surg 2006;64: 424-28.
noted that the predictions made with the calibrated device 6. Venta I, Murtomaa H, Ylipaavalniemi P. A device to predict
were in conformity with the final clinical outcome in 84% lower third molar eruption. Oral Surg Oral Med Oral Pathol
of the cases. Oral Radiol Endod 1997;84(6):598-603.
5 Surgical Anatomy
MANDIBULAR THIRD MOLAR elevation of impacted third molar. The tooth is embedded
between the thick buccal alveolar bone and a thin lingual
Modern day surgery is based on anatomy. Unless the
cortical plate (Fig.5.2).

operator builds on that soild foundation, he is no way
better then 'a hewer of flesh and a drawer of blood'. Hence
a discussion of those anatomic structures with which the

surgeon is concerned in the surgical removal of
mandibular third molar is pertinent.
The mandible consists of a horseshoe shaped body
and two flat, broad rami. Each ramus is surmounted by
two processes, viz. coronoid process and condylar
process.
The lower third molar tooth is situated at the distal
end of the body of the mandible where it meets a relatively
thin ramus (Fig. 5.1).
This meeting point constitutes a line of weakness and
a fracture may occur if undue force is exerted during
Fig. 5.2: Coronal section of mandible in the region of third molar

showing a thick buccal alveolar bone and a thin lingual plate
When the mandible is viewed from below, it will be

seen that the wisdom tooth socket lies on a prominent
ledge or shelf of lingual bone. In many instances the
lingual bone consists of a thin cortical plate less than
1 mm in thickness. Extraction can be facilitated by
removal of this thin lingual cortical plate (Fig 5.3). This
principle is employed in the lingual split bone technique.
Fig. 5.1: Occlusal view of mandible showing the location In cases where the lingual plate is very thin, attempts to
of wisdom tooth on left side (blue arrow) remove fractured apices of tooth may inadvertently lead
wall of the canal and protrude into it (Fig.5.4). In such

cases attempted elevation of a small fractured root tip
may displace it into the mandibular canal. Furthermore,
penetration of mandibular canal by instruments or
forceful intrusion of third molar roots may injure the
artery or the vein resulting in profuse bleeding.
From its start at the mandibular foramen, the canal
and its contents are surrounded by a thin layer of bone
with a configuration similar to lamina dura and this is
radiographically detectable. In cases where the roots of
the third molar are in direct contact with the neuro-
vascular bundle, the lamina dura may be partially or
Fig.5.3: View from the inferior surface of mandible to show the lingual
totally absent. Hence, the radiographic evaluation of the
shelf of bone (red dotted line) which encloses the mandibular third molar
relationship of the mandibular canal and roots of the third
to their displacement through the lingual plate into the molar forms an important part of the preoperative
lingual pouch. assessment.
The buccal bone is predominantly formed by the
buccal cortical plate of mandible and the external oblique

ridge, the latter being the site of insertion of buccinator
muscle. Reduction of the buccal plate will not permit the

same ease of surgical access and its loss tends to weaken
the mandible. The external oblique ridge is a bulky
prominence in some patients and it impedes the buccal
surgical approach to the wisdom tooth.
The interdental bone between the second and third
molar may be minimal or even missing. In such case while
using elevators extreme care should be used not to
damage the bony and periodontal support of second
molar, lest it may lead to periodontal pocket formation
in the post operative period.
Fig. 5.4: Radiograph showing close relationship of impacted

Neurovascular Bundle third molar roots to the mandibular canal
Below or alongside the roots of the third molar is the
mandibular canal. The canal is usually positioned apically Retromolar Triangle
and slightly buccal to the third molar roots. However a
variation from the usual position is not infrequent. The Behind the third molar is a depressed roughened area
canal encloses the neurovascular bundle. The which is bounded by the lingual and buccal crests of
neurovascular bundle contains the inferior alveolar alveolar ridge; the retromolar triangle. Lying lateral to the
artery, vein and nerve enclosed in a fascial sheath. Since retromolar triangle is a shallow depression, the retromolar
the calcification of the mandibular canal is completed fossa. Either in the retromolar triangle or in the fossa an
before formation of the roots of third molar, the growing opening may be present through which emerge branches
roots may impinge on the canal causing its deflection. of the mandibular vessel (Fig.5.5). This branch supplies
Occasionally roots are indented by the mandibular canal, the temporalis tendon, buccinator muscle and adjacent
and rarely penetration of the roots of the wisdom tooth alveolus. Although these are small vessels, a brisk
by this structure may occur. In the latter case, the hemorrhage can occur during the surgical exposure of the
neurovascular bundle will be torn during extraction of third molar region if the distal incision is carried up the
the tooth. Sometimes the apices may reach the superior ramus and not taken laterally towards the cheek.
Surgical Anatomy 31
Fig. 5.5: Schematic diagram showing the retromolar

vessel emerging through retromolar foramen
Fig. 5.6: Schematic diagram showing coronal section through the third
The retromolar pad, which is the soft tissue covering molar region and the relationship of important anatomical structures to
the retromolar area is predominantly made up of loose impacted mandibular third molar
connective tissue. When a gum flap is present over the

occlusal surface of third molar, it will resist the upward removal of wisdom tooth. Hence great care must be taken
movement of the tooth during elevation. Therefore a to protect it. Injury to lingual nerve will lead to prolonged
relieving incision through the overlying mucoperiosteum anesthesia of the anterior two-thirds of the tongue.
must be made before elevating the tooth. Based on studies by Pogrel(1995)1, Holzle(2001)2,
The tendinous insertion of temporalis muscle Behnia(2000)3 and Keisselbach(1984)4 on cadavers it can
terminates as two limiting prongs on the borders of the be concluded that: (1) the lingual nerve was observed at
retromolar triangle. Stripping of these fibers during the or above the crest of the lingual plate in 4.6 to 17.6% of
removal of third molar can result in postoperative pain. the cases; (2) the direct contact of the lingual nerve with
the lingual plate in the retromolar region was observed
Facial Artery and Vein in 22.3 to 62% of the cases; (3) the horizontal distance
from the lingual nerve to the lingual plate in these studies
The facial artery and anterior facial vein cross the inferior ranged from 0 to 7 mm; and (4) vertical distance from the
border of the mandible just anterior to the masseter lingual nerve to the crest of the lingual plate ranged from
muscle and have a close relationship to the second and 2 mm above the crest to 14 mm below it.
third molar. It is possible to cut these vessels if the BP On an average the lingual nerve is found about
blade slips when making a buccal cut in that region. 0.6 mm medial to the mandible and about 2.3 mm below
Hence, it is always sensible to begin the incision in the the alveolar crest in the frontal plane.
depth of the sulcus and direct the blade upwards towards From the above findings it can be concluded that
the tooth. during surgery for the removal of impacted third molar
lingual nerve injury is most likely to occur when it
Lingual Nerve traverses along or near the crest of the lingual ridge or in
the retromolar pad.
The lingual nerve lies on the medial aspect of the third Len Tolstunov (2007)5 cited four anatomical risk
molar (Fig.5.6) factors contributing to lingual nerve injury described
Frequently lingual nerve courses submucosally in below:
contact with the periosteum covering the lingual wall of 1. Lingual version of distoangular impacted lower
the third molar socket or it may run below and behind third molars: This is the first anatomical risk factor to be
the tooth. The proximity of this important nerve to the considered. Distoangular impactions are the most difficult
third molar places it in danger during the surgical mandibular impacted teeth to extract. The long axis of these
third molars is directed away from the operator toward presence of a long-standing pericoronal or periodontal
the ramus of the mandible. Radiographically, some of the infection in the retromolar region can lead to scarring and
distoangular impactions show superimposition of roots adherence of the lingual soft tissue with the lingual nerve
of the third molar on to the roots of the second molar. Roots to the lingual plate. If the lingual plate is deficient, the
of these distoangular impacted mandibular third molars lingual soft tissue can adhere directly to the exposed roots
may be directed lingually. This three-dimensional position of the third molar. This again adds to the vulnerability of
of the third molar is often called the lingual version. Thus the lingual nerve in the third molar region.
in distoangular impaction there is vulnerability of the
lingual nerve in the retromolar pad area. Implication of Lingual Nerve Anatomy
2. Lingual plate deficiency: Lingual plate deficiency in the Surgical Technique
can present itself as a dehiscence (vertical collapse or cleft)
or fenestration below the lingual crest (Fig.5.7). In such Currently the buccal approach has become the favored
cases the apices of third molar penetrates the lingual plate. one for removal of impacted lower third molars. Here
This indicates the additional risk of deflecting the the external oblique ridge is used as a marker for the
fractured roots into the lingual pouch during its incision going distally and buccally, and begins at the
attempted removal. Its occurrence is likely to be distobuccal angle of the second molar, bearing in mind
developmental and appears at a time when the third that the ramus of the mandible flares laterally and
molar forms in the limited space between the vertical posteriorly. This portion of the incision is continuous with
ramus of the mandible and the erupted second molar. A the vertical buccal release incision alongside the first or
pathological lesion in this area (e.g., cyst or tumor) can second molar. This usually allows the surgeon to gain
also erode the lingual plate and further compromise its adequate access to the lower wisdom teeth, impacted or
integrity. not and carefully manage the lingual flap which might
include the retromolar pad without endangering the
lingual nerve. If a straight line is drawn through the
central fossae of the premolars and the molars, and it is
extended through the retromolar pad, this line would end
on the lingual or medial surface of the ramus, almost
exactly where the lingual nerve usually comes down
between the medial surface of the mandible and the
hyoglossus muscle on its way anteriorly and inferiorly
through the lingual mucosa to the lateral border of the
sub-mandibular gland and the floor of the mouth. An
incision directed in any of these areas could very likely
cause a severance of the lingual nerve.
From the above discussion regarding the anatomical
Fig.5.7: Penetration of the apices of roots (blue arrows)
of lower third molar through lingual plate variation of the position of the lingual nerve and anatomical
factors contributing to lingual nerve injury, it is logical to
3. High-lateral position of the lingual nerve: High assume that proper clinical assessment of the case and
position of the lingual nerve at or above the lingual crest knowledge of anatomy plays a vital role in avoiding lingual
in the retromolar region can place it near or on the lingual nerve damage. More over there is no clinical methods to
plate. Based on studies by various authors quoted above, assess the exact course of the lingual nerve in the third
the lingual nerve can potentially be in full contact with the molar area. Miloro et al (1997)6 reported that using high-
lingual plate and at or above the crest of the lingual plate resolution magnetic resonance imaging (MRI) the precise
up to 2 mm. This again contributes to the vulnerability of in situ position of the lingual nerve in the third molar region
the lingual nerve in the retromolar pad area. can be located. In the third molar region, there were only 2
4. Local chronic inflammatory condition: Chronic of 20 cases (10%) in which the nerve was above the lingual
pericoronitis of the lower wisdom teeth is one of the most crest, and there were 5 of 20 instances (25%) in which the
common reasons for their removal. Occasionally, the nerve was in direct contact with the lingual plate. Their
Surgical Anatomy 33
study reconfirms the relative vulnerable position of this

structure during third molar surgery.
Mylohyoid Nerve
This nerve leaves the inferior alveolar nerve just before

the latter enters the mandibular foramen. It then
penetrates the spheno-mandibular ligament and proceeds
close to the mandible in the mylohyoid groove. In 16% of
the cases the nerve may be enclosed in a canal.
The nerve may be damaged during lingual approach
for the removal of impacted mandibular third molar.
Fig. 5.8: While using chisel for bone removal in the third molar region,
initially a 'vertical stop cut' is made distal to second molar to avoid
Long Buccal Nerve splintering of buccal plate of bone. This is followed by making horizontal
bone cut backward
This nerve emerges through the buccinator muscle and
then passes anteriorly on its outer surface. When the Lingual Plate
mouth is wide open, the level at which the nerve passes

through the muscle corresponds to the upper part of the Because of the extreme thinness of the lingual plate the
retromolar fossa. apices of lower third molar frequently perforates it.

Rarely injury to the nerve can occur when the Attempted elevation of fractued roots may lead to their
posterior part of the incision is placed too laterally. This displacement through the thin lingual cortex into the
results in anesthesia of the lower part of the buccal 'lingual pouch'. Difficulty will be experienced in retrieving
mucosa in the molar region. No specific treatment is such dislodged root fragments. Rarely the whole tooth may
required for this as this will heal spontaneously and the be pushed into the lingual pouch (Fig.5.9).
patient will regain sensation with in a short period. When the lingual plate is correctly removed with a
chisel it is not necessary to make a vertical stop cut distal
Bone Trajectories of Mandible to the second molar on the lingual side as it is done on the
buccal side. In this area, the thin cortex surrounding third
The bone trajectories ('grain') of the mandible run molar lingually joins the thick body of mandible and the
longitudinally. This has an important bearing while using
chisel for bone removal. A buccal chisel cut made parallel
to the superior border in the third molar region can
produce an extensive horizontal split in the buccal cortical
plate. This split in the buccal cortical plate may extend
up to the first molar denuding the roots of the teeth. This
mishap can be avoided by making a 'vertical stop cut'
(Fig.5.8) with the chisel distal to second molar and the
bevel facing posteriorly, before removing the buccal plate
around the third molar. Then for removing the buccal
plate, a horizontal cut is subsequently made backward
from a point just above the lower end of stop cut with
bevel of the chisel facing downward.
Extreme care should be taken while using the chisel.
Incorrect angulation of the chisel and the use of too great
a force can result in fracture of mandible distal to the third Fig. 5.9: Whole tooth displaced into lingual pouch
molar. beneath the mylohyoid muscle
inner plate breaks off at that junction and never extends edema may result in trismus due to secondary involve-
forwards. This is the underlying principle in the 'Lingual ment of the muscle.
split bone technique' popularized by Sir William Kelsy Fry. Mylohyoid muscle: This muscle is inserted on the
However, a careless blow with the chisel lingually mylohyoid line from canine to the third molar region.
may lead to detachment of the entire lingual plate In the lingual approach, the insertion of the muscle
including the lingula. It may be noted that the lingula is is partly severed. This leads to transient swallowing
only about 25 mm from the distal aspect of third molar. difficulty. Moreover, postoperative infection can spread
to sublingual or submandibular space.
Musculature
The various muscles surrounding the third molar region
Maxillary Third Molar
are: The maxillary third molar is situated in the tuberosity
• Buccinator - anteriorly region of the maxilla distal to the second molar. The root
• Temporalis - distally of upper third molar is very often in close proximity to
• Masseter - laterally the floor of the maxillary sinus (Fig.5.10).
• Medial pterygoid and mylohyoid - medially In cases where the sinus is large, the roots of these
Buccinator muscle: This horseshoe-shaped muscle forms teeth may protrude into the sinus resulting in the
the musculature of the cheek. It is inserted along the
development of an oro antral fistula following its removal.

external oblique ridge and continues along the Similarly attempts to remove a fractured root can result
pterygomandibular raphe. It is attached to the maxilla at in pushing the root fragment into the sinus. Cases in
the level of the apices of molar roots. which the third molar root is conical, use of a dental
During the surgical removal of deeply impacted third forceps for extraction may 'squeeze' the tooth dislodging
molar, the insertion of attachment of buccinator on the it into the maxillary sinus.
external oblique ridge may have to be severed. This The impacted upper third molar is often covered by
predisposes to marked postoperative swelling, trismus a thin layer of buccal cortical plate. Surgical removal is
and pain. facilitated by removing this plate. Since the presence of
Temporalis muscle: This fan-shaped muscle is inserted an unerupted third molar constitutes an area of weakness
on the coronoid process and anterior border of mandible. in the tuberosity, the latter may fracture during the
Two tendons can be noticed where the muscle attaches removal of the tooth. Rarely the thin buccal plate
to the anterior border of mandible. The outer tendon is enveloping the third molar may fracture during
inserted to the anterior border of coronoid process. The extraction and the tooth may be displaced into the
inner tendon is attached to the temporal crest of mandible. infratemporal space. Recovery of such a tooth will prove
The retromolar fossa is found in between these tendons. difficult because of the presence of fatty tissue and other
During buccal approach for the removal of third
molars, the outer tendon has to be sectioned to enable
reflection of the flap. This in turn will facilitate adequate
bone removal from the buccal and distal side.
Masseter: This muscle is inserted into the lateral side of
the ramus from the coronoid process up to the angle.
The muscle is rarely involved in third molar surgery.
Postoperative edema may extend posteriorly to involve
the muscle leading to trismus and pain. Additionally, pre-
operative or postoperative infection may lead to sub-
masseteric abscess formation.
Medial pterygoid muscle: This is inserted on the medial
aspect of mandible in the angle region.
Fig. 5.10: Schematic diagram of coronal section through maxillary third
Even though not directly involved in third molar molar region showing relationship of impacted third molar to the maxillary
surgery, while using a lingual approach postoperative sinus and buccinator muscle
Surgical Anatomy 35
important anatomical structures like pterygoid venous

plexus, maxillary artery and mandibular nerve.
Cases in which the maxillary wisdom tooth is
erupting buccally, it may impinge on the coronoid process
interfering with mandibular movements. This will cause
pain on closing the mouth and also on lateral excursion
of the mandible to the opposite side. In addition, it causes
ulceration of the buccal mucosa opposing the crown.
Classification of Impacted Mandibular

Third Molar
A number of classifications have been developed to aid

in the determination of surgical difficulty. A classification Fig. 5.11: Classification based on angulation of tooth
system is useful to categorize the degree of impaction (Winter's classification)
and plan a surgical approach that facilitates removal and
minimizes morbidity. It is a tool for predicting the Class I: Sufficient space available anterior to the
difficulty of removal. Most classification is based on the anterior border of ramus for the third molar to erupt.
analysis of the periapical x-ray or the orthopantomogram Class II: Space available is less than the mesio distal
(OPG).
width of the crown of the third molar

The most widely used are Class III: All or most of the third molar is located
1. Angulation (Winter, 1926) of the impacted tooth within the ramus.
(Fig.5.11): Vertical, Mesioangular, Horizontal, Teeth that are buried in the ramus are more difficult
Distoangular, Buccoangular (Figs 5.12 A and B), to remove.
Linguoangular, Inverted, Unusual. 3. Depth of impaction and the type of tissue
2. Relationship of the impacted tooth to the anterior overlying the tooth (Pell and Gregory Classification
border of the ramus (Pell and Gregory, 1942): This is an based on relationship to occlusal plane): i.e. soft tissue,
indication of the amount of space available between the partial bony, or complete bony impaction (Fig.5.14).
ramus and the distal side of the second molar which is Position A: The highest portion of the tooth (occlusal
the effective space available for tooth eruption (Fig.5.13). plane) is on a level with or above the occlusal line.
Figs 5.12 A and B: (A) Partially impacted 48 in buccal version (yellow arrow), (B) Periapical X-ray shows that the tooth is also in distoangular
position. Such tooth when deeply impacted will be very difficult to remove surgically
Fig. 5.13: Pell and Gregory Classification based on relationship

to the anterior border of ramus
Figs 5.16A to C: Classification based on dental procedural codes. (A)
Soft tissue impaction (D7220), (B) Partial bony impaction (D7230), (C)
Full bony impaction (D7240)
and 5.16 shows examples of impaction in which there is

combination of classification based on angulation of tooth
(Winter's classification), relation to anterior border of
ramus and depth of impaction (Pell and Gregory
classification).
Fig. 5.14: Pell and Gregory Classification based on relationship to the Considering the Pell and Gregory classification in a
occlusal plane of the impacted tooth to that of the second molar

study conducted by Obiechina et al (2001)7 in Nigerian
population with 473 impacted mandibular third molars;
Position B: The highest portion of the tooth is below showed that 22.62% of the teeth were in Class I,60.89%
the occlusal line but above the cervical line of second were in Class II, while 16.49% were in Class III
molar. relationship. The study also showed that 54.55%
Position C: The highest portion of the tooth is below impaction were in Position A, 31.92% were in Position B
the cervical line of second molar. while 13.53% were in Position C. The study concluded
A mesioangular impaction with a class I ramus that the level of impaction suggests that a remarkable
relationship and position A depth would be the easiest number of impacted mandibular third molars should be
type of impaction to remove. A distoangular impaction removed under general anesthesia.
with a class III ramus relationship and position C depth 4. Type of tissue overlying the tooth: i.e. soft tissue,
would involve a difficult surgical procedure. Figure 5.15 partial bony, or complete bony impaction.
5. State of Eruption
1. Erupted
2. Partially erupted
3. Unerupted
6. Number of roots
1. Fused roots (Single)
2. Two roots
3. Multiple roots
7. Classification system based on dental procedure
codes (Table 5.1 and Fig. 5.16 and Figs 5.17A and B):
This classification that is used by insurance companies is
also relevant (2005).8 These codes are based on clinical
Figs 5.15 A and B: Examples of impaction showing combination of
angulation of tooth, relationship to anterior border of ramus and depth and radiographic interpretation of the tissue overlying
of impaction. (A) Mesioangular impaction in Class I ramus relation and the impacted maxillary or mandibular third molar. A
Position A depth—an impacted tooth easy for removal. (B) Distoangular
impaction in Class III ramus relation and Position B depth—an impacted
D7220 is the removal of an impaction whose height of
tooth difficult for removal contour is above the alveolar bone and is covered by soft
Surgical Anatomy 37
Figs 5.17A to E: Horizontally impacted 47 and 48 in a 72-year-old man

who reported with discharging sinus from the right side of face of 4
months duration (A). The patient was found to have chronic anemia
(Hb. 6.4 gm/dl), but no other systemic disease. OPG of the patient
revealed a deeply impacted 48 (B-yellow circle) in the angle of mandible
as the possible focus for extra oral sinus. After getting clearance from
the physician and following transfusion of 3 units of packed red cells
(RBC concentrate) the Hb level increased to 9.7 gm/dl. Since the patient
was not willing for surgery under general anesthesia, after proper
informed consent the removal of 48 was attempted under local
anesthesia. The bone was found to be sclerosed and it was difficult to
differentiate between the tooth and bone by noting the color or texture
of the two. There was total absence of periodontal ligament for the tooth
and the tooth was very brittle. The tooth was 'anchored' to the bone
comparable to the classical description of 'glass in concrete'; the 'glass'
being the tooth and the 'concrete' the bone. Only part of the impacted
tooth alone could be removed (C-yellow arrow) after 'struggling' for an
hour. The procedure was abandoned. The case was later posted under
general anesthesia and the lower border of mandible exposed by
submandibular approach. After removal of adequate amount of bone,
taking care to avoid fracture of mandible, the tooth was successfully
removed. D shows the postoperative OPG with the impacted tooth
completely removed (yellow arrow). E shows the healed extra oral sinus
after one month.
Table 5.1: Summary of classification system based on the dental procedure codes
Dental procedural Nature of impaction Degree of difficulty Steps in surgical procedure

code of removal
D 7220 Height of contour of impacted The whole procedure Removal of the tooth is
tooth is above the alveolar bone is considered simple. accomplished by incision,
and is covered by soft tissue reflection of a mucoperiosteal
only—a soft tissue impaction. flap and elevation of the tooth.
D 7230 Superficial contour is covered Intermediate in difficulty Incision, reflection of a soft
by soft tissue and whose height tissue flap, removal of some
of contour lies beneath the amount of bone and sometimes
surrounding alveolar bone— tooth sectioning
a partial bony impaction.
D 7240 Tooth is covered with soft tissue Most difficult to remove Incision, soft tissue flap
and bone—full bony impaction. elevation, removal of overlying
bone and frequently sectioning
of tooth
D 7241 Complete bony impactions with More complicated and Incision, soft tissue flap
unusual surgical complications difficult to remove than elevation, removal of overlying
(root aberrations, proximity to D 7240. (see Figs 5.17 bone and frequently sectioning
anatomic structures, internal A to E) of tooth

or external resorption)
tissue only—a soft tissue impaction. Removal of such a classify impacted mandibular tooth in the dentulous jaws,
tooth is accomplished by incision, reflection of a no accepted classification is available to classify impacted
mucoperiosteal flap and elevation of the tooth. The whole tooth in edentulous mandible or maxilla or impacted
procedure is considered simple. A D7230 is the removal tooth associated with infection (bony/soft tissue),
of an impaction whose superficial contour is covered by osteomyelitis (Fig. 5.18) or pathological lesions like cyst
soft tissue and whose height of contour lies beneath the or tumor. Moreover local complicating factors or systemic
surrounding alveolar bone—a partial bony impaction. condition of the patient is not taken into consideration
Such teeth are removed after reflection of a soft tissue while classifying impacted mandibular third molars.
flap, removal of some amount of bone and sometimes
tooth sectioning. Such surgeries are considered
intermediate in difficulty of removal. A code D7240
connotes an impacted tooth that is covered with soft tissue
and bone—full bony impaction. Such teeth require soft
tissue flap elevation, removal of overlying bone and
frequently sectioning of tooth for removal. These
impactions are considered the most difficult to remove.
An additional code, D7241, can be used for complete bony
impactions with unusual features like root aberrations,
proximity to anatomic structures, or resorption leading
to possible surgical complications. Removal of such teeth
is more difficult than regular full bony impactions. Fig.5.18: OPG showing impacted 48 with associated osteomyelitis in a
Disadvantage of the present classification: Even 78-year-old lady who reported with recurrent pain and swelling of the
though there are a number of classifications available to right side of face of 2 years duration
Surgical Anatomy 39
REFERENCES mandibular third molar region. J Oral Maxillofac Surg

1984;42:565-67.
1. Pogrel MA, Renaut A, Schmidt B, et al. The relationship of
5. Len Tolstunov. Lingual NerveVulnerability. RiskAnalysis
the lingual nerve to the mandibular third molar region:
and Case Report. Compend Contin Educ Dent 2007;28(1):
An anatomic study. J Oral Maxillofac Surg 1995; 53:
28-32.
1178-81.
6. Miloro M, Halkias LE, Slone HW, Chakeres DW. Assess-
2. Holzle FW, Wolff KD. Anatomic position of the lingual
nerve in the mandibular third molar region with special ment of the lingual nerve in the third molar region using
consideration of an atrophied mandibular crest: An magnetic resonance imaging. J Oral Maxillofac Surg 1997;
anatomical study. Int J Oral Maxillofac Surg 2001;30: 55(2): 134-7.
333-38. 7. Obiechina AE, Arotiba JT, Fasola AO. Third molar
3. Behnia H, Kheradvar A, Shahrokhi M. An anatomic study impaction: evaluation of the symptoms and pattern of
of the lingual nerve in the third molar region. J Oral impaction of mandibular third molar teeth in Nigerians.
Maxillofac Surg 2000;58:649-51. Odontostomatol Trop 2001;24(93):22-5.
4. Kiesselbach JE, Chamberlain JG. Clinical and anatomic 8. American Dental Association. Current dental terminology.
observations on the relationship of the lingual nerve to the Chicago: American Dental Association; 2005.
6 Preoperative Planning
Diagnosis of impacted third molar should be based on A complete assessment of the possible problems
patient complaint, history, physical evaluation and which could be encountered in the surgical removal of
diagnostic test evaluation. an impacted third molar and a treatment plan can be
Preoperative evaluation of the third molar, both formulated only after a careful clinical and radiographic
clinically and radiographically is an important step for examination of the area.

the successful and speedy removal. Time spent at this
stage is time gained. A good periapical radiograph is a Clinical Examination
must. If required the periapical radiograph should be
supplemented with an occlusal X-ray. An OPG or a lateral This include (1) History taking (2) Extra oral examination,
oblique radiograph should be taken whenever intra oral and (3) Intraoral examination
radiographs are inadequate to provide the necessary
1. History Taking
information regarding the tooth or adjacent structures.
However, the former lack the details seen in a periapical Complaints of the patient: Impacted teeth very often cause
film. no symptoms and patients are unaware of its presence
until told by the dental practitioner. Symptoms when
present are usually related to pericoronitis, which may
PREOPERATIVE PLANNING HELP IN THE
be either acute or chronic in nature or complaints related
FOLLOWING WAYS
to acute pulpitis associated with dental caries. Symptoms
1. It provides a rough estimate of time required for associated with other conditions listed in Chapter 3 under
the procedure. (Put in extra 15 minutes for any indications for surgical removal may also be present.
eventuality.) Medical and dental history: An important part of the
2. Helps to exclude those cases which are beyond one's interrogation is the medical and dental history of the
competence. patient. Advances in modern medicine have resulted in
3. Expect the complications that are likely to occur and the improved survival of people with significant medical
get informed consent from the patient conditions. As a result people are living longer and
4. Helps in selection of instruments. receiving treatment for disorders that were fatal a few
5. Selection of the type of anesthesia to be employed- years ago. These patients have a relatively high risk of
whether local anesthesia or general anesthesia is developing complications from surgical procedures.
required. Most patients can tolerate surgery under Hence, it is imperative that the dental surgeon be
local anesthesia lasting from 45 minutes to 1 hour. competent to recognize and manage such cases in the
Preoperative Planning 41
safest possible manner. Apart from the fate of the patient, In an ordinary dental surgery setting, it is unlikely
neglect of the medical history can result in unpleasant that the dental surgeon will undertake a full medical
medico-legal problems. examination of the patient prior to any surgical
There are three basic aspects regarding the dental procedures. Instead the operator must rely on a proper
management of medically compromised patient. The first medical history that will help to identify those patients
is to detect such patients. This is a difficult task, especially with medical conditions that will require precautionary
when there are no significant symptoms or if the patient measures. A written questionnaire will help as a screening
is uneducated and has no idea about the disease and the measure to recognize such patients. Alternatively, if the
drug therapy. However, this does not preclude the patient is not literate the dental surgeon or the assistant
responsibility of the dental surgeon in the event any can do a thorough interrogation and the matter entered
complications occur. Secondly, if the patient is found to in the case record. The basic example is as follows:
have a systemic disease it is essential to determine the
implications of the disease or its treatment on the dental Medical Evaluation Form
management. Finally, once it has been decided, it then
remains necessary to discover how best to deal with the A detailed medical history will help to identify medical
problem. conditions which contraindicate surgical removal or
Medical Evaluation
Date
Please note to answer the questions correctly. For any clarification contact the dental staff. Your health and fitness is of
utmost importance to make sure that the dental treatment you receive will not affect adversely your general health.
Name, address and Tel. no. of your Physician
Are you suffering from/ suffered any of the following conditions/ disease?
Diabetes Yes/No Liver or Kidney Disease Yes/No
High Blood Pressure Yes/No Thyroid Disease Yes/No
Heart Attack Yes/No Asthma Yes/No
Angina Yes/No Fits or Epilepsy Yes/No
Bleeding Problem Yes/No Stroke Yes/No
Rheumatic Fever Yes/No Any other illness Yes/No
Do you consider yourself to be in the high-risk group for HIV/ AIDS/ Hepatitis B
Are you currently on any medication? Yes/No
If yes, What are they and Dose? 1.
2.
3.
Are you allergic to any drugs or substances Yes/No
If yes, What are they? 1.
2.
3.
Have you ever had adverse reaction to local or general anesthetic? Yes/No
Have you ever had any dental treatment, operation or surgery? Yes/No
If yes, list the operation, year and any complications 1.
2.
3.
Ladies- Are you pregnant? Yes/No
Are you a smoker/ chewer/ consume alcohol? Yes/No
If yes, frequency, intensity, duration?
To the best of my knowledge, all the preceding answers are true and correct. If I ever have any change in my health,
abnormal laboratory test, or if my medication change, I will inform the dentist at the next appointment without fail.
Signature Patient Bystander Doctor
& Name
modify the management of the patient with impacted 3. Administration of preoperative medication:
tooth. A detailed discussion of the medical conditions to (a) antibiotic cover, (b) steroid cover, (c) oral
be considered is beyond the scope of this chapter. sedation
However, the following are the common medical 4. Selection of anesthetic that is safe for the patient
conditions to be considered which have significant impact 5. Undertaking surgery in a hospital set up where
in the management of patients with impacted third appropriate medical back up is available.
molar: 6. Selection of medication (e.g. antibiotics and
1. Cardiovascular diseases analgesics) that is safe for the patient. For example
(a) Hypertension avoid penicillin in those with reported history of
(b) Infective endocarditis allergy.
(c) Ischemic heart disease 7. Anticipate and adequately prepare for a potential
(d) Thromboembolic disorders (patients on medical emergency. For example, acute asthmatic
anticoagulants) attack.
2. Endocrine diseases
(a) Diabetes mellitus 2. Extraoral Examination
(b) Hyperthyroidism The face and neck is examined for signs of swelling or
(c) Adrenal insufficiency redness of the cheek suggestive of infection. The lower
3. Bleeding disorders
lip is tested for anesthesia or paresthesia. The regional

4. Respiratory diseases lymph nodes are palpated for enlargement and
(a) Bronchial asthma tenderness.
(b) Chronic obstructive pulmonary disease

(COPD) 3. Intraoral Examination
5. Liver disease The following points are noted:
(a) Chronic alcoholism and Liver cirrhosis 1. Mouth opening: Normal mouth opening/micro-
(b) Viral hepatitis somia/macrosomia/trismus/hypermobility of TM
6. Pregnancy joint/habitual dislocation/fibrosis of mucosa e.g.
7. AIDS and HIV infection submucous fibrosis. In retrognathic mandible
8. Prosthetic joint replacements accessibility to third molar area is restricted, while
9. Neurological Disorders in prognathic mandible accessibility is better.
(a) Epilepsy 2. General examination of oral cavity: Oral mucosa,
(b) Stroke teeth, oral hygiene.
(c) Parkinson's disease 3. Third molar area: State of eruption of tooth, tissue
10. Patients with organ transplantation overlying the tooth (bone/soft tissue only), signs
11. Chronic renal failure of pericoronitis.
12. Allergy to drugs/ food items 4. Condition of impacted tooth: Carious or with
fillings, internal resorption (not to be mistaken for
Significance of Medical Evaluation caries), angulation of tooth, locking of crown of third
A proper medical history enables the operator to take molar beneath second molar. This is later confirmed
the necessary precautions that will ensure patient's safety with appropriate radiographs.
during the dental surgical procedure. These may be either 5. Condition of second molar and first molar: Caries,
one or a combination of the following precautions: crown/filling, distal periodontal pocket/resorption
1. Additional investigations: For example clotting of root of second molar, missing second molar.
screen for those with history of bleeding. Carious second molar or large filling/crown of
2. Alteration of patient's current medication to second molar is likely to fracture while using
facilitate surgery. For example stopping warfarin leverage in attempting to elevate third molar. The
preoperatively. Such measures must only be taken patient has to be warned of this to avoid
in consultation with the patient's physician. unpleasantness later on in the event of a mishap.
6. Amount of space available between the distal the proposed surgical procedure, the most appropriate
surface of second molar and the ascending ramus: location for this to take place, and to highlight aspects of
If the distance is small, the tooth is less accessible; if management which may require specific mention to the
large it is accessible. In the maxilla the accessibility patient.
depends on the relationship of the tooth to the Moreover, diseases of adjacent soft and hard tissues
tuberosity. Distal tilting of second molar also may proceed to advanced stages without symptoms (e.g.
decreases accessibility. associated cyst/ tumor), it is important that radiographic
7. Adjacent bone: May be infected along the mesial evaluation be performed. The most commonly accepted
surface of the tooth and may involve the second imaging modality is the intra oral periapical X-ray and
molar necessitating its extraction. Infection / panoramic radiograph. Other imaging techniques may
osteomyelitis may involve the ramus posterior to be appropriate if they provide appropriate visualization
the crown especially in cases of recurrent sub- of the entire tooth and associated structures. However, it
masseteric abscess arising in relation to must be kept in mind that radiographs may not provide
distoangularly impacted third molar. complete or accurate information as to tooth position.
8. Fracture may complicate the removal of an Most of the local factors causing difficulty in removal
impacted third molar. When the jaw contains an of third molar can be diagnosed by careful interpretation
impacted tooth, it is more vulnerable to a blow and of preoperative radiograph.
frequently fractures through an unerupted third
The following intra oral and extra oral radiographs

molar crypt. After the tooth is removed, the fracture are required:
is immobilized in the usual manner. Fracture caused
1. Periapical radiograph
by an attempted surgical removal of third molar 2. Occlusal X- ray of mandible
should be recognized and a careful record should 3. Lateral oblique view of mandible
be made of it. 4. Orthopantomogram
9. Pathological complications due to skeletal diseases
should be noted. They may increase the danger of An important criteria for a good film is that there should be a
fracture as in osteogenesis imperfecta and clear superimposition of the buccal and lingual cusps of the
osteosclerosis. In acromegaly the removal of tooth second molar upon one another in the same vertical and
is difficult because the mandible consists of massive horizontal plane which is visualized as a typical 'enamel cap'
bone. In Paget's disease the tooth may be affected appearance of the second molar.
by resorption and repair by bone make its removal
difficult. 1. Periapical radiograph: An ideal periapical X-ray
10. Presence of cysts and tumors: Small eruption cysts should include the whole third molar, its investing bone,
and large cysts may occur in relation to impacted the anterior border of ramus, the inferior alveolar canal
tooth. Generally they cause displacement of the and the adjacent second molar tooth. An important
tooth. Tumors, benign and malignant may be found criteria for a good film is that there should be a clear
involving the tooth, especially ameloblastoma. superimposition of the buccal and lingual cusps of the
Odontomes also may be found around third molar second molar upon one another in the same vertical and
tooth. horizontal plane which is visualized as a typical 'enamel
cap' appearance of the second molar. This can be achieved
by positioning the X-ray tube in such a way that the
Radiography of Impacted Mandibular
central ray will be parallel to the occlusal surface of the
Third Molar
second molar and pass through the distal cusps of the
The purpose of a careful radiological evaluation is to second molar at right angles to the film packet. In a good
complement the clinical examination by providing film the lateral image of the second molar will be sharp
additional information about the third molar, the related without vertical shortening. In a poor film with incorrect
teeth and anatomical features, and the surrounding bone. angulation, the 'enamel cap' will be absent and there will
This is necessary in order to make a sound decision about be overlapping of contact points of molars.
For taking a good periapical radiograph, the patient

is seated with the mouth open, occlusal plane of
mandibular teeth horizontal and parallel to the floor. The
film is then inserted on the lingual side of the
corresponding third molar with the anterior edge of the
film reaching up to the mesial surface of first molar. In
suspected cases of horizontal impaction, the film should
be inserted more posteriorly so that the root apices also
will be visualized in the radiograph. A film holder or a
straight 'mosquito' hemostat will help to grip the film and
position it correctly. The X- ray tube is positioned so that
Figs 6.2A and B: Location of the film and direction of central ray seen
the central ray will be parallel to the occlusal surface of
from above. (A) Average case. Note that central ray is directed along
the second molar and pass through the distal cusps of the crown of the second molar. (B) In case of a horizontal impaction.
the second molar at right angles to the film packet. Note that the central ray is directed through the middle of the crown of
the impacted tooth
Moreover, when viewed from the front the angulation of
the central ray should be parallel with the transverse
occlusal plane which is usually at an angle of 3° to 4°
above the horizontal plane (Figs 6.1 A and B).
Figs 6.3 A and B: (A) Schematic diagram showing that when the central
ray is not parallel to the transverse occlusal plane the enamel cap of
the second molar is absent, (B) If the central ray does not pass at right
angles to the film in the horizontal plane, overlapping of contact points
occur
Figs 6.1A and B: (A) Positioning of periapical film packet and angulation
of central ray in an average case (viewed from above), (B) Angulation Very often the correct positioning of periapical film
of the central ray when viewed from the front—the central ray (red arrow) in the third molar region can be difficult due to gagging
is parallel with the transverse occlusal plane (green line) which is usually reflex or pain in the floor of the mouth due to sharp edge
at an angle of 3° to 4° above the horizontal plane (blue dotted line)
of the film or difficulty in positioning the X-ray film
sufficiently posteriorly. Should these difficulties occur,
In cases of horizontal impactions, the central ray is the resulting film will be far from adequate to yield
directed through the middle of the crown of the impacted sufficient information about the impacted tooth and
tooth (Figs 6.2 A and B) and at right angles to the film surrounding area. Also the narrow viewing field obtained
packet. Lingual tilt or rotation of the second molar if in periapical film has limited diagnostic value. However,
present should be considered while positioning the tube periapical radiographs are more discriminating than OPG
and interpretation of such radiographs. and may be more helpful in detecting caries, bone height
As stated above in a good film the lateral image of at the level of second molar and root contour.
the second molar will be sharp without vertical 2. Occlusal X-ray: This will help to confirm the
shortening. But in a poor film with incorrect angulation, presence of a bucco-lingual relationship indicated by a
the 'enamel cap' will be absent and there will be periapical X-ray, and will demonstrate the exact position
overlapping of contact points of molars (Figs 6.3 A and of the crown of the tooth and the shape of laterally
B). This occurs when the central ray is not parallel to the deviated roots.
transverse occlusal plane and if the central ray does not 3. Lateral oblique view of mandible: There is
pass at right angles to the film in the horizontal plane. inevitable distortion associated with this radiograph due
4. Orthopantomogram (OPG): Recently due to easy

availability OPG has replaced the lateral oblique view of
mandible. All the information available from a lateral
oblique view can be had from OPG with less distortion
(Fig. 6.4). Routine use of OPG is an important advance in
the accurate localization of impacted teeth
OPG is considered the gold standard for surveying
the maxilla and mandible for diseases and other
pathological conditions in the lateral plane.
Fig. 6.4: OPG of a 61-year-old man showing bilaterally impacted third Different radiographic views helps to identify other
molar with their roots in close relationship to inferior alveolar conditions affecting the area (Figs 6.5 A and B)
neurovascular bundle
Interpretation of Periapical X-ray

to the need to rotate the opposite side of the mandible
out of the path of the central ray during exposure of the The radiograph should be carefully examined in a well
film. Hence, this is not as useful as a good periapical X- lit X-ray lobby. The use of a good hand lens will greatly
ray to assess the local factors causing difficulty in removal. assist the detection of small ancillary roots and the
However, this X-ray has a definite role in the following
relationship of roots to the inferior alveolar canal.

situations: The following factors are considered while
• When periapical film could not be taken due to interpreting the radiograph:
retching, trismus or some other cause. a. Access

• To provide additional information like vertical height b. Position and depth of impacted tooth
of mandible in the area, amount of bone beneath c. Root pattern of impacted tooth
deeply buried impacted tooth in a thin mandible, d. Shape of crown
existence of pathology in the vicinity like cyst / tumor e. Texture of investing bone
or double impactions. f. Relation to inferior alveolar canal
Since the introduction of OPG, the indication for the g. Position and root pattern of second molar.
use of extra oral X-ray's is limited. However, its use may a. Access: By noting the inclination of the radio-
be considered in the absence of OPG. opaque line cast by the external oblique ridge the ease of
Figs 6.5A and B: A 63-year-old lady was referred to the author with a provisional diagnosis of impacted 48 who complained of recurrent pain and
swelling of the right side of face with a lateral oblique X-ray of mandible (A) taken by the general dental practitioner (note the dark arrow). Detailed
history and findings of clinical examination was suggestive of submandibular calculus. Subsequently an OPG (B) was taken which showed a
change in position of the opaque mass which confirmed the final diagnosis of salivary calculus. The calculus was removed (see the inset picture
in figure 'B') under general anesthesia by a submandibular approach
access can be determined. If this line is vertical the access

is poor and if horizontal, access is good.
b. Position and depth of impacted tooth: This is
determined by a method described by George Winter. In
this technique three imaginary lines are drawn on the
radiograph. These lines are described as 'white', 'amber'
and 'red' lines (Figs 6.6 to 6.10).
The first line or 'white' line is drawn along the occlusal
surface of the erupted mandibular molars and extended
posteriorly over the third molar region. From this the axial
Fig. 6.8: 'WAR' lines drawn on a mesioangularly

impacted mandibular third molar
inclination or position of impacted tooth can be assessed.

For example, the 'white' line will be parallel to the occlusal
surface of a vertically impacted tooth. While in case of a

disto-angular impaction, the occlusal surface of the tooth
and 'white' line are seen to converge as if to meet in front

of the third molar.
The 'white' line also provides an indication regarding
the depth at which the tooth is lying in mandible, when
Fig. 6.6: White, amber and red lines (Winter's WAR lines)
compared to the erupted second molar.
marked in the periapical X-ray The second imaginary line or 'amber' line is drawn
from the surface of the bone lying distal to the third molar
to the crest of the interdental septum between the first
and second molar. When drawing this line it is important
Fig. 6.7: Tracing of 'WAR' lines on a horizontally impacted mandibular

third molar. 'White' line is drawn along the occlusal surface of the erupted
mandibular molars and extended posteriorly over the third molar region.
'Amber' line is drawn from the surface of the bone lying distal to the Fig. 6.9: 'WAR' lines drawn on a vertically impacted mandibular third
third molar to the crest of the interdental septum between the first and molar. Note that there is no 'red' line drawn. The point of application of
second molar. 'Red'line is a perpendicular dropped from the 'amber' elevator (marked X in red colour) is at the same level of 'amber' line at
line to an imaginary 'point of application' of an elevator the mesial aspect of the third molar
When assessing the depth of disto-angular

impactions, the perpendicular 'red' line should be
dropped to the cemento-enamel junction on the distal side
of the impacted tooth (Fig. 6.10) and not on the mesial
side as in other angulations. Use of cemento-enamel
junction on the mesial side of the impacted tooth for this
purpose will give a misleading estimation of depth.
Significance of disto-angular impaction: One of the
serious mistakes made by dental surgeons embarking on
surgical removal is to misdiagnose a disto-angular
impaction as a vertical impaction. This is because
clinically many disto-angular impactions give a false
picture of vertical impaction to a casual observer. While
many vertical impactions can be removed using a straight
elevator applied to the mesial surface of the tooth,
application of such a force to a disto -angular impaction,
Fig. 6.10: 'WAR' lines drawn on a distoangularly impacted mandibular
third molar. Note that in distoangular impactions the perpendicular 'red'
the bone lying distal to the tooth will prevent its removal.
line should be dropped to the cemento-enamel junction on the distal Further application of excessive force will cause fracture
side of the impacted tooth and not on the mesial side as in other of mandible. Hence for the removal of such tooth it is
angulations
essential that adequate space is created distal to the tooth
to differentiate between the shadow cast by the external into which the tooth is displaced before elevation is
oblique ridge and that cast by the bone lying distal to the attempted. This serious error can be avoided by noting
tooth. It is important to note that the posterior end of the the following points during the interpretation of
'amber' line is drawn on the shadow cast by the bone in periapical X-ray:
the retromolar fossa and not that cast by the external • In a vertical impaction, the anteroposterior width of
oblique ridge which lies above and in front of it. The the interdental septum between the second and third
'amber' line indicates the margin of the alveolar bone molar is same as that of the width of the septum
enclosing the tooth. Hence, when soft tissues are reflected, between the first and second molar. While in case of a
only that portion of the tooth shown on the film to be disto-angular impaction (Fig. 6.11) the interdental
lying above and in front of the 'amber' line will be visible; septum between the second and third molar is much
while the reminder of the tooth will be encased within narrower (yellow arrow) than that between the first
the alveolar bone. and second molar (blue arrow)
The third line or 'red' line is used to measure the depth
at which the impacted tooth lies within the mandible. It
is a perpendicular dropped from the 'amber' line to an
imaginary 'point of application' of an elevator. With the
exception of disto-angular impaction, the cemento-
enamel junction on the mesial surface of the impacted
tooth is used for this purpose. In a deeply impacted tooth,
the 'red' line will be longer and more difficult will be the
surgical procedure. It has been noted that for every 1 mm
increase in the length of 'red' line, extraction becomes
about three times more difficult. As a general rule, any
tooth with a 'red' line 5 mm or more is better removed
under general anesthesia. If the 'red' line is 9 mm or more,
the inferior surface of the crown of the impacted third
molar will be either at the level or below the apex of the
second molar. In such cases bone removal has to be done
with great caution to avoid accidental fracture of Fig. 6.11: Periapical radiograph showing distoangularly
mandible. impacted 48. See text for explanation
Fig. 6.12: OPG 38 and 48 with limited root development

(yellow circle). See text for explanation.
• Moreover as stated above, in case of a disto-angular Fig. 6.13: If the mesiodistal diameter of the roots is greater than the
impaction, the occlusal surface of the tooth and 'white' mesiodistal diameter of the crown; the roots must be sectioned before
removal
line are seen to converge as if to meet in front of the
third molar. periodontal ligament, and ample space exists between

c. Root pattern of impacted tooth: The number, the roots and the inferior alveolar nerve (IAN). Similarly,
shape and curvature of roots are noted. The presence of third molars with conical and fused roots are easier to
hypercementosis if any is determined. Root often appears remove than third molars with widely separated and
blunt and short when the apical portion of root takes a distinct roots. Roots with severe curvature, however, are
sharp bend in the direction of X-ray beam. Such finding more difficult to remove than less curved or straight roots.
calls for more meticulous examination of the film. Roots that curve in the same direction as the pathway of
Root morphology influences the degree of difficulty removal break less often than roots that curve in a
for removal of an impacted third molar. Limited root direction opposite to the pathway of removal. Roots with
development leads to a "rolling" tooth, which can be a mesiodistal diameter that is greater than the tooth
difficult to remove (Fig. 6.12). diameter at the cervical line must be sectioned
Such teeth are sectioned in multiple planes before longitudinally before removal (Fig. 6.13).
attempting removal. A tooth with one-third to two-thirds The presence of multiple roots may not be visible in
root development is easier to remove than a tooth with radiographs as the lingual roots will be overlapped by
full root development. Such teeth typically have a wide the buccal roots (Figs 6.14 A and B to 6.17 A and B)
Figs 6.14 A and B: (A) Periapical X-ray showing curved distal roots of 48, (B) Specimen showing two distal roots
Figs 6.15 A and B: (A) Periapical X-ray of an 18-year-old man showing impacted 38. Even though the X-ray is of good quality, only
one mesial and one distal root is visible, (B) Surgical removal of tooth was difficult and the extracted tooth showed four roots
Figs 6.16 A and B: (A) Periapical X-ray of 42-year-old man showing impacted 48. Even though the X-ray is of good quality, only
one mesial and one distal root is visible, (B) Surgical removal of tooth was difficult and the roots were removed separately
Figs 6.17 A and B: Periapical X-ray clearly showing 3 roots for 48, (B) Extracted specimen showing 3 roots
Figs 6.18A and B: (A) Periapical X-ray showing 3 roots for 38, (B) OPG shows 3 roots for 48 also
However, depending on the location of multiple roots

and the change in angulation of central ray, presence of
multiple roots can be identified (Figs 6.18 A and B).
The X-ray should be carefully examined for hyper-
cementosis or ankylosis of the roots (Figs 6.19 A and B)
d. Shape of crown: Teeth with large square crowns

and prominent cusps are more difficult to remove than
teeth with small crowns and flat cusps. The size and shape
of the crown of third molar acquire importance when the
'line of withdrawal' of the tooth is obstructed by the crown
of the second molar, a condition referred to as 'tooth
impaction' or 'locking of the crown' (Fig. 6.20).
In such a case the radiograph will show that the cusp
of third molar is superimposed upon the distal surface of Fig. 6.20: 'Locking of the crown' of impacted tooth by the second molar.
Note that the cusp of third molar is superimposed upon the distal surface
second molar. Application of force to the mesial surface of second molar
of impacted tooth in an attempt to elevate it will either
displace the second molar from its socket or damage its Rarely impacted mandibular third molar can cause
supporting structure or may fracture the mandible. This resorption of the root of the second molar. This can be
misfortune is most likely to occur when the second molar distinguished from 'tooth impaction' by the presence of
has a conical root. It can be avoided by sectioning of a break in the continuity of the shadow cast by the distal
surface of the second molar root.
impacted tooth.
Figs 6.19A and B: (A) Hypercementosis of 35 and 37 (note yellow arrows), (B) Hypercementosis of impacted 48 (yellow arrow)
e. Texture of the investing bone: With advancing age

the bone tends to become more sclerosed and less elastic.
For accurate determination of the bone texture a rigid
standardization of exposure and developing technique
is mandatory. Very often this is not practical. However
some clue regarding the texture of bone can be obtained
by noting the size of the cancellous spaces and the density
of the bone structure. If the spaces are large and the bone
structure is fine, the bone is generally elastic. On the other
hand, if the spaces are small and the bone structure dense, Figs 6.21A to C: Radiographic relationship of third molar root to inferior
the bone is more sclerotic. The more dense the bone, the alveolar nerve: (A) Cortical outline of the canal is intact. This probably
less the degree of bony expansion during luxation and represents superimposition only. (B) There is loss of cortical outline of
the nerve canal. The nerve may be grooving the tooth. (C) There is loss
more time required for its removal with a bur. of cortical outline as well as narrowing and deviation of the nerve canal,
f. Inferior alveolar canal: This structure is frequently denoting an intimate relationship of the nerve with the tooth and possibly
seen to be crossing the roots of the third molar. Very often perforation of the tooth root by the nerve
such an appearance is due to radiographic superim-
position. But occasionally it can also be due to grooving
and the IDC, a second radiograph should be taken using
or perforation of the root. This can be distinguished by
different projection geometry.

noting whether certain signs are present or not. If the third molar is found to be in close relationship
1. A band of reduced radio-opacity crossing the roots with the inferior alveolar canal, the patient should be
and coinciding with the outline of the inferior warned in advance regarding the possibility of
alveolar canal indicates that the tooth root is impairment of labial sensation following the surgical
grooved by the inferior alveolar canal. This sign is removal of tooth. Mention should be made regarding this
most likely due to decreased amount of tooth in the case record. In such cases every effort should be
structure between the X-ray source and the film. made to avoid damage to the neurovascular bundle
2. The compact bone forming the roof and floor of the during surgery. For example if the grooving is on the
canal is represented on the radiograph by parallel lingual side of the tooth, generous amount of bone is
lines of radio-opacity. Break in the continuity of one removed on the buccal side and the tooth delivered
or both of these lines is seen when the root is through the resultant defect. While in cases of apical
grooved by the inferior alveolar canal. Grooves are notching (frequently associated with mesio-angular and
usually located on the lingual side of the roots. disto-angular impactions) tooth division using bur is done
3. In cases where the radiolucent band crosses the apex to avoid nerve damage. In cases where the root is
of the root and if only the upper white line is broken, perforated by the neurovascular bundle, the site is
a notching of the root is present. adequately exposed by the removal of buccal plate of
4. Characteristic narrowing of the radiolucent band bone. The root is then carefully sectioned using a bur at
with loss of white lines is suggestive of perforation the level of the neurovascular bundle and the root
of the root by the inferior alveolar canal. fragments are then removed.
The following signs have been demonstrated to be In difficult cases where it is not possible to maintain
associated with a significantly increased risk of nerve the continuity of the neurovascular bundle it may be
injury during third molar surgery (Fig. 6.21): sectioned using a BP blade. When this is attempted
• Diversion of the inferior dental canal (IDC) adequate precaution should be taken to control the brisk
• Darkening of the root where crossed by the canal hemorrhage that follows sectioning. It is always
• Interruption of the white lines of the canal. preferable to do a nerve anastomosis by suturing the cut
In the presence of any of the above findings, great ends to facilitate nerve regeneration. Another alternative
care should be taken in surgical exploration and the is that, the cut ends may be placed in close approximation
decision to treat is carefully reviewed. If on the initial in the bottom of the socket without suturing. Usually
panoramic radiograph there is a suggestion of a sensation of lower lip will be regained within six months
relationship between the roots of the lower third molar, to one year after surgery.
g. Position, root pattern and nature of crown of Large restorations, crown and root canal therapy in
second molar: The space between the distal surface of second molar teeth also pose additional risk of damage
the second molar and the mesial surface of the impacted to second molar if elevation forces or direction of drilling
third molar has an impact on the ease of removal of the are misdirected. Instances in which full crowns or large
third molar. The closer the third molar is to the second restorations exist in the tooth adjacent to impacted third
molar, the more difficult the surgery becomes. A distal molar, informed consent should be obtained regarding
tilt of the long axis of the second molar may create possible damage to the adjacent tooth.
difficulty in the surgical removal of impacted mandibular
third molar. Moreover, if the second molar has a single
conical root it can be easily displaced by an elevator CT Evaluation (Figs 6.22A to J and 6.23A to H)
applied to the mesial surface of the impacted third molar Both the conventional imaging modalities i.e. periapical
tooth. This is especially likely to occur if the first molar is
radiographs and rotational panoramic radiographs have
missing.
Figs 6.22A to F: Shows the steps in generating reformatted CT image. (A) Panoramic radiograph showing the 3 M, (B) CT scout image with
planning slices, (C) Panoramic radiograph showing the 3 M, (D) Reformatted sagittal image of 3M, (E) Reformatted sagittal image used to plan
cross-sectional imaging, (F) Reformatted cross-sectional image showing the inferior dental canal in relation to 3M (Adapted with kind permission
from Mahasantipiya et al. Narrowing of the inferior dental canal in relation to the lower third molars. Dentomaxillofacial Radiology. 2005; 34: 154-
163)
Figs 6.22G to J: Reformatted CT images showing various relationships between the inferior dental canal and the lower third molar roots.
(G) Lingual positioning and narrowing of the canal and thinning of the adjacent cortex, (H) Buccal positioning and minor thining
of the adjacent cortex, (I) Inferior positioning of the canal without narrowing, (J) The canal between the roots and with narrowing (Adapted with
kind permission from Mahasantipiya et al. Narrowing of the inferior dental canal in relation to the lower third molars Dentomaxillofacial Radiology.
2005; 34: 154-163)
their limitations; but perhaps the greatest limitation is The judicious use of CT scan provides valuable
the lack of three-dimensional information provided. Even information on the above aspects.
though OPG offers a speedy, relatively inexpensive Because of the limitations of conventional imaging
radiograph of the jaws it has the following disadvantages: when assessing the relationship between the inferior
• Does not provide a coronal view of the third molar dental canal (IDC) and the lower third molar roots, the
area. use of computed tomography (CT) is increasing. The
• Does not show the relationship of the root apices to advent of multislice CT scanners has greatly enhanced
the inferior alveolar canal in all planes of space. the capability of CT to demonstrate the location and
• Does not provide predictable evidence of bone density. morphology of the inferior dental canal. Multislice
Figs 6.23A to H: Compares the radiographic markers on panoramic radiographs with the corresponding cross-sectional CT image. (Adapted with
kind permission from Mahasantipiya et al. Narrowing of the inferior dental canal in relation to the lower third molars. Dentomaxillofacial Radiology.
2005; 34: 154-163)
scanners are much faster than conventional CT scanners The significance of narrowing of the inferior dental
and the reformatted images are as sharp as the directly canal as demonstrated on CT is unknown.(Mahasantipiya
acquired images. Consequently, there has been a et al, 2005).1 Narrowing of the canal may also result in
significant increase in the number of cases being referred non-specific symptoms in the lower third molar regions
for pre-surgical evaluation of the relationship between in the absence of pericoronitis if the neurovascular bundle
the inferior dental canal and the lower third molar roots. is compressed. However, it can be implied that nerve
Over the past few years, with the increased use of CT to damage is more likely during surgical removal of the
assess the inferior dental canal in cases of impacted third third molar when narrowing of the canal is present.
molars, it has been noted that (Mahasantipiya et al, 2005)1 Deviation of the canal on a panoramic radiograph is the
in a relatively large number of cases, the inferior dental most reliable predictor when there is narrowing of the
canal appears to be compressed between the roots of the
canal. When there is superimposition of the canal over
adjacent third molar and the lingual or buccal cortex. It
the third molar roots or deviation of the canal in relation
has also been noted that if there is apparent canal
to the third molar roots a close relationship between the
compression there appears to be an intimate relationship
canal and the third molar is very likely.
between the roots and the cortex. Furthermore, in a
However, for a number of reasons, including cost
number of cases, there is thinning of the buccal or lingual
cortex because the canal lies partly within the cortical and radiation dose, CT is not usually considered the first
plate. All cases of impacted lower third molars radiographic technique of choice.
Cone beam computed tomography (CBCT):
demonstrating a close relationship between the canal and

at least one lower third molar on a panoramic radiograph Development of multiplane low dose cone beam CT
(3-D imaging systems) specifically for dental use now
are ideal cases for CT evaluation. However, CT evaluation

should not be done indiscriminately. provides an alternative imaging option (Fig. 6.24).
Using this modality, accurate three-dimensional
Steps in CT Evaluation (Mahasantipiya, imaging can be performed to demonstrate the
et al 2005)1 relationship between the roots of the third molar and the
inferior alveolar nerve (IAN). The current recommen-
CT imaging is to be performed using a multislice spiral
dation is that when the OPG suggests a close relationship
CT with 0.5 mm axial slices (0.5 mm/0.5 s of table feed
between the roots of the lower third molar and IAN, cone
and 0.5 mm interval reconstructions) beginning inferior
beam CT scanning should be advised. The information
to the body of the mandible and extending superiorly to
regarding the distance between the canal and teeth on
the middle of the rami. The exposure factors are to be set
dental CT scans is useful for predicting the risk of inferior
at 135 kV and 75 mA and a low frequency filter cut-off is
alveolar nerve damage. Danfort et al (2003)2 reported two
to be used in the reconstruction algorithm. Datas are
cases to compare the role of CBCT to the other imaging
acquired in the axial plane, but reformatted images are
generated in the corrected sagittal and coronal planes to
best demonstrate the location of the inferior dental canal.
Mahasantipiya et al 20051 following their study
concluded that CT evaluation is an excellent method for
localizing the canal and its relationship to lower third
molar roots as reformatted images can be generated
through the mandibular body in any plane. Narrowing
of the inferior dental canal as shown on CT is very
common when the roots of the lower third molars appear
in close relation to the canal on panoramic radiographs.
On all occasions when there is narrowing of the canal,
the canal was in intimate contact with the roots of the
adjacent third molar and the buccal or lingual cortex. On
numerous occasions there was also thinning of the cortex
owing to the canal lying partly within the cortex. Fig. 6.24: CBCT machine
capabilities not possible with standard film radiography

or tomography are available with CT, but at a higher
patient dose and examination fees. The patient effective
dose from CBCT is comparatively less than conventional
scan and also at a lower expense.
Advantages of CBCT Scanner over Regular

Medical CT Scanner
• X-ray radiation exposure to the patient is 10 times less
than a regular CT scanner. It is almost at the same level
as 10 panoramic images or at the same level as full
mouth series with periapical film.
• Much faster scan time for CBCT. Scan on a CBCT takes
10 to 40 seconds, while on a regular CT scanner it takes
a few minutes.
• Cheaper, average price of a CBCT scan could be up to
Figs 6.25A to C: CBCT images (A) horizontal, (B) parallel, and (C) 50% less than a regular medical CT scan.
cross images showing the relationship of IAN (colored and yellow arrows)
to third molar roots Locating the Lingual Nerve
options and to illustrate how multiplane visualization can Locating the lingual nerve clinically and by imaging is
assist the pretreatment evaluation and decision-making more problematic. Lingual nerve injury though less
process for complex impacted mandibular third common than inferior alveolar nerve (IAN) injury is often
molar cases. The computer-assisted imaging provides more debilitating to the patient. Loss of taste, slurring of
multiplane viewing and tracking of the mandibular canal speech, lack of sensation of tongue and trauma to tongue
through various image planes (Figs 6.25 and 6.26). are much less tolerated by the patients than the
Recent articles on the topic reiterate that cone beam consequences of IAN injury. The anatomic course of the
CT is significantly superior to panoramic images, in both lingual nerve is highly variable. Even the position of the
sensitivity and specificity, in predicting neurovascular nerve on one side did not have a statistical relationship
bundle exposure during extraction of impacted to the position of the nerve on the opposite side. Unlike
mandibular third molar teeth. Such quality imaging the IAN, imaging of the lingual nerve is rarely necessary
in the preparation for third molar surgery. Locating the
lingual nerve is best done using MRI.
SUMMARY
A detailed history must be taken, followed by clinical
examination and radiological investigations. Radiological
evaluation provides information about the third molar
and the surrounding structures. If there appears to be a
close relationship between the roots of the lower third
molar and the inferior dental canal, a second radiograph
using different projection geometry should be taken.
The following are the radiographs of choice:
• Intra-oral periapical view
• Orthopantomogram: Radiographic examination of
choice when more than one of the third molar teeth
requires to be assessed or when there is a pathology
Figs 6.26A to D: CBCT cross images showing the intimate relationship
of IAN during its course (marked red with yellow arrow) to the impacted associated.
third molar • Oblique lateral view of the mandible.
Computed Tomography (CT scan): CT scan is Although the Pederson scale can be used for
indicated where there is a complex relationship between predicting operative difficulty, it is not widely used
the third molar and the inferior dental canal or when there because it does not take various relevant factors into
is an associated pathology. However, the benefits have account, such as bone density, flexibility of the cheek,
to be weighed against the risks of high radiation exposure. and mouth opening. Other more complex preoperative
The following radiographic signs have been scales such as the WHARFE scale(MacGregor,1985)6 have
associated with an increased risk of inferior dental nerve been proposed, but in view of their complexity are rarely
injury during third molar surgery: used in routine practice. Yuasa et al (2002)7 proposed a
• Diversion of the inferior dental canal new scale that takes into account not only relative depth
• Darkening of the root where crossed by the canal (the A-C subscale in the Pell-Gregory classification) and
• Interruption of the white lines of the canal.
relation with the ramus of the mandible (the 1-3 subscale
in the Pell-Gregory classification), but also width of the
Preoperative Evaluation of
root, considered the most important factor. These authors
Difficulty of Removal
also point out that curvature of the root is an
Various methods have been proposed for the unpredictable factor, as it is often not visible in
preoperative evaluation of difficulty, but these have often radiographs. Hence, scales for the prediction of operative
been of limited value. Prediction of operative difficulty difficulty should take into account the anatomy of the
before the extraction of impacted third molars allows a root also. It is possible that the low predictive values of
design of treatment that minimizes the risk of the Pell-Gregory and Pederson scales are attributable to
complications. Both radiological and clinical information the fact that they do not take this into account.
must be taken into account. Garc´ýa-Garc´ýa et al (2000)3 In a study by Larsen et al (1991) found that the depth
showed that the Pell-Gregory scale(1933)4 which is widely
of impaction and the type of overlying tissue was the most
cited in textbooks of oral surgery, is not reliable for the
predictable in determining the length of time for
prediction of operative difficulty. Pederson (1988) 5
impaction surgery The following factors also complicate
proposed a modification of the Pell-Gregory scale that
the surgical removal:
included a third factor, the position of the molar
1. Unfavorable root morphology: Excessive curvature,
(mesioangular, horizontal, vertical, or distoangular; Table
6.1). The Pederson scale is designed for evaluation of divergent roots, hypercementosis, proximity to
panoramic radiographs. canal- more difficult procedure
2. Locking of the crown beneath second molar
Table 6.1: Criteria and scores of the Pederson scale 3. Condition of the impacted tooth (Carious or with
filling)
Criterion Value
4. Condition of second molar- carious or with filling/
Position of the molar crown or any resorption
Mesioangular 1
5. Sclerosis of adjacent bone - makes removal difficult.
Horizontal 2
Vertical 3 Chisel should not be used in such cases since the
Distoangular 4 likelihood of fracture mandible to occur is more. Use
Relative depth bur with irrigation. Operating time is prolonged in
Class A 1 older age group where bone is sclerosed.
Class B 2 6. Mouth opening: Accessibility is reduced in case of
Class C 3 trismus or small oral commissure.
Relation with ramus and available space 7. Large follicular sac around the crown: Makes
Class 1 1
Class 2 2
procedure easier. Undue increase in the space
Class 3 3 between the crown of the impacted tooth and
From the table difficulty index can be arrived as surrounding bone indicates cyst formation. The
follows: remnant of the follicle, especially if cyst formation
Difficulty score Total has started, should be removed.
Easy 3-4 8. Width of the periodontal membrane: In patients past
Moderate 5-6
middle age the space containing it is much smaller
Difficult 7-10
than in young patients. This makes removal these are important not only for the patients but also for
difficult. their family, employers and other patient associated
9. Existing fracture of the jaw. affiliations. For example, patients will need to know what
10. Local or systemic pathologic conditions they can expect during recovery, when he/ she will be
11. Age of the patient: Below 20 years the procedure is able to return to gainful activities or work or school.
easier. This is because of incompletely formed roots, Similarly risks to the surgeon and surgical team
large follicular space, incompletely formed roots should also be considered.
separated from inferior alveolar canal and greater Hence, it is prudent and necessary to consider risk
elasticity of bone. In young patients the bone texture assessment for surgical removal of third molar for three
is usually soft and resilient, but in older adults the inter-related constituencies, viz. the patient, the society
bone becomes progressively more dense, hard and and the operating team.
brittle. Hence the extraction of a partially erupted
/ impacted tooth in an elderly adult with sclerotic Patient Risk Factors
bone may cause considerable difficulty. While a Surgeons may initially provide patients with an overview
tooth with adverse root morphology in soft, resilient of the remote and common intraoperative and
bone of a young adult can be elevated expeditiously. postoperative sequelae/complications related to third
Added to this is the possibility of medical problems molar surgery and then stress the heightened risk for the
complicating surgery in older patients.
individual patient. It is well known that patients over 40

To summarize, the degree of difficulty of surgery is years have an increased risk in removal of third molars.
determined by three major factors: (1) Depth of impaction Female patients reported a longer recovery period.
(2) Type of overlying tissues, and (3) Age of the patient Surgery time of 30 minutes or longer or having all third
As a general rule, the more difficult and time molars below the occlusal plane was found to prolong
consuming the surgical procedure is, the more difficult the recovery period. Adults who undergo third molar
and prolonged is the postoperative recovery period. surgery and who miss work due to convalescence impose
Once the preoperative assessment is completed the a greater expense to society than a teenager who is absent
dental surgeon must decide whether the case can be from school or a part-time job.
performed by himself or refer the case to an oral and It has been generally observed that for the average,
maxillofacial surgeon in the best interest of the patient. If lean, healthy teenager with tissue impaction who has a
the dental surgeon plans to perform the surgery himself, positive psychosocial makeup and surgeon- friendly head
the operative plan should be so designed to avoid and neck anatomy there is a high likelihood that the
complications or manage the complications foreseen surgery will proceed rapidly with minimum post-
during the preoperative assessment. operative sequelae. On the contrary, for the obese older
patient with full bony impaction, dense bone and
Assessment of Risk dilacerated roots intimately related to the inferior alveolar
canal is more likely to experience more intraoperative
Risk assessment associated with third molar surgery trauma and a protracted postoperative course. Obese
focuses on potential short term sequela and long-term patients usually have large tongue and are more likely to
complication that occurs after surgery. Patients frequently have sleep disturbances like obstructive sleep apnea. Such
enquire about (a) postoperative pain, (b) when they can patients frequently suffer from several systemic diseases
return to gainful activity, and (c) other health-related like hypertension, diabetes that increases the surgical risk.
quality-of-life (HRQOL) issues. Postoperative compli- Moreover the increased girth interferes with the chair side
cations such as dry socket, bleeding, nerve injury and positioning of the operative team, poor visibility and
sequelae like pain, swelling, trismus should be explained compromised surgical access.
to patients before the operative consent is signed. Patients in the older age group are more likely to be
Currently patient's demand for knowledge is no medically compromised, have prolonged recovery period
longer limited to a description of complications of the following surgery, poor recovery from nerve injury and
surgical procedure. A higher level of understanding is have atrophic mandible which predisposes to jaw
required before consenting to treatment. This is because fracture.
If a patient is older the odds are increased for arise from the treatment of the patient. Risk may be
prolonged recovery, postoperative complication/ sequela defined as "exposure to a chance of an injury or loss."
and pain. Female patients with surgery time longer than Medical informed consent law requires the disclosure of
20 minutes are likely to experience more post surgical risks of and alternatives to suggested medical procedures
pain. to enable patients to make knowledgeable decisions about
It is prudent and imperative to inform and advice the course of their medical case.
high-risk patients that they should expect a protracted
Medical informed consent law requires the disclosure of risks
and painful postoperative period.
of and alternatives to suggested medical procedures to
enable patients to make knowledgeable decisions about the
Social Risk Factors course of their medical case.
Retaining asymptomatic impacted third molars may Consent is an act of reason accompanied with
increase the risk of periodontitis in susceptible patients deliberations, the mind weighing as in a balance, the good
with the associated local and systemic complications. and bad on each side. The consent that is given must be
Generally, 22% of patients may be at risk for delayed intelligent and informed and should be given after
clinical healing after third molar surgery. The effects of understanding what is given for and the risks involved.
protracted postoperative recovery after third molar None is allowed to give consent to anything intended to
surgery have an impact on the patient's family life, social cause his/her death. Currently the courts nearly
life, on the patient's employer and other gainful unanimously treat lack of informed consent as a matter
commercial interactions. Hence, this aspect also should of negligence of the physician to disclose necessary
be considered and discussed with the patient at the time information to patients. As in all other substantive areas
of planning surgery. of tort law, there must be a causal link between the
defendant's failure to disclose the risk and the injury
Surgical Team Risk Factors
suffered by the plaintiff/patient.
Repetitive physical and mental strain involved in third
molar surgery can be deleterious to the operator and to General Principle
the assistants when accumulated over time. Patient There is more to consent than getting a patient's signature
factors such as obesity and difficult surgical access also on a consent form. The principle forming the corner stone
should be evaluated during the preoperative visit. of informed consent is enunciated by Lord Scarman in
Communicable diseases of the patient are an additional the case of Sidaway Vs Board of Governors of Bethlehem
risk to the operative team. Royal Hospital.
• It is a basic concept that an individual of adult years
Informed Consent
and sound mind has a right to choose what shall
Once fitness for surgery is established, informed consent happen to his/her body.
must be obtained. • The consent is the informed exercise of a choice and
Informed consent is the legal embodiment of the that entails an opportunity to evaluate knowledgeably
concept that the right of a person over his own person is the options available and the risks attendant on each.
inviolable except under certain conditions. Section 13 of • The doctor must therefore disclose all material risks.
Indian Contract Act defines consent as "the two or more What risks is material is determined by the prudent
persons are said to consent when they agree upon the patient test, which determines what a reasonable
same thing in the same sense". The law protects the patient in the position of the patient would attach
individual's right to give informed consent by requiring significance to in coming to a decision on the treatment
the disclosure of information by the party to whom advice given.
consent is given. In the case of doctor-patient relationship There is however a therapeutic privilege for the
the onus of disclosure of information lies with the doctor doctor to withhold information, which is considered to
and the right to decide the manner in which his/her body be to the "psychological detriment" of the patient. It will
will be treated lies with the patient. So the doctor is duty be advisable not to emotionally disturb or rather upset
bound to disclose information as to the risks, which can the patient by explaining all sorts of risks and
complications involved. It is advisable to enjoin the close treatment proposed, risks involved and the prognosis.
relatives if needed, and the consent has to be obtained The relative chance of success or failure is explained
from then also in such situations. There is no requirement so that the patient can take an intelligent decision after
in law that every possible complications and side effects attaining a comprehensive view of the situation. Yet
should be informed to the patients. However recent court in practice things are not that simple. The patient may
cases show a trend by the judges to require more detailed be in dire need of treatment, but revealing the risks
explanations to be given than earlier. involved—the law of "full disclosure" may frighten
him to a refusal. This situation calls for the common
Types of Consent sense and discretion of the doctor. What should not
be revealed may at times be a problem. In such
A. Implied Consent: It is a situation where a patient by situation "Therapeutic privilege" is an exception to the
virtue of his action gives consent. When a patient rule of "full disclosure". The doctor may in confidence,
approaches a dental doctor for tooth extraction, it consult his colleagues to establish that the patient is
implies his willingness to get his tooth extracted by emotionally disturbed. Apart from this, it is good for
the doctor. However, it is always safer to get a written the doctor to reveal all risks involved, in confidence to
consent showing the position of the tooth to be one of the close relatives and involve them in decision-
extracted. making. Informed consent has now become a must in
B. Express Consent: Express consent is given when a all operation, anesthetic procedures, complicated
patient states agreement in clear terms, orally or in therapeutic procedures and any procedures, which
writing to a request. A perfectly valid consent may be carry some risk. In the years to come, with the great
given orally. However a written consent is preferable
advances in science and awareness of people regarding

as it provides documentary evidence of the agreement. their rights with respect to treatment and consent, the
Legal action regarding consent may take place years importance of informed consent will increase only.
after the consent was given and it will be difficult to In an informed consent the doctor explains to the
remember the terms of the consent. It is always better patient regarding the nature of his disease, the diagnostic
to get a written informed consent where any treatment procedures involved, the course and alternatives to the
or procedures carry some risk of injury. It also would treatment proposed, risks involved and the prognosis.
be advisable to seek written consent in the case of those
whom the physician regards as troublesome patient. Obtaining Consent
C. Blanket Consent: Some hospitals when admitting the
patients obtain consents to the effect that they are Whichever consent is obtained, whether express or
willing to undergo any type of treatment including implied, oral or written, the paramount consideration is
that care should be taken to explain the intention, nature
surgeries without mentioning any particular
and purpose of what is proposed so that the party signing
procedure. These are known as blanket consents.
it truly comprehends what is involved when his/her
However, these consents have no legal validity as they
agreement is sought. It would not be realistic to insist
do not mention any specific procedure or their
upon a written request for all examination and
complications.
procedures and common sense is required in deciding
D. Proxy Consent: It is a situation when some other
whether the consent should be evidenced in writing. It is
person is responsible for giving consent for a patient prudent to seek written consent for procedures involving
who is unable to give the consent. This is so in the case general anesthesia and surgeries and for more complex
of a legal guardian who is giving the consent on behalf and hazardous procedures and in any procedures which
of a minor or a near relative of an unconscious patient. carry some risk. It is advisable to make the person who is
Proxy consent is not legally valid if the patient is a giving the consent to write in his own handwriting so
major, is of sound mind and is in a position to give the that the validity of the consent cannot be questioned later
consent himself/herself. on. In many cases consent is really too important a topic
E. Informed Consent: In medical practice anything to be delegated to junior staff or others since it often calls
beyond the routine would require this type of consent. for careful clinical judgment and explanation.
Here the doctor explains to the patient relevant details Where two or more procedures are planned it is
regarding the nature of his disease, the diagnostic necessary to have consent for each. Sometimes when the
procedures involved, the course and alternatives to the procedures which was envisaged was amended, some
hospital staff have the habit of crossing the original dental nerve has a significant influence on the post-
description and adding the amended procedure without surgical nerve dysesthesia or paresthesia. Possibility for
getting it re-signed by the person giving the consent. This lingual nerve dysesthesia is greater when the impacted
consent has no validity. If a change is made to a planned tooth is lingually angulated.
procedure, it must be explained to the patient and a new • Oral hygiene
form should be completed, signed and witnessed. Never Patients with poor oral hygiene preoperatively have
get blanket consents from the patient. higher pain level postoperatively.
• Choice of Anesthesia
It is advisable to make the person who is giving the consent Local anesthesia carries less risk and is associated with
to write in his own handwriting so that the validity of the less patient stress. Postoperative complication rate
consent cannot be questioned later on. following third molar surgery ranges from 8.2% (general
anesthesia) to 12.6% (local anesthesia). While removal of
To conclude, a proper informed consent is a must for third molar under general anesthesia shows greater
every procedure which carries some risk. Many cases incidence of nerve injury, no link has been established
have been lost by the doctors in various judicial forums between the choice of anesthesia and nerve damage
due to failure to get a proper informed consent even during lower third molar removal. The incidence of
though there is no fall in the professional standard of care lingual dysesthesia is greater when the surgery is
given by them. The courts in UK, US, and India have performed under general anesthesia.
failed to enunciate clear limits as to the level of disclosure • Experience of the operator
of information that would constitute informed consent. Experienced surgeons are able to predict the difficulty of
It can be concluded that no physician can absolutely avoid
surgery and the factors that could delay postoperative

liability under the informed consent laws unless he or recovery.
she discloses every known risks and alternatives to every
patient. REFERENCES
Summary of risk factors in mandibular third molar
1. Mahasantipiya PM, Savage NW, Monsour PAJ, Wilson RJ.
surgery:
Narrowing of the inferior dental canal in relation to the
The following risk factors have been shown to
lower third molars. Dentomaxillofacial Radiology 2005; 34:
influence the occurrence of postoperative complications
154-63.
following third molar surgery: 2. Danforth RA, Peck J, Hall P. Cone beam volume
• Age tomography: An imaging option for diagnosis of complex
Patients above 25 years of age show significant increase mandibular third molar anatomical relationships. JCDA
in postoperative complications 2003; 31(11): 847-52.
Older patients tend to report more intense post- 3. Garc´ýa-Garc´ýa A, Gude Sampedro F, G´andara Rey J,
operative pain and are at higher risk of extended G´andara Vila P, Somoza Martin M. Pell-Gregory
operation time. classification is unreliable as a predictor of difficulty in
• Gender extracting impacted lower third molars. Br J Oral Maxillofac
Female patients appear to be more prone to post- Surg 2000; 83:585-7.
operative complications such as pain and dry socket 4. Pell GJ, Gregory BT. Impacted mandibular third molars:
classification and modified techniques for removal. Dent
especially women on oral contraceptives.
Digest 1933; 39: 330-8.
• Pre-existing pathology
5. Pederson GW. Oral surgery. Philadelphia: WB Saunders,
There is a significant increase in postoperative 1988. (Cited in: Koerner KR. The removal of impacted third
complications if there are signs of pericoronal molars-principles and procedures. Dent Clin North Am
inflammation or infection of the impacted teeth prior to 1994; 38:255-78).
surgery. 6. MacGregor AJ. The impacted lower wisdom tooth. Oxford:
• Depth of impaction and position Oxford University Press; 1985.
Deeply embedded teeth that require removal of bone 7. Yuasa H, Kawai T, Sugiura M. Classification of surgical
show higher incidence of postoperative complications. difficulty in extracting impacted third molars. Br J Oral
The position of the impacted teeth relative to the inferior Maxillofac Surg 2002; 40:26-31.
7 Instrument Tray Set-up
The instruments used for surgical removal of impacted Moreover, it helps in defining tissue planes. Whether
teeth are essentially a combination of instruments used to use local anesthetic available in vials or in cartridges
for transalveolar extraction and soft tissue surgery in the is a matter of individual preference. While operating
mouth. There are only a few special instruments that are under general anesthesia, use of local anesthesia can
required. Very often the selection of instruments is a compliment the analgesia effect of the anesthetic.
matter of personal preference. The following description Hence, its use is recommended. However, it is essential
of instruments and equipment is intended for the to seek the permission of the anesthetist before injecting
guidance of the dental surgeon who is new in the field, solution containing adrenalin since adrenalin in local
since an experienced person will have his own concept anesthetic can precipitate cardiac arrhythmias when
of an instrument tray set-up. It is essential that the bare halothane or similar drug is used as the general
minimum instruments are used depending on the case anesthetic.
with provision to meet exigencies. This is because a large 2. Instruments to incise mucoperiosteum: Usually
collection of unfamiliar instruments and an elaborate tray No.15 scalpel blade on a No.3 Bard Parker handle is used
set-up will cause embarrassment for both the patient as for incising the mucoperiosteum. Some operator's advice
well the operator and interfere with efficient progress of the use of the curved No.12 blade while making the
the surgery. The instrument tray set-up can be considered posterior cut distal to the third molar and also for buccal
under the following headings: cervical margin. If the pointed No. 11 scalpel blade is used
1. Local anesthesia care should be taken not to inadvertently injure the angle
2. Instruments to incise mucoperiosteum of the mouth or buccal mucosa.
3. Instruments to reflect mucoperiosteum 3. Instruments to reflect mucoperiosteum:
4. Instruments to retract mucoperiosteal flap Mucoperiosteum is reflected using periosteal elevator.
5. Bone cutting/tooth division instruments Howarth periosteal elevator which was originally
6. Instruments for irrigation and suction designed for use as a nasal raspatory is an ideal
7. Instruments for removal of tooth and debridement of instrument for reflecting the mucoperiosteum (Fig. 7.1).
surgical site The sharp end of the instrument is inserted in the vertical
8. Instruments for closure of mucoperiosteal flap component of the incision to verify that that the incision
9. Other equipment is down to the bone and the opposite broad curved end
1. Local anesthesia: Local anesthetic containing used for raising the mucoperiosteal flap. This instrument
vasoconstrictor (e.g. lignocaine 2% with adrenalin) can also be used as a retractor of the mucoperiosteum on
ensures adequate analgesia as well as reduces bleeding. the buccal as well as the lingual aspect of the third molar.
Instrument Tray Set-up 63
Other periosteal elevators like Burser periosteal Other retractors now available are Minnesota
elevator (Fig.7.2) is useful in elevating the retractor, Cawood-Minnesota (Figs 7.6 and 7.7) retractor
mucoperiosteum, the sharp end of the instrument is for retracting the mucoperiosteal flap and Weider tongue
inserted into the incision margin of mucoperiosteum and retractor for retracting the tongue (Fig. 7.8). In addition
the blunt end is used to elevate it. While a Freeier to the above a number of other retractors (Fig. 7.10) are
periosteal elevator (Fig.7.3) is useful in subperiosteal also available which aid in third molar surgery.
tunneling. A #9 Molt periosteal elevator (Fig.7.1) is most
widely used for elevation of subperiosteal flaps and for
completing dissection in all subperiosteal planes.
Fig. 7.1: Howarth periosteal elevators and #9 Molt periosteal elevator
Fig. 7.4: Austin's retractor
Fig. 7.2: Burser periosteal elevator
Fig. 7.3: Freeier periosteal elevator Fig.7.5: Stainless steel malleable retractor
4. Instruments to retract mucoperiosteal flap:

Numerous instruments are available for this purpose. The
array of instruments available indicates that a perfect
retractor has not been introduced so far.
Some of the useful retractors are the Austin's retractor
for retracting the flap (Fig. 7.4), Kilner retractor for
holding the lip, Lack's tongue depressor for retracting Fig. 7.6: Minnesota retractor
the tongue (Fig. 7.10) and Rowe's lingual retractor.
Malleable stainless steel/copper strips (Fig. 7.5) of
varying width which can be bend to desired shapes are
also useful instruments for retraction of the flap in third
molar surgery. Retractors are now available with suction
tip which help the operator to retract and at the same
time aid in suctioning (Fig.7.9). Fig. 7.7: Cawood-Minnesota retractor
A flat bladed retractor should always be employed

to hold the mucoperiosteal flap from site when bur is used
to remove bone. Otherwise, the bur may injure the soft
tissue flap.
5. Bone cutting/tooth division instruments: Chisel
and bur are used for the removal of bone. It is a debatable
issue as to which is the ideal one among these two. Chisel
has the advantage of rapidity, no production of heat and
no generation of bone dust. It is a quick clean method for
removing young elastic bone. However, while operating
under local anesthesia use of chisel and mallet is an
unpleasant experience for the patient. Hence, it is best
avoided and the instrument of choice then is bur.
Nevertheless chisel is an excellent instrument for use
Fig. 7.8: Weider tongue retractor while doing surgery under general anesthesia. In cases
where the mandible is thin and atrophic or when the bone
is brittle or sclerosed as in old patients it is prudent to
use bur since injudicious use of chisel can result in

splintering of bone or fracture of mandible. Similarly,
when the access is limited for the use of chisel as in case

of a deeply impacted tooth, bone removal is best
Fig. 7.9: Austin's retractor with attached suction tip accomplished by use of bur. Use of bur has the
disadvantage of generation of heat and bone debris
during drilling. Both these can be avoided by the use of
continuous irrigation and suction. It is important to note
that the handpiece should never be introduced or taken
out from the patient's mouth while the bur is still
revolving due to the possibility of causing inadvertent
injury to the soft tissues.
A rational approach will be selection of the chisel or
bur technique depending upon the case or a combination
of the two.
Use of chisel and mallet: The chisel should be
preferably of 5 to 6 mm width with tungsten carbide tip
with sharp edge (Fig. 7.11).
The shaft should be sufficiently long enough (nearly
17 cm) to project from mouth and to ensure adequate
visibility of operative site. Care should be taken to avoid
lip chafing while using the chisel. The operator should
Fig. 7.10: Various types of retractors useful in mandibular ensure that the tip of the chisel is maintained razor sharp.
third molar surgery This is because blunt end of the chisel not only mutilates
the bone but also heavier blows that will be required for
blunt instrument may result in fracture of mandible.
Surgical mallet that is used along with the chisel ideally
should weigh 255 gm (Fig.7.12). Mallet may be all metal
Fig. 7.11: Chisel for bone removal. The width of tip varies from 3 to
6 mm. Stainless steel chisels require frequent sharpening while those or with non-metallic inserts for its head to reduce noise
with tungsten carbide tips retain their sharpness for a longer time during its use. Give short, sharp, light taps with the mallet
A chisel has a beveled and a flat surface (Fig.7.14).

The two surfaces of the chisel affect the direction of bone
cut. One basic principle that should be remembered when
the chisel is driven into the bone by a mallet is that it
moves towards the direction of its plane or flat surface.
In practice this means that with the bevel superiorly, a
deeper cut will result. To plane the bone, the chisel is
used with the bevel facing towards the bone to be
removed. The chisel should be held at right angles to bone
surface to avoid splintering of bone.
An important point to be remembered while using
the chisel and mallet is that there is certain amount of
loss in force if the jaw is left unsupported. Hence, it is a
safe practice to support the mandible by the assistant
while chiseling is being done. This will also avoid damage
to the temporomandibular joint.
Fig.7.12: Surgical mallet–Fry's pattern

by wrist movement and not heavy blows. To be effective

the mallet should be used with a loose, free-swinging

wrist motion that gives maximum speed to the head of
the mallet without introducing the weight of the arm into
the blow.
The formula for kinetic energy is KE = ½ MV2, where
KE is the energy possessed by a moving body, M the mass
of the moving body and V its velocity. It may be noted
that since the velocity is squared, it is a highly important
factor. Hence, instead of a free-swinging wrist motion if
Fig. 7.13: Bone removal using chisel in the third molar region
the assistant adds the weight of the hand and arm to the is performed utilizing the grain of the bone
blow (e.g. a carpenter's blow), the mass is increased but
there is a great reduction in velocity. The net result is
that the patient is severely jarred, but the blow may be
totally ineffective from a clinical viewpoint.
The chisel should be carefully held and properly
controlled during use to avoid slippage and injudicious
injury.
Like in wood, bone also has a 'grain' which is most
marked in young adults and it decreases as the age
advances. The carpenter first determines the direction of
the grain of the wood before using the chisel. Similarly,
the operator should pay attention to the direction of the
grain of the bone while using the chisel. In the lower third
molar region, in both the lingual and buccal cortical plates
the grain runs in anteroposterior direction. Hence, a
vertical stop cut is made at the mesial end of the portion
of the bone to be removed to avoid accidental splintering
of the buccal cortical plate (Fig. 7.13). Fig. 7.14: Cutting edge and line of cut of a chisel and an osteotome
Osteotomes are bibevelled chisels and are not usually Joji Sekine et al (2000)1 reported a case of bilateral
used. However, they can be used for splitting a tooth pneumothorax with extensive subcutaneous emphysema
vertically through the buccal groove. Sometimes the tooth in a 45-year-old man that occurred during surgery to
may not split and it is then safe to use bur for sectioning extract the left lower third molar, performed with an air
the crown. Using an osteotome like a chisel for bone turbine dental handpiece. Computed tomographic
removal has to be avoided because of increased possibility scanning showed severe subcutaneous emphysema
of mandibular fracture. This is because osteotome cuts in extending bilaterally from the cervicofacial region and
a direct line and acts as a wedge causing mandible to split. the deep anatomic spaces (including the pterygo-
Use of micromotor and bur: The electric dental mandibular, parapharyngeal, retropharyngeal, and deep
engine (hanging motor) with cable arm which was in use temporal spaces) to the anterior wall of the chest.
previously has been replaced with micromotor and Furthermore, bilateral pneumothorax and pneumo-
handpiece. The introduction of the latter has completely mediastinum were present. The authors concluded that
'revolutionarized' the surgical removal of impacted the emphysema was probably caused by pressurized air
mandibular third molar. The modern day instrument set- being forced through the operative site into the
up is incomplete without micromotor, straight handpiece surrounding connective tissue.
and bur (Fig.7.15). Even though the standard dental burs are not
Similarly air driven handpiece (Fig. 7.16) which was designed for surgical purpose, they have found wide
used before the introduction of micromotor handpiece spread acceptance in surgical removal of impacted tooth.
has fell into disrepute since it has the disadvantage of The Meisinger burs which are designed exclusively for
causing surgical emphysema as well as driving the tooth the surgical purpose has the advantage of long shank
and bone particles into the soft tissues. Retention of such which permits better access. However, they are
debris in the soft tissues can result in postoperative expensive. Tungsten carbide dental burs are less
infection also. expensive compared to Meisinger series. The tungsten
carbide fissure bur (# 703, SS White) now commonly used
has sufficient cutting surface to enable bone cutting and
sectioning of tooth compared to the round bur (rose head
bur) of the same manufacturer. Hence, the former is now
widely used in oral surgery.
Some operators use small Ash's acrylic trimmers
(vulcanite burs) for bone removal around the impacted
tooth ('guttering') and also for smoothening the rough
edges of bone (Fig. 7.17).
Fig.7.15: Relatively inexpensive micromotor, straight handpiece and

control box (without inbuilt saline irrigation facility). When this is used
irrigation of the surgical site has to be done using saline taken in a
syringe
Fig. 7.16: 45º High speed fiber optic handpiece with connector. Push
button bur release uses standard friction grip burs. The manufacturer
claims that the exhaust air exits at the back of handpiece and there is
no air jet into the surgical field Fig. 7.17: Ash's acrylic trimmers (patterns 8,6, 20R)
Others use fissure bur in an angled handpiece But they are considerably more expensive than the
(Fig. 7.18). But it is preferable to use a straight handpiece standard micromotor set. Certain authors advocate the
(Fig. 7.19) since, it is easier to control during use as well use of saline irrigation from a bottle hanging from a drip
as effortless to clean, maintain and sterilize after use. stand where the flow is provided by gravity. Whatever
6. Instruments for irrigation and suction: The may be the method used, the aim is to provide continuous
overheating of bone and generation of bone dust during cooling of the bur and avoid heating of bone. Undue
the use of bur can be totally avoided by the use of heating of bone can result in necrosis of viable bone cells
continuous irrigation with saline or sterile water. A and subsequent osteomyelitis (Fig. 7.21) which has to be
practical method is to use a saline filled syringe with its avoided.
needle directed towards the revolving bur. An alternative While using saline irrigation to cool the bur it is
method is to use a system with inbuilt saline pump and mandatory to use a suction apparatus (Fig. 7.22) for
irrigation facility connected to the handpiece like that in effective drainage of the irrigant and blood as well as to
a physiodispenser (Fig. 7.20) used in implant surgery. clear the surgical site off the debris. It is the duty of the
Fig. 7.18: Angled handpiece with provision

for continuous saline irrigation
Fig. 7.19: Straight handpiece with provision Fig. 7.21: OPG showing osteomyelitis that occurred following surgical
for continuous saline irrigation removal of impacted 38. Note the bony changes in the yellow circle
Fig. 7.20: Micromotor system with facility for continuous

saline irrigation (Physiodispenser) Fig. 7.22: Suction apparatus
assistant to hold the suction tip connected to the suction work on wheel and axle principle like Winter's cross bar
apparatus without obstructing the view of the surgeon elevator (Fig. 7.24) also generate tremendous force
and at the same time held not too close to the bur. It should because of its mechanical advantage and hence should
be held at the most dependant part of the wound to ensure be avoided. Moreover their beaks can cause perforation
complete drainage of the irrigation and debris. Moreover of thin lingual plate pushing the fractured root piece into
the suction should not be used to suck pieces of crown or the lingual pouch during its attempted removal.
root or solid debris as this can block the suction tip as Elevators like straight elevator, Coupland elevator
well as confuse the operator as to where it has and Creyer elevator (Fig. 7.25) may be used with caution.
disappeared.
A powerful suction also helps to keep the surgical
field free of blood especially in the event of a torrential
hemorrhage due to accidental injury of inferior alveolar
vessels.
Sterilization of micromotor, handpiece and bur-
Handpiece and bur can be generally sterilized by
autoclaving or by methods suggested by the
manufacturer. Burs can be sterilized by cold sterilization
methods also. Handpiece must be properly cleaned after
every use and well lubricated with oil before autoclaving

to ensure that the bearing of handpiece is smooth.
Handpiece with damaged bearing can be identified by

excessive sound during its running as well as by the
reduction in speed. Use of such handpiece can result in
generation of heat during use which in turn will burn the
cheek of the patient. Moreover, it will indirectly hamper
the life of the micromotor also.
Generally micromotor and its connecting electrical
Fig. 7.24: Winter's cross bar elevators. Use of these
cord cannot be sterilized by autoclaving since it will be elevators should be avoided
damaged. Hence, they are covered with a sterile sleeve
before use to ensure sterility of the equipment (Fig. 7.23).
Fig.7.23: Micromotor and electrical cord (unsterile) covered with

sterile sleeve with the handpiece and bur exposed (which are sterile)
However, in new generation micromotors like that

used in implantology (e.g. Satellac, France) the
micromotor with the electrical cord can be autoclaved
without damage. Hence, such systems can be used
without a sterile sleeve.
7. Instruments for removal of tooth and debridement
of surgical site: Once, adequate amount of bone has been
removed to relieve the tooth of its obstruction, only slight
force with an elevator is usually sufficient to deliver it.
Dental extraction forceps in general are not advisable for
the removal of impacted tooth since its use can result in Fig. 7.25: Elevators that may be used with caution
fracture of mandible. Similarly cross bar elevators which in third molar removal
Instruments that can be safely used are elevators with of adequate length (approximately 15 cm) is required.
small mechanical advantage like Warwick James elevator Suture material of 3-0 size, which can be either of black
(Fig. 7.26). silk, linen, catgut or vicryl is used.
After the tooth has been removed, proper 9. Other equipment: Accessory equipment like
debridement of the wound is necessary to ensure operating loupe with fiberoptic head light (Fig. 7.27) help
uneventful healing. Curved mosquito hemostat is used
to remove follicular remnants and bone pieces. An
angulated curette also may be used to clean the socket
off the debris. Smoothening of rough edges of bone is
achieved either using bone file or acrylic trimmer (Fig.
7.17) on a handpiece. The socket and the soft tissue flap
are once again thoroughly irrigated with saline taken in
a syringe to wash off the debris.
8. Instruments for closure of mucoperiosteal flap: For
suturing the wound the ideal needle is a medium sized
triangular cutting needle with 11/16 circle. Advantage
of this type of needle is that the tip always points upwards
after it has passed through the tissues and it does not
injure adjacent structures such as the cheek or the tongue. Fig. 7.27: Operating loupe with fiberoptic head light
On the other hand while using half circle needle which is
popular with most dental surgeons, greater effort is

required to suture without injuring the adjacent
structures. The needle holder that is being used should
have a long shaft to suture the wound in the posterior
part of the mouth. Similarly toothed dissecting forceps
Fig. 7.28: Fiberoptic instruments
in better visualization of the surgical site. Fiberoptic

attachments to suction tip, periosteal elevators, and
retractors (Fig. 7.28) augment illumination provided by
the standard dental or operating room lighting. Use of
mouth prop (Fig. 7.29) during the procedure helps
patients to bite on it and this markedly reduces the fatigue
of the jaw. All these contribute greatly to perform the
Fig. 7.26: Warwick James elevator, curved–right and left surgery in a speedy and efficient manner.
Use of operating loupe in third molar surgery
Use of operating loupe with 2 × or 3 × (Fig.7.27)

magnification is extremely useful in third molar surgery
especially in locating fractured root tip and its removal.
The author has found it to be of an invaluable tool in
many occasions. A little difficulty may be experienced
initially with the operating loupe; but with time it can
be overcome.
REFERENCE
1. Joji Sekine, Akihiko Irie, Hiroyo Dotsu, Tsugio Inokuchi.
Bilateral pneumothorax with extensive subcutaneous
emphysema manifested during third molar surgery. A case
report. Int J of Oral and Maxillofac Surg 2000; 29(5):
Fig. 7.29: Autoclavable silicone mouth props 355-57.
8 Operative Procedure
PATIENT POSITIONING that the head, neck and shoulders are covered and only
the face is exposed. Some authors compare this draping
The dental chair is adjusted in such a manner which is
to that of a nun's veil or coif. Another easier and less

comfortable for the patient and at the same time enables cumbersome alternative is to cover the head of the patient
the operator and the assistant to have a clear view of the with a disposable cap (as worn by the surgeon). Another
surgical site (Fig. 8.1). Generally, for operative procedures sterile towel is used to cover the patient's chest, arms and
in mandible the occlusal plane of lower teeth should be lap. This towel is secured with two towel clips at the level
parallel to the floor and for the maxillary teeth the occlusal of the shoulder clipped to patients clothing or fastened
plane of the upper teeth at 45° angles to the floor. around the neck with a towel clip.
The instruments are arranged in a rational order of Preparation of the surgical site: Before preparing the
their intended use (not cluttered) on a sterile towel intraoral surgical site it is always desirable to wipe the
placed over the instrument tray of the dental chair or patient's face with an antiseptic solution like povidone-
more preferably on a separate instrument trolley (Figs iodine (Betadine). The third molar area is then swabbed
8.2 and 8.3). with 0.5% solution of chlorhexidine or betadine.
If there is delay in starting the surgery, the
Alternatively the patient can be given a mouth wash of
instruments should be covered with another towel to
the above antiseptic. This is followed by the administra-
avoid contamination and to maintain the sterility of the
tion of local anesthetic injection.
instruments.
The surgeon and the assistant then wear cap and face
mask. This is followed by scrubbing the hands up to the
elbow level. Rings, watches, bangles and bracelets harbor
microorganisms causing infection and hence they are
removed before starting the scrubbing. A scrubbing time
of three to five minutes is ideal. After scrubbing it is best
to wear a sterile gown by the surgeon and the assistant
or at least the front portion of the dress is covered by a
sterile towel fixed at the level of the shoulder by two towel
clips (Fig. 8. 1). This followed by donning of sterile gloves.
Draping the patient: Ideally the head and the front
part of the body of the patient should be draped, thus
exposing only the face. For this the patient's head is
covered with a sterile towel, the edge of which is brought Fig. 8.1: Patient seated in dental chair and draped.
under the chin and fixed with towel clip. This ensures Note the position of the surgeon and the assistant
Fig. 8.2: Instruments arranged on an instrument trolley
should be available while using intravenous sedation.

General anesthesia may be needed for complex and

lengthy procedures as well as for apprehensive and
uncooperative patients. But it must be recognized that
general anesthesia carries greater risk compared to local
anesthesia.
Palpation of Anatomical Landmarks
Before starting the surgical procedure, palpation of the

region and locating the anatomical landmarks is essential.
The pterygomandibular fold covering the pterygo-
mandibular raphe is usually very prominent when the
mouth is opened wide. The external oblique ridge is then
located. Next, the anterior part of the ramus with the
coronoid notch and medially the retromolar fossa should
be identified followed by the medial tendon of temporalis.
Fig. 8.3: Bare minimum instruments required for impaction surgery
arranged over the instrument tray of the dental chair. No surgery should The lingual shelf is palpated. Locating the anatomical
be undertaken without these instruments landmarks will give information regarding the under-
lying bone and will help the operator as to where the
incision is to be given.
Choice of Anesthesia The standard operative plan can be divided into the
following stages:
Methods of anesthesia for the surgical removal of 1. Incision to gain access to the area
impacted tooth include local anesthesia, local anesthesia 2. Removal of adequate amount of bone
with intravenous sedation, and general anesthesia. In 3. Sectioning and delivery of tooth from the socket
general dental practice, the former two methods are 4. Debridement
considered appropriate. Adequate training and facilities 5. Closure of the incision
Operative Procedure 73
1. Incision and Designing the Flap

The first step in removing the impacted tooth is to reflect
a mucoperiosteal flap. The flap should be of adequate
size to permit access, allow adequate visibility and to
ensure unhindered healing without periodontal pocket
formation distal to second molar. It is needless to point
out that all the basic surgical principles involved in
designing a flap should be observed here also. The most
important factor in designing the flap is the position of
the third molar which in turn dictates the amount of bone
removal required and the need for tooth sectioning. As a
general rule, the deeper the third molar, the more Fig. 8.5: Standard triangular flap with a release incision in the anterior
aspect. Note that the incision should not be continued posteriorly in a
extensive is the bone removal required and the necessity straight line, because the mandible diverges laterally
for tooth sectioning. In such instances, flaps with
vestibular extensions are recommended. More over, due artery, the buccal artery, is sometimes encountered while
consideration should be given for the lingual nerve, giving the releasing incision, the injury of which will lead
buccinator muscle and the periodontium distal to second to mild bleeding. In cases where more exposure is needed
molar while designing the flap. the vertical incision can be placed between the second
The most commonly used flap is the envelope flap and first molar as shown in the Figure 8.6.
(Fig. 8.4), which extends from just posterior to the position The incision then passes cervically behind the second
of the impacted tooth anteriorly to the level of the first molar to the middle of its posterior border. It is then
molar. The posterior end of the incision is directed extended posteriorly and laterally along the anterior
buccally along the external oblique ridge. border of the ramus for a maximum of 2.5 cm depending
If greater access is required to remove a deeply on the exposure required. (Extension of the incision
impacted tooth, the envelope flap may not be sufficient. further posteriorly may result in prolapse of buccal pad
In such cases, a release incision is given on the anterior of fat or lead to marked trismus and swelling post
aspect of the incision, creating a triangular flap (Fig.8.5). operatively). The incision should not be continued
This incision is started from a point approximately 6 mm posteriorly in a straight line, because the mandible
down in the buccal sulcus and then extended obliquely diverges laterally. If the incision is extended straight, the
upwards to the gingival margin to a point at the junction knife will enter the sublingual space and is likely to
of the posterior and middle thirds of the second molar damage the lingual nerve. The lateral extension also
(Fig. 8.5). avoids small vessels emerging from the retromolar fossa.
Experience has showed that the envelope incision is The sharp end of the periosteal elevator is inserted
usually associated with fewer complications and tends in the region of vertical incision to ensure that the incision
to heal more rapidly that the triangular flap. A small has reached up to bone. If not, the sharp tip of the
Envelope flap
Fig. 8.4: Envelope flap design. Note the Fig. 8.6: Where more exposure is needed the vertical incision of the
position of lingual nerve triangular flap is placed between the second and first molar
instrument is employed to sever the remaining The most recent advance is the use of high speed,
attachment. The blunt end of the instrument is then high torque electric drill, which significantly reduce the
passed beneath the mucoperiosteum to reflect the soft time required for bone removal and tooth sectioning.
tissue in the correct plane. Care should be taken not to Electric drill (micromotor and handpiece) is considered
strip the periosteum from the mucosa while reflecting. the instrument of choice in the present day impaction
The mucoperiosteal flap is then reflected laterally to the surgery. It has the advantage of rapid bone cutting with
external oblique ridge with a periosteal elevator and held minimal discomfort to the patient. At the same time the
in this position with an Austin's retractor (third molar possibility of the development of emphysema associated
retractor). The flap reflection should be limited to external with an air driven handpiece is avoided.
oblique ridge laterally, because reflecting beyond this area A few surgeons still prefer to use chisel and mallet
leads to increased dead space resulting in more edema or air driven hand piece for bone removal.
postoperatively. The most common technique using a chisel is the
Certain authors advice the use of a 'Minnesota 'lingual split bone technique' introduced by Ward (1956)2
retractor' to hold the flap (Fig. 7.6). This retractor is placed in which a section of bone lingual to the wisdom tooth is
just lateral to the external oblique ridge and is stabilized fractured off to facilitate the removal of the impacted
against the lateral surface of the mandible. The retractor tooth. This technique in which the socket is saucerized
should be held using a few fingers at its distal end so that
was developed to reduce infection at a time when this
it can be toed out laterally without the hand holding it
was common and fatalities were not unknown.

blocking the vision of the operator.
In a 20 year retrospective audit on removal of 2088
Reflection of lingual mucoperiosteum is kept to the
teeth by lingual access method for third molar surgery

minimum to avoid injury to lingual nerve. When reflected
under general anesthesia conducted by Moss CE and
the retractor should be held carefully to avoid
Wake MJC (1999)3 it was noted that a lingual approach
compression of the lingual nerve.
does not appear to be associated with higher post-
Extensive reflection of flap is avoided to reduce post-
operative morbidity. Chisels were the preferred
operative pain and swelling. A clinical trial was carried
instruments for bone removal. When a broad Hovell's
out by Clauser et al (1994)1 to evaluate the influence of
retractor was used instead of a Howarth's elevator, lingual
incision and reflection of flap on pain after the removal
nerve morbidity was lower. Lingual nerve morbidity in
of partially erupted mandibular third molars. The patients
underwent bilateral extraction of partially impacted all cases was temporary; was present after 16 of the 2088
mandibular third molars with a standard incision on one lingual retraction procedures, i.e. 0.8%. The authors
side (control) and without incision (test) on the other side. concluded that the lingual approach should be used only
The nonsurgical approach did not increase the operating by specialists and should be audited, and other operators
time and appeared to be an effective way of reducing should use only a buccal approach.
postoperative discomfort after extraction of partially In a study reported by Absi et al (1993),4 on one side
erupted third molars. the lingual split method by chisel was used to remove
impacted mandibular third molars. On the other, the
2. Bone Removal buccal approach using surgical bur was used to remove
The next major step is to remove the bone around the the tooth. There were no statistically significant
impacted tooth. The amount of bone removal varies with differences between the two methods in relation to pain,
the depth of impaction. As stated in the previous chapter, facial swelling, sensory loss, infection, or periodontal
the bone removal around the impacted tooth can be pocket depth distal to the second molar. There were also
accomplished either by use of bur, or chisel and mallet no statistically significant differences between duration
or a combination of the two methods. Whatever may the of procedures; mean operating time with burs was 8.28
method used (which may be of individual preference), min (range 4-15 min) and with chisels 7.57 min (range 4-
the aim is to remove sufficient amount of bone to free the 15 min). This study provided no evidence of difference
tooth from obstruction and to provide a point of in either efficiency or outcome between two standard
application for the elevator. methods of removing lower third molars.
In a recent study by Praveen G et al (2007)5 morbidity

rates following the use of different surgical techniques
were assessed. The techniques employed were surgical
bur technique, lingual split technique and simplified split
bone technique. The conclusion of the study was that the
lingual split technique was more painful than the other
two techniques. Surgical bur technique had more swelling
than the other two. The simplified split bone technique
had the least morbidity than the lingual split and surgical
bur technique. However, as stated previously most of the
patients may not tolerate the jarring effect of chisel and
mallet while operating under local anesthesia. Hence it
will be preferable to opt for rotary instruments for bone
removal and tooth sectioning for surgery under local
Fig. 8.7: “Guttering method”—A deep vertical gutter using bur is made
anesthesia. alongside the buccal aspect and if required on the distal aspect of the
When an air driven hand piece is used it is essential tooth
that the hand piece exhausts the air out of the surgical
site to prevent emphysema or air embolism. instances, the mandibular canal may be buccally placed
The hand piece used should be sterilized, usually in and at a more superior level than normal. In such cases
a steam autoclave. Copious irrigation using cold saline injury to contents of the canal will occur more easily.
or distilled water is done to prevent heating of bone and Bone covering the mesial aspect of the impacted tooth
subsequent bone necrosis. Cooling the bone by way of is also removed by this method. Drilling in the region of
irrigation will also reduce the postoperative pain and the mesial surface of impacted tooth should be kept to
edema. The use of a high vacuum suction to clear the the minimum to avoid damage to the distal aspect of the
surgical site while irrigation is used can not be over adjacent second molar. While removing bone on the
emphasized. distolingual aspect extreme care is taken to protect the
The buccal cortex contributes greatly to the strength lingual nerve from bur by way of proper retraction. It is
of the mandible. Hence buccal bone removal should be advisable not to remove any bone on the lingual aspect
kept to minimum to avoid weakening of the mandible due to the likelihood of damage to the lingual nerve. A
and subsequent fracture. The bone on the buccal and the variety of burs can be used to remove bone, but the most
distal aspect of the impacted tooth is removed down to commonly used are the #8 round bur and a #703 fissure
the level of the cervical line. Further bone removal if bur.
required is done in a manner not detrimental to the Besides exposing the tooth and removing the
strength of mandible and at the same time not sacrificing obstructions, an additional aim of bone removal is to
the efficiency of surgery. This is achieved by drilling a create a point of application for the elevator. When this
deep vertical gutter alongside the buccal aspect and if has been achieved moderate force alone is sufficient to
required on the distal aspect of the tooth. This 'guttering displace the tooth. If the tooth is still resistant the operator
method ' will ensure that the height of the buccal plate is should discard the elevator and plan for further bone
maintained without weakening the mandible and at the removal or consider tooth sectioning.
same time adequate space is created around the tooth to Elevation of tooth from the socket: If adequate
permit its free movement (Fig. 8.7). amount of bone covering the tooth has been removed, an
While using this method, as the bur reaches the apex attempt can be made to elevate the tooth from the socket.
of the tooth, the inferior alveolar canal may be inadver- An excessive force should not be used for this purpose.
tently opened. This will result in brisk hemorrhage from Application of a great amount of force without adequate
inferior alveolar vessels, which can be controlled with bone removal can result either in fracture of the tooth or
pressure pack or bone wax. But sometimes damage to fracture of the mandible. Due to the above risk dental
the inferior alveolar nerve can occur resulting in extraction forceps and elevators with great mechanical
anesthesia over the distribution of mental nerve. In rare efficiency like cross bar elevators are contraindicated for
the removal of impacted third molar. Once the obstructing Coupland's chisels are held between the thumb and fore
bone has been removed, only a slight amount of force finger like a 'pen grasp' and not a 'palm and thumb grasp'
alone is needed to deliver the tooth. Elevators with less used for holding straight elevator. When used correctly
mechanical efficiency like Warwick James elevator these instruments exert adequate leverage to luxate and
(straight and curved type) and Coupland chisels are remove the tooth and at the same time prevent the
recommended for this purpose. The # 301, Crane pick possibility of a mandibular fracture. At the time of
and Cogswell B elevators also serve this function well. elevating the tooth, the index finger of the operator's left
Paired, sharp pointed elevators such as the Winter's cross hand should rest on the occlusal surface of the wisdom
bar elevators are capable of applying extreme force, and tooth to judge its movement and the other fingers support
their use should be avoided. This is because excessive the mandible.
force can result in unfavourable root fracture, buccal or Because the impacted tooth has never sustained
lingual bone loss, damage to the adjacent second molar occlusal force, their periodontal ligament space is wider
or even fracture of mandible. These elevators are also and less tenacious and they can be easily displaced if
useful in removing bone in the furcation that is retaining adequate bone is removed and elevation forces are
a root fragment. But a root fragment so elevated is pushed applied in a proper direction.
against an intact wall of bone and is more likely to fracture In order to apply the elevator, a point of application
or defy removal than it would if removed in a mesial
(purchase point) is required. This is prepared either in
direction with the assistance of a well placed purchase
the bone as described previously or a bur cut of sufficient

point as required (Figs 8.8A and B).
size is made on the tooth by drilling. The point of
It is a common practice to use a broad elevator
application for the elevator is decided on the basis of the

between the buccal surface of the impacted tooth and the
angulation of the tooth and the curvature of the roots.
external oblique ridge in order to elevate a tooth or root
This should be deep enough and placed in substantial
fragment. This technique places the external oblique
portion of tooth structure so that the elevation of segment
ridge, one of the buttresses of the mandible and the
occurs rather than fracture. Certain authors' advice the
lingual plate at risk of fracture. If such a fracture is
use of Cogswell B elevator which has a smooth surface at
unrecognized, a substantial late presenting sequestrum
the tip and is less likely to cause fracture when used to
or immediate lingual nerve injury is possible (Farish and
engage a purchase point.
Bouloux, 2007)6. Delicate instruments (e.g. Warwick
James elevator) alone are needed to luxate/to remove 3. Sectioning and Tooth Delivery
impacted mandibular third molar if adequate exposure,
bone removal and sectioning of tooth are performed. Once the tooth has been sufficiently exposed and if it is
Elevators with less mechanical efficiency like still resistant to the use of elevator it is time to consider
Warwick James elevator (straight and curved type) and tooth sectioning. The tooth is sectioned into appropriate
Figs 8.8A and B: (A) Attempt to elevate the remaining root fragment using a Cryer elevator in a distal direction removes interdental bone but
forces the root against the intact distal socket wall, where it resists removal. (B) A well placed purchase point in the distal root fragment allows a
Cogswell B elevator to guide the root mesially, where it meets no resistance to removal
pieces for easy delivery from the socket. Sectioning of

tooth reduces operating time and also avoids the need to
remove additional amount of bone to accommodate the
elevated tooth. Tooth sectioning is performed either with
a bur or a chisel. In the standard technique, first section
is generally done at the neck of the tooth using bur. This
will facilitate the removal of the crown followed by the
roots in one piece. However, in cases where the roots are
divergent or have conflicting path of withdrawal, the
roots may have to be divided and removed separately.
It may be noted that the manner of sectioning of
crown and root will vary depending on each case and
Fig. 8.9: Incorrect sectioning of crown (broken line) leaves a segment
there can be deviation from the standard technique. that is wider at the bottom than the top. Its subsequent removal is
Farish and Bouloux (2007)6 stated that the following blocked. Correct line of section is shown as continuous line
key points should be observed while performing tooth
sectioning:
1. When it is determined that a tooth should be
sectioned vertically (for example in a case of

mesioangularly impacted mandibular third molar),
the line of sectioning is first planned and it is them

moved approximately 1.5 to 2 mm more anterior
than initially felt necessary. This adjustment helps
to prevent inadvertently sectioning the tooth too
distally, which often occurs as a result of the
obstructing position of the second molar.
2. While sectioning, the tooth is generally divided into
three quarters of the way from the buccal to the
lingual aspect using bur. The reminder is then split
with a straight elevator or a similar instrument. This
not only prevents injury to the lingual cortical plates
but also reduces the possibility of damaging the Fig. 8.10: Possible damage to inferior alveolar neurovascular bundle if
the bur is carried to the full width of the tooth inferiorly. Hence bur is
lingual nerve. used to cut only three fourth width of the tooth and the rest of the tooth
3. Vertical cuts should be placed carefully so that the is separated using a suitable instrument like Warwick James elevator
line of sectioning of crown/tooth does not angle
from the perpendicular. If the sectioning line varies bur is limited to three fourth of the width of the
from the perpendicular and is directed posteriorly tooth. The rest of the tooth is separated with
(Fig. 8.9) the sectioned segment will be wider at the leverage using an instrument like curved Warwick
bottom than at the top. In such cases, elevation is James elevator.
hindered.
4. While sectioning the tooth in the superior to inferior Modifications for Removal of Impacted Tooth
direction if the bur is carried to the full width of the
tooth to reach its 'bed', there is a possibility of Even though the principles involved in the technique of
damaging the contents of the canal (Fig. 8.10). If such third molar removal is fundamentally the same, some
a mishap occurs, there will be brisk bleeding from modifications have to be made depending upon the
the inferior alveolar vessels. If the inferior alveolar angulation of the tooth. This is because the path of
nerve is injured, this will later lead to anesthesia in withdrawal of third molar is along the line of least
the distribution of mental nerve. Hence the entry of resistance and hence the site of application of elevator is
dependant upon the angulation of the tooth i.e. a. Removing necessary distal bone using bur and
mesioangular, horizontal, vertical and distoangular dislodging the tooth a little more distally. Then the
impaction. tooth is removed.
The mesioangular impaction (Figs 8.11A to C) is b. Sectioning the distal half of the crown from the buccal
usually considered to be the least difficult to remove. groove to just below the cervical line on the distal
After reflecting the mucoperiosteum and exposing the aspect of tooth. This portion of the tooth is removed,
crown, the buccal gutter is extended mesially to reach and then the reminder of the tooth is delivered with a
the mesial surface of impacted tooth beneath the small straight elevator placed on the mesial aspect.
cementoenamel junction. This will ensure that when the c. Purchase point of the elevator is changed to buccal side
elevator is introduced, the tip of the elevator can engage and a firm upward force is exerted. A purchase point
beneath the cervical cementum on the mesial aspect. on the buccal side of the tooth can be prepared with a
Using the interdental bone as the fulcrum when the drill and then a Cryer's elevator is used to deliver the
elevator is rotated, the tooth turns distally. This distal tooth.
movement of the tooth converts the initial mesial In cases, where the mesioangular tooth is 'locked'
angulation of the tooth into a vertical position. Use of beneath the distal convexity of the crown of the second
further force with the elevator will deliver the tooth. In molar, tooth division is done at the cervical region to
certain instances, the mesially inclined molar will assume section the crown. The coronal portion is then ejected out
a vertical position following elevation, but further of the socket by applying force below its inferior surface.
movement can be hindered by the distal bone. In such The roots are then loosened by engaging the bifurcation
cases any of the following method can be used to take and it is also taken out.
out the tooth:
Figs 8.11A to C: Steps in the surgical removal of mesioangular impaction. (A) Bone removed up to cervical line using bur, (B)
Sectioning of tooth, (C) Tooth delivery using elevator
Moreover, if leverage is applied to a mesioangular

tooth whose roots are in close contact with the mandibular
canal, the apex of the root will be forced downwards
crushing the neurovascular bundle. In such instances,
crown sectioning will prevent damage to canal contents,
since roots can be moved forwards and upwards into the
vacant space previously occupied by the crown (Figs
8.12A to C)
While applying elevator mesially care should be
taken not to dislodge restoration or fracture the crown of
second molar already weakened by dental caries.
Similarly the operator should be vigilant not to denude
the bone on the distal aspect of the second molar while
inserting the elevator mesial to the impacted third molar.
The horizontal impaction (Figs 8.13A to D) usually
requires removal of more bone than the mesioangular
impaction. When the tooth is deeply impacted it usually Figs 8.12A to C: Need for sectioning to avoid injury to mandibular canal.
engages either the crown or root of the second molar
(A) Mesioangular impaction with roots in close relation to mandibular

canal, (B) Mesial application of force using an elevator forces the root
which makes its removal difficult. Adequate bone is into mandibular canal, (C) Division of the tooth avoids damage to
removed superiorly to expose the whole width of the
contents of the canal.
Figs 8.13A to D: Steps in the surgical removal of a horizontally impacted mandibular third molar. (A) Bone removal to expose the width of the
crown and the upper third of the root, (B) Crown sectioned at the cervical region, (C) After removal of the crown, the distal root sectioned at the
furcation is brought forwards into the space occupied by the crown, (D) Removal of the mesial root
crown and the upper third of the root. The point of very deeply. The procedure for bone removal and
application of elevator is procured below the mesiobuccal sectioning is similar to that of a mesioangular impaction.
aspect of the impacted crown. The tooth is then sectioned Here also the bone is removed first from the occlusal,
at the cervical region and the crown is removed from the buccal, and distal aspect. The distal half of the crown is
socket. The root is then brought forwards into the vacant then sectioned and removed, and the tooth is elevated
space previously occupied by the crown and it is then by applying a small straight elevator at the mesial aspect
removed either in a single piece or after sectioning. of the cervical line. Another alternative is to make a
In cases where the impacted tooth is not locked purchase point on the buccal side of the tooth as in
beneath the distal convexity of the crown of the second mesioangular impaction and the tooth is then delivered
molar and when adequate amount of distal bone has been using a Cryer's elevator.
removed, it is possible to turn the tooth into a vertical In less deep vertical impactions, where a wide
position by application of force in the mesial aspect. This follicular sac exists behind the third molar mesial
is similar to the procedure already described for the application of force with an elevator can easily dislodge
removal of mesioangular impactions. Use of further force the impacted tooth out of the socket and no bone removal
with the elevator will expel the tooth out of the socket or is required. When adequate bone removal is not
force can be applied on the buccal side to remove the performed on the distal aspect of the crown or when there
tooth. is no follicular sac behind the third molar, application of
In all cases of sectioning, the cut should be kept within excessive force on the mesial aspect of the impacted tooth
the tooth structure to prevent damage to the lingual with an elevator can result in fracture of mandible. In
tissues and the inferior alveolar canal. cases where the roots are widely divergent, crown is
The vertical impaction (Figs 8.14A to C) is one of the divided first followed by sectioning of roots and its
more difficult ones to remove, especially if it is impacted subsequent removal.
Figs 8.14A to C: Steps in the surgical removal of a vertically impacted mandibular third molar. (A) Bone removal to expose the width of the crown,
(B) Distal half of the crown sectioned up to the furcation and it is removed along with the root, (C) Mesial half of the tooth is elevated by mesial
application of force at the cervical line
A deep, vertically impacted third molar below the (guttering) around the full crown of the tooth to a depth
cervical line of the second molar and fully covered with below the cervical line. This will permit to create a point
bone present a difficult challenge for the surgeon. In such of application of elevator on the buccal aspect of the tooth.
cases, the tooth should be exposed and a buccal and distal Then using the buccal cortical plate as the fulcrum, force
trough created. The tooth is then elevated en mass with is applied to elevate the tooth out of the socket upwards
subsequent sectioning of crown in a horizontal fashion. and distally. If some movement is obtained, the distal
The roots can be elevated in one piece or sectioned and portion of the crown or the complete crown can be
removed as separate pieces with the elevation of distal sectioned in a horizontal fashion from the roots and
preceding that of the mesial. It is important that the removed. The sectioned crown may be sectioned again if
operator should attempt to preserve as much root inadequate space is available for its removal. It is
structure as possible to serve as a 'handle' for elevation. preferable in this case to section the tooth segments
This is because, dealing with small segments that have further as needed rather than to remove more bone. This
not been luxated is where most difficulty is encountered will ensure preservation of the structural integrity of the
in third molar removal. mandible. The roots are then delivered together or
The distoangular impaction (Figs 8.15A to C) is sectioned and delivered independently with a Cryer's
considered to be the most difficult tooth to remove. This elevator.
is because the pathway of delivery for an elevated Generally in distoangular impaction, surgery is more
distoangular impaction is into the vertical ramus of the difficult than other angulations because more distal bone
mandible. The goal of the technique for removal of these must be removed, to permit the distal rotation of the tooth.
teeth is to create an adequate buccal and distal trough The tooth tends to be elevated posteriorly into the ramus
Figs 8.15A to C: Steps in the surgical removal of a distoangularly impacted mandibular third molar. (A) Bone removed to expose the full crown of
the tooth to a depth below the cervical line, B) Crown sectioned in a horizontal fashion from the roots and removed, (C) Roots are then delivered
together or sectioned and delivered independently with a Cryer's elevator
of the fractured piece is doubtful it may be detached

gently from the periosteum without causing injury to
lingual nerve which may be lying nearby. Finally the
socket and the wound margins (including under surface
of mucoperiosteum) is irrigated with saline to remove
bone and tooth debris. It has been observed that, the more
irrigation is used, the less likely the patient is to develop
a dry socket, delayed healing, or other complications.
5. Wound Closure
Bleeding from the socket is completely arrested before
attempting closure. Troublesome bleeding from the
socket can be controlled using bone wax, surgicel or
Figs 8.16A to C: (A) Intraoral periapical X-ray of a distoangularly
impacted (complete bony impaction) 48 with the apex close to the
gelfoam. Post operative bleeding from the depth of the
mandibular canal. Attempted extraction of the tooth without adequate socket coupled with a tight suture will cause the blood to
bone removal by a general dental practitioner resulted in fracture of escape into surrounding tissue spaces leading to buccal
mandible (note the yellow arrows in B and C)
or lingual hematoma or ecchymosis. The flap is then
returned to its original position and the initial suture

of the mandible. Attempt to exert more force when placed just distal to the second molar. It is opined that
resistance is encountered will result in fracture of the
this suture reduces the possibility of the development of

mandible (Figs 8.16A to C).
periodontal pocket distal to the second molar. The needle
In cases where tooth sectioning is required, the distal
is passed from the buccal to the lingual side. Certain
root should be elevated first followed by the mesial root.
authors advice the other way. Additional sutures are then
Once the tooth is delivered, do not throw it away.
placed as necessary. The sutures should be just tight
Examine it carefully to note whether it has come out in
enough to hold the flap. Over tightening is avoided at all
full or any part of the fractured root or crown is there in
costs. The vertical component of the incision is left
the socket. Only after full satisfaction the tooth is
unsutured since it will act as a wound toilet. In cases
discarded. The tooth may be shown to apprehensive and
suspicious patients and their by stander. This is a practice where the anterior vertical incision has been carried
that can be considered depending on the case. forwards up to the mesial aspect of second molar, the
wound is closed with two sutures. Here the first suture
4. Debridement is placed between the first and second molar by passing
the needle from lingual to buccal side through the
Once the impacted tooth is delivered from the alveolar
process the surgeon must pay strict attention to debriding interdental space between the two. After this the second
the wound of all particular bone chips and other debris. suture is placed in the usual position distal to second
This is best accomplished by mechanically debriding the molar. If the flap is not repositioned properly and sutured
socket and the area under the flap with a periapical cruet. correctly it may be heaped up over the crown of the
A bone file is used to smooth any rough and sharp edges second molar. This will lead to its ulceration due to
of the bone. Instead an acrylic trimmer on a handpiece impingement of the upper teeth during closure of the
also can be used. A mosquito hemostat is employed to mouth and final breakdown of the wound.
remove any remnant of the dental follicle in order to The patient is then asked to bite firmly on a gauze
prevent the formation of a cyst later on. Fractured piece for 30 mts. to one hour or till the bleeding stops.
interdental septum or large pieces of bone is also removed Following the procedure oral and written post-
using a hemostat. In certain instances a fractured portion operative instructions can greatly help the patient and
of lingual plate may remain. Using a hemostat it is also ensure better patient compliance.
palpated to determine whether it is mobile. If it is having Removal of Impacted Mandibular Third Molar in
adequate attachment it may be left as such. If the vitality an Edentulous Mandible: The basic principles regarding
Figs 8.17 A to D: Steps in the surgical removal of horizontally impacted right mandibular third molar tooth. (A) Periapical radiograph,
(B) Pre operative view of impacted tooth, (C) Incision marked, (D) Mucoperiosteum reflected
Figs 8.17E to H: Steps in the surgical removal of horizontally impacted right mandibular third molar tooth contd.
(E) Bone removal and tooth division, (F) Surgical site after debridement, (G) Suturing completed, (H) Specimen
Figs 8.17A to H: shows the steps in the surgical removal of a horizontally impacted right mandibular third molar.
the removal remain same in this situation also. However, In cases where the patient has been using complete
technically the surgery is more difficult due to the denture for some time, the impacted third molar may
following reasons: slowly erupt into the oral cavity causing pain and
• Patient is often elderly and hence the bone is more ulceration. Removal of such tooth is easier than deeply
sclerosed and less elastic. impacted ones which very often remain symptom less.
• Absence/reduced periodontal tissue for the tooth. Patients should undergo a proper preoperative
• Associated systemic diseases which may complicate physical examination to rule out the possibility of any
the surgical procedure. systemic disease which may modify or complicate the
• Vertical height of mandible is reduced due to planned surgical procedure. Radiographic examination
resorption following loss of teeth. should include periapical, occlusal, OPG and if required
• Major part of the angle of mandible is replaced by the a lateral oblique film of mandible. X-rays should be of
impacted tooth, thus reducing the overall strength of good quality to reveal the position, size and shape of the
the jaw making it more prone to fracture. impacted tooth including the root and also the investing
• Use of chisel for removal of bone and for splitting of bone. In deeply impacted tooth periapical X-rays are often
tooth should be avoided to prevent the possibility of inadequate to visualize the tooth completely including
fracture of mandible. Instead use of bur with the roots. Hence in such cases OPG or extraoral X-rays
continuous saline irrigation is employed for the above are mandatory. While evaluating the radiograph, due
purpose. consideration should be given to the amount of bone

Figs 8.18 A to D: Steps in the removal of an impacted mandibular third molar in an edentulous jaw- (A) Third molar region of edentulous mandible-
right side, (B) OPG showing horizontally impacted right third molar (yellow arrow), (C) Incision placed, (D) Mucoperiosteum reflected to expose
the bone
Figs 8.18E to H: Steps in the removal of an impacted mandibular third molar in an edentulous jaw contd. (E) Drill holes made in the buccal cortical
plate overlying the impacted tooth (yellow arrows), (F) Multiple drill holes made in the cortical plate, (G) Drill holes connected using bur (chisel can
also be used to connect the drill holes), (H) Buccal cortical plate removed to expose the crown
Figs 8.18 I to L: Steps in the removal of an impacted mandibular third molar in an edentulous jaw contd. - (I) Crown sectioned at the cervical
margin, (J) Sectioned crown removed (note the black arrow pointing towards the root), (K) Root pushed into the space (note interrupted arrow)
created by the removal of the crown and the root is then removed, (L) Specimen
Figs 8.18 M to O: Steps in the removal of an impacted mandibular third molar in an edentulous jaw contd. -
(M) Socket after debridement, (N) First suture placed, (O) Suturing completed
Figs 8.18 A to O: Show the surgical steps in the removal of an impacted mandibular third molar in an edentulous jaw
between the inferior border of the mandible and the apex Summary of Surgical Procedure
of the tooth as well as the thickness of the buccal and
lingual cortical plates. Any associated infection should be treated pre
Intraoral versus extraoral approach: The type of operatively with systemic antibiotics, chlorhexidine
approach to be employed is dictated by the amount of mouth rinses, local dressing and lavage prior to surgery.
bone overlying the impacted tooth. If the tooth is The surgical procedure generally involves raising of
superficial with minimum bone coverage it can be soft tissue flaps for exposure, removal of bone using either
considered for removal via intraoral approach under local chisel or bur with water-cooled irrigation, delivering the
anesthesia. If on the other hand there is considerable tooth with or without division, and wound toilet.
amount of bone superior to the impacted tooth (i.e. the The surgical procedure to be carried out depends on
tooth is situated closer to the lower border of mandible), the following:
removal of that much amount of bone to access the tooth • Status of eruption of the tooth
intra orally is likely to further weaken the mandible • Type of impaction
leading to fracture of the jaw intra operatively or post- • Proximity to surrounding structures e.g. relationship
operatively. In such cases a wiser option is to remove the of the inferior dental and lingual nerves.
tooth by an extraoral approach (submandibular While the raising of tissue flaps is always associated
approach) under general anesthesia by an experienced with post-operative pain and trismus a smaller incision
oral and maxillofacial surgeon. with minimal reflection will result in less pain and
Before attempting surgical removal of impacted swelling. Removal of the impacted teeth through the
mandibular third molar in an edentulous jaw it is always buccal approach without lingual tissue retraction
prudent to inform the patient regarding the possibility minimizes the risk of lingual nerve damage. When the
of jaw fracture and obtain the consent. surgery is performed with lingual split technique together
with lingual flap retraction, the incidence of lingual nerve operation for detailed planning or refer it to a specialist.
injury appears to be even greater. The placement of a How many impacted teeth should be removed in one
periosteal elevator or lingual nerve retractor to protect operation will depend upon the difficulty of the operative
the lingual tissue during surgical removal of impacted procedure as well as upon the age and the physical
wisdom teeth appears to increase the incidence of lingual condition of the patient. To be on the safer side, if all the
nerve damage. However, lingual nerve injury associated third molars are impacted, it is better to perform the
with lingual flap retraction is found to be temporary. surgery in two sittings.
There is conflicting evidence as to the most appropriate
form of protection for the lingual nerve. Generally,
REFERENCES
minimal interference to the lingual soft tissue is associated
with a low incidence of lingual nerve injury. Retention 1. Clauser C, Barone R. Effect of incision and flap reflection
of the lingual plate gives optimum protection to the on postoperative pain after the removal of partially
lingual nerve during removal of impacted third molar. impacted mandibular third molars. Quintessence Int 1994;
Exposure or intra-operative opening the mandibular 25(12):845-49.
canal during surgery greatly increases the incidence of 2. Ward TG. The split bone technique for removal of lower
inferior alveolar nerve paresthesia. Excessive removal of third molars. British Dental Journal 1956;101:297-304.
bone and vertical sectioning of the impacted teeth may 3. Moss CE, Wake MJC. Lingual access for third molar
lead to inferior alveolar nerve injury. Any suspicious
surgery: a 20-year retrospective audit. Br J Oral Maxillofac

pathological material should be sent for histopathological Surg 1999;37:255-58.
examination. Occasionally, a small fragment of the apical
4. Absi EG, Shepherd JP. A comparison of morbidity

root of a vital tooth may be left behind if its removal following the removal of lower third molars by the lingual
carries a greater risk of complication than retention. In split and surgical bur methods. Int J Oral Maxillofac Surg
these situations, the patient should be informed and 1993;22(3):149-53.
recorded in the case notes. 5. Praveen G, Rajesh P, Neelakandan RS, Nandagopal CM.
Specific methods may vary among dental surgeons Comparison of morbidity following the removal of
based on training and experience, but they all should mandibular third molar by lingual split, surgical bur and
correspond to basic and established principles of surgical simplified split bone technique. Indian Journal of Dental
techniques. It is sensible not to be too dogmatic in one's Research 2007;19(18):15-18.
approach to the problem. 6. Farish SE, Bouloux GF. General technique of third
The experienced and the mature surgeon knows molar removal. Oral Maxillofacial Surg Clin N Am
when it is in the best interest of the patient to defer an 2007;19:23-43.
9 Other Methods for Removal of
Impacted Lower Third Molar
The standard surgical technique of removal of impacted indicated. The various steps involved in the procedure
third molar has been described in the previous chapter. are given in Figures 9.1 A to C.
However there may be instances where other methods In a case reported by Jones et al (2004)3 a 48-year-old
of surgical removal also have to be considered. This is man who, after a 5 year history of recurrent infection and
intermittent trismus associated with a deeply impacted
because, no technique is suited to every case and it will

be ideal to learn the different methods and choose the lower right third molar tooth, presented to the accident
appropriate one depending upon the case. and emergency department with severely limited mouth
opening, extensive facial swelling and pyrexia. The lower
1. Sagittal split ramus osteotomy: This technique has
right third molar was later removed successfully through
been conventionally used for the surgical correction of
a sagittal split ramus osteotomy approach. This case
mandibular excess (push back) and for mandibular shows that the sagittal split osteotomy have a valuable
deficiency (advancement). Recently this has been used role in the removal of deeply impacted lower third
to remove deeply impacted mandibular third molars as molars, particularly when they are in close proximity to
reported by Amin (1995)1 and Toffanin (2003)2 and Jones the inferior alveolar nerve.
(2004)3. This is not done as a standard procedure for In another case reported by Amin (1995)1 elective
removal of impacted tooth, but performed when sagittal splitting of the mandible was used to gain access
Figs 9.1A to C: Schematic diagram showing steps in the surgical removal of impacted mandibular third molar by sagittal split ramus osteotomy.
(A)Incision in the buccal sulcus extending posteriorly along the coronoid process, (B) Sagittal splitting of the ramus showing the impacted third
molar inside, (C) Removal of impacted tooth
Other Methods for Removal of Impacted Lower Third Molar 89
to an impacted lower third molar, which was intimately Tay (2007)4 reported 2 cases; a 17-year-old girl with
involved with the inferior alveolar nerve. a deeply impacted left lower second molar and another a
The main disadvantages of conventional surgical 12-year-old boy with a deeply impacted left lower first
technique if used in the above case reports are: the great molar and a complex odontome in place of the left lower
extent of bone to be removed, limited visibility, high risk second molar. In both cases, computed tomograms
of injury to the inferior alveolar nerve, and fracture of showed the location of the mandibular canal in relation
the mandible. In comparison, sagittal split ramus to the deeply impacted teeth and the buccal cortex. The
osteotomy gives good access, conserves bone that would deeply impacted teeth (and odontome in the second case)
otherwise have been removed, and allows the nerve to were completely removed piecemeal and both patients
be seen and avoided. However, the osteotomy puts the recovered well and showed evidence of bony healing on
occlusion at risk (although this is rare) and there is a risk radiography 6 months later. The second patient had mild
of an unfavorable split in either the proximal or distal paresthesia of his left lower lip and chin, which resolved
segment (2%). This is about twice as high if the third molar after a month.
is impacted. The published incidence of disturbance of 3. Lingual Split technique (Figs 9.3A to H): This
the inferior alveolar nerve is high: as much as 58% at six technique was first described by Ward in 19565. The
months, and 35% at one year postoperatively. technique continues to be popular in the United Kingdom
2. Buccal corticotomy: An alternative approach that but has not gained wide acceptance in the United States
offers access to deeply impacted mandibular teeth is by (Farish and Bouloux, 2007).6 The method involves the use
buccal corticotomy A trapezoidal mucoperiosteal flap is of a chisel and mallet to remove or displace the lingual
raised in the mandibular molar region, and a rectangular plate of bone adjacent to lower third molar. A small
window is made over the deeply impacted tooth using a amount of buccal bone is often removed to facilitate
narrow fissure bur, with the mesial and distal cuts almost exposure of the crown and provide a point of application
reaching the inferior border of the mandible (Fig. 9.2). for an elevator. Although tooth division is usually not
The buccal corticotomy window is removed with an required, it can be achieved with a chisel. Several minor
osteotome. The deeply impacted molar is exposed, modifications to the original technique have been
divided with a bur and removed. The alveolar nerve reported. Although the lingual split technique is well
bundle is often in close proximity and may be seen after suited to patients being operated under general
the tooth has been removed. The bony fragment removed anesthesia or sedation, it is not appropriate for surgery
at buccal corticotomy is replaced and secured with wires conducted purely under local anesthesia. This procedure
or plates and screws at the mesial and distal edges, and is suitable mainly for young patients where the bone is
the wound is sutured. elastic and where the grain is prominent. Surgery is
comparatively quick and clean if the case selection is
correct. Moreover, this technique has the advantage of
reducing the size of the blood clot by means of
saucerization of the socket. Possibility of development
of transient lingual nerve anesthesia (rarely permanent)
in the postoperative period is considered a major
disadvantage. This may be the reason for the lack of
popularity for the technique. The exact cause and the
timing of lingual nerve injury are not well understood
and may be multifactorial. Most studies that evaluate
lingual nerve injury are retrospective, involve small
sample sizes or are poorly controlled for multiple
confounding variables and should be interpreted with
some caution. Temporary lingual nerve injury has been
reported to vary from 0.8% to 20%, where as permanent
Fig. 9.2: Showing bone cut in buccal corticotomy. injury has been reported to vary from 0% to 1%.
Figs 9.3A to H: (A) Incision marked, (B) Reflection of lingual mucoperiosteum and placement of chisel for buccal vertical stop cut (C) Horizontal
bone cut to the distobuccal aspect of third molar for removal of buccal bone, (D) Positioning of chisel on the distolingual aspect of the crown of the
third molar held at an angle of 45° to the bone surface and pointing in the direction of the lower second premolar of the opposite side. (E) Excising
bone on the distal aspect of third molar, (F) Application of a straight elevator on the mesial aspect of third molar to elevate the tooth. (G) Fractured
lingual plate is grasped with a fine artery forceps and is freed from its soft tissue attachments by blunt dissection, (H) Closure of the wound after
debridement, irrigation and hemostasis. A single suture placed distal to the second molar is sufficient for adequate closure. The vertical incision
in the anterior part is left unsutured
Steps in the Surgical Procedure roots of the second molar. This cut must extend from
the crest of the alveolar bone superiorly to a point
Position of the operator: When removing a lower third
inferiorly that allows buccal exposure of sufficient
molar on the right side, the operator must stand on the
right side of the patient. While for the removal of a lower tooth structure to place an elevator either mesially or
left third molar the surgeon must stand on the left side of buccally depending on the type of impaction.
the patient (Farish and Bouloux, 2007)6. This is in contrast c. Then, using a 5 mm chisel with the bevel facing
to the bur technique, which is usually performed with superiorly a horizontal cut is made backwards from a
the surgeon standing on the right side of the patient for point just above lower end of the stop cut to the
all third molar teeth. distobuccal aspect of third molar. The sectioned piece
The surgical technique remains relatively the same of the buccal bone is loosened and removed thereby
regardless of the Pell and Gregory classification of exposing a portion of the third molar crown. The next
impaction. Occasionally a bur may be needed to facilitate step is to obtain a point of application for the elevator
tooth division and bone removal. A rubber mouth prop mesial to the impacted tooth. This is achieved using
is placed between the teeth on the side contralateral to the chisel by excising a triangular piece of bone
surgery. bounded anteriorly by the lower end of the stop cut
a. Standard incision (as shown in the figure) is given. The and above by the anterior end of the horizontal cut.
buccal flap is then raised in a subperiosteal plane using d. The most difficult and crucial aspect of the lingual split
is as follows. This step can be considered the most
a #9 periosteal elevator. The flap should be extended

just slightly beyond the external oblique ridge to critical one in which the lingual nerve is at risk. Here
the distolingual bone is fractured inwards by placing
prevent excessive dead space beneath the flap. A 2-0

silk traction suture is then placed through the apex of the cutting edge of a 5 mm chisel just posterior to (as
the triangular flap. The suture should be clamped with shown in the figure) and pointing in the direction of
a heavy hemostat 6 to 8 inches from the flap, which is the lower second premolar of the opposite side. In its
then allowed to rest on the skin of the cheek so that correct position the cutting edge of the chisel will be
the flap is kept retracted. parallel to the external oblique ridge. (On the other
Attention is then directed to raising a lingual flap, hand if the cutting edge is held parallel to the internal
which is done carefully in a subperiosteal plane. A oblique ridge, the lingual split will extent to the
sharp and a slightly curved periosteal elevator such coronoid process). Then a few light taps with the mallet
as #9 Molt or a Freeier periosteal elevator is well suited will separate the lingual plate from the alveolar bone
for this purpose. The flap should be raised along a making it to hinge on the lingual soft tissue. This step
broad length extending from the mesial aspect of the will ensure that the main part of the shelf-like support
second molar to the lingual aspect of the anterior to the impacted tooth is lost and thus the main
ramus. This helps to reduce the tension placed on the resistance to its effective delivery is eliminated. The
lingual nerve which adheres to the periosteum. The anterior aspect of the fractured lingual cortex usually
inferior aspect of the pterygomandibular raphe, extends as far as the mesial aspect of the third molar,
superior constrictor muscle along with a small portion while the posterior aspect may extend up to 1 cm
of the mylohyoid muscle is included in this flap. It distally. The posterior extend of the fracture is limited
should be remembered that the lingual nerve enters by the natural bony lingual concavity behind the third
the sublingual space by passing between the superior molar. The inferior extend of the fracture typically
constrictor and mylohyoid muscles. At this point the involves the mylohyoid ridge (Fig. 9.4).
nerve is immediately beneath the periosteum and is If the bone fails to split favourably, it must be
at risk from trauma. After the elevation of the lingual presumed that the chisel is wrongly aligned. In such
flap, a Hovell's retractor is placed beneath the flap and an event the instrument should be realigned. Incorrect
allowed to sit passively. angulation of the chisel blade (for example directed
b. Using a sharp 3 mm chisel a vertical stop cut is made perpendicularly down to the inferior border or
(with the bevel of the chisel facing posteriorly) at the retromolar area) and use of too great a force may cause
anterior part of the wound just behind the level of the fracture of mandible distal to the third molar.
mandibular third molars in mesioangular and vertical

position can be elevated from the socket with gentle force.
However, in cases of distally tilted tooth additional bone
removal may be required posteriorly. Similarly
horizontally impacted teeth with their crown tightly
engaged behind the crown of second molar also will pose
a problem for removal. Such cases will have to be
managed by sectioning of tooth.
Modifications: The Winter's classification and Pell and
Gregory classification has some bearing on the
applicability of the lingual split technique and any
modification needed including the use of bur for bone
Fig. 9.4: When viewed from the lingual side the inferior extent of lingual
cortex fracture can be seen which typically extends up to mylohyoid removal and tooth sectioning.
ridge. Distoangular impaction: The position of the tooth may
limit the accessibility of distolingual bone for the
e. Next, the bone that remains distal to the tooth and placement of chisel for the final osteotomy cut. This in
between the buccal and lingual cut is excised. turn results in a poorly controlled bone split. In such cases
it is sensible to remove the crown or its distal part using
f. Then a fine bladed straight elevator is applied mesial

to the impacted tooth and with a gentle upward and bur to allow proper chisel placement.
Tooth located in the ramus: These teeth also present a
backward force the tooth is elevated out of the socket.

During this backward movement of the tooth, the problem in performing the osteotomy of the lingual plate.
fractured lingual plate is displaced lingually aiding the If the bony contour at the distal aspect of the tooth allows
removal of tooth. placement of the chisel just inside the lingual cortex so as
g. The fractured lingual plate is grasped with a fine artery not to cause inadvertent fracture of the ramus, then the
forceps and is freed from its soft tissue attachments procedure can be continued in the standard manner. If
by blunt dissection. Often the inferior extent of the the bony morphology is such that a controlled split is
fractured lingual plate is attached to the mylohyoid unlikely, it is prudent to use bur technique.
muscle, which is then removed with a periosteal Tooth in Class III position: Such teeth are deeply located
elevator. This step in effect brings about saucerization in the mandible. Here the initial buccal exposure is
of the socket which in turn reduces the size of the socket accomplished using either a bur or chisel, the former
promoting rapid healing. being more useful when there is inadequate access. The
h. The sharp edges of the bone is then smoothened with further use of lingual split technique can remove the
a rongeur and bone file. Failure to do this causes areas tooth.
of bony prominences leading to patient discomfort, Mesioangular and horizontal impaction: Even though
potential bone exposure on the lingual aspect and they are readily removed using the lingual split
possible injury to lingual nerve. The wound is then technique, a variable quantity of bone overlying the tooth
copiously irrigated with normal saline. The wound is may require the use of bur before the lingual osteotomy.
then inspected for hemostasis, retraction suture placed Because only then can the surgeon visualize the
initially removed and the wound closed primarily with distolingual bone and correctly place the chisel to ensure
3-0 catgut. Usually a single suture placed distal to the a predictable lingual split.
second molar is sufficient for adequate closure. The Sectioning of tooth (tooth division): Sectioning of
vertical incision in the anterior part is left unsutured. the impacted tooth may be required because of the
This will act as a wound toilet permitting escape of angulation of the tooth or unfavourable root pattern, both
blood in the event of mild oozing in the postoperative of which decides the path of withdrawal. The two
period. common reasons for the use of bur according to Farish
Once the adequate amount of lingual plate is and Bouloux (2007)6 are: (1) Failure to gain adequate
removed by this technique majority of impacted buccal or superior exposure of the unerupted tooth and
(2) Unfavourable relationship between the roots and identification and subsequent retrieval will be made easy.
inferior alveolar nerve (IAN). The IAN is almost Division of the crown can be accomplished using a bur
invariably located laterally with respect to the roots of or osteotome or a combination of both; the former being
the third molar. Hence is less likely to be traumatized more preferable. When a wide fissure bur (SS White# 703)
when the tooth is displaced lingually. is used for sectioning a horizontally impacted tooth with
Occasionally the preoperative radiographic 'locking', a space is created into which the crown can be
appearance suggests an intimate relationship between the dislodged and freed of its obstruction. In such a case, if
IAN and roots or clinically the angulation of the tooth an osteotome is used no such additional space for
seems to suggest that the roots may be lateral to IAN. movement of crown is created.
Removing the crown with a bur in combination with Moreover, sectioning of the crown with a bur is
lingual split allows the crown to be removed lingually technically easier and safer, while the use of osteotome is
and the roots elevated away from IAN. more dangerous. The osteotome that is being used for
If moderate degree of controlled force fails to deliver tooth division should be 17 cm long and 6 mm wide. For
the tooth, there is no justification to increase the force or splitting the tooth longitudinally through the root
to use powerful elevators like the cross bar elevators to bifurcation, the osteotome is placed in the buccal
dislodge the tooth. In such cases movement of the tooth anatomical groove between the mesial and distal cusps
may be obstructed by the anterior surface of the ramus at an angulation of 45° to vertical axis of the tooth (Fig.
or 'locking' of the tooth behind the second molar. This
9.6). Usually, a single blow with moderate force is all that
necessitates bone removal from the distal aspect of the

is sufficient to effect the cleavage of the tooth.
tooth or sectioning of the crown (Figs 9.5A to C).
Osteotome has the hazard of causing mandibular
When the tooth is deeply impacted and/or when the

fracture if the site of placement of the instrument is
bone is sclerotic as in old patients, it is better to discard
incorrect or the force is directed in the wrong direction
chisel and resort to the use of bur. In a young adult
because of the inherent elasticity of the bone, even or the blow is of excessive force. It is safer to section a
horizontally impacted tooth may not need sectioning. A tooth which is slightly mobile in the socket, so that the
similar case in an aged patient will require tooth division. full force of the mallet blow is not transmitted to the bone.
More over it is technically difficult to chisel small amounts Considering the danger and sometimes the
of bone from the depth or around the impacted tooth in ineffectiveness of the osteotome, a better option is to
an attempt to mobilize it. And in such cases bur is a much employ a combination of bur and osteotome for
viable alternative with regard to better access and speed sectioning the tooth. A small groove is drilled in the crown
of surgery. of the tooth and then an osteotome is used to complete
Before planning to section the crown, it is prudent to the split. The bur cut will ensure a predictable line of split
expose the cervical one third of the root, so that its while using the osteotome.
Figs 9.5A to C: (A) When the crown of the impacted tooth is 'locked' behind the second molar its movement is obstructed when elevation is
attempted. Removal of such tooth is facilitated by the division of the tooth using an osteotome (B) or sectioning of crown using bur (C); the latter
being easier and less dangerous.
Yeh (1995)9 reported a modification of the original

technique which is based on an osteomucoperiosteal flap.
The technique described is simple, and it requires less
time and causes less tissue trauma than other accepted
techniques. The bone exposure and bone loss are minimal.
The complication rate is extremely low.
Robinson and Smith (1996)10 recommended avoiding
a lingual flap with the lingual split technique to reduce
the frequency of lingual nerve injuries, though elevation
of lingual flap is an integral part of the original technique.
Pichler and Beirne (2001)11 performed a compre-
hensive review of literature and a meta-analysis
comparing lingual split, bur technique with lingual flap
and bur technique without lingual flap. They found an
incidence of temporary nerve injury of 9.6%, 6.4% and
Fig. 9.6: Use of an osteotome for sectioning the crown. 0.6% respectively. The incidence of permanent nerve
injury was reported as 0.1%, 0.6% and 0.2% respectively.
Even though there are reports of lingual nerve injury, Although the lingual split technique seems to result in
both transient and permanent, studies have shown that an increased incidence of temporary lingual nerve injury,
lingual split technique may avoid periodontal pocket the incidence of permanent nerve injury seems to be less
formation compared to buccal approach using bur. A than with the bur technique. It seems prudent to avoid a
study was conducted by Chang et al (2004)7 to compare lingual flap with the bur technique because of the
the periodontal healing of mandibular second molars reported three fold increase in the incidence of permanent
after the removal of impacted mandibular third molars nerve injury. Bouloux (2007) 6 opined that careful
using distolingual alveolectomy (lingual split technique) elevation of a lingual flap with appropriate sharp
done using chisel and tooth division technique using bur. periosteal elevator and placement of a suitable retractor
The results showed better periodontal healing and bone are key factors in reducing the incidence of lingual nerve
healing when distolingual alveolectomy was performed, injury. Additional factors likely to influence the incidence
especially in the removal of deeply impacted mandibular
of lingual nerve injury include age, surgical time,
third molars.
perforation of lingual plate, nerve exposure and surgeon's
experience.
Modification of Lingual Split Technique 4. Lateral trepanation technique (Figs 9.7A to E): This
Ever since the introduction of this technique numerous technique first described by Bowdler Henry12, 13 in 1969
modifications has been suggested to overcome the is indicated to remove partially formed un erupted third
complications associated with the procedure. molar in 9 to 18 years age group patients. The main
Lewis (1980)8 suggested a modification. He said that advantages of the procedure are that the bone healing is
the creation of a buccal defect immediately distal to the excellent, alveolar height is preserved and there is no bony
second molar for the insertion of an elevator in the defect or periodontal pocketing distal to second molar
standard technique may cause pocketing to occur compared to later removal of wisdom tooth by
postoperatively. The method described by him minimizes conventional methods.
periosteal reflection, almost completely avoids loss of
bone, and effectively reduces the use of rotary Surgical Steps
instrumentation. The planning of the soft tissue flaps and
bony cuts assists in primary wound closure, obliteration a. The external oblique ridge is palpated and an extended
of dead space, and reduction of postoperative morbidity. S-shaped incision is made from the retromolar fossa
Figs 9.7A to F: (A) 'S' shaped incision from the retromolar area to the first molar region, (B) Reflection and retraction of mucoperiosteum (C) Use
of bur and chisel to remove the buccal bone overlying the tooth bud, (D) Exposure of tooth bud and its removal (E) Remnants of the dental follicle
are curetted out or removed using a hemostat, (F) Closure of the wound using three or four sutures
directed towards the external oblique ridge. Anteriorly elevator is used to eject the tooth out. In certain
the incision curves down along the buccal mucoperio- instances there is a tendency for the bud or the
steum up to the anterior border of first molar. It is developing tooth to rotate in its crypt or the socket-
important to leave a cuff of 5 mm width of like a pea in a pod. If any difficulty is experienced in
mucoperiosteum distobuccal to second molar effecting the delivery of the tooth, it can be overcome
undisturbed. by excising a little more bone from the periphery of
b. The buccal mucoperiosteum is then reflected and held the window using a bur.
away using a Bowdler Henry retractor. e. Remnants of the dental follicle are then curetted out
c. Using a round bur on a straight hand piece the exact or removed using a hemostat. Due to the close
position of the tooth bud/ developing tooth is located. proximity of neurovascular bundle, curettage of the
Usually this will lie more anteriorly than expected. lower part of the cavity is contraindicated.
Following this using the bur, vertical cuts are made in f. The bone margins are then smoothened and the wound
the buccal cortical plate anterior and posterior to the copiously irrigated with normal saline. Closure of the
tooth crypt. The two vertical cuts are then connected wound is then done using three or four sutures.
at the superior aspect by a horizontal cut. A chisel is Authors generally advice this technique of
then placed in the superior horizontal cut with its bevel germectomy for: (a) developing third molars which are
facing laterally and the buccal plate is out fractured. likely to get impacted in the future; (b) to gain space in
Care is taken not to disturb the roof of the crypt. the posterior segments of the lower jaw when distalization
d. The fractured buccal plate is removed using a hemostat of first and second molars is necessary; (c) in case of
to expose the tooth bud in its crypt. A Warwick James excessive anterior-posterior mandibular growth.
There are conflicting reports in the literature, some (coronectomy) merit consideration. The intention of
of which favour and others differ. Chiapasco et al (1995)14 coronectomy or partial root retention is that the part of
conducted a study to analyze and compare complications the root intimately related to IAN is left undisturbed.
and side effects after removal of 1,500 mandibular Adequate amount of root must be removed below the
impacted third molar teeth in three age groups i.e. group crest of the lingual and buccal plates of bone to enable
A, 9 to 16 years; group B, aged 17 to 24 years; and group bone to form over the retained roots as part of the normal
C, older than 24 years of age. The study showed no healing process (Pogrel, 2007)16. At the same time it is
significant difference in the complication rate between also important not to mobilize the roots, because of the
groups A and B, but complications significantly increased possible damage to IAN or the mobile roots might become
in group C. a foreign body initiating infection.
Chossegros et al (2002)15 conducted a prospective
randomized study to identify the need for lingual nerve
protection for lower third molar germectomy. Data from Contraindications to Partial Odontectomy
a total of 300 germectomy procedures were included in
• Active infection around the tooth particularly
this study. It was observed that there was no lingual nerve
involving the radicular portion.
injury after third molar germectomy, regardless of
• Mobile teeth - any retained mobile root will act as a
whether or not lingual nerve protection was used.
foreign body becoming a nidus for infection.
5. Partial Odontectomy: Injury to inferior alveolar
• Horizontally impacted tooth along the course of the

nerve (IAN) is a possible complication following surgi-
nerve, because sectioning of such a tooth will damage
cal removal of impacted mandibular third molar. Hence
the IAN. Hence the technique is more applicable for

it is advisable to carry out a technique that may reduce
vertical, mesioangular and distoangular impactions.
the possibility of injury. The technique of partial odon-
Technique-Prophylactic antibiotic is administered to
tectomy (coronectomy, deliberate root retention) is one
ensure adequate concentration of antibiotic in the pulp
procedure that can be considered to protect the IAN. Even
chamber of the tooth to be sectioned. Incision and
though it has been suggested by many authors in the past,
elevation of the mucoperiosteal flap is similar to the
currently the technique does not enjoy a strong body of
conventional method as shown in the Figure 9.8.
support (Pogrel, 2007)16. Previously, the relationship be-
tween the roots of mandibular third molar and IAN were
assessed radiographically using an orthopantamograph
(OPG). The following radiographic features suggest an
intimate relationship:
• Darkening of the root and interruption of the white
line of the canal
• Narrowing of the canal
• Deflection of the roots
Studies have shown that those cases showing
intimate relationship between the roots of teeth and IAN,
14% developed nerve injury. Recently with the
development of low dose cone beam CT, accurate three-
dimensional imaging can be performed to demonstrate
the relationship between the roots of the third molar and
the IAN. The current recommendation is that when the
OPG suggests a close relationship between the roots of
the lower third molar and IAN, cone beam CT scanning
should be advised.
Fig. 9.8: Line of incision is similar to the conventional incision (broken
Rationale: Cases in which an intimate relationship is line). It is made along the external oblique ridge to the distobuccal angle
confirmed, the technique of partial odontectomy of the second molar and then a releasing incision is made into the sulcus
The flap is retained with a Minnesota-type retractor. using bur is done up to two thirds of the buccolingual
A lingual flap is then raised without tension on the lingual width. Then fracture off the crown of the tooth. However,
nerve and the lingual tissues are then retracted with this procedure can cause mobilization of the root
appropriate lingual retractor like the Walters- type. The fragment and may require its removal in the same sitting.
crown of the tooth is then sectioned using a # 701 type Studies have shown that the technique of
fissure bur at an angle of approximately 45° (Fig. 9.9). coronectomy is a comparatively safe procedure with
The crown is totally transected so that it can be relatively few intraoperative and postoperative
removed with tissue forceps alone and does not need to complications. Transient lingual nerve anesthesia has
be fractured from the roots. This minimizes the possibility been reported following the use of lingual retractor.
of mobilizing the roots. Since the lingual plate of bone Animal studies have shown that vital root remain with
can be inadvertently perforated during the procedure, minimal degenerative changes. Postoperative radio-
the use of a lingual retractor is essential during sectioning. graphs taken at regular intervals have shown that in
The Walters type lingual retractor (KLS Martin, approximately 30% of the cases there is an appreciable
Jacksonville, Florida) is a suitable instrument because it coronal migration of the root fragments away from the
has no sharp edges, is shaped to fit the lingual side of IAN. Follow up radiographs showed that late migration
mandible and has an extension that engages the internal of root fragments occurs, but it is unpredictable. Even if
oblique ridge. it occurs, the roots move farther away from the IAN into
Once the crown is removed the fissure bur is used to a safer position from where it can be removed more easily
reduce the remaining root fragments so that the if required. The technique of leaving the root fragments
remaining roots are at least 3 mm below the crest of the at least 3 mm below the crest of alveolus seems
buccal and lingual plates in all dimensions. Thus the appropriate. Because such a procedure has shown to
shaded portion as shown in Figure 9.9 is removed. No encourage bone formation over the retained root
attempt is made to perform root canal therapy or any fragments. This has been validated in animal studies.
other procedure to treat the exposed vital pulp of the In summary, the technique of partial odontectomy is
tooth. worthy of consideration in cases in which the OPG and
If necessary, a periosteal incision can be made to cone beam CT scan shows an intimate relationship
advance the buccal flap to obtain a water tight primary between the roots of mandibular third molar and IAN.
closure of the wound using one or more vertical mattress 6. Orthodontic extraction: This is an orthodontic -
sutures. A postoperative radiograph is taken to assess surgical procedure that has been found to be useful for
the location and size of the retained root fragment. the safe extraction of impacted third molars with a high
An alternative technique has been suggested which risk of neurological complication due to the close
avoids the use of a lingual retractor. In this technique proximity to mandibular canal. The usefulness of the
after raising a buccal flap, the sectioning of the crown procedure has been reported by Checchi et al (1996)17,
Marchetti et al (2004)18 and recently by Alessandri Bonetti
et al (2007).19
The orthodontic extraction operation comprises of six
phases19:
Phase 0 Assessment of surgical risks
Phase 1 Creation of orthodontic anchorage
Phase 2 Surgical exposure of the third molar crown
Phase 3 Orthodontic extrusion of the third molar
Phase 4 Clinical and radiographic assessment of the
extrusion level
Phase 5 Third molar extraction
Fig. 9.9: Diagrammatic representation of coronectomy technique. Note The anchorage consists of a stainless steel lingual arch
the lingual retractor in place to protect the lingual nerve. The bur is welded to the first molar bands and buccally on the
directed at an angle of 45° to section the crown. Following this the gray
area marked is removed to place the remaining root potion of the tooth extrusion side, a stainless steel sectional wire tied from
2 to 3 mm below the crest of bone second molar to the first bicuspid.
A week after the surgical exposure of the third molar Periodic clinical and radiographic examination is
crown and bonding of the bracket to it, a rectangular conducted to evaluate the extrusion of the tooth. This
stainless steel sectional wire is placed. This cantilever is allows the surgeon to determine the best time to carry
the system's active part; placed into the auxiliary tube on out the extraction at a time when adequate bone has been
the side of the first molar and tied to the bracket on the formed separating the root from the mandibular canal
third molar. This allows the tooth to extrude, thus setting (Figures 9.10 A to E, 9.11 A and B, 9.12 A and B; Courtesy
it apart from the mandibular canal. The cantilever must to Dr Giulio Alessandri Bonetti, Bologna, Italy for the
be untied, reshaped, and reactivated every 4 to 6 weeks. photographs).
Figs 9.10A and B: (A) Preoperative OPG showing horizontally impacted 38, (B) OPG showing
orthodontic eruption of impacted 38 completed after nine months
Figs 9.10C to E: Close up view of the radiograph- (A) Initial picture, (B) On completion of extrusion,
(C) 6 months post extraction.
The following are the advantages of this technique:

(a) risk of direct trauma to the nerve is eliminated, (b)
reduced need for instrumentation, (c) tooth is in a
favourable position for surgery and is easily luxated, (d)
quicker and easier extraction leads to less postoperative
oedema, pain and trismus (e) possibility of mandibular
fracture associated with removal of deeply impacted third
molar is avoided, (f) development of an infra bony
periodontal defect on the distal side of the adjacent second
molar is prevented by this technique.
However, the technique has the following
disadvantages: (a) the orthodontic appliance may cause
some discomfort due to impingement on the soft tissues,
(b) the procedure involves two operations ie. exposure
of the third molar crown initially and later extraction of
the tooth, (c) more time consuming than a surgical
removal of tooth, (d) require good co-operation between
the surgeon and the orthodontist, (e) more expensive

because it involves a greater number of appointments.
Figs 9.11A and B: (A) Preoperative OPG showing mesioangularly Based on the aforementioned considerations, it is
impacted 48, (B) OPG showing orthodontic eruption of impacted 48 clear that the orthodontic extraction approach cannot be
completed after eight months
used on a routine basis (Alessandri Bonetti et al, 2007)19.
Each case of impaction must be considered separately
and this approach should be chosen only in carefully
selected cases. Factors such as tooth position, integrity of
the dental arch, overall periodontal situation, and
patient’s psychological profile must be carefully
evaluated before attempting the procedure.
SUMMARY
Recent contributions have shown that the risk of

development of pathology in presence of impacted third
molars is quite low. A certain morbidity associated with
the different procedures described above may be
expected. Hence a very careful risk to benefit ratio must
be considered while selecting an alternate procedure,
instead of the standard surgical method of removal of
impacted mandibular third molar.
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10 Surgical Removal of Impacted
Maxillary Third Molar
Surgical management of upper third molars in general is 5. Aberrant position sometimes associated with
less complex compared to lower third molars. They cause pathological condition such as cyst
less discomfort, are more likely to erupt, and are simpler
to remove unless unerupted and encased in bone.

Removal of upper third molars results in far less
postoperative morbidity, and general anesthetics are

rarely required.
The commonest type of impaction in maxillary third
molar is vertical (Peterson et al, 2003).1
Classification of impacted maxillary third molars:
The system of classification of upper wisdom tooth is
essentially same as that for impacted mandibular third Fig. 10.1: Classification of impacted maxillary third molar
based on angulation
molar. Nevertheless, there are some additional
parameters to be considered which will aid in pre-
operative assessment of the case and guide in planning
the surgery for a successful outcome.
1. State of Eruption
1. Fully erupted
2. Partially erupted
3. Unerupted Within the bone
Immediately beneath the soft tissues
2. Angulation of the Tooth (Figs 10.1 to 10.3)
1. Vertical - 63%
Fig. 10.2: Periapical X-ray showing mesioangularly impacted 38
2. Mesioangular - 25%
3. Distoangular - 12% 3. Pell and Gregory Classification
4. Laterally displaced with the crown facing the
cheek, horizontal, inverted and transverse This is based on the relative depth of the impacted
positions- less than 1% maxillary third molar (Fig.10.4).
Indications for the Removal of Maxillary

Third Molar
1. Extensive dental caries which is beyond restoration

and causing food stagnation
2. Recurrent pericoronitis
3. Buccally or distally erupting tooth causing the patient
to adopt a bite of convenience to avoid cheek biting.
(Adopting such a bite of convenience leads to
temporomandibular joint pain in certain cases)
4. Tooth involved in pathological process such as cyst.
Fig. 10.3: OPG showing horizontally impacted maxillary
third molars (yellow oval) 5. Over erupted and non functional upper third molar-
When the opposing mandibular third molar has been
Position A Occlusal surface of third molar is at the removed, the maxillary third molar tends to over erupt
same level as that of second molar. leading to food impaction between the latter and
Position B Occlusal surface of third molar is located second molar (Fig.10.5). This in turn leads to
between occlusal plane and cervical periodontal problems and dental caries of maxillary
second and third molar.
line of second molar.

Position C Occlusal surface of third molar is at or
above the cervical line of second molar.
Fig. 10.4: Pell and Gregory classification based on relative

depth of impacted maxillary third molar
4. Relationship of Impacted Maxillary Third

Molar to the Maxillary Sinus Fig. 10.5: Schematic diagram showing over erupted upper third molar
(red arrow) leading to food impaction (blue arrow) between second and
1. Sinus approximation (SA): No bone or a thin partition third molar tooth
of bone between the impacted maxillary third molar
and maxillary sinus. Additionally because of over eruption, the upper
2. No sinus approximation (NSA): 2 mm or more bone third molar impinges on the edentulous lower third molar
between the impacted maxillary third molar and area upon closure of the mouth and causes ulceration
maxillary sinus. (Fig.10.6).
6. Buccally erupting upper third molar impinging on the
5. Nature of Roots coronoid process during mandibular movements leads
to pain during movement. Furthermore traumatic
1. Fused (conical ) ulceration and hyperkeratosis of the buccal mucosa
2. Multiple—Favorable/Unfavorable also can occur due to constant irritation.
Surgical Removal of Impacted Maxillary Third Molar 103
to panoramic radiograph in the pre operative evaluation

of impacted maxillary third molars. The CT scan was
more precise than the panoramic radiograph for
measurement of the level of impaction of the third molar,
measurement of the third molar displacement, bone
height separating the third molar roots and the sinus, and
for assessing the length of roots in the sinus. The CT scan
was equally accurate for measurement of the distance
separating the crowns of second and third molars
(Figs 10.7A to D).
Fig. 10.6: Schematic diagram showing over erupted upper third molar
(red arrow) impinging in lower third molar area causing ulceration (blue A
arrow)
7. Interference with placement of prosthesis—Erupting

upper third molar will interfere with placement of a

denture causing pain and/or retention problem. Hence
they have to be removed.
Local Contraindications for Removal

1. Symptom-less upper third molar completely B
embedded in bone. Figs 10.7A and B: (A) Impacted left maxillary third molar not visible in
2. Upper third molar positioned high in the alveolus— the periapical X-ray, (B) OPG of the same patient showing impacted
28 placed high in the tuberosity region of the maxilla (yellow circle)
surgical removal of such teeth carry the risk of
displacing the tooth into the maxillary antrum or
infratemporal fossa.
3. Deeply impacted tooth, the removal of which may
damage the adjacent second molar.
It has been observed that an impacted upper third
molar tooth may begin to erupt and eventually reach the
surface making its removal easy.
Radiographic Examination
The following are the useful radiographs-
1. Periapical X-ray
2. Orthopantomogram (OPG)
3. Occlusal X-ray
4. True lateral view—occasionally helpful
5. PNS view of maxilla—if associated pathology like cyst
or tumor is suspected
6. CT scan—especially if associated pathology like cyst
or tumor is suspected.
Figs 10.7C and D: (C) Axial CT scan of the patient showing impacted
Bouquet et al (2004)2 reported that CT scan gives 28 (yellow circle), (D) Coronal CT scan of the patient showing impacted
better qualitative and quantitative information compared 28 (yellow circle)
Determining the Degree of Difficulty • Dense and non-elastic bone as in old age
of Removal • Multirooted tooth with large bulbous roots
• Large maxillary sinus expanded to include the
1. Angulation: While considering the angulation and roots of third molar
degree of difficulty of removal vis - a- vis mandibular • Use of excessive force to elevate the tooth which
third molar, it has been found that the same has divergent roots.
angulations in mandibular third molar cause opposite • Mesioangular impactions where the tuberosity is
degree of difficulty for maxillary third molar frequently heavier and surrounding bone thinner.
extraction. For example in case of maxillary third 6. Other factors influencing the degree of surgical
molars, vertical and distoangular impactions are difficulty : These factors are similar to that of impacted
easiest to remove, while mesioangular impactions are mandibular third molar. Morphology of the tooth
more difficult, i.e. exactly the opposite of mandibular especially that of the root plays a vital role in this
third molars. Mesioangular impactions in maxillary regard.
third molar are more difficult to remove because the • Tooth with roots which are thin, separated and
bone that is overlying the tooth which must be with curvature are difficult to extract. Fortunately
removed is on the posterior part of the tooth and is majority of maxillary third molars have fused
comparatively dense than in vertical or distoangular conical roots.
impaction. Moreover, accessibility is also less for a • Hypercementosis of roots make removal difficult.
tooth in mesioangular position. • Tooth with a wide periodontal space is easier to

2. Position in buccoangular direction: This also extract. When periodontal space decreases as in
contributes to determining the degree of difficulty of old age, surgical removal is difficult
removal. Generally crown of maxillary third molars • Tooth with a wide follicular space is easier to
are directed towards the buccal aspect of the alveolar remove than with no follicular space.
process. This makes the overlying bone thin and easy • Bone when it is less dense and more elastic as in
to expand. In such cases, a definite bulge can be felt on young patients makes extraction easier. While in
the buccal aspect. Rarely, the impacted maxillary third old age when bone becomes denser and less elastic
molar is positioned towards the palatal aspect of the removal of tooth is more complicated.
alveolar process. This necessitates removal of more • Close relationship of a deeply impacted tooth to
bone to gain access and thereby increases the difficulty adjacent second molar makes the removal difficult,
of removal. When the crown is directed palatally, a since more bone should be removed to avoid
bony deficit may be palpated on the buccal aspect of damage to second molar.
alveolar process. Digital palpation followed by • Fusion of third molar with roots of second molar
radiographic examination will help to determine the makes removal difficult.
buccopalatal position of maxillary third molar. • Presence of large restoration on second molar
3. Type of overlying tissues or Degree of eruption: requires the judicious use of elevator to luxate the
Similar to mandibular molars; tooth which has only impacted tooth.
soft tissue covering is easier to remove than complete • Difficult access due to small oral aperture or
bony impaction. trismus complicates the removal.
4. Proximity to maxillary sinus: Frequently the impacted
maxillary molar is in close approximation to the floor
Surgical Anatomy
or posterior wall of the maxillary sinus. Removal of
such tooth may result in oro-antral communication or a. Maxillary tuberosity: The impacted maxillary third
displacement of the tooth into the sinus. Necessary molar is located in the tuberosity. It is surrounded by
steps should be taken to prevent this. cancellous bone and a thin buccal cortical plate
5. Proximity to maxillary tuberosity: Because of comparable to an egg shell. The palatal cortical plate
proximity of impacted tooth to tuberosity, it can be is thick and dense. Such an anatomy dictates that the
fractured during extraction of impacted maxillary third upper third molar should be removed by a buccal
molar. Factors contributing to this hazard are: approach.
b. Mucoperiosteum: The buccal and distal side of the e. Buccal pad of fat: This is present between the buccinator
tuberosity is covered by mucoperiosteum of normal and masseter muscle. During surgery, accidental
thickness in which is found branches of posterior perforation of the buccinator muscle by surgical blade
alveolar artery and vein. On the palatal aspect, the or retractor may result in prolapse of the buccal fat
tuberosity is covered by thick mucoperiosteum pad into the operative field. Sudden visualization of a
containing greater palatine neurovascular bundle. This yellowish material will be distressing for the operator.
is located at the junction between the alveolar process No attempt is made to remove the prolapsed fat by
and horizontal part of maxilla. pulling it out. If this is attempted more fat will come
c. Maxillary sinus: Impacted maxillary molar is located out. Instead, that part of fat may be resected or pushed
close to the floor of the maxillary sinus. Very often there back and a suture given.
will be only a thin plate of bone separating the floor of f. Pterygopalatine fossa: This narrow space is located
the sinus from the third molar root (Fig.10.8). In rare posterior to the maxillary tuberosity and the pterygoid
instances, this thin plate of bone may be absent and process forms the posterior boundary. The fossa is
the root of third molar may protrude into the maxillary limited medially by the vertical plate of palatine bone.
sinus. Similarly, the extension of maxillary sinus and Laterally, this fossa communicates with the
its floor into the tuberosity area also varies. The close infratemporal fossa. Excessive pressure exerted in a
proximity of third molar root increases the possibility posterior direction during elevation of an impacted
of accidentally pushing the third molar or its root into
maxillary third molar may cause its displacement into

the maxillary sinus. The extension of sinus into the the pterygopalatine fossa.
tuberosity weakens this area leading to accidental
g. Infratemporal fossa: This area is bounded anteriorly by

fracture of maxillary tuberosity while luxating a firmly the posterolateral surface of the maxilla, medially by
fixed upper third molar. lateral pterygoid plate, and laterally by the ramus of
d. Muscles: On the buccal side the buccinator muscle is the mandible. Superiorly this fossa reaches up to the
inserted on the lateral aspect of the tuberosity above inferior orbital fissure. There are a number of important
the molar teeth. The exact position of the attachment anatomical structures contained in this space. During
of buccinator muscle in relation to molar roots has a
surgical removal of maxillary third molar it may be
surgical implication with regard to spread of infection
displaced through the thin distal bone into the
from the molar either to the buccal vestibule or into
infratemporal fossa.
the buccal space.
Extraction of erupted maxillary third molar: Use of
The inferior head of the lateral pterygoid muscle
dental forceps for the extraction of erupted upper wisdom
originates from the outer surface of the lateral
tooth carries the risk of fracture of maxillary tuberosity
pterygoid plate, which is located immediately behind
from excessive force. Similarly extraction of partially
the tuberosity area. Damage to this muscle will lead
erupted upper third molar with conical roots has the
to postoperative trismus.
hazard of displacing the tooth into the sinus. Hence, for
the removal of erupted and partially erupted upper third
molar the use of a curved Warwick James elevator is
recommended (Fig.10.9). In cases where the tooth is
erupted, the curved blade of the instrument is inserted
between the second and third molar with the concave
side facing posteriorly. Then a gentle force is exerted in a
downward and outward direction. If the tooth is resistant
and great force is exerted in a backward direction, it can
result in fracture of the maxillary tuberosity.
Steps in the operative procedure for removal of
unerupted third molar (Figs 10.10A to D): One of the
Fig. 10.8: Schematic diagram showing the relationship of impacted difficulties that will be encountered during its surgical
maxillary third molar to the floor of the maxillary sinus removal is the limited access due to the presence of the
Fig. 10.9: Use of a curved Warwick James elevator

for removal of maxillary third molar
Figs 10.11A and B: Incision for palatal diagonal flap described by

Darichuk (2005)3 - (A) Occlusal view, (B) Buccal view
A simple yet effective flap design for maxillary third

molar surgery, the palatal diagonal flap (Figs 10.11A
and B) has been described by Darichuk (2005).3 This flap
provides excellent surgical access to the maxillary third
molar region and permits placement of a suitable
retractor, preventing displacement of a maxillary third
molar during elevation.
Figs 10.10A to D: Steps in the surgical removal of a mesioangularly

impacted maxillary third molar. (A) Incision to raise a triangular flap,
(B) Mucoperiosteal flap reflected, (C) Overlying bone removed from
occlusal and buccal aspect up to the cervical line and elevation of tooth,
(D) Suturing completed
coronoid process. This can be overcome by opening the

mouth only partially. The basic technique for the surgical
removal of maxillary third molar is similar to that of the
mandibular third molar.
Incision: It starts from the mesial aspect of first molar
and extends posteriorly beyond the distobuccal aspect
of second molar and then continued into the tuberosity.
If greater access is required as in case of a deeply impacted
tooth, a release incision can be given in the mesial aspect
of second molar to raise a triangular flap.
Using a Howarth's periosteal elevator the
mucoperiosteum is reflected. This is a useful instrument Figs 10.12A
for retracting the flap also.
Fig. 10.13: Potts elevator; right and left side
Figs 10.12A and B: (A) Bone removal achieved on the occlusal and
the buccal aspect of tooth down to the cervical line to expose the entire
crown, (B) Delivery of the tooth using a Potts elevator
Removal of overlying bone—Bone removal is

restricted to the occlusal and the buccal aspect of the tooth

down to the cervical line to expose the entire crown
(Fig. 10.12 A). This is achieved using chisel or bur; but
the latter is preferable. Additional bone is removed on
the mesial aspect of the tooth above the height of contour
of the crown to create space for the insertion of an elevator
and to act as a purchase point. This bone removal can be Fig. 10.14: Martin tooth-grasping forceps
accomplished using a chisel with hand pressure since the
maxillary bone is generally thin. This can also be achieved forceps (Fig. 10.14) are useful in the removal of tooth or
using a Potts elevator or a periosteal elevator. fragments after adequate elevation.
Unlike mandibular third molars, maxillary third The following points should be borne in mind while
elevating the tooth:
molars rarely need sectioning. This is because the
1. Due to the proximity of the maxillary sinus and the
overlying bone is usually thin and elastic. In cases where
infratemporal fossa no upward pressure should be
the bone is thicker, sclerotic and less elastic as in old
exerted during bone removal and delivery of the tooth.
patients, tooth removal is facilitated by bone removal
2. This can be avoided by creating sufficient room
rather than tooth sectioning. Chisel is contraindicated to
between the height of contour of the crown (i.e. above
section maxillary teeth due the danger of displacement the maximum bulge of the tooth) and surrounding
of the tooth into the maxillary antrum. bone so that the tip of the elevator can be placed above
Sectioning of maxillary third molar should be the height of contour of the tooth. Then pressure is
avoided and considered only as a last resort because small exerted in a distobuccal direction.
fragments can be displaced into the sinus or infratemporal 3. Moderate pressure is exerted distally, buccally and
fossa. occlusally (i.e. downward and outward) with the fore
Delivery of the tooth: This is achieved using small finger placed posterior to maxillary tuberosity to detect
straight elevators or a # 301 elevator with force exerted tuberosity fracture if it occurs.
in the distobuccal direction. Some operators prefer angled 4. In case of any suspicion regarding the accidental
elevators which easily gains access. Further elevation (Fig. opening into the sinus, every effort should be made to
10.12 B) and delivery can be achieved with a Potts elevator ensure proper closure and the patient instructed
(Fig.10.13). A hemostat and a Martin tooth- grasping appropriately.
second molar at the occlusal aspect of the alveolar process

with the bevel facing towards the cheek. The assistant,
using the mallet gives short taps to result in the removal
of a thin length of buccal bone from the distal aspect of
second molar to the tuberosity. The chisel is then
positioned slightly superiorly and the process repeated.
When sufficient bone has been removed, a Cryer or
Warwick James elevator is positioned to engage the
Fig. 10.15: Laster retractor mesial aspect of the crown of the third molar and the tooth
is displaced buccally. The soft tissue follicle is removed
Farish and Bouloux (2007)4 advice the use of the with a sharp curette and a curved hemostat. Sharp bony
Minnesota retractor or periosteal elevator to be placed edges are then smoothened with a rongeur and bone file.
distal to impacted maxillary third molar during final The wound is then copiously irrigated with saline and
elevation so that it will not be displaced under the flap primarily closed with 3-0 catgut sutures in the vestibular
and into the infratemporal fossa. A Laster retractor is an part of the incision.
ideal retractor for this purpose because it engages the Endoscopic surgery for removal of ectopic
tuberosity, provides excellent access and prevents maxillary third molars: Hasbini et al (2001)5 reported a
displacement of tooth. rare case of an ectopic third molar at the level of the
Debridement and Closure: The procedure is similar osteomeatal complex treated by endoscopic surgery.
to that of mandibular third molar. A single suture is all Computed tomography of the paranasal sinuses revealed
that is needed to secure the wound. The suture is passed that an aberrant tooth was obstructing the osteomeatal
from the palatal side of the interdental papilla between complex and bulging into the ethmoid infundibulum.
the first and second molars into the anterior end of the Opacity of the entire left maxillary sinus indicated the
buccal flap. Rapid healing of the wound occurs with presence of an associated cyst formation. A transnasal
minimum postoperative problem. endoscopic sinus technique was employed to create a
Frequently, upper third molar sites do not require large middle meatal antrostomy and to remove the tooth
suturing because the wound is held in proper position as well as the cystic contents and cyst wall. The
by gravity and the surrounding soft tissues. endoscopic surgical approach used in this case caused
Modification of standard technique using chisel: less morbidity than do the more common methods (e.g.
A technique using chisel has been described by Farish the Caldwell-Luc procedure) of removing ectopic teeth
and Bouloux (2007).4 In this method a small mouth prop from the sinus. For lateral or posterior teeth, the authors
is placed between the teeth on the contralateral side. After advised a combined transfacial-transnasal approach, in
administration of local anesthesia, an oblique incision is which a trocar is inserted through the anterior canine
made from the distopalatal aspect extending obliquely fossa; the trocar allows for the introduction of a probe to
over the tuberosity toward the distobuccal aspect of dislodge the tooth in a medial direction under direct
second molar and then extended into the vestibule. This vision. Any related cystic structures can be evacuated at
oblique incision permits easy closure of the wound, often the same time. The dislodged ectopic tooth and associated
without the need for suturing. The buccal flap is then cyst can then be extracted through a middle meatal
elevated to include the maxillary tuberosity. A Laster antrostomy that was created during the transnasal
retractor (Fig.10.15) can be easily positioned with the endoscopic sinus approach.
small cup- shaped tip firmly engaging the tuberosity. This Di Pasquale et al (2006)6 reported a case of a 14-year-
retractor also protects the cheek and by engaging the old girl in which CT of the paranasal sinuses demons-
tuberosity effectively prevents displacement of the third trated a left unilateral maxillary sinus opacification that
molar tooth into the infratemporal fossa. had been produced by an ectopic molar. The tooth was
The retractor is held in the left hand while the surgeon removed via an endoscopic approach rather than with a
stabilizes the chisel with the other hand. The chisel is held traditional Caldwell-Luc procedure. A nasal endoscope
parallel to the occlusal plane and the cutting edge was used to create a middle meatal antrostomy and
positioned adjacent to the distal aspect of the erupted deliver the tooth and its cystic contents.
Complications During Surgery of Impacted reapplied to the opening. If the second attempt is also
Maxillary Third Molar unsuccessful, further attempts should be stopped and the
patient placed on a course of antibiotics and nasal
1. Displacement of tooth into maxillary sinus: This is decongestants. Retrieval can be accomplished via a
most likely to occur when the maxillary third molar is Caldwell-Luc approach along with the closure of oro-
partially erupted and has conical roots which are closely antral fistula.
related to the floor of the sinus. Attempted extraction of Sverzut et al (2005)8 reported a case of an impacted
such a tooth using extraction forceps can dislodge the right maxillary third molar that was accidentally
tooth into the maxillary antrum (Figs 10.16A and B). A displaced into the maxillary sinus during extraction. It
similar accident can occur when excessive force is exerted was surgically retrieved two years later after maxillary
for elevating a buried wisdom tooth with poor visibility sinus exposure through Caldwell-Luc approach under
at the point of application of the elevator. The closer the general anesthesia.
root tip of the impacted tooth is to the floor of the sinus In cases of accidental tooth displacement into the
and higher the initial position of the tooth in the alveolus, maxillary sinus, the most accepted treatment is the
the higher the chance for this mishap to occur. removal of the dislodged tooth to prevent future
If the entire tooth is dislodged into the maxillary sinus infections, preferably during the same surgical procedure,
it should be removed as early as possible to prevent if possible. However, delayed treatment does not always
infection. Pogrel(1990)7 stated that the initial attempt at precipitate immediate active sinus disease. In the event
retrieval should be a suction placed at the opening into the professional is not experienced and skilled enough
the sinus. If this procedure does not allow delivery, then to perform the retrieval surgery and/or the patient is not
the sinus may be irrigated with saline and the suction tip in physical and/or psychological condition to support
the maxillary sinus surgical intervention at the same
session, the dentist must be prepared to adequately
handle the situation. The case may be either referred to
an oral and maxillofacial surgeon or the procedure for
retrieval of the displaced tooth must be postponed to a
future date when the patient feels more comfortable. In
the meantime the patient must be given antibiotic,
analgesic and anti-inflammatory medication as indicated.
2. Dislodgement into soft tisues: Accidental
displacement of upper third molar into the buccal soft
tissues (Fig. 10.17) and into the infratemporal fossa may
occur. Usually this occurs: (a) when an adequate buccal
flap is not raised prior to attempting surgical removal,
(b) decreased visibility during surgical extraction,
(c) incorrect extraction technique, (d) distolingual
angulation of tooth, (e) third molar crown above the level
of the adjacent molar root apices.
The tooth will be usually lateral to the lateral
pterygoid plate and inferior to the lateral pterygoid
muscle (Peterson et al, 2003).1 Following such an accident,
the patient experiences severe pain and trismus. Such
displaced tooth should be removed as early as possible
to avoid development of infection. If good access and light
are available the surgeon should make a single cautious
Figs 10.16A and B: (A) Preoperative OPG showing tooth displaced effort to retrieve the tooth with a hemostat or Allis'
into right maxillary sinus (yellow interrupted line), (B) Coronal CT scan
showing the position of the tooth in the maxillary sinus with opacification forceps. Surgical access is gained through an incision
of maxillary sinus as well as the ethmoid sinus along the crest of the alveolus. Often the displaced tooth
molar towards the socket with finger pressure high in

the buccal sulcus. If this technique is unsuccessful, an
aspirator tip can be introduced into the socket of the
displaced tooth in a posterior direction. If both attempts
fail, the tooth should be left in situ and the patient referred
to an oral surgeon. An explanation of what has happened
should be provided.
A radiograph is required to establish the position of
the tooth. A periapical radiograph is usually of limited
value because of the extent of displacement of the tooth.
A panoramic film is preferable, but it may not adequately
demonstrate the spatial relation of the displaced tooth to
adjacent anatomical structures. Computed tomography
(CT) can be helpful to assess the exact location of the
displaced tooth in the axial plane. Three-dimensional CT
reconstruction may also be desirable (Matthew, 2007).9
It is not always necessary to remove a displaced
maxillary third molar, unless chronic infection, pain or a
Fig. 10.17: Axial CT scan showing tooth displaced

into buccal soft tissues malocclusion develops or if trismus restricts jaw
movement. However, the patient might request its
can be found lying deep in the tissues. The tooth is usually removal in the absence of symptoms. Once, the decision
not visible and blind probing will result in further is made to retrieve the displaced maxillary third molar
displacement. If the tooth could not be removed after a from the infratemporal fossa, general anesthesia is
single effort, the incision should be closed. The patient preferred because the surgical approach might have to
should be informed that the tooth has been displaced and be modified intraoperatively. Local anesthetic solution
will be removed later. Postoperative antibiotic is with vasoconstrictor is administered into the soft tissues
administered to prevent infection. During the initial to reduce bleeding.
healing phase fibrosis occurs and stabilizes the tooth in a An intraoral approach is typically made in the
firm position. The tooth should be removed four to six posterior sulcus and a mucoperiosteal flap is raised with
weeks later by an oral and maxillofacial surgeon. a periosteal elevator, which might reveal the tooth. If the
If displaced tooth lies medial to the ramus of tooth cannot be located, image-intensifying cineradio-
mandible (Peterson et al, 2003),1 it may interfere with graphy (Dawson, 1993)10 might be of value. A Gillies
opening of the mouth and there is a possibility for approach can be made via an incision in the hairline; the
infection to occur. In such instances also once the initial displaced tooth is palpated and pushed inferiorly using
fibrosis occurs, the tooth will not migrate. If there is no a Howarth periosteal elevator introduced deep into the
mandibular restriction, patient can be given the option temporalis fascia (Dawson,1993).10 Using an 18-gauge
not to remove the tooth. However, this should be properly spinal needle with stiletto in situ instead of a Howarth
documented. elevator to push the tooth inferiorly avoids the need for
an incision in the temporal region (Orr, 1999).11
Prevention and Management If the displaced tooth still cannot be retrieved or if it
is high in the infratemporal fossa, a transantral approach
Sufficient removal of buccal bone is necessary before is possible with careful dissection of the posterior wall of
placing an elevator to deliver the maxillary third molar the maxillary sinus (Winkler et al, 1977).12 Alternatively,
from its socket. With good retraction of soft tissues, the a hemicoronal incision permits access via elevation of skin
tooth can be observed carefully at all times during from the temporalis fascia. Dissection then proceeds
elevation. In the general practice setting, once it is through fascia and muscle to the lateral wall of the orbit
established that the tooth has been displaced into the soft (Gulbrandsen,1987).13 At this point, one expects the tooth
tissues, it is sometimes possible to manipulate the third to be seen or palpated and retrieved. Once a displaced
maxillary third molar has been retrieved, the soft tissues computerized tomography (CT) scan in tooth localization,
are debrided and closed in layers with sutures. Antibiotics and the difficulty in treating this complication,
are indicated to prevent infection in the infratemporal particularly when the tooth migrates towards the base of
space. the skull, were emphasized by the authors. Prevention
Patel et al (1994)14 reported that imaging and retrieval of maxillary third molar displacement into the
of an impacted maxillary third molar displaced into the infratemporal fossa predominates over removal and is
infratemporal fossa is difficult. The case requires urgent achieved by adequate flap design, correct extraction
referral and hospitalization for removal under general technique, and a distal retractor during surgical
anesthetic. The use of image intensification equipment extraction. In the case of displacement, no effort to retrieve
in theatre allows removal of such a displaced tooth with the tooth is recommended because of the risk of
minimal morbidity and is recommended. Prevention of hemorrhage, neurologic injury, and further displacement
displacement with the use of a distal retractor is strongly of the tooth. The authors recommended that the patient
recommended when surgically removing impacted should be treated with antibiotics and referred to an oral
maxillary third molars. and maxillofacial surgery department for expert
Dimitrakopoulos and Papadaki (2007)15 reported a management.
case of a maxillary third molar displaced into the To summarize a tooth displaced into the infra-
infratemporal fossa, with difficulty in localization due to
temporal fossa is retrieved through the following
the synchronous creation of oroantral communication
approaches (Dimitrakopoulos et al, 2007)15:

(Figs 10.18A to C).
1. Long incision in the maxillary sulcus to expose the
The patient was referred to the oral and maxillofacial
lateral and posterior walls of the maxilla. The tissues

surgery department and underwent successful surgical
are then reflected to locate the tooth.
treatment through an intraoral access. The causes of tooth
In many cases such an incision is inadequate to
displacement into the infratemporal fossa, the aid of a
access the displaced tooth especially when it is located
higher up near the skull base. For this reason the
following approaches have been suggested to facilitate
retrieval of the tooth.
2. Resection of the coronoid process to allow a wider
operative field.
3. An extraoral approach with wide exposure of the
pterygomaxillary fossa. This method involves
considerable morbidity.
4. Removal through an osseous window in the posterior
wall of the maxillary sinus in connection with a
Caldwell -Luc operation.
5. Using a hemicoronal incision and dissection down to
the lateral wall of the orbit.
6. A standard Gilles approach and push the displaced
molar in the infratemporal fossa using a Howarth
periosteal elevator and deliver the tooth into the mouth
through the intraoral incision.
Figs 10.18A to C: OPG and CT scan of a tooth displaced into the 7. Push the tooth from the infratemporal fossa into the
infratemporal fossa. (A) OPG taken immediately after the unsuccessful mouth through the previously performed buccal
extraction showed the third molar lying superior and posterior to maxillary incision with an 18-gauge spinal needle introduced at
tuberosity (yellow arrow), (B) Coronal CT scan and (C) Axial CT scan
showed tooth (yellow arrows)out side the maxillary sinus at the lower the temporal region deep to zygomatic arch.
part of infratemporal space. (Adapted with kind permission from 3. Damage to adjacent second molar: While removing
Dimitrakopoulos I., Papadaki, M. Displacement of a maxillary third molar
into the infratemporal fossa: Case report. Quintessence Int. 2007; 38
the bone overlying the impacted tooth using bur or chisel,
(7): 607-10) damage to second molar may occur resulting in exposure
of the pulp. Similarly, if the elevator force is not correctly and sectioning of tooth using bur is employed to extract
applied it can result in inadvertent subluxation of second the tooth.
molar. Both these contribute to postoperative pain. Measures to prevent tuberosity fracture include use
4. Fracture of maxillary tuberosity: This is a common of a periosteal elevator to ensure separation of the
complication while removing an erupted or an erupting periodontal ligament from the tooth and palpation with
upper third molar tooth and is rarely associated with an a finger of the non operating hand to evaluate the
unerupted wisdom tooth. This is because in case of an expansion of the cortical plate upon luxation.
impacted upper third molar tooth, the bone covering the 5. Oro-antral communication/fistula: Comparatively
tooth is thin and this fractures easily. Hence, extensive this is a rare complication to occur. Once detected it
should be repaired surgically as soon as possible.
fracture of the tuberosity does not occur as in case of an
An oro-antral communication (OAC) is any opening
erupted tooth. Fracture of the tuberosity is more likely to
between the maxillary sinus and the oral cavity. Unless
occur if dental forceps alone are used without initially
diagnosed and treated the walls of this communication
mobilizing it with an elevator like Warwick James
may epithelialize and become an oro-antral fistula (OAF).
elevator.
OAC occurs most frequently following extraction of first
The anatomic position of the tooth at the end of the molar teeth, followed by second molar teeth. An incidence
dentoalveolar arch is such that the posterior portion has of 0.008 to 0.25% OAC has been reported with maxillary
no support and maxillary sinus extends into the third molar removal. It is likely that the incidence of OAC
tuberosity region or the bone in the tuberosity is soft and from maxillary third molar removal is underestimated
osteoporotic. Preoperative radiographic evaluation of the because it may be self-limiting in some cases and in the
sinus proximity and bone thickness can help to anticipate case of impacted third molars, usually a flap is closed
tuberosity fracture. In a study by Chipasco et al (1993)16 over the extraction site, leading to healing. OACs smaller
the extraction of 500 maxillary impacted third molars was than 2 mm in diameter closes spontaneously without any
accompanied by three cases of fracture of the maxillary treatment.
tuberosity, indicating an incidence of 0.6%. Various methods for closure of OAC and OAF have
In the event that a large area of tuberosity fractures been described over the years, including gold foil, buccal
before the tooth become mobile, effort should be taken flaps, various palatal flaps, tongue flaps, pedicled buccal
to conserve the tuberosity. If it is essential that the tooth fat pad (PBFP), cheek flaps and placement of
should be removed (e.g. infected tooth/symptomatic bioabsorbable root analogs. Bouloux and colleagues
tooth), then the surrounding bone is removed using drill (2007)17 prefer the use of the PBFP for closure of OAFs.
and roots sectioned. The tooth can be thus removed The use of PBFP for closure of OAF was first described
by Egyedi in 1977. The description of this technique
atraumatically and the tuberosity assessed for viability
included the placement of a split-thickness skin graft over
by evaluation of the attached periosteum for vascular
the PBFP. Research has shown that this graft does not
supply. Attention should be given to fastidious closure
need to be covered and epithelializes within a few weeks.
of palatal and buccal mucosal tears. In cases where it is
The success rate reported for the procedure varies from
not possible to preserve the tuberosity due to inadequate
92.8 to 100%.
periosteal attachment, it is then necessary to dissect out 6. Prolapse of buccal pad of fat: Even though this is a
the tuberosity along with the tooth and then repair the rare complication to occur, it can cause great
resulting defect. Removal of large amount of tuberosity embarrassment to the surgeon as well as the patient. This
can lead to development of an oro-antral fistula or a large occurs when the buccal fat pad space is inadvertently
defect in the area creating a prosthetic problem. entered during the procedure when the incision is carried
If there is no urgent need to remove the tooth (e.g. markedly into the cheek. Pushing the prolapsed fat back
tooth is not infected) and if the bone fragment is large, it into the cheek and giving a suture is all that is sufficient.
is desirable to immobilize the fractured tuberosity using If an attempt is made to pull out the prolapsed fat, more
a cap splint or an arch bar extending from the wisdom and more of fat will come out. Hence no attempt is made
tooth to the adjacent teeth. When adequate union has to remove the prolapsed fat; rather it is pushed back into
occurred, open technique with removal of overlying bone the wound and then closed with a suture.
REFERENCES surgical removal? [ Point of Care]. J Can Dent Assoc 2007;

73(4 ): 311-12.
1. Peterson LJ, Ellis E, Hupp JR,Tucker MR. Contemporary 10. Dawson K, MacMillan A, Wiesenfeld D. Removal of a
Oral and Maxillofacial Surgery, Fourth Edn. 2003, Mosby maxillary third molar from the infratemporal fossa by a
St. Louis, pp 185-237. temporal approach and the aid of image-intensifying
2. Bouquet A, Coudert JL, Bourgeois D, Mazoyer JF, Bossard cineradiography. J Oral Maxillofac Surg 1993; 51(12):
D. Contributions of reformatted computed tomography 1395-97.
and panoramic radiography in the localization of third 11. Orr DL. A technique for recovery of a third molar from the
molars relative to the maxillary sinus. Oral Surg Oral Med infratemporal fossa: Case report. J Oral Maxillofac Surg
Oral Path Oral Radio and Endo 2004;98(3): 342-47. 1999; 57(12):1459-61.
3. Darichuk L. How do I gain access to the area of the 12. Winkler T, von Wowern N, Odont L, Bittmann S. Retrieval
maxillary tuberosity for removal of the third molar or other of an upper third molar from the infratemporal space. J
surgery? [Point Care] J Can Dent Assoc 2005; 71(10):738-39. Oral Surg 1977; 35(2): 130-32.
4. Farish SE, Bouloux GF. General technique of third molar 13. Gulbrandsen SR, Jackson IT, Turlington EG. Recovery of a
removal. Oral Maxillofacial Surg Clin N Am 2007; 19: 23-43. maxillary third molar from the infratemporal space via a
5. Hasbini AS, Hadi U, Ghafari J. Endoscopic removal of an hemicoronal approach. J Oral Maxillofac Surg 1987; 45(3):
ectopic third molar obstructing the osteomeatal complex. 279-82.
Ear Nose Throat J 2001; 80(9): 667-70. 14. Patel M, Down K. Accidental displacement of impacted
6. Di Pasquale P, Shermetaro C. Endoscopic removal of a maxillary third molars. British Dental Journal 1994; 177(2):
dentigerous cyst producing unilateral maxillary sinus 57-59.

opacification on computed tomography. Ear Nose Throat 15. Dimitrakopoulos I, Papadaki M. Displacement of a
J 2006; 85(11):747-48. maxillary third molar into the infratemporal fossa: Case
7. Pogrel M. Complications of third molar surgery. Oral report. Quintessence Int 2007; 38(7): 607-10.
Maxillofac Surg Clin North Am 1990; 2: 441. 16. Chipasco M, De Cicco L, Marrone G. Side effects and
8. Sverzut CE, Trivellato AE, Lopes LM F, Ferraz EP, Sverzut complications associated with third molar surgery. Oral
AT. Accidental Displacement of Impacted Maxillary Third Surg Oral Med Oral Pathol 1993; 76: 412.
Molar: A Case Report. Braz Dent J 2005; 16(2): 167-70. 17. Bouloux Gary F, Steed Martin B, Perciaccante Vincent J.
9. Matthew I. What should I do if a maxillary third molar is Complications of third molar surgery. Oral Maxillofacial
inadvertently displaced into the adjacent soft tissues during Surg Clin N Am 2007; 19: 117-28.
11 Postoperative Care
and Instructions
POSTOPERATIVE CARE dry, blood clots within a few minutes. But in the mouth
where things are wet, it takes 6-8 hours for the clot to
Proper written or oral instruction in essential not only
form and the bleeding to subside. Slight bleeding or

for the over all success of the surgical procedure but also
oozing causing redness in the saliva is very common.
for a smooth postoperative period. The patient and the
by stander should be informed that unnecessary pain and For this reason, the gauze will always appear red when
complications like infection, bleeding and swelling can it is removed. Saliva washes over the blood clot and
be minimized if the instructions are followed carefully. dyes the gauze red even after bleeding from the socket
has actually stopped.
Immediately Following Surgery • Excessive bleeding may be controlled by first gently
rinsing with ice cold water or wiping any old clots from
• Bite on the gauze pad placed over the surgical site for
the mouth and then placing a gauze pad over the area
an hour. After this time, the gauze pad should be
and biting firmly for sixty minutes. Repeat as
removed and discarded. It may be replaced by another
gauze pad if there is bleeding. necessary.
• Avoid vigorous mouth rinsing or touching the wound • If bleeding continues, bite on a moistened tea bag for
area following surgery. This may initiate bleeding by thirty minutes. The tannic acid in the tea bag helps to
dislodging the blood clot that has formed. form a clot by contracting the bleeding vessels. This
• To minimize swelling, place ice packs to the side of can be repeated several times.
the face where surgery was performed. • To minimize further bleeding, sit upright, do not
• Take the prescribed pain medications as soon as become excited, maintain constant pressure on the
possible so that it is digested before the local anesthetic gauze (no talking or chewing) and avoid exercise.
effect has worn off. Avoid taking medications in empty • If bleeding does not subside after 6-8 hours, inform
stomach to avoid nausea and gastritis. the doctor.
• Restrict activities on the day of surgery and resume
normal activity when one is comfortable. Excessive
physical activity may initiate bleeding.
Swelling
• Do not smoke under any circumstances. • The swelling that is normally expected is usually
proportional to the surgery involved. Simple tooth
Bleeding extraction generally do not produce much swelling.
However, if there was a fair amount of cheek retraction
• A certain amount of bleeding is to be expected and bone removal involved with the surgical proce-
following surgery. On the skin where the surface is dure, mild to moderate swelling can be expected on
Postoperative Care and Instructions 115
the affected side. The swelling will not become appa- increased pain, is usually indicative of infection. The
rent until the evening or the day following surgery. It doctor should be intimated should this occur.
will reach its maximum on the second or the third day
postoperatively.
Pain
• The swelling may be minimized by the immediate
application of ice bag following the procedure to the • Postoperative pain is only mild or moderate and is
side of the face where surgery was performed. If ice controlled easily by the use of mild analgesics like
bag is not available sealed plastic bag filled with aspirin, paracetamol, ibuprofen or combinations of
crushed ice may be used. The bag can be covered with aspirin, phenacetin and codeine.
a soft cloth to avoid skin irritation • Pain or discomfort following surgery is expected to
• The ice bag should be applied for 20 minutes on and last 4 to 5 days. For many patients, on the third and
five minutes off for the afternoon and evening fourth day require more pain medicine than on the
following the surgery. After 24 hours, ice has no first and second days. Following the fourth day pain
beneficial effect. should subside more and more everyday.
• Warm mouth washes and vigorous swishing should • Many medications for pain can cause nausea or
be avoided for 12 to 24 hours following surgery since vomiting. It is wise to have something in the stomach
it may interfere with formation of blood clot. This (yogurt, ice cream, pudding or apple sauce) before
eventually results in postsurgical bleeding. Sometimes
taking pain medicines (especially aspirin or ibuprofen).

this interferes with the formation of blood clot with Antacids or milk of magnesia can help to prevent or
the ensuing complication of dry socket.
reduce nausea.
• Once, the initial oozing of blood has stopped (i.e. after • If the pain is very severe it indicates the possibility of
12 to 24 hours) warm saline mouth washes (half something going wrong and the most likely cause is
teaspoon salt in a glass of water) may be used fourth
the development of infection. In such an instance the
hourly. The mouth should be filled with normal saline
doctor should be contacted.
as hot as the patient can tolerate and the head is held
• Use of powerful analgesics is best avoided since the
to one side in such a way the fluid lies over the area of
use of such analgesics may mask the onset of post-
surgery. When the fluid cools it should be expectorated
operative complication.
and the process repeated. Regular use of mouth wash
• While taking analgesics do not drive an automobile or
markedly relieves the pain and edema.
work around or operate heavy machinery. Similarly
• Bright red, hard, hot swelling that does not indent with
alcohol should be avoided along with analgesics.
finger pressure which is getting bigger by the hour
would suggest infection. This usually would develop
around the third or the fourth day after surgery when Antibiotics
normally the swelling should be decreasing in size. If
• Antibiotics are not given as a routine procedure after
this happen, the doctor should be consulted.
oral surgery. The over use of antibiotics leading to the
development of resistant bacteria is well documented.
Temperature So careful consideration is given to each circumstance
• It is normal to run a low grade temperature (99-100°F) when deciding whether antibiotics are necessary. In
for 2-3 days following oral surgery. This reflects the specific circumstances, antibiotics will be given to help
immune response of the body to surgery. A high prevent infection or treat an existing infection.
temperature (>101°F) might exist for 6-8 hours after • When antibiotics are prescribed it should be taken on
surgery but no more than that. schedule in the correct dosage as directed by the doctor
• Antipyretics (e.g. paracetamol 500 mg) every 4-6 hours until they are finished.
will help to reduce the temperature. • Discontinue antibiotic use in the event of a rash or other
• A temperature >101°F several days after surgery, unfavorable reaction. Contact the doctor immediately
especially if accompanied by hard swelling and if any allergy develops.
Diet of blood clot in the socket. Smoking contributes to the

development of the painful complication 'Dry Socket'.
• Drink plenty of fluids. Try to drink 5 to 6 glasses on
the first day.
Activity
• Drink from a glass or a cup and do not use a straw.
The sucking motion will suck out the healing blood • Keep physical activities to a minimum for 6-12 hours
clot and start the bleeding again. following surgery.
• Avoid hot liquids or food till the anesthesia effect wears
off. Otherwise, it can result in burning/scalding of lips Suture Removal
and tongue.
• Sutures should be left in place for about seven days.
• Soft food and liquids can be eaten on the day of Report to the doctor after seven days for suture
surgery. The act of chewing does not damage anything, removal. In the event absorbable sutures are placed,
but should avoid chewing sharp or hard objects at the they need not be removed.
surgical site for a week.
• Return to a normal diet as soon as possible unless
Summary of Instructions to Patient Following
otherwise directed. Eating multiple small meals is Surgical Removal of Impacted Tooth
easier than three regular meals for the first few days.
1. Remove the gauze pack after 30 mts to one hour.

2. Apply ice (ice cubes taken in a polythene bag) on
Oral Hygiene the face for the first 24 hours.
3. For the first day take cold liquids or semisolids.

• Good oral hygiene is essential to proper healing of any
4. Avoid warm saline gargle in the first 24 hours.
oral surgery site.
5. There may be mild to moderate swelling on the side
• Brushing of teeth can be resumed from the night of
of the face for three to four days.
surgery onwards. Avoid disturbing the surgical site
6. Mild bleeding/oozing of blood can be there from
so as not to loosen or remove the blood clot.
the surgical site for one to two days. In the event of
• Mouthwashes have an alcohol base and it may irritate excessive bleeding bite on a fresh piece of sterile
fresh oral wounds. After a few days, dilute the gauze and inform the doctor.
mouthwash with water and rinse the mouth. 7. In the first few days difficulty may be experienced
in opening the mouth. To avoid this, from the next
Stiffness of Jaw (Trismus) day of surgery onwards try to open the mouth
forcefully.
• Perform active jaw opening from the next day of 8. From the next day onwards after surgery or once
surgery to prevent development of jaw stiffness. This the oozing of blood has completely stopped, warm
will not cause tearing of the suture. saline mouth-baths can be used at fourth hourly
• If the muscles of the jaw become stiff, chewing gum at intervals. Avoid application of dry heat on the face.
intervals will help to relax the muscles. Use of warm, 9. Tooth brushing have to be done from the next day
moist heat to the outside of the face over these muscles on wards.
also will help to relieve this. 10. Take the drugs prescribed by the doctor at regular
intervals.
11. Avoid alcohol, smoking, physical exercise and long
Smoking journey for the next few days.
• Smoking retards healing dramatically. Nicotine 12. Report for review to the doctor as suggested for
constricts the blood vessels which slows the formation suture removal.
12 Drug Therapy
The sequelae of third molar surgery include pain, edema, their usefulness in prevention of infection following third
trismus, infection, dry socket etc. Various drugs are used molar surgery.
to minimize or eliminate these outcomes. The objective Based on various reports it seems that the risk of
is to make the surgical procedure as pleasant as possible postoperative infection after third molar surgery increases
to the patient without causing serious side effects. in the presence of following factors:
Drugs can be administered prophylactically or 1. Increased time of surgery
empirically. A drug that is administered before a surgical 2. Decreased operator experience
procedure is referred to as prophylactic therapy, while 3. Increased surgical complexity
that is administered after the procedure is referred to as 4. Higher incidence following mandibular third molar
empirical therapy. removal
5. Age-patients older than 34 years
The use of prophylactic antibiotics in third molar
Use of Antibiotics
surgery does, in fact, reduce the incidence of dry socket.
One of the primary goals of the surgeon in performing Although systemic antibiotics are effective in the
any surgical procedure is to prevent postoperative reduction of postoperative dry socket, they are no more
infection as a result of surgery. To achieve this goal, effective than local non systemic measures like copious
prophylactic antibiotics are necessary in some surgical irrigation, preoperative rinses with chlorhexidine, and
procedures. placement of antibiotics in the extraction socket. The
In general the rationale for the use of antibiotic is incidence of antibiotic related complications such as
based on wound classification. The following table on allergy, bacterial resistance, gastrointestinal (GI) side
the next pages hows the classification of various types of effects and secondary infections are not outweighed by
wounds and the indication for antibiotic prophylaxis. the benefits. Therefore the routine use of perioperative
Surgery for the removal of the impacted third molars systemic antibiotic administration does not seem to be
fits into the category of clean/contaminated surgery. The valid.
incidence of infection is usually between 2% and 3%. It is The results of study by Poeschl et al (2004)1 showed
difficult and probably impossible to reduce infection rates that specific postoperative oral prophylactic antibiotic
below 3% with the use of prophylactic antibiotics. treatment after the removal of lower third molars does
Therefore, it is unnecessary to use prophylactic antibiotics not contribute to a better wound healing, less pain, or
in third molar surgery to prevent postoperative infections increased mouth opening and could not prevent
in the normal healthy patient. Although the literature inflammatory problems after surgery. And therefore is
contains many papers that discuss the use of prophylactic not recommended for routine use. This finding is
perioperative antibiotics, there is essentially no report of supported by the findings of Hill (2005).2
Type of wound Features of wound Example of maxillofacial/ Risk of infection Indication for anti-
oral wound biotic prophylaxis
Clean wound Free of infection or inflamma- Surgery of TM joint, facial Less than 2% Optional
tion. Wound does not involve cosmetic surgery
alimentary, biliary, respiratory
or genitourinary tract.
Clean contaminated Associated with elective proce- Orthognathic surgery 3% to10% Recommended
wound dures involving alimentary, biliary, Surgical removal of impac- Optional/
respiratory or genitourinary tract. ted tooth, dental extraction Recommended
Contaminated wound Inflamed tissue such as cellulitis Maxillary fracture in a patient 20% Recommended
with active maxillary sinusitis
Dirty wound Spillage of pus into surgical site Mandibular fracture through 40% Recommended
an impacted third molar that
is draining pus
However, in a recent study by Halpern et al (2007)3 also well accepted that patients who are afflicted with
has shown that following third molar removal the use of any systemic disease that compromises the immune
intravenous antibiotics (penicillin and clindamycin in defense system against bacterial infection (e.g.
those allergic to penicillin) administered prophylactically neutropenia, leukopenia, splenectomy, leukemia,
decreased the frequency of surgical site infection. The myeloproliferative diseases) are candidates for antibiotic
authors cannot comment on the efficacy of intravenous
therapy before and after third molar surgery. There is
antibiotics in comparison to other antibacterial treatment
also no controversy regarding administration of
regimens, e.g. chlorhexidine mouth rinse or intra socket
antibiotics. preoperative antibiotic therapy in the management of
The comparison of various studies poses a fascial space infection or dentoalveolar abscess associated
tremendous challenge because of the variability in with impacted third molars. Similarly antibiotics are
parameters and the methods used for each study. indicated for patients susceptible to subacute bacterial
Even though surgery of impacted third molar do not endocarditis and also for prosthetic joint replacement
commonly result in serious nosocomial infections, efforts cases.
to prevent prolonged recovery periods caused by delayed Early in the antibiotic era, prophylactic antibiotic
wound healing and wound infection are beneficial therapy was thought to be associated with higher rates
economically. Considering the cost of antibiotic of infection and resistance. This belief was disproved in
therapy compared to hospital stay/absenting from work, a study conducted by Bruke in 1961. This study also
antibiotics should be administered to all patients who showed that the timing of administration of prophylactic
have increased susceptibility to infection. antibiotics has great significance. The timing of a surgical
Patients who undergo surgical removal of third molar
incision should correspond with the peak systemic
are generally healthy and are not likely to develop
concentration of the antibiotic administered. It has been
postoperative infection. Factors that increase the risk of
determined that the ideal timing for prophylactic
postoperative infection in any surgical patients include
diabetes, cirrhosis, end-stage renal disease, corticosteroid antibiotic therapy is 30 minutes to two hours before
therapy, old age, obesity, malnutrition, massive trans- surgery. This is followed by additional coverage
fusion, preoperative comorbid disease and American extending for one to two half-lives of the prescribed
Society of Anesthesiologists (ASA) patient classification antibiotic for the length of the operation. Moreover, the
III, IV and V. dose of the antibiotic should be twice the therapeutic dose.
Use of prophylactic or empiric antibiotic therapy is In the absence of infection antibiotics should not be
recommended for patients with comorbid diseases. It is continued beyond the operative day.
Drug Therapy 119
• The timing of a surgical incision should correspond with • Amoxicillin 3 gm orally, 45 minutes before surgery
the peak systemic concentration of the antibiotic under local anesthesia.
administered. • Clindamycin 600 mg orally, 30 minutes before
• The ideal timing for prophylactic antibiotic therapy is 30 surgery under local anesthesia for patients allergic
minutes to two hours before surgery. to penicillin.
• The dose of the antibiotic should be twice the • Benzyl Penicillin 600 mg IV/IM on induction for
therapeutic dose. procedures under general anesthesia.
• Erythromycin lactobionate 500 mg IV on induction
Proper administration of antibiotic prophylaxis
for surgery under general anesthesia for patients
requires evaluation of various factors such as the type of
allergic to penicillin
surgery performed, organisms involved, choice of
The above dose may be followed with an additional
antibiotic, its dosage and administration. Identification
oral dose 6 hours after the initial dose.
of the organism involved in infection at third molar sites
To conclude, an analysis of the current literature on
has been difficult. Studies have shown a higher
the topic supports routinely prescribing and not
prevalence of anaerobic organisms even when the
prescribing antibiotics as part of the removal of
periodontal probing depths were normal. However
asymptomatic impacted third molars, thus making it
studies have shown that aerobic streptococci were the
surgeon's preference. For patients with active infection
most commonly found organism present in infected third
and medically compromised patient who is more
molar wounds. This variety in the microbial population

susceptible to infection, prophylactic antibiotics are
causes difficulty in selecting the appropriate antibiotic.
indicated and should be administered one to two hours
In the event that the operator is planning to give an

before the surgical procedure. The presence of anaerobic
antibiotic the following principles should be considered
bacteria at the third molar area without the evidence of
before prescribing antibiotics:
periodontal disease supports the use of prophylactic
1. The surgical procedure should harbor a significant risk
antibiotics in all cases of impacted mandibular third molar
for infection, for example:
removal. A strong argument against the routine use of
• Long procedure (> 30 minutes) or difficult surgery
prophylactic antibiotics in third molar removal is the
involving significant tissue trauma.
possibility of emergence of antibiotic resistant strains.
• Where there is existing infection in and around
However, till date this occurrence has not been
the surgical site.
documented in cases of third molar removal (Mehrabi et
2. Administration of the antibiotic must be immediately
al, 2007).4
prior to or within 3 hours after the start of surgery:
• The ability of systemic antibiotics to prevent the
development of a primary bacterial lesion is Use of Anti-inflammatory Drugs and Steroids
confined to the first 3 hours after inoculation of
the wound. As a result of the trauma occurring during surgical
• Commencing prophylactic antibiotic cover the day extraction of third molars inflammatory response occurs
before surgery only leads to the development of resulting in edema, pain and trismus after the operation.
resistant organisms. Maximum edema after surgical extraction of third molars
• Continuing antibiotics for days after surgery has was found to occur between 48 to 72 hours (Peterson,
not been shown to decrease the incidence of 1998)5. This occurs because of the release of cytokines,
wound infection. prostaglandins, and histamine from leukocytes,
3. Prophylactic antibiotics should be given at twice the endothelial cells and mast cells. The increase in osmotic
usual dose over the shortest effective time so as to pressure within injured tissues and leakage from
minimize the potential side-effects of long term use capillaries are responsible for the expansion of tissues that
(e.g. diarrhea) and to prevent the growth of resistant occurs with edema. Corticosteroids have been shown to
strains of bacteria. reduce edema following third molar surgery (Messer et
4. There are many antibiotic prophylactic regimens al, 1975).6 Steroids act by interfering with capillary
currently used. The following are just a few that may vasodilation, leukocyte migration, phagocytosis, cytokine
be considered. production and prostaglandin inhibition. The inhibition
of capillary vasodilation prevents entry of intravascular acute glaucoma and certain type of psychosis. Relative
fluid into interstitial space. The leakage of fluid and contraindications include diabetes mellitus, hypertension,
leukocytes results in irritation of free nerve endings and osteoporosis, peptic ulcer disease, infection, renal disease,
this in turn cause release of pain mediators, including Cushing's syndrome and diverticulitis. The adminis-
prostaglandin and substance perioperative corticoste- tration of perioperative steroids may increase the
incidence of dry socket after third molar surgery, but the
roids act to prevent inflammation and reduce pain at the
data is lacking as to the precise degree of increase.
site of insult. The anti-inflammatory action of steroids is
Recent work on the use of corticosteroids would
dependent on the dose and increases as the plasma
suggest that these drugs are of great value in reducing
concentration in proximity to the surgical site reaches the postoperative sequelae after third molar surgery. Short-
therapeutic range. term steroid therapy is not associated with the
The use of perioperative corticosteroids to minimize development of adrenal crisis. However, there is no
swelling, trismus and pain has gained wide acceptance consensus of opinion regarding the ideal preparation and
in the practice of oral and maxillofacial surgery. However, dosage to be used following surgery of impacted molar.
the method of usage is extremely variable. The one which Patients on long-term steroid therapy: Continuous
is most effective has yet to be clearly delineated. daily administration of corticosteroids for a month results
The body's daily production of cortisol is 15 to 30 in suppression of adrenal glands and internal
mg, which may increase up to 300 mg during a stressful corticosteroid production. Such patients require a
event. The normal concentration of cortisol in a healthy doubling of the steroid dose on the day of the surgery,
patient is 13 µg/ dL. This may increase up to 50 - 73 µg/ followed by gradual tapering postoperatively back to the
dL in septic shock.
original daily dose. Adrenal insufficiency may occur up

The most widely used steroids are dexamethasone to one year after cessation of steroid therapy. Even if these
and methylprednisolone. Both of these are almost pure patients have discontinued their steroid therapy for up
glucocorticoids with little mineralocorticoid effect. Also, to one year, a tapering dose of steroids may be required
these two appear to have the least depressing effect on for surgery. Intraoperative adrenal insufficiency most
leukocyte chemotaxis. Common dosages of dexa- commonly presents as hypotension that is resistant to
methasone are 4 to 12 mg given IV at the time of surgery. fluid treatment but responds to steroid therapy. When
Additional oral dosages of 4 to 8 mg. twice a day for the adrenal insufficiency is suspected preoperatively, cortisol
day of surgery and 2 days afterwards leads to the stimulation test can be performed. An initial cortisol level
maximum relief of swelling, trismus and pain. is obtained first. Adrenocorticotropic hormone is then
Methylprednisolone is most commonly given IV 125 mg injected and the cortisol level estimated in one hour. If
at the time of surgery followed by significantly lower the cortisol level does not increase, a diagnosis of primary
doses, usually 40 mg 3 or 4 times daily taken orally for adrenal insufficiency can be made.
the day of surgery and for 2 days after surgery. It is The adverse effects of prolonged steroid adminis-
important to note that a tapered dose of steroids after tration are extensive. They include poor wound healing,
third molar surgery is prescribed not to compensate for hypertension, electrolyte abnormality, psychosis,
adrenal suppression; but rather to correlate with the euphoria, osteoporosis, hyperglycemia, central obesity,
decline in surgical stress in the 72 hour postoperative abdominal striae, thin skin, glaucoma, myopathy,
period. The bioavailability of glucocorticoids after oral amenorrhea, hirsutism, acne and adrenal insufficiency.
Short term steroid therapy like that used following third
administration is remarkably high and may provide
molar surgery is not associated with the above side
effects that parallel intravenous administration.
effects.
Gastrointestinal side effects, however, are known to occur
from oral intake. Steroids given orally three to four hours
Use of Non-steroidal Anti-inflammatory
before surgery lessen gastrointestinal upset. In an
Drugs (NSAIDs)
outpatient environment, patient compliance may not
always be optimal with regards to timing of intake. High Post-operative pain and inflammation following surgical
dose, short-term steroid use is associated with minimal removal of impacted third molars are also managed with
side effects. They are contraindicated in patients with non-steroidal anti-inflammatory drugs (NSAIDs). The
gastric ulcer disease, active infection, active tuberculosis, edema occurring after the surgical extraction of third
Drug Therapy 121
molars may cause pain because of the pressure it exerts constipation and tolerance. The most common opioid
on the masticatory muscles. Moreover, since the edema preparations include oxycodone, hydrocodone and
fluid creates an environment prone to infection, in order codeine. Ibuprofen and diclofenac sodium are NSAIDs
to relieve the post-operative swelling, anti-inflammatory with high analgesic efficacy and are commonly
drugs may be administered. During the primary phase prescribed. Adverse effects of NSAIDs include gastro-
of cellular healing, called the inflammatory reaction, non- intestinal bleeding and pain, tinnitus, and renal failure.
steroidal anti-inflammatory drugs act by inhibiting the When comparing the analgesic efficacy of opioids,
prostaglandin synthesis. Therefore, they are frequently NSAIDs and combinations of these medications, the
used after surgical procedures in order to reduce the soft combined formulations provided the highest efficacy.
tissue edema and pain by suppressing inflammation. Surprisingly, opioids when used alone are less effective
than NSAIDs in relieving pain after third molar removal
Combining Steroids and NSAIDs and these drugs alone cannot be recommended for this
purpose. Dependency is rare with the short term use of
Buyukkurt et al (2006)7 reported that the combination of opioids.
a single dose of prednisolone and diclofenac is well-suited NSAIDs act by reducing the production of peripheral
to the treatment of postoperative pain, trismus, and prostaglandins, thromboxane A 2 and prostacycline
swelling after dental surgical procedures and should be production by inhibiting COX enzyme. COX-1 receptors
used when extensive postoperative swelling of soft tissue are found within all tissues while COX-2 receptors are
is anticipated. present only in inflammatory and neoplastic tissues. The
Schultze-Mosgau et al (1995)8 conducted a study to use of COX-2 inhibitors was initially favored over classical
assess the efficacy of ibuprofen and methylprednisolone NSAIDs because of nearly 50% reduction in the side
in the treatment of pain, swelling and trismus following effects associated with NSAID administration such as
the surgical extraction of impacted third molars. This peptic ulcer disease and renal failure. However, recent
regimen included 32 mg of methylprednisolone 12 hours studies have shown that COX-2 inhibitors induce
before and after the procedure and 400 mg of ibuprofen thrombosis in patients with a history of coronary artery
three times per day on the day of the operation and for disease or cerebrovascular accident.
the first two postoperative days. It was concluded that The ideal agent for use after third molar surgery
this perioperative regimen of methylprednisolone and should alleviate pain, reduce swelling and trismus to a
ibuprofen significantly reduced pain, swelling, and minimum, promote healing and have no unwanted
trismus following the unilateral extraction of impacted effects. Of course, such an agent does not exist. For relief
maxillary and mandibular third molars. of pain, analgesics are the obvious choice. Where possible,
Antihistamines and enzymes chymotrypsin, an analgesic with additional anti-inflammatory properties
hyaluronidase has been shown to be of little value in should be used. Seymour et al (2003)9 reported that
controlling postoperative edema and pain. soluble aspirin 900 mg provides significant and more
rapid analgesia than paracetamol 1,000 mg in the early
Use of Analgesics postoperative period after third molar surgery.
Patients should be encouraged to take analgesics
Postoperative analgesics can affect either central or either before the onset or at the time of onset of pain or
peripheral pain receptors. Common centrally acting discomfort rather than waiting till the pain becomes
analgesics include opioid narcotics. Peripherally acting unbearable.
analgesics primarily inhibit prostaglandins. Examples Long-acting local anesthetic solutions may be of value
include acetaminophen, aspirin, and cyclo-oxygenase in some situations where extreme pain is likely to be a
(COX-1 and COX-2) nonsteroidal anti-inflammatory feature in the immediate post-operative period. However,
drugs (NSAIDs). there are no strict criteria for identifying such cases pre-
Perioperative administration of opioids decreases operatively.
pain, increases tolerance to pain, and a pleasing sedating Studies have shown that administering a dose of
effect. However, opioids can produce several untoward analgesic preoperatively markedly reduces postoperative
effects such as respiratory depression, nausea, vomiting, pain.
SUMMARY OF PERIOPERATIVE REFERENCES

DRUG THERAPY 1. Poeschl PW, Eckel D, Poeschl E. Postoperative prophylactic
antibiotic treatment in third molar surgery-a necessity? J
Use of Antibiotics Oral Maxillofac Surg 2004; 62(1): 3-8.
2. Hill M. No benefit from prophylactic antibiotics in third
The routine use of antibiotics in third molar removal is molar surgery. Evid Based Dent 2005; 6(1):10.
not recommended. However, antibiotics may be 3. Halpern LR, Dodson TB. Does prophylactic administration
considered in the following situations- of systemic antibiotics prevent postoperative inflammatory
• Presence of acute infection at the time of operation complications after third molar surgery? J Oral Maxillofac
• Significant bone removal Surg 2007; 65(2): 177-85.
4. Mehrabi M, Allen JM, Roser SM. Therapeutic agents in
• Prolonged operation time preoperative third molar surgical procedures. Oral
• Patient is at increased risk of infection Maxillofacial Surg Clin N Am 2007; 69-84.
5. Peterson LJ. Postoperative pain management. In: Peterson
LJ, Ellis E, Hupp JR, Tucker MR, (Eds). Contemporary oral
Use of Steroids and maxillofacial surgery. 3rd edition. St Louis (MO):
Mosby; 1998: 251.
Where there is a risk of significant postoperative swelling, 6. Messer EJ, Keller JJ. Use of intraoral dexamethasone after
pre- or perioperative administration of dexamethasone extraction of mandibular third molars. Oral Surg Oral Med
or methylprednisolone has been shown to reduce Oral Path 1975; 40: 594-98.
swelling and discomfort 7. Buyukkurt MC, Gungormus M, Kaya O. The effect of a

single dose prednisolone with and without diclofenac on
pain, trismus, and swelling after removal of mandibular

Use of Analgesics third molars. Oral Maxillofac Surg 2006; 64(12): 1761-66.
8. Schultze-Mosgau S, Schmelzeisen R, Frolich JC, Schmele
Oral analgesics such as paracetamol or ibuprofen are H. Use of ibuprofen and methylprednisolone for the
commonly advised for outpatients. The new COX-2 prevention of pain and swelling after removal of impacted
selective inhibitors such as rofecoxib have superior third molars. J Oral Maxillofac Surg 1995; 53: 2-7.
9. Seymour RA, Hawkesford JE, Sykes J, Stillings M, Hill CM.
analgesic effects without the common gastrointestinal An investigation into the comparative efficacy of soluble
side-effects. NSAIDs may also be helpful in reducing aspirin and solid paracetamol in postoperative pain after
postoperative swelling. third molar surgery. Br Dent J 2003; 194(3):153-57.
13 Complications of Impaction
Surgery
Studies have shown that surgical removal of impacted carried out by experienced practitioners and not by
third molars is associated with an incidence of occasional surgeons. However, surgeons are not created
complications around 10%. These complications can be
by divine right and need training to gain the requisite

classified as the expected and the predictable ones, such level of experience. This will unfortunately result in a
as swelling and pain, and more severe complications such higher level of complications even when residents are
as fracture of the mandible. The overall incidence and closely supervised.

severity of the complications are directly related to the
Complications may occur:
depth of impaction, age of the patient, the relative
A. During the surgical procedure
experience and training of the surgeon and the time taken
B. Immediate postoperative period
for the procedure.
C. Late postoperative period.
In a study conducted by Haug RH (2005)1, the sample
was provided by 63 Oral and Maxillofacial Surgeons and
was composed of 3,760 patients with 9,845 third molars A. Complications during the Surgical
who were 25 years of age or older. Alveolar osteitis was Procedure
the most frequently encountered postoperative problem
(0.2% to 12.7%). Postoperative inferior alveolar nerve These are a found to occur during each major step of the
anesthesia/paresthesia occurred with a frequency of 1.1% surgical procedure viz.
to 1.7%, while lingual nerve anesthesia/paresthesia was 1. Incision
calculated as 0.3%. All other complications also occurred 2. Bone removal
with a frequency of less than 1%. 3. Tooth sectioning
In a recent study by Waseem Jerjes et al (2006)2, 1087 4. Elevation of the tooth.
patients who underwent surgical removal of third molar Possible complication which can occur during each
teeth were prospectively examined to analyze the possible of the above step and appropriate preventive steps that
relationship between postoperative complications and the can be taken to avoid these will be explained.
surgeon's experience parameter. Seven surgeons; three 1. Complications during incision
specialists in surgical dentistry and four oral and Following the standard incision for the reflection of flap
maxillofacial Senior House Officers (OMFS residents) that is described above only a mild bleeding will occur
carried out the surgical procedures. The study concluded which can be easily controlled. Excessive bleeding may
that the higher rate of postoperative complications in the occur in the following situations:
residents group suggests that at least some of the a. Pre-existing local inflammation which is inadequately
complications might be related to surgical experience. controlled. Hence attention should be paid for
This raises a number of important issues related to adequate control of local infections like pericoronitis
training. Ideally, third molar removal should only be before contemplating the surgery.
b. Bleeding from retromolar vessels: If the incision is carried • Laceration of soft tissues: During use the bur may
upwards towards the coronoid process instead of slip and get driven into the buccal or lingual soft
directing it out wards towards the cheek, retromolar tissue. This will cause laceration of the tissue and
vessels may be cut. These small vessels emerge from a on the lingual side it may injure the lingual nerve.
small foramen; retromolar foramen located at the apex If the bur is revolving while the hand piece is being
of the retromolar triangle or in the retromolar fossa. If taken in and out of the mouth, the soft tissues of
these vessels are injured, the ensuing bleeding can be the cheek and the lips can get abraded or lacerated.
troublesome interfering with further reflection of the Hence make sure that the micromotor has stopped
flap. The bleeding can be easily controlled with completely before these acts.
pressure pack. • Injury to inferior alveolar neurovascular bundle:
c. Bleeding from facial vessels: This is an unusual While 'guttering' bone on the buccal side of the
complication to occur; and if it happens a torrential impacted tooth, as the bur reaches the apex of the
hemorrhage can result. The facial vessels (artery and tooth, the mandibular canal may be inadvertently
vein) cross the inferior border of mandible at the level opened. This will result in brisk hemorrhage from
of the anterior border of masseter. These vessels can inferior alveolar vessels, which can be controlled
be injured if the anterior incision is carried too with pressure pack or bone wax. But sometimes
vertically down into the buccal sulcus and at the same
damage to nerve can also occur resulting in
time pierces the periosteal envelope and reaches the
anesthesia in the distribution of mental nerve. In

muscle. This mishap can be avoided by holding the
rare instances the mandibular canal may be
sharp edge of the blade directed superiorly and making
buccally placed and at a more superior level than

the incision from down towards the teeth. Should this
the normal. In such cases injury to contents of the
misfortune occur, the bleeding can be arrested
canal will occur more easily during 'guttering'.
temporarily by external digital compression of the
• Injury to adjacent tooth: Drilling in the region of
vessels where they lie over the bone. For permanent
the mesial surface of impacted tooth should be
hemostasis, the artery or vein has to be clamped with
kept to the minimum to avoid damage to the distal
a hemostat and ligated.
aspect of the adjacent second molar.
d. Damage to lingual nerve: Utmost care should be taken
• Injury to lingual nerve: While removing bone on
while making incision on the lingual aspect in the third
molar region due to the possibility of injuring the the distolingual aspect extreme care is taken to
lingual nerve which lies superficially and in close protect the lingual nerve from bur by way of
proximity to the tooth. A vertical incision should never proper retraction. It is advisable not to remove any
be given on the lingual aspect of the mandible in this bone on the lingual aspect due to the possibility
region for the same reason. of causing damage to lingual nerve.
2. Complications during bone removal • Necrosis of bone: Even though this is a late
a. Use of bur: Provided reasonable precautions are taken, complication, it occurs due to inadequate cooling
use of bur will not cause problem during use. But the of the rapidly revolving bur which in turn causes
possibility of following complications should be borne overheating of bone and its subsequent necrosis
in mind while using hand piece and bur. followed by sequestration. Profuse irrigation of the
• Accidental burns: An improperly maintained hand surgical site using sterile saline can avoid this
piece with a damaged bearing can get heated up mishap.
during usage. If this is not detected by the gloved • Emphysema: Air driven handpiece has the
fingers of the operator, accidental burning of the disadvantage of causing surgical emphysema as
cheek and lip of the patient will occur. This will well as driving the tooth and bone particles into
not be felt by the patient since the above regions the soft tissues. Retention of such debris in the soft
will be anesthetized. Burns can be very painful tissues can result in postoperative infection also.
during the healing period and will be associated Using micromotor and handpiece can avoid this
with delay in healing. complication
Complications of Impaction Surgery 125
b. Use of chisel: Chiseling is a relatively safe, speedy, i.e. apical to the cemento -enamel junction with bur
and efficient means of bone removal when used held at right angles to the long axis of the tooth. If the
correctly. When used improperly it can also cause bur cut is not correctly angulated or bur cut is done at
the following substantial damages. different sites, it will be difficult to separate the crown
• Splintering of bone: When chisel is used to remove and remove it.
the buccal cortical plate covering the impacted • Injury to mandibular canal: During tooth sectioning if
tooth, the split can sometimes extend forwards the bur is carried to the full width of the tooth in the
along the buccal aspect of the teeth and denude superior inferior direction, to reach its 'bed' there is a
the teeth of external cortical plate. This happens possibility of damaging the contents of the canal. This
because on the buccal and lingual side in the can lead to severe bleeding from the vessels during
posterior aspect of mandible the 'grains' runs the surgery and later on numbness of the lower lip.
antero- posteriorly. Hence, a vertical stop cut is Hence the entry of the bur is limited to three-fourths
made first at the mesial end of the portion of the of the width of the tooth. The rest of the tooth is
bone to be removed to avoid accidental splintering separated with leverage using an instrument like
of the buccal cortical plate. curved Warwick James elevator. But this has the
Similarly when splitting the lingual plate, if the cutting disadvantage of sometimes leaving a thin shelving
edge of the chisel is held parallel to the internal oblique edge of root extending forwards along the floor of the
ridge, a splintering of lingual plate will occur, with socket. This will make the subsequent root removal
the split extending up to the coronoid process. To avoid more difficult.
this, the bevel of the chisel should be held at an angle • Breakage of bur: This can occur either due to the
of 45° to the bone surface and pointing in the direction application of a heavy pressure or due to the repeated
of the lower second premolar of the opposite side. In use of the same bur. Used burs should be discarded
its correct position the cutting edge of the chisel will and a fresh bur used in each case. Binding of the bur
be parallel to the external oblique ridge. in the tooth structure is another reason for fracture.
• Fracture of mandible: If the chisel is carelessly Tapering fissure burs are less likely to bind than flat
placed and if a blow with considerable force is fissure burs and hence the former is preferred for tooth
delivered it can lead to fracture of mandible. sectioning. Recovery of a fractured bur tip from the
• Displacement of tooth into lingual pouch: A hard bone or tooth structure is a difficult endeavor.
chisel blow directed on the buccal side of the Use of osteotome
wisdom tooth may fracture the lingual wall of the • Compared to osteotome, chisels are ineffective to
socket, displacing both the tooth and the fractured achieve a clean section of the tooth. Hence the former
lingual plate into the lingual pouch. one is used. However, osteotome can not create a space
• Injury to lingual nerve: While working on the into which the sectioned crown could be moved. Hence
distal aspect of the impacted third molar, slippage more than one section is necessary. Conversely if a
of the chisel can severe the lingual nerve unless it wide bur is used then sufficient space will be created
is adequately protected with a retractor. into which the sectioned crown can be moved enabling
• Injury to second molar tooth and soft tissues: its removal.
Wrong positioning of the chisel blade or slippage • Fracture of mandible, injury to lingual nerve, second
of the instrument can injure the second molar or molar or soft tissues and displacement of tooth into
the adjacent soft tissue. lingual pouch are other possible complications
3. Complications during sectioning of tooth associated with the use of an osteotome.
Tooth can be sectioned using bur or osteotome: Unless 4. Complications during elevation of tooth
this is carefully performed it can lead to the following A number of complications which are listed below may
complications: occur during this stage of surgery:
Use of bur • Fracture of impacted tooth/ root: This is considered
• Incorrect line of sectioning of crown: The ideal site for to be the most common complication to occur during
sectioning of the crown is the cervical portion of tooth this stage and is most often due to inadequate removal
of bone. It may also be due to already weakened tooth

structure due to caries, resorption or restoration.
Adequate bone removal and proper assessment of the
tooth preoperatively can prevent this. Facture of the
root also can occur. All efforts should be made to
remove the root tip. It must be remembered that
aggressive and destructive attempts to remove roots
may cause more damage than benefit.
• Injury to second molar: Injudicious elevation of
impacted tooth using second molar as the fulcrum can
Figs 13.1A and B: (A) Application of excessive force (red arrow) using
result in the subluxation or expulsion of the latter. This an elevator mesial to impacted third molar without adequate removal of
risk is more if the second molar has conical roots or overlying bone, forces the adjacent teeth in opposite directions (yellow
arrows) resulting in extensive shear force. This result in fracture of
when first molar is missing. Similarly fracture of the
mandible (B) shown as blue arrow
crown or dislodgement of filling / artificial crown of
second molar can also occur during elevation of propagation along the line of weakness caused by the
wisdom tooth. The incidence of damage to restorations third molar in its socket. The instrument in use is almost
of the second molar has been reported to be 0.3 % to always the large straight elevator and the operator tries
to elevate the wisdom tooth distally and occlusally using
0.4%. Teeth with large restorations or carious lesions

are always at risk of fracture or damage upon elevation. excessive force.
Correct use of surgical elevators and adequate bone Weakening of mandible due to excessive removal of
removal can help prevent this. Possibility of such a bone or a thin and atrophic mandible due to resorption
mishap has to be informed to the patient pre- as in old age or bone weakened by local pathological
operatively and all precautions taken to avoid it. conditions are contributory factors (Figs 13.2 to 13.5).
• Fracture of mandible: Mandibular fracture as a result An intra-operative fracture must be suspected when
of third molar removal is a recognized complication a loud crack accompanies sudden loosening of a tooth
and has significant medico legal and patient care that was very resistant to elevation. Inspection of the
implications. It should be included in all third molar
extraction consent forms (Bouloux et al 2007). 3
Mandibular fracture during or after surgical third
molar removal is however a rare one. The incidence
has been reported to be 0.0049% (Libersa et al, 2002).4
Possible predisposing conditions, such as increased
age, mandibular atrophy, concurrent presence of a cyst
or tumor and osteoporosis have been implicated in
increasing the risk of mandibular fracture. The preangular
region of mandible is an area of lowered resistance to
fracture because of its thin cross-sectional dimension and
an impacted tooth occupies a relatively significant space
of this weak area. The concurrent presence of a
dentigerous cyst around the third molar or a radicular
cyst around the second molar and the removal of the tooth
and any surrounding bone to mobilize it will further
weaken this area.
Fracture is almost always caused by the application
of excessive tensile or shear forces across the superior Figs 13.2A and B: Conditions causing weakening of mandible
predisposing to fracture during surgical removal of impacted tooth. (A)
border of the mandible in the third molar area (Fig.13.1). Dentigerous cyst involving angle of mandible, (B) Atrophy of mandible
This results in the initiation of a fracture and its in old age. Sclerosis of bone / osteoporosis is also a contributory factor
operative site will demonstrate a fracture through the

tooth socket. Displacement of the fracture will be
accompanied by a change in the patient's occlusion. The
diagnosis must be confirmed radiographically (Fig. 13.6).
Alternatively, a patient may present in the post
surgical period with a fractured jaw secondary to trauma.
This happens because removal of tooth leaves a defect in
the jaw and temporarily renders the jaw more susceptible
to fracture from minor trauma especially when
unwarranted bone removal has been done. Studies have
shown that the fractures occurred 5 to 28 days after the
tooth removal. It has been concluded that the major risk
factor for this complication seemed to be advanced age
in combination with a full dentition.
Fig. 13.3: Extensive dentigerous cyst associated with impacted 38
Regardless of the mechanism, mandibular fractures
that occur during or soon after the extraction of the
mandibular third molars are usually non displaced or
minimally displaced. Such hairline fractures that extent

from an extraction site are not easily identified and clinical
suspicion may require CT if the initial panoramic film
gives negative results. The practitioner should treat the

fracture definitively just as if the patient were a trauma
patient. Failure to do so may result in further
complications. If this mishap occurs, the case has to be
referred to a specialist for expert management. The patient
should be informed of this disaster and all records
relevant to the case like radiographs and clinical notes
preserved. The line of management includes removal of
Fig. 13.4: Impacted 48 (complete bony impaction) in edentulous the remaining portion of the impacted tooth followed by
mandible. The angle of mandible is weakened by the presence of fixation of fracture by eyelet wiring and maxillary
impacted tooth. Extensive removal of bone for extracting the tooth will
further weaken the mandible predisposing to fracture
mandibular fixation or upper border wiring or bone
plating or other methods of fixation. The line of
management is dictated by the amount of bone loss,
degree of displacement and the accessibility.
• Dislodgement of tooth/crown into the lingual pouch
or lateral pharyngeal space: Mandibular third molars
can be iatrogenically displaced into the sublingual,
submandibular, pterygomandibular and lateral
pharyngeal spaces. Weakened or thin lingual plate,
lingual obliquity of impacted tooth, insufficient
reflection of overlying mucoperiosteum, inadequate
bone removal, excessive or uncontrolled force during
elevation are considered the main causes for this
accident. Adequate reflection of overlying gingiva and
Fig. 13.5: OPG showing impacted 48 in a congenitally atrophic mandible. placing a finger over the wisdom tooth to assess its
Note the thin amount of basal bone beneath 48 (yellow arrow), which is
likely to get fractured during surgical removal of impacted 48. Note the movement during elevation can help to a great extent
root stumps of 46 (white arrow) to prevent this complication. Lower third molars that
Figs13.6 A to D: (A and B) Radiographs of mandible showing fracture of left angle of mandible (yellow arrows) in a 54-year-old female which
happened during attempted removal of impacted 38 by a general dental practitioner, (C and D) Postoperative radiographs following open reduction
and internal fixation using mini plates alongwith surgical removal of impacted 38
are pushed through a perforation in the thin lingual suction are mandatory for success. Also care should be
alveolar bone normally pass inferiorly into the taken to protect the lingual nerve. Locating the displaced
mylohyoid muscle. tooth is challenging due to the limited working area and
A fractured root also can be displaced into the lingual hemorrhage with resultant compromised visualization
pouch during its attempted removal from the socket. and blind probing that may result in further displacement.
See Figure 5.9 in Chapter 5. A combination of intraoral and extraoral approach may
To retrieve a tooth or root displaced into the lingual be required in certain instances to remove the tooth.
space, pressure is exerted beneath the mandible externally Gay-Escoda and associates (1993)5 reported a case in
to prevent its further displacement downwards and at which a patient underwent extraction of a displaced
the same time using the index finger of the other hand to mandibular third molar that was found between the
milk the tooth / root back into the socket through the platysma and sternocleidomastoid muscle. It was
breach in the lingual plate. If required the lingual gingiva removed via transcutaneous approach. The authors
may be reflected as far as the premolar region and the opined that the tooth might have undergone progressive
mylohyoid muscle incised to gain access to the migration as a result of inflammatory reaction.
submandibular space and deliver the tooth. It is then Esen and colleagues (2000)6 described a case in which
grasped using a hemostat and removed. Good light and a patient presented months after attempted extraction of
a mandibular third molar with progressive limitation in

mouth opening, edema of left neck and dysphagia. A
panoramic film revealed a tooth in the pterygomandi-
bular region. CT scans showed the precise location of the
tooth at the anterior border of the lateral pharyngeal space
beneath the left tonsillar region. The tooth was removed
transorally from the tonsillar fossa (after completion of a
tonsillectomy) through a vertical incision from the
tonsillar fossa to the retromolar trigone.
In cases where the tooth / root have been further
migrated downwards and backwards into the lateral
pharyngeal space, the patient will be complaining of
severe pain on swallowing. An extra oral approach will
be necessary to reclaim the tooth and to avoid the
development of an infection.
Ortakoglu et al (2002) 7 reported a case of
displacement of lower third molar into the lateral
pharyngeal space during surgical removal. The
radiological examination included panoramic, occlusal

and computerized tomographic (CT) views to localize the
tooth correctly. The radiological findings showed that the Figs 13.7A to C: Radiographic views of a tooth displaced into
pterygomandibular space. (A) Periapical X-ray (note the yellow arrow
tooth was displaced into the pterygomandibular region. pointing towards the tooth), (B) Axial CT scan showing the displaced
Removal of the tooth under local anesthesia via lingual tooth (yellow interrupted oval), (C) OPG shows the displaced tooth (white
approach was performed. The incision was made on the interrupted circle). [Courtesy: Ortakoglu et al]
alveolar crest between the anterior edge of the ramus and

downwards (Fig.13.8) with the apices piercing the
lingual mucoperiosteum of the second molar. After
mandibular canal and injuring the neurovascular
reflection of the mucoperiosteal flap, the lateral bundle. This happens more commonly in cases of
pharyngeal space was reached by blunt dissection. In this
mesioangular and horizontal impactions. Injury to
area the tooth was located in a horizontal position and
vessels can result in brisk hemorrhage. Bleeding can
removed carefully. be controlled by immediately packing the socket with
Figure 13.7 shows the various radiographic views of
gauze. Once the initial severe bleeding is controlled,
a tooth displaced into the pterygomandibular space.
bone wax can be applied or placing a pack of
Some authors suggest that the displaced tooth must
be removed at the initial surgical attempt to avoid
development of infection. However, others propose a 3-
4 week waiting period to allow the development of
fibrous tissue around the tooth thereby immobilizing it.
This will enable its removal in the second attempt. Such
a line of management has the possibility of development
of infection unless antibiotics are administered. Delayed
intervention in the event of a displaced tooth into the
lateral pharyngeal space carries the risk of infection,
thrombosis of the internal jugular vein, erosion of the
carotid artery or one of its branches and interference with
cranial nerves IX to XII (Bouloux et al, 2007).3
• Injury to mandibular canal: While elevating the tooth
as the crown moves upwards, the roots may be forced Fig 13.8A
hemorrhage to occur. The incidence of clinically

significant bleeding following third molar extraction
ranges from 0.2 to 5.8%. Excessive hemorrhage resulting
from extraction of mandibular molars is more common
than bleeding from maxillary molars. In a study
conducted by Chiapasco et al (1993) 8 the rate of
postoperative bleeding for mandibular and maxillary
third molar extraction was 0.6% and 0.4%, respectively.
These complications occurred mostly in cases of deep
distoangular and horizontal impaction in the mandible.
In the maxilla, high vertically positioned molars were
most often implicated.
Jensen (1974)9 reviewed 103 cases of postoperative
hemorrhage after oral surgery and made several
important observations. He found that the male to female
ratio was 2:1, and the age range was 21 to 45 years. There
Figs 13.8A and B: (A) While elevating the tooth; as the crown moves
upwards, the roots may be forced downwards with the apices piercing was a personal or family history of bleeding in 25% of
cases. Postoperative bleeding occurred within 8 hours of
the mandibular canal, (B) Injury to the neurovascular bundle and

resulting hemorrhage. Damage to inferior alveolar nerve also can occur
the surgery in 75% of cases. The general physical
resulting in anesthesia in the distribution of mental verve
condition of the patient was not affected in 84% of cases.
Among cases in which the location of the bleeding was

Whitehead's Varnish or antibiotic cream on gauze and identified, 7% had an arterial source and 72% involved
leaving it in position for one or two days. Other hemorrhage from the soft tissue. A single site of bleeding
alternatives are gelatin sponge (Gelform) or oxidized was found in 43% of cases. 10% had inadequate
cellulose (Oxycel) to control the bleeding. Unlike the postoperative instructions. Local control was successful
gelatin sponge, oxidized cellulose can be packed into in 84% of patients. Hematological investigations revealed
the socket under pressure. Damage to inferior alveolar no diagnosable bleeding abnormalities, except in 4
nerve also can occur in a similar situation resulting in patients with previously known coagulation deficiencies.
anesthesia in the distribution of mental verve. The hemorrhage can be either intraoperative or
While working in the depth of the socket to retrieve postoperative and its etiology being either local or
a fractured root, the root piece can be inadvertently systemic in nature. Systemic conditions such as
pushed into the canal resulting in injury to the contents. hemophilia A or B and von Willebrand's disease are often
If bleeding occurs it has to be controlled by the methods diagnosed early in patient's life. Management of these
described above. Any further attempt to remove the patients include close coordination with the hematologist
fragment through the socket is futile and buccal cortical and maximum use of local measures, including the
plate in the region has to be removed to expose the root fabrication of a customized dressing plate before surgery.
to effect its removal. Anticoagulant drugs such as warfarin sodium and
antiplatelet medications such as aspirin should be
discontinued/switched to other drugs in the preoperative
Post Surgical Sequelae and Complications
period.
Following the surgical removal of an impacted third Local factors that result from soft tissue damage and
molar, certain normal physiological responses will occur injury to blood vessels represent the most common cause
as sequelae. These range from mild bleeding and swelling of postoperative hemorrhage. Intraoperative and
to trismus. Even though the patient has been for warned, postoperative bleeding can be minimized by using good
all these are disagreeable to the patient and hence, they surgical technique, minimum trauma to the hard and soft
should be kept to the minimum. tissues and avoiding damage to inferior alveolar
1. Hemorrhage: If adequate hemostasis is achieved neurovascular bundle. Nevertheless as a result of physical
at the time of surgery, it is unlikely for postoperative exertion or raise in blood pressure or due to any of the
local or systemic causes (bleeding diathesis) post opera- 15 mm Hg or any drop in the diastolic blood pressure
tive bleeding can occur. indicates significant hypovolemia (defined as more than
The most effective way to achieve hemostasis 30% of total blood volume lost). Intraoral examination
following surgical removal of impacted tooth is the with adequate lighting of the oral cavity and oropharynx
application of a moist gauze pack over the site of the will allow identification of the bleeding area. Direct
surgery and bite with adequate pressure for 45 minutes. pressure with gauze is then applied for 20 to 30 minutes.
Preparations of zinc sulphate (Zingisol) or glycerine This measure is usually sufficient to control bleeding,
tannic acid (Sensoform Gum Paint, Stolin Gum Astrin- since the reason for bleeding is some secondary trauma
gent) can be used to wet the pack as these will act as associated with the patient sucking the socket. If the
styptics and stop bleeding (Table 13.1). bleeding continues, infiltration of local anesthetic (with
Rarely bleeding from inferior alveolar vessels or facial 1:100,000 epinephrine) should be done. In contrast to the
vessels may occur. After locating the source of bleeding, common misconception that any clot that has formed
packing the site or clamping and ligature of the vessel is should be left in place, all clot and debris must be removed
done. When bleeding occurs from the socket, attempting to allow examination of the socket. The socket should be
to control it by tight suturing across the socket is futile curetted and suctioned to identify the source of bleeding.
and hazardous. This is because bleeding may still If the source is not arterial, then any of a variety of local
continue with blood not collecting in the oral cavity but hemostatic agents can be used. If an arterial source is
rather spreading into the tissue spaces beneath the identified (indicated by pumping of bright red blood),
sutures. This may lead to hematoma formation in the base the vessel must be ligated. If the bleeding is from soft
of the tongue or parapharyngeal space ultimately tissue and is arterial in nature but does not involve the
resulting in respiratory obstruction. neurovascular bundle, it is usually amenable to cautery.

Treatment of post extraction bleeding starts with a Bleeding from bone can be managed with bone wax or
review of the patient's medical and surgical history. Vital various other hemostatic agents described below. If the
signs and clinical status should be monitored source is intra-alveolar, then absorbable packing may be
continuously. An attempt to quantify the amount of blood placed into the socket, and maintained thereby sutures.
loss is helpful. Hypotension due to loss of blood volume Oral fibrinolysis from salivary enzymes may be a cause
can be measured by blood pressure and heart rate. An for postoperative bleeding. The use of fibrin stabilizing
increase in the heart rate of more than 15 beats/minute, agents such as epsilon aminocaproic acid or tranexamic
a decrease in the systolic blood pressure of more than acid may be helpful in such cases.
Table 13.1: Styptics and local agents for the control of hemorrhage.
Name Action Application

Monsel's solution-contains Precipitates protein and aids clot Wet a gauze pack with the drug and
ferric sulphate formation then bite on the gauze pack
Sensoform Gum Paint-contains Precipitates protein and aids clot Wet a gauze pack with the drug and
glycerine tannic acid formation then bite on the gauze pack
Mann hemostatic-mixture of tannic Precipitates protein Wet a gauze pack with the drug and
acid, alum and chlorobutamol then bite on the gauze pack
Silver nitrate, ferric chloride Precipitates protein Wet a gauze pack with the drug and
then bite on the gauze pack
Folded tea bag Precipitates protein Bite over a folded tea bag
Adrenalin Induces vasoconstriction. Should not Applied with a gauze pack in a
be used in patients with hypertension concentration of 1:1000.
or cardiac diseases. Vasoconstrictor effect is reversible
and hence watch for recurrence
of bleeding.
The following materials can be placed in the socket causes a delay in the healing of the socket, this is reserved
to achieve hemostasis. (Table 13.2). for more persistent bleeding.
Absorbable gelatin sponge: The most commonly used Surgicel comes in knit form whereas Oxycel comes
and the least expensive is the absorbable gelatin sponge in a microfibrillar form. Surgicel has the fibers which are
(Gelfoam). This material is placed in the socket and held knit together and they are solid fibers whereas Oxycel
in place with a figure - of -eight suture placed over the has hollow fibers but they essentially work the same way.
socket. The absorbable gelatin sponge forms a scaffold Surgicel is relatively acidic and is thought to cause some
for the formation of blood clot and the suture helps to small vessel contraction. Like gelfoam, it works at the
same point in the intrinsic pathway of clotting causing
keep the sponge in position during the coagulation
contact activation. Hence, functional clotting factors are
process. A gauze pack is then placed over the socket and
needed in order for this to work. It is thought to be
is held with firm pressure. relatively bacteriostatic when compared to other
Oxidized cellulose: Another material that can be used hemostatic agents. The theory behind this is that because
to control bleeding is oxidized regenerated cellulose of its relatively low pH, it deactivates and denatures some
(Surgicel and Oxycel). The material promotes coagulation of the bacterial proteins especially those related to
better than the absorbable gelatin sponge, because it can antibiotic resistance, thus making them more susceptible
be packed into the socket under pressure. The gelatin to antibiotics. It needs to be applied dry and absorbs
sponge on the other hand becomes very friable when wet within four to eight weeks.
and can not be packed into a bleeding socket. However, Topical thrombin: If there is some doubt regarding
since the packing of the socket with oxidized cellulose patient's ability to form clot, a liquid preparation of topical
Table 13.2: Local hemostatic agents useful for controlling bleeding from extraction socket
Name Source Action Application

Gelfoam Absorbable gelatin sponge Scaffold for blood clot formation Place into the socket and retain in place
with suture
Surgicel Oxidized regenerated Binds platelets and chemically Place into socket (It cannot be mixed
methyl cellulose precipitates fibrin through low pH with thrombin)
Avitene Microfibrillar collagen Stimulates platelet adherence Mix fine powder with saline to desired
and stabilizes clot; dissolves consistency
in 4 to 6 weeks
Collaplug Preshaped, highly cross- Stimulates platelet adherence Place into extraction site
linked collagen plugs and stabilizes clot; dissolves
in 4 to 6 weeks
Collatape Highly cross-linked collagen Stimulates platelet adherence Place into extraction site
and stabilizes clot; dissolves
in 4 to 6 weeks
Thrombin Bovine thrombin (5,000 or Causes cleavage of fibrinogen Mix fine powder with calcium chloride and
10,000 U) to fibrin and positive feed back spray into desired area. Alternatively mix
to coagulation cascade with gelfoam before application
Fibrin glue Bovine thrombin, human Antifibrinolytic action of aprotinin Requires specialized heating, mixing and
(Tiseel) fibrin, calcium chloride delivery system; inject into extraction site
and aprotinin
Horsley's Bee's wax - 7 parts Acts by mechanical occlusion Large quantity can cause foreign body
Bone wax Olive oil - 2 parts granuloma and infection. Hence, to be
Phenol - 1 part used judiciously.
thrombin (prepared from bovine thrombin) can be This is essential to avoid the patient going into
saturated onto a gelatin sponge and inserted into the hemorrhagic shock and its attended complications.
socket. The thrombin bypasses all the steps in the Moghadam (2002)10 reported a case of life-threatening
coagulation cascade and helps to convert fibrinogen to hemorrhage occurring immediately after extraction of
fibrin enzymatically, which forms a clot. The sponge with third molars and resulting in airway compromise.
topical thrombin is secured in place with a figure - of - Massive intraoperative bleeding is a rare occurrence
eight suture. A gauze pack is then placed over the socket. and can be secondary to a mandibular / maxillary arterio-
Collagen: This is another material that can be used to venous malformation (AVM), which can be either low
control bleeding from a socket. Collagen promotes flow (venous) or high flow (arterial). The presence of such
platelet aggregation and thereby accelerates coagulation. a malformation in the mandible or maxilla is potentially
Collagen is currently available in several different forms. life-threatening secondary to torrential hemorrhage if
Microfibrillar collagen (Avitene) is available as a loose tooth extraction is attempted. In a series reported by
and fluffy material that can be packed into the extraction Guibert-Trainer et al (1982)11 eight percent of patients died
socket. This is then held in place using suture and gauze as a result of massive hemorrhage during tooth extraction.
pack. A more highly cross-linked collagen is supplied as AVMs are comparatively rare in the orofacial region
a plug (Collaplug) or as a tape (Collatape). These compared to other pars of the body. In the maxillofacial
materials can be more easily packed into the socket. region AVMs are often apparent on physical examination
However, they are more expensive.
and panoramic radiography (Bouloux et al, 2007).3 A

If local measures are not successful then the situation
history of recurrent or spontaneous bleeding from the
needs to be managed urgently, especially if the patient
gingiva is the most frequent sign. Other physical findings

becomes symptomatic. The surgeon should consider
include gingival discoloration, hyperthermia over the
performing additional laboratory screening tests to
lesion, a subjective feeling of pulsation and the presence
determine whether the patient has a profound hemostatic
of a palpable bruit. Mandibular AVMs usually appear as
defect. Consultation with the hematologist is advisable
multilocular radiolucencies on radiographic studies,
in such instances for the further management of the case.
although significant lesions may be nonapparent.
Figure 13.9 shows the general management protocol and
Angiography is essential to confirm the diagnosis and
algorithm for the treatment of post extraction bleeding.
assess the extent and vascular architecture of the lesion.
Airway, breathing and circulation must be assessed.
Treatment of AVMs involves either surgical excision or
As in all emergencies, airway management is the first
embolization.
step in stabilizing the patient. Uncontrollable intraoral
hemorrhage can quickly lead to airway compromise 2. Edema (Table 13.2): This is an expected sequelae of
either because of an expanding hematoma in the neck or third molar surgery. Patients with round puffy face
from blood pooling in the airway. The size and spread of frequently develop more swelling than those with a lean
a hematoma depends on its vascular origin (capillary, face. Postoperative swelling usually subsides rapidly in
venous or arterial) and the tissue into which it is bleeding two or three days. If it persists, it is suggestive of infection
(muscle, fat or interstitia). The location of the hematoma or hematoma formation and it has to be managed
can be delineated using CT scan with contrast. accordingly. Parenteral administration of corticosteroids
Hematomas stop expanding when the pressure of the is found to be extremely useful to minimize postoperative
pooling blood exceeds the vascular pressure of the edema. The role of application of ice packs to the face to
bleeding site. If the hematoma continues to expand reduce the swelling is controversial. Ice pack applied
obstructing the airway surgical exploration of the site, intermittently for the first 24 hours definitely makes the
evacuation of hematoma and ligation of the vessel has to patient more comfortable and reduces the pain. However,
be done. opinion among investigators is divided regarding the
In the event of considerable blood loss, replacement effectiveness of ice application.
therapy in the form of whole blood or blood substitutes Mac Auley DC (2001)12 stated that ice, compression
should be considered in a hospital setting after and elevation are the basic principles of acute soft tissue
hematological examination and medical consultation. injury. After a thorough literature review he found that
Fig 13.9: Algorithm showing the general management protocol and treatment of post extraction bleeding
temperature change within the muscle depends on the mucosa post-surgery more effectively and that the
method of application, duration of application, initial duration of surgery appears not to influence temperature
temperature, and depth of subcutaneous fat. The evidence variations. In the postoperative phase they recommend
from this systematic review suggests that melting iced a rational application of ice packs appropriate to the
water applied through a wet towel for repeated periods constitution of each patient.
of 10 minutes is most effective. The target temperature is Filho et al (2005)14 reported that cryotherapy (ice
reduction of 10-15 degrees C. Using repeated, rather than application) was effective in reducing swelling and pain
continuous, ice applications help to sustain reduced in their sample. Despite playing no role in the reduction
muscle temperature without compromising the skin and of trismus, the authors recommend its use.
allows the superficial skin temperature to return to The effect of external application of local cold on
normal while deeper muscle temperature remains low. swelling, trismus, temperature and pain postoperatively
It was concluded that ice is effective, but should be in surgical removal of impacted mandibular third molars
applied in repeated application of 10 minutes to be most was studied in a cross-over study comprising 45 patients
effective. by Forsgren et al (1985).15 They concluded that the
Studies by Sortino et al (2003) 13 indicate that external application of cold after the surgical removal of
application of an ice pack controls the temperature of the impacted mandibular third molars does not appear to
Table 13.3: Differential diagnosis of postoperative swelling
Condition Cause Time of onset Clinical features Management

Emphysema Entry of air into tissues During the procedure Feeling of crepitus/air Minimum emphysema-
in the tissue may be left as such or a
pressure dressing given.
Massive spreading
emphysema-emergency
management to maintain
airway, antibiotics to
prevent infection
Normal post Normal inflammatory 3 to 4 hours after the Pain not marked, non Ice application, drug
operative reaction of body procedure tender, soft swelling, therapy, pressure
oedema subsides rapidly bandage
Hematoma Bleeding into tissue Immediately following Persists longer, tense Removal of sutures,
planes primary or surgery or a few hours and tender, change drainage of hematoma,
reactionary later in colour of the skin hot saline mouth wash,
or mucosa antibiotic therapy if
infected
Abscess Infection of the 2 to 3 days later Severe pain and tender- Incision and drainage if
formation/ surgical site ness, raise of temperature, pus has formed, culture
Infection fluctuation if abscess and sensitivity of pus,
has formed antibiotics and supportive
therapy
improve the postoperative course, either on a short or mouth opening significantly wider in the immediate
long-term basis. postoperative period in the drain group subjects as
A recent animal study was conducted by Nusair compared to the other. There was no significant difference
(2007)16 to note the effect of local application of ice bags in the severity of pain between the two groups. Facial
on facial swelling after oral operations in rabbit. It was swelling was found to be significantly less in the drain
observed that there was no significant difference between group subjects. The number of patients with wound
the test and control sides 24 or 48 hours postoperatively. breakdown, edema, and bleeding was found to be less in
Pressure bandages also have a role in minimizing the the drain group than in the no drain group. Thus, the
edema. Oral preparations of chymotrypsin or postoperative problems, in general, were less in the
serratiopeptidase have been advocated by various surgical drain group as compared to the no drain group.
authors to control postoperative swelling. The swelling 3. Trismus: Mild difficulty in opening the mouth is
usually reaches its maximum by the end of the second also an expected sequelae of third molar surgery. It has
postoperative day and is usually resolved in a week's been noted that those patients who have been given
time. steroids for the control of edema, also tend to have less
Another adjuvant measure suggested in reducing trismus. Some patients have a misconception, that it is
post operative oedema and pain is the use of a small the suture that is preventing normal opening and hence
surgical tube drain. In a study conducted by Rakprasitkul avoids mouth opening lest the suture may break. Such
et al (1997)17, the insertion of a small surgical tube drain patients should be identified and properly instructed to
with primary wound closure (drain group) was perform jaw exercise. Active jaw exercise started the day
compared to a simple primary wound closure (no drain after surgery and continued till the suture removal will
group) after removal of impacted third molars. The ensure adequate mouth opening. The earlier the patient
operation time was found to be significantly longer and starts on normal diet and regular oral hygiene habits the
better will be mouth opening at the time of suture noted that patients who have received steroids for control
removal. of oedema usually complaints of less pain.
When severe trismus occur the possibility of Usually, postoperative pain lasts up to the third post
hematoma formation, excessive stripping of muscle operative day. Should it persist after that period, patients
insertion and infection especially in the submasseteric should be recalled for evaluation.
space should be considered. 5. Infection: The incidence of infection following the
Protracted trismus is unusual following third molar removal of third molars is very low when strict aseptic
surgery. If this happens, active jaw exercise, hot technique has been followed. Infection after third molar
fomentation, short wave diathermy and massage have surgery have been reported to vary from 0.8 to 4.2%. It
to be considered. may develop either in the early or in the late postoperative
4. Pain: Pain following atraumatic and expeditious period. Mandibular sites are more commonly affected. It
surgery is usually minimal and this can be controlled with has been suggested that the risk factors for postoperative
mild analgesics. Unduly prolonged surgery, excessive infection include age, degree of impaction, need for bone
cutting of dense bone, improper handling of soft tissues removal, or tooth sectioning, presence of pericoronitis,
and low pain threshold of the patient; all contributes to surgeons experience, use of antibiotics and clinical setting
postoperative pain. Dry socket, hematoma formation and (hospital versus office procedure). The benefit of
infection are the usual causes of severe pain. perioperative or postoperative systemic antibiotics on the
The post surgical pain begins when the effect of the incidence of infection is debated and cannot be
local anesthesia subsides and reaches its maximum recommended routinely. The use of antibiotics is
intensity during the first 4 to 8 hours. Lago-Méndez et al discussed in detail in appropriate sections (Chapter on
(2007)18 observed that there is a statistically significant Drug Therapy).

relationship between the surgical difficulty and Nearly half of the infections are the localized,
postoperative pain. Pain after extraction of mandibular subperiosteal abscess which occurs two to four weeks
third molar is directly proportional to the surgical postoperatively. This usually happens due to debris left
difficulty and duration of the procedure. under the mucoperiosteal flap. It is treated by surgical
Maintenance of good oral hygiene preoperatively has drainage and antibiotic therapy.
been found to be related to postoperative pain. Studies The strategic position of the mandibular third molar
by Peñarrocha et al (2001)19 reported that poor oral at the junction of a number of different fascial spaces
hygiene before the surgical removal of impacted lower (Fig.13.10) requires that any infection in this area must
third molars is correlated with greater postoperative pain. be taken seriously because of the ability of such an
Maximum postoperative pain was recorded 6 hours after infection to spread along the fascial planes and
extraction, with peak inflammation after 24 hours. compromise the airway.
Patients with poor oral hygiene reported higher pain
levels throughout the postoperative period and more
analgesic consumption in the first 48 hours. In contrast,
oral hygiene appeared to exert no influence on either
trismus or inflammation.
A plethora of analgesics is available for the
management of post surgical pain. Analgesics should be
given before the effect of local anesthesia subsides. That
way the pain is easier to control, requires fewer drugs,
and may require a less potent analgesic. Certain authors
advice that administration of analgesics before surgery
may be beneficial in the control of postoperative pain.
There is a strong correlation between postoperative pain
and trismus, indicating that pain may be one of the
principle reasons for limitation of mouth opening after Fig. 13.10: Spread of infection from mandibular third molar area
the removal of impacted third molars. Hence, it has been to various fascial spaces (marked with black arrows)
Infections in the buccal space and buccinator space not subside; rather it increases in size. Sometimes infection
are usually localized on the lateral side of the mandible. can be of late onset developing after the initial edema
Submasseteric infections occupy the potential space has subsided. In either case the significant features are
between the lateral side of the mandible and the masseter severe pain, marked tenderness and a raise in
muscle. This space is not lined by fascia. However, temperature. If pus forms there will be flactuation. If the
infection in this area is in direct contact with the masseter onset of infection is detected sufficiently early, its further
muscle and usually induces intense spasm in the muscle progress can be terminated by administration of
resulting in profound trismus. antibiotic. Antibiotic therapy will also prevent the spread
Pterygomandibular space infections (Fig.13.11) of infection into adjacent facial spaces.
occupy the fascia- lined space between the medial Once abscess has formed, it should be drained first,
pterygoid muscle and the medial aspect of the mandible. followed by antibiotic therapy. Culture and sensitivity
Infections in this area cause trismus and sometimes of pus will help to identify the organism as well to select
airway embarrassment also. the antibiotic which the organism is sensitive to. Penicillin
The submandibular space is formed by the splitting is the antibiotic of first choice considering the mixed
of the investing layer of fascia of the neck to enclose the nature of the organism involved. Metronidazole can also
submandibular salivary gland and is in continuity with be added to increase coverage against anaerobic
the pterygomandibular and parapharyngeal spaces. organisms. The use of clindamycin as an alternative drug
Infections in this region can cause airway embarrassment. has become popular because it provides aerobic and
Parapharyngeal space infections occur between the anaerobic coverage. The selection of antibiotic should be
pharyngeal mucosa and superior constrictor muscle. carefully done considering the most likely microorganism
Infections in this region are potentially life-threatening involved, the possibility for allergic reactions, side effects
and may produce significant airway embarrassment and complications.
requiring urgent attention. Infections may also involve
the retropharyngeal tissues and subsequently the
Infections of Delayed Onset
mediastinum with disastrous results.
Infections from maxillary third molar may spread to Hematomas or food trapped under the flap have been
the maxillary vestibule, buccal space, deep temporal space cited by some authors as possible causes of delayed-onset
or infratemporal fossa. infections. However, the most possible cause of this
Following surgical removal of third molar when complication is the dead space created beneath the soft
infection spreads to soft tissues, the initial edema does tissue lying behind the second molar. A possible source
for the bacteria could be the gingival sulcus of the adjacent
second molar. The fact that the vertical and mesioangular
third molars are more prone to develop late infections
could also explain this theory, because their crown is in
very close relation to the root of the adjacent second
molar. The observation that infection is more likely
following removal of deeply situated third molar indicate
that the surgical aggression and the amount of ostectomy
are related to delayed -onset infections. Heavy smokers
also seem to be more susceptible to this complication.
6. Alveolar osteitis (Dry socket): This is usually
regarded as a localized osteitis involving either the whole
or a part of the condensed bone lining the tooth socket.
The condition is characterized by an acutely painful
extraction socket, exposure of bare bone and socket
containing broken down blood clot.
Fig. 13.11: Pterygomandibular space infection following surgical removal
of 48. Note the swelling and erythema (yellow circle) and the associated Incidence of alveolar osteitis following the removal
trismus of impacted mandibular third molars varies between 0.3%
and 25%. In cases treated under general anesthesia in the the bacterial contamination of the surgical site by the
operation theatre, especially when antibiotic has been following methods:
administered dry socket rarely occurs. Nevertheless, its A. Oral prophylaxis and controlling gingival inflamma-
incidence is high following operations under local tion before surgery
anesthesia. This cannot be attributed to the effect of local B. Presurgical irrigation with antimicrobial agents such
anesthesia or the vasoconstrictor adrenalin contained in as chlorhexidine
it. Mandibular extractions are more prone to develop dry C. Copious irrigation of operative site with saline
socket than maxillary extractions. The pathogenesis of D. Placing small amounts of antibiotics such as
dry socket has not been clearly defined. But it is most tetracycline or lincomycin in the socket
likely due to the lysis of the fully formed blood clot before E. Prophylactic administration of metronidazole in a
it is replaced by the granulation tissue. This fibrinolysis dose of 200 mg eighth hourly starting on the day of
occurs during the third and the fourth day. The source of the procedure and continued for three days.
the fibrinolytic agents may be from the tissue, saliva or Administering only the minimum amount of local
bacteria. Birn (1973) 20 suggested that the trauma anesthetic solution required to produce analgesia and
associated with extraction causes release of tissue factors removal of tooth with least trauma as possible can also
leading to activation of plasminogen to plasmin. The help to prevent this complication.
plasmin in turn causes fibrinolysis and dissolution of In a randomized, double-blind, placebo-controlled,
blood clot. The etiopathogenesis of dry socket is shown parallel-group study by Hermesch et al (1998)21 subjects
in Figure 13.12. were instructed to rinse twice daily with 15 ml of 0.12%

A number of bacteria are known to possess chlorhexidine or placebo mouth rinse for 30 seconds for
fibrinolytic activity and it has been recently suggested 1 week before and 1 week after the surgical extractions.
that Treponema denticolum may have an etiological role This regimen included a supervised pre surgical rinse
in the onset of dry socket. The role of bacteria is based on also. From the study it was confirmed that the
the fact that systemic and topical antibiotic prophylaxis prophylactic use of 0.12% chlorhexidine gluconate mouth
reduces the incidence of dry socket by approximately 50 rinse results in a significant reduction in the incidence of
to 75%. The incidence of dry socket seems to be higher in alveolar osteitis after the extraction of impacted
smokers and in female patients who take oral contra- mandibular third molars. In addition, oral contraceptive
ceptives. Its occurrence can be reduced by bringing down use in females was confirmed to be a risk factor for the
development of alveolar osteitis.
Management of dry socket: Essentially it includes
irrigation of the socket, gentle mechanical debridement
and placement of an obtundent dressing (Fig.13.13). The
Fig 13.12: Schematic diagram showing the

etiopathogenesis of Dry socket Fig. 13.13: Obtundent dressing in dry socket
dressing which usually contains zinc oxide and eugenol foramen or the lingual nerve. It may be the result of
on cotton wool is tucked loosely into the socket. It must instrument slippage (e.g. scalpel), cutting too deeply with
not be packed tightly or it may set hard and will be a bur (e.g. while sectioning a tooth), over-zealous
difficult to remove it later. retraction (e.g. of a lingual or buccal flap), pushing root
This dressing will have to be changed on alternate tips into a canal or foramen or mechanically damaging
days. The pain usually resolves within two to three days. the canal contents with an instrument while probing for
An effective drug for the management of dry socket is a root tip. Trauma may result in complete severing of the
"Alvogyl" (Septodont-France). It contains iodoform, nerve, partial severing, complex hematoma formation
butylparaminobenzoate, eugenol, penghawar, excipient with fibrosis, impingement by bone or a root tip or simple
ad. It is supposed to be antiseptic,analgesic,and stretching. These injuries can be devastating for the
hemostatic. After irrigating the socket take a little of the patients because of their effects on speech, mastication,
material using a tweezer (Fig.13.14) and place it in the swallowing, and social interactions. Fortunately most of
socket. It may be removed the next day and fresh dressing the injuries recover spontaneously. However some may
reinserted if the patient still complaints of pain. remain permanent with varying outcome ranging from
A dressing containing Whitehead's varnish on ribbon mild hypoesthesia to complete paresthesia and
gauze is another alternative for hastening the healing and neuropathic responses resulting in chronic pain
relieving pain. (Whitehead's varnish contains benzoin 10 syndromes.
parts, idoform10 parts, storax 7.5 parts, balsam of Tolu 5 Pain, temperature and proprioception are transmitted
parts, solvent ether 100 parts). Patient should be seen centrally through the lingual, mental, inferior alveolar,
regularly after placement of dressing, which may need infraorbital and supraorbital nerves. Each of these sensory
to be changed several times to eliminate the symptoms. modalities must be evaluated in the neurosensory
The use of intra-alveolar dressings in sockets where the assessment of patients and monitored for recovery
inferior alveolar neurovascular bundle is exposed is not postoperatively.
recommended. Analgesic tablets and warm saline mouth The incidence of neurologic injuries from third molar
washes are also advised. But they are often unnecessary surgery may be related to multiple factors such as:
after local measures have been undertaken a. Experience of the surgeon
7. Nerve Injury: Surgical removal of mandibular b. Proximity of tooth to the inferior alveolar nerve (IAN)
third molar may cause injury of the lingual and inferior c. Deep horizontal and distoangular impactions
alveolar nerve resulting in anesthesia or paresthesia. d. Surgery performed under general anesthesia (GA)-
Nerve injury can occur when surgical procedures are due to supine position of the patient, possibility for
performed close to the inferior alveolar canal, the mental greater extent of soft tissue reflection and greater
surgical force, more difficult case selection for surgery
under GA.
Brann et al (1999)22 observed that lingual and
inferior alveolar nerve damage was five times more
frequent when lower third molars were removed
under general anesthesia rather than under local
anesthesia. This could not be explained in terms of
surgical difficulty, preoperative pathology, age or
anatomical position.
e. Patients age over 35 years
f. Completely formed roots
g. Depth of impaction
h. Use of rotary instruments
i. Surgical sectioning of tooth
Incidence of nerve injury is about 3 %. The lingual
nerve injuries that result from third molar surgery have
Fig. 13.14: Alvogyl (Septodont-France) been reported to occur in 0.5% to 22% of all patients. It is
injured during soft tissue flap reflection or during bone time from injury and degree of observed sensory
removal. The inferior alveolar nerve is injured during recovery. The Sunderland classification emphasizes the
removal of complete bony impaction or during attempted fascicular structure of the nerve and the amount of nerve
removal of root. Only a small portion of these anesthesia damage. Seddon proposed three categories of nerve
and paresthesia problems remain permanent. injury viz. neuropraxia, axonotmesis and neurotmesis.
Radiographic signs suggestive of intimate association of Later, Sunderland expanded the Seddon classification to
the third molar with the canal are diversion of the path include five degrees of nerve injury. (Table 13.4)
of the canal by the tooth, darkening of the apical end of i. Neuropraxia (Sunderland first-degree injury): This
the root indicating that it is included within the canal is the mildest form of injury usually resulting from
and interruption of the radio opaque white line of the stretching or mild compression. The axon and the
canal. When these signs are noted extra precautions such nerve sheaths remain intact and there is a temporary
as adequate bone removal or sectioning of the tooth conduction block. Significant traction injury may
should be performed. Proper patient education and result in vascular stasis with focal demyelination.
informed consent are mandatory in such cases to avoid The nerve regains function slowly with an initial
malpractice claims in the future. onset of tingling followed by the return of normal
sensation. This usually occurs within days to weeks
of the initial injury. The prognosis is very good.
Classification
Microsurgery is not indicated unless a foreign body
Nerve injury results in various degrees of axon or nerve is present.

damage and these inturn results in relatively recognizable ii. Axonotmesis (Sunderland second-degree injury):
patterns of clinical symptomatology. Seddon (1943) and This occurs as a result of damage to the nerve bundle
Sunderland (1951) developed classification of nerve due to crush or significant traction that causes
injuries based on the degree of nerve disruption. These sufficient nerve injury that there is some degree of
classifications are based on the degree of injury affecting Wallerian degeneration distal to the site of injury
the endoneurium, perineurium, and epineurium and with maintenance of the nerve sheath. There is no
supporting tissues. Seddon's classification is based on the degeneration of endoneurium, perineurium or
Table 13.4: Showing Seddon and Sunderland classification of nerve injury
Injury classification Cause Healing Management

Neuropraxia (Seddon) Minor nerve compression or Spontaneous recovery in less Not indicated unless foreign
First-degree injury traction injury than 2 months body is impeding nerve
(Sunderland) regeneration
Axonotmesis (Seddon) Crush or traction injury Spontaneous recovery in 2-4 Not indicated unless foreign
Second-degree injury months.Up to one year for body is present
(Sunderland) complete recovery
Third-degree injury Compression, traction or Some spontaneous recovery, Microsurgery is indicated if
(Sunderland) crush injury but not complete there is no improvement in
three months
Fourth-degree injury Compression, traction, Poor prognosis for Microsurgery is indicated if
(Sunderland) injection or chemical injury spontaneous recovery. High there is no improvement in
possibility for neuroma three months
formation
Neurotmesis (Seddon) Traction, avulsion or Poor prognosis. Extensive Microsurgery is indicated if
Fifth-degree injury laceration of nerve trunk fibrosis, neuroma formation or there is no improvement in
(Sunderland) neuropathic changes three months or development
of neuropathic response
epineurium, which allows for the axons to rege- Clinical Neurosensory Testing
nerate. Return of sensation requires regrowth of the
axons along the nerve sheath. This process may be Neurosensory testing should be performed to assess the
incomplete and often takes six months to one year degree of sensory impairment, monitor recovery and to
for return of sensation. Microsurgery is not determine whether microsurgery is indicated.
indicated unless a foreign body is preventing nerve Neurosensory testing can be divided into two based on
the specific receptor stimulated; viz. mechanoceptive and
regeneration.
nociceptive testing. Table 13.5 shows the neurosensory
Third and fourth degree: Sunderland injuries does
testing, the method of assessment and its significance.
not have a corresponding Seddon category. Third-
Mechanoceptive testing: This includes two point
degree injuries result from moderate to severe
discrimination, static light touch, brush strokes and
crushing or traction of the nerve. Wallerian
vibrational sense. Mechanoceptive testing should precede
degeneration is present. Disruption of the
nociceptive testing.
endoneurium does not allow complete regeneration
Nociceptive testing: This includes pain stimuli and
of the axon which results in mild to moderate
thermal discrimination.
permanent nerve disturbances. Microsurgery is
Testing should be performed in a reproducible
indicated if there is no sensory recovery after three
manner. The affected area is first mapped using bush
months.
strokes to differentiate normal from abnormal areas. This
Fourth-degree injuries occur with endoneural and

is then recorded on a standard testing form or marking
perineural disruption. Neuronal loss occurs with
directly on the patient's skin and photographing. This is
possibility of neuroma formation, intraneural scars

important for documentation.
and fibrosis. Prognosis for spontaneous recovery is
poor. Microsurgery is indicated if there is no
significant improvement after three months. Lingual Nerve Injury
iii. Neurotmesis (Sunderland fifth-degree injury):
The lingual nerve supplies general sensation to the
When there has been complete transection of the
mucosa of the anterior two-thirds of the tongue,
nerve with loss of continuity of both the axons and
sublingual mucosa, and the mandibular lingual gingiva.
the nerve sheath, the prognosis for recovery is much
Lingual nerve injury is a well-known neurological
poorer. The nerve responds by proliferation of complication of lower third molar surgery. The reported
Schwann cells, nerve buds and fibroblasts. This incidence of injury to the lingual nerve after third molar
results in an amputation neuroma at the end of the extraction has a range of 0.6% to 2.0% (Pogrel, 1995).24
peripheral nerve. If the ends line up reasonably well Inadvertent injury to lingual nerve can result in various
and the nerve buds can find their way through the degrees of paresthesia, dysesthesia and anesthesia in the
scar tissue to the distal tract, there may be a partial anterior two-thirds of the tongue, floor of the mouth and
recovery of sensation in the area of lost innervation. lingual gingiva. Severance of the lingual nerve will result
The sensations felt by the patient will include: in a variable loss of taste because of the involvement of
anesthesia or numbness, paresthesia or tingling the chorda tympani nerve, which runs within the lingual
and/or dysesthesia or pain. If the ends do not line nerve sheath. Consequent to lingual nerve injury patients
up, there may be complete and permanent loss of complaints of drooling of saliva, tongue biting, thermal
sensation. If recovery has not occurred within 18 burns, changes in speech and swallowing and alteration
months then a neurotemesis has almost certainly in taste perception. Lingual nerve injury occurs by direct
taken place. Microsurgery is definitely indicated for compression during incision or excision of bone during
this group of injuries. third molar removal, periodontal surgery, tumor removal,
Studies by Robinson (1992)23 in cats suggest that in cases of trauma or whenever procedures are performed
section injuries are more likely to result in persistent in the retromolar area.
sensory abnormalities of lingual nerve than crush Studies by various investigators have shown that the
injuries. following factors related to the surgical technique of
Table 13.5: Neurosensory testing, method of assessment and its significance
Neurosensory testing Method of assessment Significance/purpose

Static light touch Using Von Frey monofilaments. Monofilament A-beta fibers and pressure perception
is applied perpendicular to the skin. If this is
not available a wisp of cotton is used to stoke
the skin.
Two point discrimination Using ECG caliper, boley gauge, or two-point Normal values for inferior alveolar and
anesthesiometer. The test is repeated in lingual nerve distributions are approximately
2 mm increments until the patient can no 4 mm and 3 mm respectively.
longer perceive two distinct points.
Brush directional discrimination Using fine hair brush or the baseline Von Frey Assesses the integrity of large myelinated
monofilament used for static light touch. A-alpha and A-beta fibers.
Brush is stroked across the skin in a 1 cm
area and the patient is asked whether he/she
perceive the sensation and direction of the
stroke. For a normal result stroke should be
appreciated in 90% of the application.
Pin pressure nociception Using a sterile dental needle which is applied Asses the free nerve endings innervated by
in a quick prick fashion of sufficient intensity the lightly myelinated A-delta and
to be perceived by the patient. Appropriate unmyelinated C-fibers

response is the perception of sharp and not
just pressure. Alternatively a pressure
algesiometer may be used
Thermal discrimination Cold sensation–using a cotton applicator Cold is mediated by the unmyelinated
sprayed with ethyl chloride.Heat sensation- C-fibers Heat is transmitted by A-delta fibers.
using heated gutta percha. Minnesota
thermal discs also can be used.
Diagnostic nerve blocks Used in assessment of patients who have Helps to isolate the affected region of the
pain as a presenting symptom. Dilute local nerve and determine what level of fiber is
anesthetic (LA) agents can block the small affected.If diagnostic nerve blocks are
nerve fibers, while higher concentrations are effective in reducing/in relieving pain
required to block the larger myelinated fibers. microsurgery may be indicated.
These blocks are usually initiated at the
periphery and then administered centrally
along trigeminal nerve pathways.
impacted mandibular third molar contribute to lingual After analyzing the literature, it was interesting to
nerve damage (Readers may please refer chapter on note that the lingual nerve injuries were observed more
surgical anatomy for anatomical risk factors contributing often (40% to 70% of the time) on the right side (Renton
to lingual nerve injury): 2001)25, (Pogrel 1999).26 According to Len Tolstunov
a. Poor flap design (2007) 27 , it could be explained by the hand-eye
b. Uncontrolled instrumentation coordination, an acquired trait that becomes stronger with
c. Fracture of the lingual plate age, growing motor skills, and professional experience.
d. Stretching and compression of the nerve while It appears that most right-handed operators working on
retracting the lingual flap the right side of the patient can easily visualize the buccal
e. Trauma to nerve as a result of local anesthetic injection- side of the lower right third molar and the lingual side of
penetration through or into the nerve by the injection the lower left third molar. They cannot directly see the
needle. lingual side of the lower right third molar. This blind zone
during the surgery forces the operator to rely on his or is another cause of nerve damage especially when
her past experience, as well as on tactile sense. This factor the lingual bone is pierced or cut. Again, this can
may compromise intimate hand-eye coordination, adding be avoided with careful, adequate, deliberate
a guess factor to the procedure and increasing the risk of retraction, controlled instrumentation and direct
lingual nerve injury. The opposite is true for a left handed vision of the surgical field. Aggressive curettage and
operator working on the left side of the patient with follicle removal should be avoided on the lingual
regard to the mandibular left third molar. side of the socket. Although there is a theoretical
possibility of residual cyst formation due to retained
follicle, this complication is comparatively rare and
Prevention of Lingual Nerve Injury
relatively easy to deal with when it does occur.
A. Presurgical recognition of the risk factors: Distoangular During suturing, sutures should be placed
impactions (which are very often the most difficult superficially in the lingual flap to avoid possible
to remove) and the amount of bone coverage can nerve trauma.
be determined on initial clinical and radiographic Following the accepted technique of buccal approach
examination. A radiographic examination can also one can gain sufficient access to the third molar, if it is
show an overlap of roots of the third and second partially or fully impacted. As stated previously,
mandibular molars in case of a distoangular variations in the course of the lingual nerve made clear
by anatomical dissections indicate that it occasionally
impaction. This may alert an operator of a possible

lingual version of the roots of the third molar. passes through the retromolar pad. This reinforces the
Deficiency of the lingual plate may sometimes be obligatory use of the buccal incision.
palpable or can be determined with a probe during Distoangular impaction deserves more attention
initial examination. Occasionally, palpation of the especially when it is necessary to remove bone covering
soft tissue next to the lingual cortex can depict a the distocclusal portion of the tooth before removing the
superficially located lingual nerve. Presence of a tooth. This requires great care in gaining access to the
chronic inflammatory or infectious condition in the area. The lingual flap has to be retracted to expose the
retromolar region, such as chronic pericoronitis, can bone to be removed by drilling or by use of chisel. It is of
be obtained from the history and clinical utmost importance that this lingual flap be protected at
examination. Chronic pericoronitis is a well-known all times by means of a properly placed and designed
indication for extraction of third molars. An irony retractor so that the lingual flap is not damaged or
is that under certain circumstances it may become excessively compressed because this is an area where the
a risk factor of the lingual nerve injury. The presence lingual nerve might be encountered. Because a periosteal
of all the above anatomical risk factors in a clinical elevator may not be a broad enough retractor to totally
situation is rare. protect the nerve, special retractors have been developed
B. Proper surgical technique: With the buccal approach for this purpose such as Ward's, Meade's, Hovell's and
under direct vision, with all incisions made buccal Rowe's retractors. Recently, attention has been focused
to the third molar along the anterior border of the on the safety of lingual flap retractors with some studies
ramus, careful bone removal, management and particularly critical of the narrowness of the Howarth's
protection of the flap during drilling and elevation periosteal elevator. Other articles have also shown that
of the tooth structure, the lingual nerve can be though lingual nerve retraction during third molar
preserved during the surgery of mandibular third removal may cause transient damage, it is not associated
molars. Obviously, the lingual flap has to be with permanent damage and it has been suggested that
carefully retracted with a safe type of retractor when lingual nerve retraction should be used in the removal of
it is necessary to protect the flap during removal of third molars when necessary. A broader lingual retractor
bone, sectioning of tooth, and elevation of sectioned as compared to a Howarth's elevator was much less likely
portions of the tooth. Uncontrolled instrumentation to be associated with sensory loss.
is negligence and is one of the causes of damaging In a prospective study by Rood (1992)28 permanent
or severing the lingual nerve. Bone removal and damage was found to be significantly related to bone
tooth sectioning with a relatively high speed drill removal using a surgical drill. He concluded that
Howarth's periosteal elevator may not provide adequate fracture of mandible or after bilateral sagittal split
protection to the lingual nerve when a surgical drill is osteotomy (BSSO).
used. Razukevicius (2004)31 in his study on 195 patients,
There are conflicting reports regarding lingual nerve who had fracture of mandibular angle region identified
protection using subperiosteal insertion of retractors. In three degrees of inferior alveolar neural lesion. After
a prospective randomized study reported by Albio et al reduction and fixation of fracture, sensory recovery takes
(2000)29 designed to evaluate the efficacy of protecting place: in case of minor lesion of nerve in 21 days and
the lingual nerve by subperiosteal insertion of a retractor moderate lesion in 28 days. In severe lesion of inferior
in 300 patients, only an incidence of 1.33% of temporary alveolar nerve, the function still does not recover even in
lingual nerve dysesthesia was noted. No permanent 90 days after fracture reduction.
disturbances were found. The study suggested that In a prospective study by Becelli et al (2002)32 to
routine application of a lingual protecting instrument evaluate sensory disturbances development in patients
during surgical removal of a third molar is not necessary who underwent BSSO; thermal sensibility, nociception,
in the hands of an experienced surgeon. and two-point discrimination, were assessed. It was
Whatever precautions are taken, rarely lingual nerve found that the highest rate of spontaneous recovery of
injury may still occur. The aim of a study conducted in the entire inferior alveolar nerve function was observed
at the sixth month. This finding witnesses how
Finland by Irja Ventä et al (1998)30 was to examine
neuropraxia and axonotmesis give a spontaneous
malpractice claims for nerve injuries associated with third

recovery that most frequently occurs within 6 months
molar removals and determine whether they are
from surgery, independently of the age and sex of the
concentrated among specialists, among less experienced

patient. The persistence of anesthesia over 12 months
dentists, or in certain geographic areas. During 1987-93
could be a sign of neurotmesis.
there were 139 claims for permanent sensory or motor
In a follow-up of 1107 dentoalveolar operations in
disturbances related to removal of lower third molars in
the post- canine region by Schultze-Mosgau et al (1993)33
Finland. The lingual nerve was injured in 54% and the
it was observed that 24 (2.2%) had temporary sensory
inferior alveolar nerve in 41% of the claims. In 91% of the
disturbances of the inferior alveolar nerve and 16 (1.4%)
cases the injury occurred in relation to surgical removal
of the lingual nerve. Permanent disturbances were not
of the tooth and in 6% in relation to simple extraction.
present. Complete recovery had occurred by 6 months
The claims were distributed among 123 dentists, of whom in all cases.
78% were dental surgeons, 15% specialists in oral and Studies have shown that a number of factors have
maxillofacial surgery and 7% other specialists. been shown to be associated with a higher incidence of
Compensation was paid to the patients in two-thirds of inferior alveolar nerve damage following surgical
the cases indicating that the dentists authorized to decide removal of impacted mandibular third molar. They are:
claims very often considered these injuries avoidable. The a. Full bony impactions
authors concluded that proper diagnosis, treatment b. Horizontal impactions
planning, good surgical technique and detailed patient c. Use of burs for bone removal/ tooth sectioning
information are essential steps in each case. In cases where d. Apices extending into or below the level of the
risks are obvious, referral to an oral surgeon is neurovascular bundle
recommended. e. Clinical observation of the bundle during surgery
Inferior alveolar nerve injury: Compared to lingual f. Excessive hemorrhage into the socket during surgery:
nerve, injuries of inferior alveolar nerve have a much This can cause pressure on the nerve. Subsequent clot
more favorable prognosis. The area of the lip supplied organization and fibrosis may result in additional
by this nerve has a collateral innervation from C II and nerve damage.
the mental nerve of the opposite side. g. Age of the patient: In patients over 25 years incidence
The possibility of sensory impairment of inferior of nerve damage is slightly higher which may be
alveolar nerve is less likely to occur following surgical related to more difficult surgical procedure as age
removal of wisdom tooth than compared to that after advances.
Diagnosis and Management of Nerve Injury Regular follow-up following nerve injury must
therefore be carried out. A suggested regimen (Kaban
The diagnosis of nerve injury is usually obvious. The et al 1997)34 consists of evaluations (1) every 2 weeks for
patient presents post-operatively with the complaint that 2 months; (2) every 6 weeks for 6 months; (3) every 6
the local anesthetic effect has not worn off or that they months for up to 2 years ; and then (4) annually for an
have 'odd' sensations in their lip or tongue. The sensory
indefinite period. In most cases of nerve damage, recovery
branches of the trigeminal nerve transmit sensations of
occurs over six to eight weeks and the reminder usually
pain, pressure, temperature, touch and proprioception.
within six to nine months. There is still some possibility
In addition, the chorda tympani nerve which
of recovery up to 18 months, but after two years, further
accompanies the lingual nerve carries taste sensation from
spontaneous recovery is rare.
the anterior two thirds of the tongue. Because these
sensations are relayed by different diameters of nerve
fiber, differential loss and recovery of these components Management
can and do occur. Hence, it is generally recommended
that monitoring of all components of sensation should Complete transection of the lingual or inferior dental
be done. Loss of all sensory components carries a worse nerve requires immediate nerve repair by an experienced
prognosis and is more likely to indicate a continuity surgeon. Where there is partial damage, gentle
defect. debridement and the maintenance of good apposition of
The first step in the diagnosis of nerve injury is to the ends is normally undertaken. The patient should be
carefully determine the nature of the sensations. If the informed of the situation. Recent studies have shown that
patient has tingling, the diagnosis is neuropraxia and the significant improvement in nerve function can be
prognosis is usually good. It means the nerve has been achieved by surgical intervention and repair.
minimally damaged and that it should return to normal a. As in all cases, careful diagnosis and risk assessment
sensation. If the complaint is numbness without tingling, is the most important management tool in prevention
the prognosis is less clear. In these situations the progress of complications. This involves, first of all a thorough
overtime is diagnostic. If after three to six months, the knowledge of the anatomy of the innervation of the
patient has a return of tingling and then normal sensation, mouth and the course of the various nerves. It is
they have had an axonotmesis and the prognosis is important to remember that the lingual nerve lies in
reasonably good. If after six to twelve months there is no the soft tissue on the lingual aspect of the mandible in
return of sensation, it is likely that the nerve has been the third molar area. Careful assessment of
severed with extensive nerve degeneration (neurotmesis) radiographs will allow the identification of the position
and the progress is much poorer. of the mental foramen as well as the relationship of
Fig. 13.15: Pattern of return of sensation of tongue

following mild lingual nerve injury
Contraindications for trigeminal microsurgery: The

following are the contraindications for trigeminal nerve
microsurgery:
1. Central neuropathic pain
2. Evidence of improving sensory function
3. Hypoesthesia acceptable to the patient
4. Metabolic neuropathy
5. Severely medically compromised patient
Fig. 13.16: Pattern of return of sensation to lip and chin 6. Extremes of age
following mild injury to inferior alveolar nerve 7. Excessive time since injury.
Classification of nerve repair: Depending on the
the inferior alveolar canal to the roots of the molars, in timing relative to the initial injury it is classified as:
particular the third molar. a. Primary nerve repair: Performed immediately at the
b. If the risk assessment reveals an increased risk, time of an observed nerve injury
preventative measures must include a thorough b. Delayed primary repair: Done within a few weeks
informed consent about the possibilities of temporary following the injury
or permanent nerve damage. c. Secondary repair: Performed at a later stage, i.e. before
c. If nerve injury occurs, despite appropriate preventative one year if reinnervation of distal end organs is to be
measures, the patient should be followed up with expected. Significant distal nerve scarring and atrophy
careful documentation of the nature of the sensation occur by one year which makes microsurgery less
(or lack of it) as well as the distribution of the problem. predictable.

For this record, simple tissue maps are very useful. The case should be referred to a microsurgeon who
d. In most cases very little other than reassurance can be can perform the repair.
done to improve the situation. Time up to 6 to 12 Procedure of Trigeminal Microsurgery
months is usually required to fully diagnose the nature
of the defect. Often patients may be left with a residual The procedure is done under general anesthesia using
defect that is smaller in size and has less dense sense an operating microscope. Repair may also be performed
of numbness than the original distribution of the using an operating (surgical) loupe. But an operating
problem. microscope with multiple heads allows the surgeon and
e. Medical management: Corticosteroids have been tried the assistant simultaneous views of the surgical field.
Instruments needed consist of microforceps, scissors,
with variable success. Neurotropic vitamins have been
beaver blade, needle holder and nerve hooks.
suggested by some authors.
Basic steps in microsurgery are: (a) exposure, (b)
f. Physiotherapy and acupuncture have been tried with
hemostasis, (c) visualization, (d) removal of scar tissue,
varying success rates.
(e) nerve preparation, and (f) nerve anastomosis without
g. Surgical intervention: Microsurgery performed by
tension.
specially trained surgeons can achieve good results. Transoral approach is commonly used for
microneurosurgery. The inferior alveolar nerve (IAN) is
Indication for Trigeminal Nerve Microsurgery exposed either through an intraoral vestibular incision
followed by decortication of the buccal plate or through
The following are the indications for microsurgery: an extraoral approach. The lingual nerve is approached
1. Nerve transection either through a paralingual or lingual gingival sulcus
2. No improvement in hypoesthesia in three months incision.
3. Development of pain caused by nerve entrapment or External neurolysis is the surgical procedure to free
neuroma formation the nerve from its tissue bed and remove any restrictive
4. Pressure of a foreign body scar tissue or bone in the case of IAN injuries. For some
5. Progressively worsening hypoesthesia or dysesthesia patients, external neurolysis may be the only surgical
6. Hypoesthesia that is intolerable to the patient procedure indicated. The nerve is then examined carefully
to assess the need for any additional surgical procedure. Alternatives to nerve grafting: Several other materials
Foreign bodies such as endodontic filling material, tooth have been suggested for nerve grafting such as alloplastic
fragments or implant materials are removed at this point. tubules, skeletal muscles and vein grafts. The technique
Internal neurolysis is indicated when there is of entubilization using alloplastic materials is an
evidence of nerve fibrosis or gross changes in the external alternative to nerve grafting because there is no donor
appearance of the nerve. This procedure requires opening site morbidity and the alloplastic material could guide
of the epineurium to examine the internal fascicular the regenerating axon.
structure of the nerve. (Because the trigeminal nerve has
Outcome of Trigeminal Nerve Microsurgery
a sparse amount of epineurium, any manipulation can
lead to further scar tissue formation. Hence some The literature available on the postoperative outcome of
surgeons question the use of this procedure). If complete trigeminal microsurgery is limited.
fibrosis is observed, the affected segment is excised and There is little standardized manner in assessing
the nerve prepared for primary neurorrhaphy. outcome, and the numbers studied are very limited
Excision of neuromas is performed to permit especially when it comes to the lingual nerve. In clear
reanastomosis of complete nerve injuries in an effort to cases of nerve impingement by bone spicules or root tips,
decompression may be helpful depending on the timing
re-establish continuity and allow for nerve regeneration.
after the injury. Removal of traumatic neuromas and
After excision of the neuroma or non viable nerve tissue,
reanastomosis may also be performed. Repair may entail
the resulting segments are examined to ascertain whether

decompression, direct suture, or grafting. If continuity
normal tissue is present, which is determined by the
defects are noted, nerve grafting has also been attempted
presence of herniated intrafascicular tissues. The next step with some success. In 1996, Robinson reported 13 patients
is the approximation of the two ends of the nerve without in whom the lingual nerve was repaired by apposition
tension, the procedure called primary neurorrhaphy. and epineural suture. The mean duration post injury was
Approximation is done using a 7-0 or smaller epineural 16 months. There was some sensory restoration and some
suture. Tension greater than 25 g has been demonstrated taste recovery.
to have a deleterious effect on nerve regeneration due to Pogrel et al (1993)35 reported that repair between
the possibility for gaping and formation of scar tissue. three and six months following injury has the best results.
Nerve grafting: Nerve grafting is indicated in cases In their study of 43 patients who underwent micro-
where there is a continuity defect or where repair can neurosurgery for various types of injuries, and have been
not be achieved without tension. The selection of a donor followed for at least one year, found four (9.3%) with
site for interpositional nerve grafting is considered based essentially complete return of sensation; five (11.6 %) with
on several factors such as: (a) nerve diameter, (b) good return; 19 (44.2%) with some return; 13 (30.2%) with
fascicular pattern, (c) correlation of neural function such no return; and two (4.6%) with a decrease in sensation.
as sensory or motor, (d) ease of graft procurement, (e) Dodson and Kaban (1997)36 performed an evidence
based study to formulate treatment guidelines for
donor site morbidity. For trigeminal nerve repairs, the
operative management of trigeminal nerve injury. Their
sural and greater auricular nerves meet most of these
summary of recommendation include; (a) tension free
requirements. The average diameter of IAN is 2.4 mm
primary repair whenever possible, (b) use of autogenous
and for the lingual nerve it is 3.2 mm. While the sural
nerve grafts when direct primary repair is not possible,
nerve is approximately 2.1 mm in diameter and the (c) use of autogenous nerve grafts or hollow conduits used
greater auricular nerve 1.5 mm diameter. Thus there is for entubilization of nerve gaps 3 cm or smaller when
no exact match available for trigeminal nerve grafting. direct repair is not possible.
Cross-sectional shape of IAN and lingual nerve is In a study reported by Pogrel (2002)37, 51 patients
generally round; whereas the sural nerve is flat and underwent microneurosurgical exploration and repair of
greater auricular nerve is oval. Moreover the fascicular inferior alveolar and lingual nerve. In 5 patients, no injury
number and size of the fascicles of these donor and could be detected at surgery, and no corrective surgery
recipient nerve also does not match, which also affects was performed other than decompression. In 26 patients,
the regeneration of the nerve. excision and direct anastomosis were performed, and in
an additional 20 patients, nerve gap reconstruction was and Legionella in dental compressed air lines may be
performed. In 16 of these 20 patients, reconstruction was passed into tissue spaces. Subcutaneous emphysema has
performed with an autogenous vein graft, and in also been reported following the use of air syringes,
2 patients, a Gore-Tex tube graft (WL Gore and Associates, hydrogen peroxide and patient activities such as sneezing
Inc, Flagstaff, AZ) was used to bridge the nerve gap. In and nose blowing.
2 patients, an autogenous nerve was used. 34 of the repairs 9. Hematoma: A hematoma is a collection of blood
were made on the lingual nerve, and 17 were made on in a virtual space. Sutures should be placed with
the inferior alveolar nerve. With the use of established minimum tension just to approximate the edges of the
criteria, 10 patients were considered to have had a good wound. Over tight sutures with no wound toilet and
improvement in sensation, 18 patients were considered further bleeding from bone or soft tissue results in
to have had some improvement in sensation, and 22 hematoma. Once hematoma is diagnosed, one or two
patients were considered to have had no improvement sutures may be removed to drain the collected blood and
in sensation; one patient reported an increase in to control the hemorrhage. Failure to do so will result in
dysesthesia after surgery. The author concluded that organization of hematoma and subsequent infection or
microneurosurgery can provide a reasonable result in fibrosis
improving sensation in the inferior alveolar and lingual 10. Pain during swallowing: Projecting piece of
nerve. More than 50% of patients experienced some lingual plate or including the mucosa of the floor of the
improvement in sensation, and dysesthesia did not mouth while suturing frequently results in this. Tearing
develop after surgery in any patient who did not have it of the mylohyoid or superior constrictor muscle also
before surgery. results in pain during swallowing. Edema of the pharynx
Transected lingual nerves that undergo microsurgical or associated with hematoma formation also contribute
repair can result in the recovery of taste, regeneration of to this post operative difficulty. Following operations
fungiform taste receptors and recovery of some under general anesthesia, sore throat occurring post
neurosensory function. Hence early repair of complete operatively can be attributed to use of a dry throat pack
lingual nerve injury is recommended to provide the or trauma to the soft tissues of the throat from the end of
optimal chance for return of gustatory function. suction tip.
Patients with chronic pain after trigeminal nerve 11. Pyrexia: Slight elevation in body temperature
injuries may have varied outcomes based on their specific immediately following surgery is anticipated. This will
presenting complaints. Various studies have shown an return to normal in about 12 to 24 hours. If pyrexia
overall reduction of 50% in pain severity. The greatest continues beyond this time, possibility of wound infection
reduction in pain was observed in patients with or pyrexia due to systemic causes should be suspected.
hyperalgesia and hyperpathia. 12. Osteomyelitis: This is a more serious infection of
8. Surgical Emphysema: Use of high speed air driven the bone. The commonest type to occur is the
hand piece or excessive gagging during or after oral subperiosteal type, when pus collects beneath periosteum
surgical procedure leads to this complication. Surgical and obstructs the periosteal blood supply to the outer or
emphysema of the neck and mediastinum as a inner cortical plates. This will result in sequestration of
consequence of attempted extraction of a third molar the cortical plates. The treatment is drainage of the pus
tooth using an air turbine drill has been reported in the and antibiotic therapy. If only small sequestra are present
literature. This is a potentially life-threatening compli- it will be extruded spontaneously along with the pus.
cation. Hence the use of air turbines for the removal of Large sequestra when present have to be removed
bone or for the division of teeth is to be deprecated. surgically.
It is postulated that air is forced into the subcutaneous Intramedullary osteomyelitis is a more serious
and fascial tissue planes and into the mediastinum. Air- complication. When it occurs following surgical removal
powered drills which are unsuitable for use in oral of impacted wisdom tooth (Fig.13.17), it frequently
surgery, are those which vent air forward into soft tissues, progress to pathological fracture of mandible. Due to
the air carrying an unsterile mixture of water and oil with concurrent formation of involucrum there is little mobility
it. Potential microbial contaminants such as Pseudomonas or displacement of fragments in such cases.
Figs 13.17A and B: (A) Radiograph showing osteomyelitis of mandible that developed following surgical removal of impacted third molar in a
52-year-old lady (yellow oval). The case was managed by sequestrectomy and antibiotic therapy, (B) Postoperative X-ray
Avascular necrosis of bone is another complication while performing surgery under general anesthesia.
similar to osteomyelitis in which portions of buccal or Studies have shown that in most patients with
lingual cortical plate gets sequestrated. This occurs due to anterior disk placement with reduction, extraction of third
excessive stripping of the periosteum from the mandible molar was unlikely to have been the etiologic factor.
followed by failure of its reattachment. This interferes with Due to the result of strain in the temporomandibular
the revascularization leading to necrosis due to joint during removal of impacted mandibular third molar,
compromised blood supply. Factors contributing to patient may experience pain in the affected joint area post
avascular necrosis are extreme sclerosis of bone, presence operatively. This may be due to traumatic effusion or
of pus beneath the periosteum, and damage to the central subluxation of the joint subsequent to tearing of the
blood supply of mandible; the inferior alveolar artery. The capsular ligament. Frequently the condition resolves by
condition is manifested as a small swelling at the angle of itself but sometimes it requires treatment if pain persists
the mandible with minimum pain. Radiographic for a longer period. Nonsurgical modalities such as rest,
examination will give the appearance of an intramedullary heat, muscle relaxants and a simple bite raising appliance
osteomyelitis with a pathologic fracture. Surprisingly the will relieve the pain usually.
patient will have minimum discomfort. Unless secondarily Removal of wisdom tooth may exacerbate a
infected the condition does not require active treatment. preexisting TMJ problem. Epidemiological studies have
When large sequestra protrude through the overlying shown that up to 60% of the population may suffer from
mucosa, they should be removed. some degree of temporomandibular joint dysfunction at
13. Temporomandibular joint (TMJ) complications: some time. Hence oral and maxillofacial surgeons should
It has been suggested that because the procedure of include an examination of the TMJ region, including an
extracting mandibular third molars involves the patient evaluation of joint sounds, opening and excursive
opening the mouth wide for an extended period of time movements and temporal / masseter / pterygoid muscle
and exerting a variable amount of force on the mandible, tenderness in all preoperative third molar extraction
it is possible to overload or injure one or both TMJs. This patients.
is especially so if the surgeon did not use the correct Development of post operative TMJ problem can be
surgical technique or has failed to support the mandible best prevented by judicious application of force, allowing
while removing the mandibular third molar or if the the patient to bite on a mouth prop and rest every few
patient's protective mechanism for opening was exceeded minutes if the procedure is prolonged.
14. Fracture of instruments: Especially that of sharp existing conditions such as: (a) age greater than 25 years,
ones can occur. The tapering end of a periosteal elevator (b) pre-existing periodontal defects i.e. attachment level
or tip of a cross bar elevator or tip of a bur can get (AL) greater than 3 mm or probing depth (PD) greater
fractured and get wedged deep in the bone. Its presence than 5 mm, (c) horizontal or mesioangular impaction. In
has to be verified using a radiograph if not clinically the event of having all three risk factors present there
visible before attempting its removal. If not retrievable, seems to be a predictable benefit in treating the
the patient should be told and the fact is recorded in the dentoalveolar defect at the time of extraction. Although
notes. nonresorbable guided tissue regeneration (GTR),
15. Periodontal pocket formation distal to second demineralized bone powder (DBP), and autologous
molar: Recently there has been a renewed interest in this platelet-rich-plasma (PRP) all work well in the setting of
direction. Removal of third molars is often carried out to high-risk mandibular third molars, DBP is the simplest
preserve periodontal health or to treat existing perio- and most inexpensive to use. Dodson (2007)39 reported
dontitis. Post operative periodontal pocket formation that, having patients with all three risk factors present is
occurs especially when there is an existing periodontal an uncommon occurrence. When the risk factors are
pocket prior to surgery, or when there is poor post- present Dodson recommends grafting the third molar
surgical local plaque control. Moreover, the impacted socket with DBP. Generally 2 cc of DBP is adequate to fill
tooth removed will be mesio angularly placed, with pre the socket. The wound is closed primarily with a
surgical crestal radiolucency seen in radiographs in resorbable suture and the patient is placed on an antibiotic
association with inadequate plaque control after mouth rinse and a short course of oral antibiotic (e.g.
extraction. This can predispose to a persistent localized penicillin) for 5 to 7 days. However the efficacy of the
periodontal problem (Kan et al, 2002).38 The use of barrier antibiotic or mouth rinse is unknown.
membrane to prevent this complication has been repor- 16. Aspiration /Swallowing of tooth: This is a possible
ted. complication associated with the removal of impacted
The greatest bone defects occur in older patients tooth. All third molar extraction procedures carry the risk
where there is an osseous defect on the distal aspect of of tooth aspiration. The use of properly placed
second molar or in whom third molars have already oropharyngeal gauze pack is essential in preventing this
resorbed part of the second molar. In contrast to older complication while operating under general anesthesia.
patients, in most young patients bone height after third The use of intravenous deep sedation may compromise
molar removal appears similar to the preoperative level. the protective reflexes of the airway. The aspiration or
Some studies have even shown a gain in bone level swallowing of a tooth or portion of a tooth is usually the
following surgery. Hence, there seems to be a general result of a patient coughing or gagging.
agreement that post operative periodontal health around Elgazzar et al (2007)40 reported a case of an aspirated
second molar is better if the third molar is removed when impacted lower third molar during its removal under
the patient is young. local anesthesia. The problem was recognized imme-
Role of reconstructive technique after third molar diately during the surgical procedure. The patient, a 23-
surgery to prevent periodontal defects. year-old male, was subjected to urgent radiological
There have been a number of studies to find out examination. The aspirated tooth was detected in the right
whether there is a role for reconstructive technique or bronchus and eventually removed by rigid bronchoscopy.
any specific intervention following third molar removal Most foreign bodies can usually be removed by
to improve the long-term periodontal health on the distal skillful application of endoscopic techniques. Never-
aspect of adjacent second molar. The results of the study theless, spherical foreign bodies, such as teeth remain
showed that routine intervention to improve the difficult to manage. In a case reported by Ulkü et al
periodontal parameters on the distal aspect of the second (2005)41 the treatment of a patient who had a tooth lodged
molar at the time of third molar removal is not indicated in the right lung by open surgical approach was discussed
in all the cases. However, there is a small proportion of along with treatment options.
patients who are at an increased risk of periodontal Summary of complications associated with impacted
defects following third molar removal due to the pre- third molar surgery.
The most common complications are as follows: 8. Chiapasco M, De Cicco L, Marrone G. Side effects and com-
• Pain, swelling and trismus are common post-operative plications associated with third molar surgery. Oral Surg
features of third molar surgery, with maximum pain Oral Med Oral Pathol 1993;76(4):412-20.
about 6 hours after surgery. These post operative 9. Jensen S. Hemorrhage after oral surgery. An analysis of
sequelae/complications can cause significant 103 cases. Oral Surg Oral Med Oral Pathol 1974;37(1):2-16.
deterioration in quality of life of the patient for the 10. Moghadam HG, Caminiti MF. Life-threatening hemorr-
hage after extraction of third molars: Case report and
first 4 to 5 post-surgical days
management protocol. J Can Dent Assoc. 2002;68(11): 670-
• Dry Socket/Alveolar Osteitis
74.
• Wound infection/post operative infection
11. Guibert-Tranier F, Piton J, Riche MC, et al. Vascular malfor-
• Post-operative bleeding
mations of the mandible (intraosseous hemangiomas): the
• Lingual and inferior alveolar nerve injuries importance of preoperative embolization. A study of 9
– transient disturbances of the inferior alveolar nerve cases. Eur J Radiol 1982;2:257
– transient disturbances of the lingual nerve 12. Mac Auley DC. Ice therapy: how good is the evidence? Int
– permanent nerve disturbances J Sports Med 2001;22:379-84.
Most of these nerve injuries are transient in nature. 13. Sortino F, Messina G, Pulvirenti G. Evaluation of post-
• Another less common complication is periodontal operative mucosa and skin temperature after surgery for
pocketing, which occurs distal to the second impacted third molar. Minerva Stomatol. 2003;52(7-8):
mandibular molar. 393-99.
• Fracture of mandible is a rare complication with an 14. Filho JRL, Silva EDO, Camargo IB, and Gouveia FMV. The
incidence of 0.0049% influence of cryotherapy on reduction of swelling, pain and
• Other severe, rare and unexpected complications can trismus after third-molar extraction- A preliminary study.
also occur following third molar surgery due to poor J Am Dent Assoc 2005; 136(6):774-78.
clinical case assessment or due to careless and 15. Forsgren H, Heimdahl A, Johansson B, Krekmanov L. Effect
unorthodox surgical practice. of application of cold dressings on the postoperative course
in oral surgery. Int J Oral Surg 1985;14(3):223-28.
16. YM Nusair. Local application of ice bags did not affect
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18. Lago-Méndez L, Diniz-Freitas M, Senra-Rivera C, Gude-
2. Waseem J, Mohammed El-M, Brian S, Bilquis B, Tahwinder
Sampedro F, Gándara Rey JM, García-García A. Relation-
U, Sapna D'Sa, Mohammed Al-K et al. Experience versus
ships between surgical difficulty and postoperative pain
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in lower third molar extractions. J Oral Maxillofac Surg
Medicine 2006;2:14.
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3. Bouloux GF., Steed MB., Perciaccante V J. Complications
19. Peñarrocha M, Sanchis JM, Sáez U, Gay C, Bagán JV. Oral
of third molar surgery. Oral Maxillofac Surg Clin N Am
hygiene and postoperative pain after mandibular third
2007;19:117-28.
molar surgery. Oral Surg Oral Med Oral Pathol Oral Radiol
4. Libersa P, Roze D, Cachart T, et al. Immediate and late
Endod 2001;92(3):260-64.
mandibular fractures after third molar removal. J Oral
20. Birn H. Etiology and pathogenesis of fibrinolytic alveolitis.
Maxillofac Surg 2002;60:163.
5. Gay-Escoda C, Berini-Aytes L, Pinera-Penalva M. Int J Oral Surg 1973;2:211.
Accidental displacement of a lower third molar: report of 21. Hermesch CB, Hilton TJ, Biesbrock AR, Baker RA, Cain-
a case in the lateral cervical position. Oral Surg Oral Med Hamlin J, McClanahan SF, Gerlach RW. Perioperative use
Oral Pathol 1993;76:159. of 0.12% chlorhexidine gluconate for the prevention of
6. Esen E, Aydogal LB, Akcali MC. Accidental displacement alveolar osteitis: efficacy and risk factor analysis. Oral Surg
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pharyngeal space. J Oral Maxillofac Surg 2000;58:96. 381-87.
7. Ortakoglu K, Okçu KM, Karasu HA, Günaydin Y. Acci- 22. Brann CR, Brickley MR, Shepherd JP. Factors influencing
dental displacement of impacted third molar into lateral nerve damage during lower third molar surgery. Br Dent J
pharyngeal space. Turk J Med Sci 2002;32:431-33. 1999;186(10):514-6.
23. Robinson PP. The effect of injury on the properties of 33. Schultze-Mosgau S, Reich RH. Assessment of inferior
afferent fibres in the lingual nerve. Br J Oral Maxillofac alveolar and lingual nerve disturbances after dentoalveolar
Surg. 1992;30(1): 39-45. surgery and of recovery of sensitivity. Int J Oral Maxillofac
24. Pogrel MA, Renaut A, Schmidt B, et al. The relationship of Surg 1993;22(4):214-17.
the lingual nerve to the mandibular third molar region: an 34. Kaban, Pogrel, Perrott. Complications in Oral and
anatomic study. J Oral Maxillofac Surg 1995;53:1178-81 Maxillofacial Surgery. WB. Saunders, Philadelphia, 1997;
25. Renton T, McGurk M. Evaluation of factors predictive of
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35. Pogrel MA, Kaban LB. Injuries to the inferior alveolar and
Maxillofac Surg 2001;39: 423-28.
lingual nerves. J Calif Dent Assoc 1993;21(1):50-54.
26. Pogrel MA, Thamby S. The etiology of altered sensation in
the inferior alveolar, lingual, and mental nerves as a result 36. Dodson TB, Kaban LB. Recommendations for management
of dental treatment. J Calif Dent Assoc 1999;27:531-38. of trigeminal nerve defects based on a critical appraisal of
27. Len Tolstunov. Lingual nerve vulnerability: risk analysis the literature. J Oral Maxillofac Surg 1997;55:1380-86.
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nerves during the removal of impacted mandibular third 38. Kan KW, Liu JKS, Lo E CM., Corbet E F, Leung WK. Resi-
molars. Comparison of two methods of bone removal. Br dual periodontal defects distal to the mandibular second
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29. Albio JG, Imaz R, Escoda CG. Lingual nerve protection
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prevent periodontal defects after third molar surgery? Oral
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Odontologica Scandinavica 1998;56(4):193-96. 40. Elgazzar RF, Abdelhady AI, Sadakah AA. Aspiration of
31. Razukevicius D. Stomatologija. Baltic Dental and an impacted lower third molar during its surgical removal
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osteotomy: An analysis of spontaneous recovery patterns tooth aspirated during dental extraction: a case report. Aust
observed in 60 patients. J Craniofac Surg 2002;13:2. Dent J 2005;50(1):49-50.
14 Ectopic Teeth and
Unusual Cases
The occurrence of ectopic teeth (ectopic simply means There have been reports of ectopic maxillary molars
'wrong position') at sites other than their immediate in maxillary sinus 2,6,7 and of ectopic mandibular third
dental environment is rare. A few reports of tooth molar in the condylar region. 8,9
displacement in the maxillary sinus, nasal cavity, orbit, Wong et al (2007)5 reported a rare case of ectopic
chin, mandibular ramus, condyle, and coronoid process molar medial to the coronoid process of the mandible
have been published.1,2,4 The etiology of ectopic teeth is (Figs 14.1A to D) that caused a chronic discharging sinus
not always known, but it includes developmental into the mouth, recurrent facial swelling and pain. The
abnormalities, overcrowding, trauma, sepsis or iatrogenic tooth was removed under general anesthesia by an intra-
activity such as displaced during extraction. 1,3 oral approach after making an incision along the anterior
Presumably, the etiologic factor is related to the type of border of the ramus.
tooth (e.g. incisor, canine, third molar, or supernumerary) For ectopic mandibular third molars located in the
and its immediate anatomic environment. Patients with condylar process of the mandible various approaches
an ectopic tooth impaction can remain asymptomatic over have been suggested to gain access for the removal of
the course of their lifetime. But when such a tooth the tooth. Bux and Lisco (1994)8 reported a case of third
migrates, particularly one that is accompanied by a cyst, molar located in the subcondylar region removed by a
patients can experience significant morbidity and require submandibular approach. Tumer et al (2002)9 reported
intervention. another case of ectopic tooth in a similar position which
There are four treatment options (Wong et al, 2007)5 was removed through a preauricular approach. Szerlip
for ectopic teeth: observation, intervention, relocation or (1978)10 reported a case of ectopic third molar located in
extraction. If no symptoms or pathology is evident, the condylar process of the mandible removed by an
observation may be the treatment of choice. Intervention intraoral approach.
consists of a brief period of orthodontic therapy or the Büyükkurt et al (2005)12 reported a case of ectopic
removal of the teeth. Relocation refers to the repositioning eruption of a maxillary third molar tooth in the maxillary
of an ectopic tooth surgically or orthodontically. The aim sinus that caused chronic maxillary sinusitis. This was
of intervention or relocation is to maintain the integrity later removed by a Caldwell-Luc approach. Recently
of the arch and occlusion. However, extraction should endoscopic approach for the removal of tooth in maxillary
be considered if the above measures are deemed sinus has been suggested by other authors.
impossible or the tooth is symptomatic or associated with In a recent article Suarez-Cunquerio et al (2003)11
infection or pathologies such as cystic changes. employed an endoscopic approach to remove an ectopic
Figs 14.1A to D: Ectopic molar medial to the coronoid process of the mandible. (A) OPG showing a tooth associated with the coronoid process
of mandible, (B) Axial CT scan showing the tooth on the medial side of the coronoid process, (C) Intraoperative view with retractors, (D) The
ectopic tooth after removal. (Adapted with kind permission of Wong et al)
mandibular third molar in the condylar process. They

claimed the following advantages: (a) good illumination,
(b) clear and magnified visualization of the operating
field, (c) more conservative surgery, (d) risk of damage
to facial nerve is minimal and (e) scars on the skin could
be avoided. The authors advocated endoscopy for
removal of third molars not only in the condylar process
but also in other ectopic locations such as the maxillary
sinus and the nasal fossa. However, adequate training is
essential. Fig. 14.2: Radiograph showing mandibular third molar erupting from
the inferior border of mandible. Patient presented with chronic
The following are some of the cases of ectopic teeth discharging sinus in the left submandibular region. The impacted tooth
treated by the author. was removed under general anesthesia by submandibular approach.
Ectopic Teeth and Unusual Cases 155
Fig. 14.6: Showing all the third molars impacted with 'kissing molars' in
the mandible associated with dentigerous cyst
Fig. 14.3: Impacted mandibular third molar near the condyle and
associated dentigerous cyst. Patient presented with chronic discharging
sinus in the right parotid region. The impacted tooth along with the cyst
was removed under general anesthesia by submandibular approach
Figs 14.7 A to C: An 18-year-old girl reported with complaints of

unerupted lower first and second molars on the left side. (A) Intraoral
view showing unerupted 36 and 37 and partially erupted 38, (B) OPG
showing impacted 36, 37, and 38. CT scan was taken to ascertain the
relationship of inferior alveolar nerve (IAN) to the impacted teeth. (C)
Coronal CT scan showing IAN (red arrow) lingual to the impacted teeth.
Figs 14.4A to D: Impacted 48 in the ramus. (A) A 53-year-old male All the impacted molars were removed under general anesthesia via
patient presented with chronic discharging sinus in the right intraoral approach
submandibular region (dark broken line), (B) OPG revealed impacted
48 (yellow broken line) in the ramus, (C) Intraoral examination showed
missing 46,47, and 48. Note that the bone in the anterior border of
ramus is intact. The impacted tooth (D) was removed under general
anesthesia by submandibular approach
Figs 14.8A to C: (A) A 26-year-old male patient presented with chronic

discharging sinus in the right cheek, (B) Right lateral oblique view X-
ray of the mandible showed impacted mandibular third molar in the
ramus in an inverted position with a surrounding radiolucent area
Fig. 14.5: Impacted 38 in the left ramus (yellow broken line). Due to suggestive of a dentigerous cyst. The impacted tooth along with the
chronic infection, there was bone destruction in the anterior part of ramus surrounding cyst wall was removed under general anesthesia by
(dark arrows) in front of the tooth. Surgical removal of tooth was done submandibular approach, (C) Postoperative right lateral oblique view
under local anesthesia via intraoral approach X-ray of mandible
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10.
1. Bodner L, Tovi F, Bar-Ziv J. Teeth in the maxillary sinus- 8. Bux P, Lisco V. Ectopic third molar associated with a
imaging and management. J Laryngol Otol 1997; 111: 820- dentigerous cyst in the subcondylar region: Report of a
24. case. J Oral Maxillofac Surg 1994; 52: 630-32.
2. Elango S, Palaniappan SP. Ectopic tooth in the roof of the
9. Tumer C, Eset AE, Atabek A. Ectopic impacted mandibular
maxillary sinus. Ear Nose Throat J 1991; 70: 365-66.
third molar in the subcondylar region associated with a
3. Pracy JP, Williams HO, Montgomery PQ. Nasal teeth. J
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Laryngol Otol 1992; 106: 366-67.
231-33.
4. Jude R, Horowitz J, Loree T. A case report. Ectopic molars
that cause osteomeatal complex obstruction. J Am Dent 10. Szerlip L. Displaced third molar with dentigerous cyst—
Assoc. 1995; 126: 1655-57. An unusual case. J Oral Surg 1978; 36: 551-52.
5. Wong YK, Liew JCH, Tsui SHC, Cheng JCF. Ectopic molar 11. Suarez-Cunqueiro MM, Schoen R, Schramm A, Gellrich
near the coronoid process: Case report. Quintessence Int. NC, Schmelzeisen R. Endoscopic approach to removal of
2007; 38: 597-600. an ectopic mandibular third molar. Br J Oral Maxillofac
6. Goh YH. Ectopic eruption of maxillary molar tooth—An Surg 2003; 41: 340-42.
unusual case of recurrent sinusitis. Singapore Med J 2001; 12. Büyükkurt MC, Tozoglu S, Aras MH, Yolcu Ü. Ectopic
42: 80-81. eruption of a maxillary third molar tooth in the maxillary
7. Buyukkurt MC, Tozoglu S, Aras MH, Yolcu U. Ectopic sinus: A case report. J Contemp Dent Pract 2005; 6:
eruption of a maxillary third molar tooth in the maxillary 104-10.
15 Recent Advances and the
Future of Third Molars
The advisability of the removal of asymptomatic impacted Laskin(1979) 1 and Selinger and colleagues (1966) 2
third molars by early prophylactic surgical extraction has recognized that some teeth such as third molars pose
been debated in dentistry for many years. Despite a 1979, problems for people and they achieved limited success
conference on third molar removal sponsored by the at inhibiting odontogenesis using cryogenics and
National Institute of Health, no unanimity of agreement sclerosing agents in dogs. Their research focused on
has been reached within the profession and decisions on stopping succedaneous premolar tooth development after
whether to extract third molars largely are based on initiation when considerable tooth tissues already had
practitioners' experiences and bias. The conference did formed. Succedaneous premolars develop in a slightly
conclude that impacted third molars represent an abnormal different manner and position than nonsuccedaneous
state. While proponents of the routine surgical extraction human third molars.
of third molars believe that early extraction is preferable Since, the initiation of third molars occurs at or near
to the potential for pathological degeneration and disease the surface of the jawbone just millimeters below the oral
of these teeth later in life, clinicians who do not support mucosa, their location is relatively accessible in children.
routine prophylactic extraction feel that there is a lower In lower mammals that have third molar developmental
risk of pathological degeneration and disease compared stages comparable with those of humans, early studies
with the risks of surgery. have shown that selective third molar agenesis can be
The mandate for dentistry in the 21st century calls accomplished with several minimally invasive techniques
for continued efforts directed toward eliminating dental that use electrosurgery and laser energy (Anthony R
disease and enhancing the overall health and well-being Silvestri, DMD, unpublished data, January 2002). Even
of patients by translating scientific discovery into clinical small amounts and concentrations of locally delivered
practice. Hence, there is opportunity to extend the teratogens such as alcohol have stopped third molar
mandate to the paradoxical third molar and the dilemma development in rats (Anthony R Silvestri, DMD,
it creates for patients. unpublished data, January 2002). The lack of expression
of certain growth factors3,4 the presence of vitamin-
derived retinoic acid derivatives5,6 and the presence of
Intentional Therapeutic Agenesis of the Tooth
commonly ingested food additives like citral7 have been
Because no third molar exists from birth until nearly five shown in the basic science literature to have dramatic
years of age, a window of opportunity exists for the effects on tooth bud initiation and early tooth
elimination of third molars before they form. development. It may be possible to selectively stop the
One theoretical clinical possibility is intentional development of third molars by specifically targeting
therapeutic agenesis of third molars before initiation epithelial dental lamina migration, the initiation of tooth
when no third molar tooth tissues exist. Gordon and bud development or the earliest initial stages of tooth
development with extremely small quantities of a locally 4. Frazier-Bowers SA, Guo DC, Cavender A, et al. A novel
delivered therapeutic agent. mutation in human PAX9 causes molar oligodontia. J Dent
Res 2002; 81(2): 129-33.
5. Kronmiller JE, Beeman CS. Spatial distribution of
REFERENCES
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2. Selinger LR, Archer WH, Thonard JC. Inhibition of tooth JV. Expression of nuclear retinoic acid receptors during
development with a sclerosing agent, sodium tetradecyl mouse odontogenesis. Differentiation 1994; 57(3): 195-
sulfate. J Dent Res 1966; 45: 236-42. 203.
3. Peters H, Neubuser A, Kratochwil K, Balling R. Pax9- 7. Kronmiller JE, Beeman CS, Nguyen J, Berndt W. Blockade
deficient mice lack pharyngeal pouch derivatives and teeth of the initiation of murine odontogenesis in vitro by citral,
and exhibit craniofacial and limb abnormalities. Genes Dev an inhibitor of endogenous retinoic acid synthesis. Arch
1998; 12: 2735-47. Oral Biol 1995; 40: 645-52.
Recent Advances and the Future of Third Molars 159
SUMMARY AND LEARNING POINTS
1. Assessment of the unerupted and impacted third 5. Proper case assessment and careful surgical
molar must involve history (including medical technique can prevent unwanted complications.
history) taking, clinical examination and 6. In third molar surgery, the buccal approach with
radiological investigations. minimal lingual soft tissue retraction minimizes the
2. Asymptomatic and pathology-free impacted third likelihood of lingual nerve injury.
molars need not be removed. 7. Excessive bone removal is not recommended.
3. Impacted third molars should not be removed to 8. The routine use of antibiotics in third molar removal
prevent late anterior crowding. is not recommended.
4. The main indications for removal of impacted third
molars are dental caries and third molar associated
infections.
LEARNING POINTS
Unerupted and Impacted Third Molars • List radiographic features used in the assessment of
impacted teeth.
• Define impaction of teeth and odontectomy. • Analyze any periapical and panoramic radiograph of
• Describe the location of mandibular third molars in the mandibular third molar region.
relation to the osseous areas of the mandible.
• State the relative degree of difficulty as determined
• Describe the surgical significance of the osseous
by angulation of the impacted third molar on
anatomy in the region of mandibular third molars.
radiographic examination.
• Describe the relationship between the neurovascular
• Describe the outline for mucoperiosteal flaps that will
bundle and mandibular third molar teeth.
avoid injury to the critical anatomic structures of the
• Describe the surgical significance of the position of the
mandibular third molar area.
inferior neurovascular bundle.
• Describe the technique for removing bone to expose
• Describe the surface (soft tissue) anatomy of the area
impacted third molar including appropriate
distal to the mandibular third molar.
instruments.
• Describe the surgical significance of the soft tissue area
• Describe the technique for placement of a purchase
distal to mandibular third molars.
• Describe the anatomical location of the facial artery. point and the appropriate instruments for this
• Describe the surgical significance of the facial artery. procedure.
• Describe the location of the lingual nerve. • Describe the instruments used for elevation using
• Describe the surgical significance of the lingual nerve purchase points.
including the most likely cause for surgical damage. • Describe the methods used for tooth sectioning and
• State the primary indications for removal of the appropriate instruments.
mandibular third molars. • Describe the procedure of preparation of the wound
• State the primary contraindications for removal of prior to closure.
mandibular third molars. • Describe the procedure for closure of the incision.
• State whether or not a mandibular third molar should • Describe the step-by-step sequence for the removal of
be removed given a specific clinical situation the following classification of impactions, including
• List the most significant features involved in assessing the names of the instruments you would need:
acceptable radiographs for the degree of surgical — mesioangular
difficulty. — horizontal
— vertical — follicle
— distoangular. — relationship to maxillary sinus
• State the relative degree of difficulty from easy to — root number and configuration
difficult for the various angulations. — potential for root fracture
• Describe the surgical significance of the following — root development
anatomical structures to removal of impacted — potential for tuberosity fracture
maxillary third molars. — bone density and elasticity
— maxillary sinus — relationship to second molar.
— buccal fat pad • State three clinical factors you should evaluate prior
— infratemporal fossa to extraction of impacted maxillary molars and
— maxillary tuberosity describe how these influence surgical difficulty.
— coronoid process • Describe the outline of the incisions used to expose
— zygomatic process of the maxilla an impacted maxillary molar in positions A, B,
— palate. and C.
• State the indications for removing impacted maxillary • Describe the technique for bone removal to expose an
third molars. impacted maxillary third molar.
• State the contraindications for removing impacted • Describe the technique and instruments used for
maxillary third molars. elevation of an impacted maxillary third molar.
• Describe the ideal timing for removing maxillary third • Describe preparation and closure of the wound
molars and state reasons following removal of an impacted maxillary third
• State the radiographic views and techniques most molar.

likely to provide useful information for surgical • State the advantages and disadvantages of the mallet
planning. and osteotomy technique for the removal of impacted
• Given a periapical or panoramic radiograph of an teeth.
impacted maxillary molar, evaluate relative difficulty • State the advantages and disadvantages of the surgical
of impacted maxillary third molar removal based on micromotor/rotary instruments for the removal of
the following factors: impacted teeth.
— height • List the complications resulting from the removal of
— combined root width impacted teeth.
Section 2
Management of Impacted Canine

Chapter 16 Introduction
Chapter 17 Localization of Impacted Canine

Chapter 18 Modalities of Management of Impacted Canine

Chapter 19 Surgical Exposure of Impacted Maxillary Canine
Chapter 20 Orthodontic Eruption of Impacted Canine
Chapter 21 Surgical Removal of Palatally Impacted Maxillary Canine
Chapter 22 Removal of Labially Positioned Impacted Maxillary Canine
Chapter 23 Management of Impacted Mandibular Canine
Chapter 24 Surgical Repositioning/Autotransplantation
Chapter 25 Unerupted and Impacted Supernumerary Teeth
16 Introduction
The maxillary canine is second only to the mandibular disciplinary approach combining the specialties of Oral
third molar in its frequency of impaction. The permanent and Maxillofacial Surgery, Periodontology and
maxillary canine is considered impacted when its Orthodontics.

eruption is retarded in relation to the normal eruption
sequence of the other dentition. Maxillary canine
Incidence and Epidemiology

impaction is diagnosed by clinical and radiographic
findings illustrating that no spontaneous eruption can be Permanent maxillary canine impactions occur in 1 to 3%
expected. Normally, in the mandible, the eruption of the general population, second only to the impaction
sequence of the permanent dentition follows an anterior of third molars in frequency. These impactions occur
to posterior pattern. However, in the maxilla, eruption twice as often in women than in men and five times more
of the premolars follow the incisors; the canines are then often in Caucasians than Asians. In about 85% of these
expected to erupt into the dental arch at 10 -12 years of cases, the impacted teeth are located palatal to the dental
age (Table 16.1). arch, in the remaining 15% of cases, the impactions are
located labially. There is some evidence that patients with
Table 16.1: Average age of eruption for permanent Class II division 2 malocclusion and tooth aplasia may
teeth in years be at a higher risk to the development of an ectopic canine.
Maxilla Mandible Impacted canines occur 20 times more frequently in the
maxilla than in the mandible.
Central incisor 7-8 6
Lateral incisor 8 7-8
Canine 10-12 9-10 Development and Eruption Pattern
1st Premolar 10-12 10-12
2nd Premolar 10-12 12 Broadbent (1941) 1 stated that calcification of the
1st Molar 6 6 permanent maxillary canine crown starts at one year old,
2nd Molar 12 12 between the roots of the first deciduous molar, and is
complete at 5-6 years. By the age of 12 months the crown
The normal eruption path of maxillary canines can be of the tooth is found between the roots of the primary
altered as a result of a variable eruption sequence in the molar. At 3-4 years of age the canine passes over the line
maxilla, as well as by limited space conditions such as of the primary incisors to lie on the labial side of the root
crowding. Early diagnosis and treatment of this condition of the lateral incisor (Miller, 1963).2 At the age of four
is essential to reduce the risk of other tooth eruption years the primary first molar, the first premolar germ and
disturbances. Optimal management of impacted canine lie in a vertical row. Subsequent growth on the
permanent maxillary canines involves an inter- facial surface of the maxilla provides space for the
forward movement of the canine so that its cusp comes

to lie medial to the root of the deciduous canine. Moss
(1972)3 stated that the canine remains high in the maxilla
just above the root of the lateral incisor until the crown is
calcified. It then erupts along the distal aspect of the lateral
incisor resulting in closure of the physiological diastema
if present and correction of the so called 'Ugly Duckling'
dentition ( Kurol et al, 1997).4
Coulter and Richardson (1997) 5 quantified the
movements of the maxillary canine in three-dimensions
using lateral and posteroanterior cephalometric
radiographs from the Belfast Growth Study taken
annually between 5 and 15 years of age. It was shown
that the canine travels almost 22 mm during that time. In
the lateral plane the canine showed a significant
movement in a buccal direction between 10 and 12 years Fig. 16.1: Eruption of 13 prevented due to presence
of age. Before this age the movement was in a palatal of supernumerary tooth
direction. About three-quarters of the root is formed

before eruption and root formation is complete two years

after eruption. Hurme (1949)6 stated that the gingival
emergence of the maxillary canine after 12.3 years in girls

and 13.1 years for boys was late. Thilander and Jacobsson
(1968)7 regarded 13.9 years for girls and 14.6 years as very
late for boys as by this time 95% should have erupted.
The maxillary canine is the last tooth to erupt in the upper
arch with a deciduous predecessor and therefore is most
susceptible to environmental influences such as
crowding.
Fig. 16.2: OPG of the patient in Fig. 16.1 showing supernumerary
Etiology of Canine Impaction tooth (small yellow arrow) preventing eruption of 13 (big yellow arrow)
The exact etiology of impacted maxillary canine remains

unknown, but probably multifactorial. Primary causes
that have been associated with this condition are the rate
of root resorption of the deciduous teeth, trauma to the
deciduous bud, disturbances in tooth eruption sequence,
non-availability of space (Figs 16.1 and 16.2), rotation of
tooth buds, premature root closure and canine eruption
into cleft areas (Fig. 16.3). Secondary causes of impaction
include febrile diseases, endocrine disturbances and
vitamin D deficiency. Impacted canine can be associated
with other conditions (Figs 16.4 to 16.6).
Arch length discrepancy (crowding and spacing) is
also implicated in the etiology. A space deficiency may
result in the tooth erupting buccally or its impaction
(Jacoby, 1983).8 Thilander and Jacobsson (1968)7 stated
that crowding may be a factor in labial impaction, but
not in palatal impaction. Jacoby (1983)8 found that in 85 Fig. 16.3: Bilaterally impacted maxillary canine in a cleft patient
Introduction 165
Figs 16.4A to D: A patient with cleidocranial dysostosis showing multiple impacted teeth. (A) OPG of the patient, (B) Intraoral view of the patient
showing absence of teeth. Patient is wearing upper denture, (C) Radiograph of chest showing missing clavicle, (D) Due to the absence of clavicle
the patient can bring the shoulders together
percent of cases where the canine erupted palatally excessive space in the canine area. Other suggested causes
adequate space was present in the arch. He suggested of palatal impaction are trauma to the maxillary anterior
that a possible explanation for canine impaction to be region at an early stage of development (Brin et al, 1993).9
Two theories have been proposed to explain the
dental anomaly of canine impaction the guidance theory
and the genetic theory.
Guidance theory: This theory in its simplest form
regards the distal aspect of the lateral incisor root as the
guide to allow the canine to erupt safely into position. If
the lateral incisor is anomalous or missing this guidance
is absent resulting in palatal displacement of the canine.
Becker et al (1981)10 found a 5.5 percent rate of congenital
absence of lateral incisors in large group of patients with
palatal canines. This was 2.4 times the rate in the general
population. It was hypothesized that the lateral incisor
was not sufficiently developed at the time when its root
would have as the most important factor for the guidance
of the canine. Oliver et al (1989)11 found that lateral
incisors on the side of canine impaction were generally
Figs 16.5A and B: (A) Nasally erupting canine, smaller than on the non-impacted side in a sample of 31
(B) Specimen after extraction Caucasian subjects.
Delayed exfoliation of the primary canine may result Canines play a role in functional occlusion and form
in continued palatal movement of the permanent the foundation of an esthetic smile. They are considered
successor. However, Thilander and Jacobsson (1968)7 the 'corner stones' of the dental arch. As such, any factors
considered this persistence of a primary canine to be a that interfere with the normal development of canines
consequence rather than a cause of impaction. Other and their eruption can have serious consequences.
possible causes include pathological lesions, ankylosis, Possible sequelae of canine impaction include root
odontomes, or supernumerary teeth. There may also be resorption of impinging teeth, referred pain, infection,
a higher incidence of impaction of the maxillary canine dentigerous cyst and self-resorption. Hence, impacted
following alveolar bone grafting in patients with cleft lip maxillary canines need necessary attention and
and palate (Semb and Schartz, 1997).12 management at an early stage and every effort is made
Maxillary canines which usually develop high in the to bring them into normal occlusion as far as possible or
maxilla, are among the last teeth to erupt and must course remove them surgically.
a considerable distance before erupting. The following
local factors are also attributed to canine impaction: Classification of Impacted Maxillary Canines
i. The greater distance the canine has to travel from
Classification helps much in the diagnosis and treatment
its point of development to normal occlusion.
planning. The following classification suggested by
ii. The bone as well as the mucoperiosteum on the
Archer (1975)13 is very practical:
palatal side is very thick and hinders eruption of
Class I : Impacted canines in the palate
canines if their growth is directed palatally.

1: Horizontal
iii. The root of the canine is more fully formed at the
2: Vertical
time of eruption, compared to other teeth, and this
3: Semivertical
may minimize the eruptive force.
Class II: Impacted canines located on the labial surface
iv. The crown of the developing permanent canine lies
1: Horizontal
immediately lingual to the long apex of the primary
canine root. Any condition affecting the primary 2: Vertical
canine can cause deviation in the position and 3: Semivertical
direction of growth of the permanent canine. Class III: Impacted canine located labially and palatally
v. The canines are the last of the permanent teeth to - crown on one side and the root on the other side
erupt (except the third molars) and hence are Class IV: Impacted canine located within the alveolar
vulnerable for a long period of time to any process - usually vertically between the incisor and first
unfavorable environmental influences. premolar
vi. The canines erupt between teeth already in Class V: Impacted canine in edentulous maxilla.
occlusion and the erupting second molar may Impacted canine can be in unusual positions like
further reduce the space inverted position (Fig. 16.6).
vii. The mesiodistal width of the primary canine is much
less than that of the permanent one. Sequelae of Canine Impaction
Due to the above reasons, there is an increase in the 1. Internal or external resorption of the adjacent
potential for mechanical disturbances, resulting in their teeth—This is the most common sequela. It has been
displacement and subsequent impaction. estimated that 0.7 percent of children in the 10-13
Genetic theory: This theory is based on the year old age group have permanent incisors
observation that palatally impacted maxillary canines are resorbed as a result of canine impaction. Root
often associated with other dental abnormalities, such as resorption can be expected in about 12.5 percent of
tooth size, shape, number and structure, all of which have the incisors adjacent to impacted maxillary canines.
been found to be genetically linked. These anomalies are Resorption of the lateral incisor is more common
thought to arise in embryonic development from a shared than the central incisor. Females are more likely to
hereditary trait. Evidence for this includes the fact that be affected than males. If the canine has migrated
palatal impactions occur in conjunction with other dental to a position medial to the mid-root of the lateral
anomalies and often occur bilaterally. Furthermore, incisor, resorption is more likely. In addition, if the
gender differences are apparent as well as familial and angulation of the long axis of the canine to the
population differences. midline on an orthopantomogram exceeds 25
Introduction 167
possibility of resorption:
— The cusp of the canine is in contact with the
root of the adjacent tooth
— The lamina dura of the alveolus is missing
— The root contour of the adjacent tooth is
irregular in an area facing the impacted canine.
Currently tomography is the only reliable diagnostic
method for determining the degree of resorption.
However, the increase in the radiation dose in the
CT, i.e. equivalent to five to six intraoral periapical
X- rays is a disadvantage. But some authors consider
that this is acceptable considering the diagnostic
advantage.
2. Proclination of lateral incisor—Due to pressure
effect from erupting cuspid, instead of resorption
Fig. 16.6: OPG showing impacted 23 in an inverted of root of lateral incisor, there may be proclination
position (black arrow)
of the lateral incisor. Very often the patient consults
degrees the risk increases by 50 percent. Lateral the dental practitioner for the correction of the
incisors are more commonly resorbed palatally and proclined tooth or spacing between the upper
at the mid root level than at the cervical or apical anterior teeth (Figs 16.7A to D). The patient will be
regions. There appears to be no association between unaware of the impacted cuspid.
enlarged follicles surrounding the canine and the 3. Cyst formation (Figs 16.8A to D)—Development of
potential for resorption. dentigerous cyst and adenoameloblastoma in
Diagnosis of resorption from periapical X-ray or relation to impacted cuspid is not uncommon.
OPG is not always reliable due to overlapping of 4. Miscellaneous complications—Marginal break-
the impacted canine with the lateral incisor. The down of supporting bone around adjacent teeth
following findings in a dental film suggest the may occur in certain instances.
Figs 16.7A to D: Impacted upper cuspid causing proclination of lateral incisor tooth. (A) A 14-year-old girl consulted the dental practitioner for
correction of her proclined left upper incisor tooth (black arrow), (B) View from the side showing unerupted left upper cuspid, (C) View from the
palatal aspect showing proclined lateral and spacing between the teeth, (D) Periapical X-ray showing impacted 23
Figs 16.8A to D: Impacted canine associated with extensive dentigerous cyst in the right maxilla in a 10-year-old boy (A) Swelling of the right side
of the face, (B) Intraoral photograph showing bulge in the right upper buccal sulcus, (C) OPG showing impacted 13 (white arrow). Note the
extensive bone destruction in relation to roots of 14 and 15 (yellow arrows), (D) PNS radiograph showing opacity of right maxillary sinus (yellow
interrupted oval) extending into right nasal cavity and the impacted 13 (white arrow). The case was managed by enucleation of the dentigerous
cyst and removal of impacted 13 under general anesthesia
Resorption of impacted canine may occur at a later 7. Thilander B, Jacobsson SO. Local factors in impaction of
stage. Loss of vitality of incisor, poor esthetics of retained maxillary canines. Acta Odontologica Scandinavia 1968;
primary canine, eruption of the impacted canine under a 26: 145-68.
prosthesis are possible sequelae of canine impaction. 8. Jacoby H. The etiology of maxillary canine impactions.
American Journal of Orthodontics 1983; 83: 125-32.
REFERENCES 9. Brin I, Solomon Y, Zibermann Y. Trauma as a possible
1. Broadbent BH. Ontogenic development of occlusion. Angle etiologic factor in maxillary canine impaction. American
Orthodontist 1941; 11: 223-41. Journal of Orthodontics and Dentofacial Orthopedics 1993;
2. Miller BH. The influence of congenitally missing teeth on 104: 132-37.
the eruption of the upper canine. Transactions of the British 10. Becker A, Smith P, Behar R. The incidence of anomalous
Society for Orthodontics 1963; 17-24. maxillary incisors in relation to palatally displaced cuspids.
3. Moss JP. The unerupted canine. Dental Practitioner 1972; Angle Orthodontist 1981; 51: 24-29.
22: 241-48. 11. Oliver RG, Mannion JE, Robinson JM. Morphology of the
4. Kurol J, Ericson S, Andreason JO. The impacted maxillary maxillary lateral incisor in cases of unilateral impaction of
canine. In: Andreason JO (Editor): Textbook and Colour maxillary canine. British Journal of Orthodontics 1989; 16:
Atlas of Tooth Impaction, Munksgaard, Copenhagen 1997;
9-16.
124-64.
12. Semb G, Schwartz O. The impacted tooth in patients with
5. Coulter J, Richardson A. Normal eruption of the maxillary
canine quantified in three dimensions. European Journal alveolar clefts. In: Andreason JO (Editor): Textbook and
of Orthodontics 1997; 19(2): 171-83. Colour Atlas of Tooth Impactions. Munksgaard,
6. Hurme VO. Ranges of normalcy in the eruption of Copenhagen 1997; 331-48.
permanent teeth. Journal of Dentistry for Children 1949; 13. Archer WH. Chapter 5, Oral and Maxillofacial Surgery,
16: 11-15. WB Saunders Co., 5th Edn 1975; 1:325.
17 Localization of
Impacted Canine
Management of impacted canine requires precision both Labially impacted canine in contact with the apical third
in planning and execution. It is not enough for the dental of the lateral incisor root can cause deflection of the root
surgeon to know that an unerupted tooth is present. lingually and tilting of the crown labially. However, it
Rather the exact position of the tooth and its precise should be considered that crown of a palatally impacted
relationship to other erupted teeth should be established. tooth, which is in contact with the gingival or middle third
The presence and position of the canines can be of the lateral incisor root, can also move the crown of the
ascertained by three simple methods: visual inspection, lateral incisor labially. All these findings are indicative
palpation and radiography. of a potential impaction of maxillary canines.
Patients should be examined by eight or nine years Premolar eruption before canine emergence may also
of age to determine whether canines are erupting in a indicate a disturbance in the eruption of the latter.
normal position and to assess whether the potential for Adjacent teeth should be examined for mobility and
impaction exists (Abron et al, 2004).1 Early detection may to determine the condition of the periodontal tissues.
reduce treatment time, complications, complexity and Vitality testing of adjacent teeth, especially upper lateral
cost. Locating the exact position is important to decide incisors, prior to surgery should be done as a routine
the best treatment option and also to plan the surgical procedure. It is better to discover that an unerupted
procedure, if any needed. Impacted maxillary canines are canine is related to a non-vital lateral incisor of dens
found three times as frequently on the palatal side as on invaginatus type before surgery than after the operation.
the labial side. They are almost always rotated from 60 to If a sinus is present a probe should be passed along it in
90 degrees on their longitudinal axis and are usually in an attempt to feel any underlying tooth. The maxillary
an oblique position. Frequently they are found in a canine area is a rare site for supernumeraries but
horizontal position. occasionally a dentigerous cyst is found to be present in
relation to the crown of the impacted canine.
Palpation- Bidigital palpation of the maxillary canine
Clinical Examination
region from labial vestibule and palatal roof is also useful
Inspection: Evidence of impaction can be observed in an for the localization of impacted canines. Canines are
over retained primary canine. Carefully look for any readily detectable one to one-and-a-half years prior to
bulge either on the labial or on the palatal side of the eruption. It should be noted, however, that asymmetries
arch. Possible signs of impending impaction include: lack in the alveolar processes of young children might not
of canine prominence in the buccal sulcus by age of ten always be indicative of canine impaction, but may be due
years, discordance between the exfoliation of the to vertical differences in eruption.
deciduous canine and eruption of permanent canine and The clinical signs that implicate an impacted
the presence of inclination of the lateral incisor crown. maxillary canine include:
1. Delayed eruption of the permanent canine or Radiographic examination should be implemented

prolonged retention of the primary canine.1 if clinical methods are inconclusive (Figs 17.1A to C). An
2. Absence of a normal labial canine bulge in the ideal radiographic examination of an impacted maxillary
canine region.2 canine should reveal not only the shape and position of
3. Delayed eruption, distal tipping, or migration of the the root apex, but also the position of the crown, vertical
permanent lateral incisor.3 inclination of the canine, presence of any follicular cyst,
4. Loss of vitality and increased mobility of the and above all root resorption of the adjacent permanent
permanent incisors.4 teeth. A review of literature revealed that various
Radiographic localization helps to supplement the
radiographic and imaging methods have been proposed
findings of inspection and palpation. In deeply impacted
and are being tried worldwide in the localization of
canine bidigital palpation is inconclusive, very often
impacted teeth.5,6 Radiographic examinations can be
radiography is the only means of localization.
It has been suggested that radiographic evaluation broadly grouped into two: Accurate methods like
prior to the age of 10 years are of little benefit. computerized axial tomography, cone beam, and 3D CAT
Radiographs are indicated before 11 years of age if there elaboration such as 3D imaging; in addition to which real
is an asymmetric path of eruption as determined by 3D stereo-lithographic models can also be generated. The
palpation, if the lateral incisor is late in eruption or is second group is the less accurate methods, which include
tipped labially, if the lateral incisor is missing or there is plain radiographs like panoramic radiography, occlusal
a family history of impacted canine. After the age 11, radiography, anteroposterior and lateral radiographic
radiographs are indicated in all individuals with views, which are based on image magnification and
unerupted and non-palpable canine. superimposition.
Figs 17.1A to C: Showing the conventional 2 D imaging (A) Panoramic radiography, (B) Full mouth periapical
X-ray with two X-rays of impacted tooth from different angles, (C) Occlusal radiograph
Localization of Impacted Canine 171
The conventional radiographic methods are based on Magnification

two main principles:
1. The cone shift or parallax technique, which aims to For a given focal spot film distance, objects away from
register the relative displacement of an object in the film will be depicted more magnified than objects
relation to the environment. closer to the film; this is the principle of 'Image Size
2. The degree of magnification of the imaged object, Distortion' (See Fig. 17.2).
in comparison with the surrounding teeth, may also There are two methods based on this principle:
give an indication of the malposition of the impacted a. Status—X-Radiography (Ostrofsky, 1976) 12—This
tooth. technique makes use of the fact that the anode of the
status—X-machine is considered to have an almost
Parallax
This method involves taking of two radiographs and the
use of the principle of horizontal or vertical parallax. This
method was first introduced by Clark (1909). 7 The
horizontal parallax involves taking of two radiographs
at different horizontal angles and with the same vertical
angulation. Due to parallax the more distant object
appears to travel in the same direction as the tube shift

and the object closer to the tube appears to move in the
opposite direction; the so called Same Lingual Opposite

Buccal (SLOB) rule; or this can be equally remembered
as Buccal Opposite Palatal Same (BOPS)}. The cone shift
technique may also be applied when the radiographs are
taken at different vertical angulations (vertical parallax).
The different combinations that are commonly tried based
on the technique of parallax include:
1. Two intraoral periapical radiographs taken at
different horizontal angles (Clark, 1909).7 Fig. 17.2: Showing how magnification increases
with increase in the object film distance
2. One maxillary anterior occlusal and one maxillary
lateral occlusal (Southall and Gravely, 1989).8 point source of X-radiation. Here a special tube is
3. One periapical and one maxillary anterior occlusal inserted in the mouth of the patient and the film held
radiograph (vertical parallax; Rayne, 1969).9 around the face by the patient. Hence, there is a point
4. One panoramic and one maxillary anterior occlusal source of radiation and the laws of central projection
radiograph (vertical parallax; Keur, 1986).10 apply—the object closer to the source is magnified.
5. One panoramic radiograph alone when a Panorex b. Panoramic Radiography (OPG) (Figs 17.3 and 17.4)—
machine is being used (Turk and Katzenell, 1970).11 This is a fundamental examination which gives an
Clark's rule is extremely useful in cases in which the overview but does not permit precise localization of
position of the canines is such as to give a superimposition an impacted canine. The principle of image distortion
with respect to a chosen dental reference point. However, can be applied in panoramic radiography. If a canine
care should be taken about the fact that the radiographs is relatively magnified in comparison to the adjacent
being compared should be identical with respect to all teeth in the arch or the contralateral canine, it will be
other factors other than the angulation of the X-ray beam. located closer to the tube, i.e. palatally, and if the size
It is also unfavorable from a biologic perspective as a is relatively diminished it will be located further away
single exposure for an intraoral radiograph amounts to from the tube, i.e. labially. This method is most effective
about 2.4 to 4.3 µS (micro Sievert). when the canine is not rotated, not in contact with the
by magnification. It has been suggested by many

researchers that a single panoramic radiograph alone is
not sufficient for proper localization of impacted
maxillary canines.13, 16-19
Other methods reported for radiographic localization
of impacted maxillary canine are the vertex occlusal
radiograph19 and the panoramic radiograph, where
image sharpness and relationship of the canine cusp tip
with the lateral incisor root is assessed. The right angle
technique involves two films taken at right angles to each
other (Figs 17.5A and B) so that the canine can be located
in three dimensions, e.g. lateral skull and posteroanterior
Fig. 17.3: OPG of a girl aged 13 years showing impacted 23 (yellow

circle), 35 and 45 (yellow arrows). Even though the clinical examination
showed a slight bulge on the labial aspect of the region of 23, during
surgery it was noted that the tooth was actually laying labiopalatally
with the crown on the palatal side
incisor root and there should be no tipping of the

incisor roots.13, 14
A study conducted by Mason et al in 200115 to

compare two different radiographic techniques for
localization of impacted maxillary canines: vertical
parallax (from a panoramic and a maxillary anterior
occlusal radiograph) and magnification (from a single Figs 17.5A and B: The right angle technique
panoramic radiograph), showed that localization with
cephalogram20 or lateral skull and panoramic radio-
vertical parallax was more successful overall than with graph21 or a periapical X-ray and an occlusal X-ray.
magnification.15 Almost 90% of the palatally impacted
Occlusal radiographs can be made with different
canines could be correctly detected with both techniques,
angulations. The most frequently used projection for the
and only less than half of the buccal canines were detected maxillary canine localization is the true occlusal view
by parallax and less than 0.1% buccal canines detected
(Fig. 17.6). In this view the central ray passes through the
glabella and falls perpendicular to the film.
Fig. 17.4: OPG showing bilaterally impacted maxillary canines in

horizontal position (yellow oval) and left mandibular canine (yellow arrow) Fig. 17.6: True occlusal view of maxilla showing bilaterally impacted
transposed to right side maxillary canines and retained deciduous canines (yellow arrows)
By this technique, localization can be done by

determining the position of the cusp of the canine in
relation to the roots of the lateral incisors in a labial-
palatal plane. The disadvantages to be mentioned
include high dose of radiation especially to the lens,
thyroid and cerebral structures.
Points to be Noted from the Radiograph

• Labiopalatal position of the tooth- whether the
impacted tooth is lying labially, palatally or directly
above the standing teeth
• Direction of the long axis of the unerupted canine and
its relationship to adjacent tooth
• Size, shape and root pattern of the canine
• Condition of the adjacent teeth
• Position of the its crown and root apex relative to the
adjacent teeth, in vertical, mesiodistal, and labiopalatal
dimensions
• Presence of associated cyst, odontomes or super-
numerary teeth
• Curvature of the root of impacted tooth—In some
instances the root appears to be straight with a blunted
end; when in actuality it is a hooked root. This happens
because the long axis of the tooth coincides with the
path of the X-ray. Figs 17.7A and B: (A) Periapical films in a 13-year-old patient show 23
Other extraoral views like the posteroanterior and (white arrows) in an impacted position lingual to 21 and 22, (B) CT
scans show the crown of the ectopic positioned 23 located palatally
true lateral skull views can be used for assessing the (white arrow) close to the roots of 21 and 22. The roots of the incisors
mediolateral and anteroposterior position of the impacted are exposed, but there is no resorption of the roots. The width of the
maxillary canines. The true lateral view of skull is a dental follicle of 23 indicates low eruptive activity of the tooth
cardinal investigation in orthodontic treatment planning
as it gives indication of the direction of mandibular Tomography, e.g. polytomography and computed
growth. With regard to impacted teeth it indicates the tomography are useful especially in cases where there is
position in the vertical plane only. It may not be useful in root resorption of adjacent teeth.22 Computed tomo-
cases of bilateral impactions as there will be superi- graphy is a technique which uses a series of radiographic
mposition of both sides. Posteroanterior views of the jaws axial sections to produce a computer generated three-
provide partial indication as to the position of the dimensional image (Figs 17.7 to 17.10A to D).
impacted canines in the vertical plane and give the exact CT scan is a precise method of radiographic
inclination relative to a trans-orbital line, but does not localization; however, its use is limited by cost and
give information of the same in the labiopalatal plane. increased radiation exposure. Various studies on the
Radiographic evaluation is used not only to verify the efficacy of CT over conventional radiography have been
position and location of the impacted tooth, but also to reported in the literature.23,24 All of these point out to the
examine the areas adjacent to the impaction, which may disadvantage of excessive exposure and time
play a critical role in the treatment planning. Almost all consumption for completion of the procedure. With the
of the above mentioned conventional radiographic recently improvised Multi Slice Spiral CT using
techniques have the disadvantage of superimposition of mutiplanar (Fig. 17.11) and 3D reconstruction, there is a
the shadows, which has led to the need for better imaging marked reduction in the examination time and risk of
techniques like computed tomography. accidental movement. It also enables a significant
Fig. 17.9: CT scan shows 13 (yellow arrow) erupting ectopically and 23

(white arrow) normally. The follicle of 13 is widened at the crypt and
surrounded by a cortical lining. The follicle extends buccally and has
partly exposed the root of 12. Such follicle should be sent for histo-
Fig. 17.8: CT scan shows 13 and 23 erupting buccally to 12 and 22 pathological examination to rule out development of a dentigerous cyst
respectively. The follicles have caused the buccal plate of the alveolar
bone to bulge (yellow arrows) and extend asymmetrically into the
captures a large volume of area requiring minimal
cancellous bone (white arrows). There are contacts between the

impacted canines and the adjacent roots of the incisors; but with no amount of generated X-rays. The machine rotates 360°
root resorption of the latter (black arrow) around the head within 10 seconds and captures 288 static
images. The computer then reassembles these primary

reduction in radiation exposure without loss of image images and creates a secondary reconstruction of 512
quality. 25-27 The CBCT (Cone Beam Computerized conventional CT slices that contain all volumetric data
Tomography) represents a real technologic breakthrough acquired from the patient scan (Figs 17.12 to 17.16). Recent
in the recent years. This is a variation of CT imaging studies on the comparison of all available imaging
technique and provides excellent quality images with modalities for localization of impacted maxillary canines
much lower radiation than conventional medical CTs.28 have also concluded that CBCT provides elements which
The CBCT shoots out a cone-shaped X-ray beam and escape during traditional radiographic analysis and
Figs 17.10A to D: (A,B) Intraoral periapical films of erupting maxillary canines. (A) Extensive apical resorption of root of 12 (white arrow) due to
pressure from impacted 13, (B) Resorption of the root distally on 22 (yellow arrows) due to impacted 23, (C) CT scans showing the canine 13 cusp
tip in contact with root of 12 (white arrow), (D) CT scans showing the canine 23 in contact with 22 (yellow arrow)
Fig. 17.11: Reconstructed multiplanar sagittal image demonstrates

an impacted maxillary canine with dilaceration of root
Fig. 17.14A to D: 3-D CBCT images of impacted maxillary

canine—Frontal and palatal views
Figs 17.12A and B: (A) Reformatted panoramic image from CBCT

showing impacted left mandibular canine and hypertrophy of left coronoid
process, (B) Sequential cross-sectional images of the left mandibular
canine
Figs 17.15A to D: 3-D CBCT images of impacted

maxillary canine—Lateral and ¾ lateral views
therefore recommended for impacted teeth localization

as well as for other craniofacial structural anomalies.29
Case report: A 13-year-old girl reported to her dental
practitioner with complaints of spacing in the upper
anterior region. On examination, there was missing
(possibly impacted)11 and 13 (Figs 17.17A and B).
Unerupted 11 and 13 could neither be visible nor
palpable on the labial or palatal aspect. Occlusal X-ray
(Figs 17.17 C) showed impacted 11 (green arrow)and 13
(yellow arrow). However, the root of 11 was not visible,
Fig. 17.13: Three dimensional computed tomography image of the suggesting the possibility of a labiopalatal position of 11
upper and lower teeth using shaded surface display software or a dilacerated 11. OPG (Fig. 17.17D) also did not yield
Figs 17.16A to G: Root visualization of left maxillary central incisor and canine using CBCT
Figs 17.17A to D: (A) Preoperative labial view of the patient showing unerupted 11 and 13, (B) Palatal view, (C) Occlusal
X-ray of maxilla showing impacted 11 (green arrow) and 13 (yellow arrow), (D) OPG showing the impacted teeth (yellow circle)
Figs 17.17E to H: (E) Lateral view of maxilla showing impacted teeth (yellow circle), (F) Sagittal CT scan image showing impacted 11 (green
arrow) and 13 (yellow arrow), (G) Sagittal CT scan image showing impacted 13 (yellow arrow) and erupted 12 (white arrow), (H) Periapical X-ray
Figs 17.17I to L: (I) Coronal CT scan image showing impacted 11 (green arrow) and 13 (yellow arrow), (J) Coronal CT scan image showing
impacted 11 (green arrow) and 13 (yellow arrow), (K) Axial CT scan image showing impacted 11 (green arrow) and 13 (yellow arrow), (L) Axial CT
scan image showing impacted 11 (green arrow) and 13 (yellow arrow)
Figs 17.17M to P: (M) Impacted 13 visible (yellow arrow) after raising the flap and adequate bone removal, (N) Impacted 11 (green arrow) visible
after removal of 13, (O) Surgical site after removal of impacted central incisor and canine tooth, (P) Specimen after removal -dilacerated central
incisor (green arrow), canine (yellow arrow)
additional information (yellow circle). True lateral view of the latter being close to the nasal floor. Since the root
of maxilla (Fig. 17.17E) revealed impacted 11 and 13 of 11 is not visible, it is suggestive of a labiopalatal position
(yellow oval) at a high level close to the floor of the nose. of the tooth. Figure 17.17J is the coronal CT image at the
With all the information available it was still difficult to level of the premolars, i.e. a little more posterior to the
ascertain the exact location of the impacted teeth as well previous one showing impacted 13 (yellow arrow) and
as to choose regarding the type of approach to be used, cross-section of the root of 11 (green arrow), suggesting
i.e. labial or palatal approach. Hence, a CT scan was that 11 is lying in a labiopalatal position. Figure 17.17K
considered. Sagittal, coronal and axial cuts of the region shows the axial CT at the level of the middle 1/3 of the
were obtained. Figure 17.17F shows sagittal image in the roots of the erupted teeth. This image depicts the crown
edentulous region of 11. It depicts impacted 13 (yellow of impacted 13 (yellow arrow) and a part of impacted 11
(green arrow). Figure 17.17L is the image at the apical
arrow) anterior to 11 (green arrow), the latter being close
third of roots of the erupted teeth, i.e. an image at a more
to the floor of the nose. Figure 17.17G shows sagittal
superior level than the previous image. It shows a part of
image in the region of erupted 12; i.e. this image being
the impacted 13 (yellow arrow) and impacted 11 (green
more lateral to the previous one. In this cut the impacted arrow) which appears to be in a labiopalatal position. The
13 (yellow arrow) is labial to erupted 12 (white arrow). conclusion from the above imaging studies were as
Impacted 11 is not visible, suggesting that it is close to follows:
the midline. IOPA X-ray (Fig. 17.17H) of the region is 1. Impacted 13 is in a semi vertical position, located on
given for comparison which shows that not much of the labial side close to the root of 12.
useful information is provided by it regarding the labio- 2. Impacted 11 is in a labiopalatal position, close to the
palatal position of the tooth. Figure 17.17I is the coronal floor of the nose.
CT image at the level of the canine showing impacted 13 3. Impacted 13 is in a more labial position than impacted
(yellow arrow) and impacted 11 (green arrow), the crown 11.
4. The tip of the crown of impacted 13 is at the level of CT scans are also extremely useful in determining
the coronal third of the root of 12. the relation ship of impacted canine to structures like
5. The level of the crown of impacted 11 is at the level of maxillary sinus or roots of adjacent teeth as shown in the
the apical third of the erupted teeth. figures below ( Figs 17.18A to H and 17.19A to F).
6. The tip of the root of impacted 11 extends up to second To summarize the traditional radiographic techni-
molar region (in CT images not shown here). ques form an indispensable part of diagnosis and
With all the above information the case was posted treatment planning in cases of impacted teeth. They are
for surgery under local anesthesia with premedication. easy to carry out, cost effective, providing useful
A combined labial and palatal approach was planned. A information and a general vision of the position of the
labial mucoperiosteal flap was first elevated. Following impacted tooth with respect to the surrounding
adequate bone removal, crown of impacted 13 (yellow structures. However, it does not permit the exact
arrow) was visualized (Fig. 17.17M). Impacted 13 was localization of the canines in three-dimensional space.
then removed. The crown of impacted 11 came into view Computer-assisted tomography; particularly CBCT
(Fig. 17.17N). Surprisingly it was the palatal aspect of provides high resolution images with superior quality.
crown of 11 (green arrow) that came into view suggesting They reveal information that can never be obtained from
a dilaceration for the tooth. Next a palatal flap was conventional radiographs and hence can be considered
elevated. After adequate bone removal impacted 11 was as the imaging modality of choice in cases of impacted
removed in toto. Figure 17.17O shows the surgical site teeth or other craniofacial anomalies in selected cases.
after debridement before closure. Specimen of 11 (green However, selection of cases should be judicious to avoid
arrow) shows the dilaceration of the tooth and normal unnecessary radiation to the patient. Moreover, the risk
root (yellow arrow) of 13 (Fig. 17.17P). versus benefit ratio should be considered in each case.
Figs 17.18A to D: (A) Intraoral frontal view of the patient showing retained deciduous canine in the right maxilla, (B) Lateral view of the patient,
(C) OPG showing impacted 13 (yellow circle); the relationship of the root of canine to maxillary sinus is not clear, (D) Occlusal radiograph (yellow
arrow)
Figs 17.18E to H: CT scan of the patient: (E) Coronal CT showing the tip of the root is seen projecting into the right maxillary antrum (yellow arrow)
and the tooth lies in an oblique fashion, (F) Axial CT showing a follicle is seen surrounding the crown of the impacted tooth and anteriorly the crown
is covered only by a thin buccal cortical plate (yellow arrow), (G) Sagittal CT showing impacted canine lying superior to central and lateral incisor
(yellow circle), (H) The tooth was removed in one piece by a labial approach
Fig. 17.19A to C: (A) Intraoral view of the patient showing missing/impacted 43, (B) OPG showing impacted 43 and
supernumerary, (C) Coronal CT showing oblique position of impacted 43 and supernumerary
11. Turk MH, Katzenell J. Panoramic localization. Oral

Surgery, Oral Medicine, Oral Pathology 1970; 29:212-15.
12. Ostrofsky MK. Localisation of impacted canines with
status—X-radiography. Oral Surgery, Oral Medicine, Oral
Pathology 1976; 42:529-33.
13. Fox NA, Fletcher GA, Horner K. Localising maxillary
canines using dental panoramic tomography. British Dental
Journal 1995; 179:416-20.
14. Wolf JE, Mattila K. Localisation of impacted maxillary
canines by panoramic tomography. Dentomaxillofacial
Radiology 1979; 8:85-91.
15. Mason C, Papadakou P, Roberts GJ. The radiographic
localization of impacted maxillary canines: A comparison
of methods. European Journal of Orthodontics 2001; 23:
25-34.
16. Chaushu S, Chaushu G, Becker A. The use of panoramic
radiographs to localize displaced maxillary canines. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 88(4):
511-16.
17. Chaushu S, Chaushu G, Becker A. Reliability of a method
for the localization of displaced maxillary canines using a
single panoramic radiograph. Clin Orthod Res 1999; 2(4):
Figs 17.19D to F: Computer screen image showing CT sections through 194-99.

mandible in the region of impacted teeth (yellow arrows), (D) Sagittal 18. Gavel V, Dermaut L. The effect of tooth position on the
image of unerupted canines on panoramic radiographs.
view, (E) Coronal view, (F) Axial view showing the close relationship of
impacted tooth to the roots of lower incisors. Considering the deep European Journal of Orthodontics 1999; 21:551-60.
position of the impacted teeth necessitating removal of considerable 19. Hitchin AD. The impacted maxillary canine. Dental
amount of bone and the possibility of damage to incisors it was decided Practitioner 1951; 2:100-103.
to defer the surgery for a later date with frequent follow-up 20. Broadway RT, Gould DG. Surgical requirements of the
orthodontist. British Dental Journal 1960; 108:1187-90.
21. Coupland MA. Localisation of misplaced maxillary
REFERENCES canines: Orthopantomograms and PA skull views
compared. American Journal of Orthodontics and
1. Abron A, Mendro RL, Kaplan S. Impacted permanent Dentofacial Orthopaedics 1987; 91:483-92.
maxillary canines: diagnosis and treatment. Columbia 22. Ericson S, Kurol J. Radiographic examination of ectopically
Dental Review 2004; 9:15-22. erupting maxillary canines. European Journal of
2. Hitchin AD. The impacted maxillary canine. British Dental Orthodontics 1987; 10:115-20.
Journal 1956; 100:1-14. 23. White SC, Pharoah MJ. Oral Radiology - Principles and
3. Brin I, Becker A, Shalhav M. Position of the maxillary interpretation, 5th edn. Mosby Co. St. Louis 2004
permanent canine in relation to anomalous or missing 24. Freisfeld M, Dahl IA, Jäger A, Drescher D, Schüller H. X-
lateral incisors: a population study. European Journal of ray diagnosis of impacted upper canines in panoramic
Orthodontics 1986; 8:12-16. radiographs and computed tomographs. J Orofac Orthop
4. Kettle MA. Treatment of the unerupted maxillary canine. 1999; 60(3):177-84.
Dental Practitioner and Dental Record 1958; 8:245-55. 25. Chen Y, Duan P, Meng Y, Chen Y. Three dimensional spiral
5. Southall PJ, Gravely JF. Radiographic localization of computed tomographic imaging: a new approach to the
unerupted teeth in the anterior part of the maxilla: A survey diagnosis and treatment planning of impacted teeth. Am J
of methods currently employed. British Journal of Orthod Dentofacial Orthop 2006; 30(1):112-16.
Orthodontics 1987; 14:235-42. 26. Jason Cooke, Horn-Lay Wang. Canine Impactions:
6. Jacobs S G. Localization of the unerupted maxillary canine: incidence and management. Int J Periodontics Restorative
Additional observations. Australian Orthodontic Journal Dent 2006; 26(5):483-91.
1994; 13:71-75. 27. Kim KD, Ruprecht A, Jeon KJ, Park CS. Personal computer-
7. Clark C. A method of ascertaining the position of unerupted based three dimensional computed tomographic images
teeth by means of film radiographs. Proceedings of the of the teeth for evaluating supernumerary or ectopically
Royal Society of Medicine 1909; 3:87-90. impacted teeth. Angle Orthod 2003; 73(5):614-21.
8. Southall PJ, Gravely JF. Vertical Parallax radiology to 28. Walker L, Enciso R, Mah J. Three-dimensional localization
localize an object in the anterior part of the maxilla. British of maxillary canines with cone-beam computed
Journal of Orthodontics 1989; 16:79-83. tomography. Am J Orthod Dentofacial Orthop 2005; 128(4):
9. Rayne J. The unerupted maxillary canine. Dent Practit 1969; 418-23.
19: 194-204. 29. Maverna R, Gracco A. Different diagnostic tools for the
10. Keur JJ. Radiographic localization techniques. Australian localization of impacted maxillary canines: clinical
Dental Journal 1986; 31:86-90. considerations. Prog Orthod 2007; 8(1):28-44.
18 Modalities of Management of
Impacted Canine
A systematic approach should be employed in the Before deciding upon any treatment, all options
treatment of unerupted canine. Before any sort of should be discussed with the patient in detail and a
treatment procedures are undertaken, a diagnosis, written consent obtained if any surgical treatment is
assessment and treatment plan must be made; a complete planned. Every effort should be made to bring the
treatment plan which includes the surgical, orthodontic, impacted canine into normal occlusion if possible.
periodontal, prosthodontic and conservative treatment
is required.
Extraction of Deciduous Canine
There are different lines of management of the
impacted maxillary canine depending on the age of the This is considered as an interceptive method of
patient, stage of root formation, presence of associated management. This is indicated when the maxillary canine
pathology, condition of the adjacent teeth, position of the is not palpable in its normal position and the radiographic
tooth, patient's willingness to undergo orthodontic examination confirms palatally impacted canine. Removal
treatment, available facilities for specialized treatment
of the primary canine may show less favorable results
and patient's general physical condition. The specific
where the permanent canine is located in a more medial
surgical procedure and the orthodontic mechanisms
position or when the patient is older than the ideal age
involved for treatment of impacted canines will vary
group of 10 to 13 years. Studies have shown that the
depending upon the degree of impaction, the horizontal
extraction of primary canines at 10 to 13 years of age may
overlap of the impacted tooth, the canine angulation, and
resolve the palatally impacted permanent canines in
localized crowding.
approximately 60-80% of cases, when local space
Studies have addressed horizontal overlap in
reference to the canines and lateral incisors. The chance conditions are favorable. However, this treatment does not
of canine impaction recovery is poor when the horizontal necessarily eliminate or ensure correction of the problem
overlap of the maxillary canine root is more than one- and therefore, surgical intervention should be considered
half of the width of the lateral incisor root. An if desired results are not obtained within one year of the
achievement of 91% resolution for palatal impaction has deciduous extraction. Even though this is the standard
been reported in cases where the crown of the canine is approach each case should be planned accordingly.
distal to the midline of lateral incisor when treatment was In patients over 13 years of age other alternative
initiated. In contrast, the success rate was reported to be treatment options should be considered. Shown below is
less than 64% when the canine crown is mesial to the the radiograph of a 14-year-old boy who reported with a
midline of the lateral incisor. Palatally impacted swelling of the left maxilla, multiple unerupted
permanent maxillary canines are usually located over the permanent teeth and retained deciduous root stumps.
roots of the lateral and central incisors or horizontally OPG showed a dentigerous cyst involving the left maxilla
high in the roof of the mouth. in relation to impacted 25 (yellow oval) and impacted
Modalities of Management of Impacted Canine 183
canines and premolars (Fig. 18.1). The case was treated graphic follow-up. The most frequent complication
by enucleation of cyst, removal of impacted 25 and appears to be follicular cystic degeneration, although
extraction of retained deciduous teeth. The case was the frequency of this is unknown. Other odontogenic
followed up regularly. A follow-up OPG taken six months tumors may arise very rarely. There may be localized
later revealed that all the impacted teeth have started loss of attachment and marginal breakdown of the
erupting (Fig. 18.2). The case report substantiates the view adjacent teeth, which may necessitate the removal of the
that it is always advisable to wait for a while before a canine and the affected teeth. There is a need to regularly
decision is taken regarding surgical removal of impacted monitor the unerupted canine with respect to the
teeth, especially when the impacted teeth are in a possible complication mentioned above. It is not known
favorable position to erupt, even though it is beyond the what is the optimal time interval between radiographs
normal time of eruption. should be, to reduce the radiation dosage for the patient
The elimination of dental crowding in the arch and detect any lesion. No active treatment could be
particularly in the canine/premolar area can possibly recommended if:
stimulate eruption into the arch (Kurol et al, 1997).1 How- The patient does not want treatment
ever, Kuftinec et al (1995)2 recommended that irreversible There is no evidence of resorption of adjacent teeth or
decisions such as extraction of permanent teeth to allow other pathology.
canine eruption should be delayed as long as possible. Ideally, there is a good contact between the lateral
incisor and first premolar or good aesthetic/prognosis

No Treatment—Leave the Tooth in situ for deciduous canine.
In some cases it may be preferable to carry out no active There is severely displaced canine with no evidence
treatment except that of regular clinical and radio- of pathology, particularly if it is remote from dentition,
provided it is monitored radiographically.
Completely formed canine tooth without any
associated pathology and well above the apices of the
adjacent teeth especially in an elderly individual can be
left alone. But regular check-up may be needed.
Surgical Exposure of the Tooth
In cases where there is sufficient space for eruption of

the canine and where the root formation is not complete,
simple exposure of the crown of the tooth may help to
Fig. 18.1: OPG showing a dentigerous cyst involving the left maxilla in utilize the eruptive force and aid in normal alignment of
relation to impacted 25 (yellow oval), impacted canines and premolars the tooth.
in maxilla and retained deciduous root stumps
Surgical Exposure and Orthodontically

Assisted Eruption
This is the most desirable approach for an impacted
canine provided all the criterias are fulfilled. This method
is dealt in detail in the next chapter.
Criteria to be fulfilled before attempting surgical
orthodontic management of impacted canine include:
1. Favorably impacted canine
2. Good patient cooperation for the long orthodontic
Fig. 18.2: OPG taken six months later showing the teeth that were and surgical approach
impacted previously, i.e. 13, 14, 15, 23 and 24 have started erupting 3. No associated medical problems
Often, maxillary canines that are displaced palatally Surgical Removal with Posterior Segmental
will not erupt without orthodontic treatment because of Osteotomy
the dense palatal bone, thick palatal mucosa and increased
The unfavorable impacted tooth is surgically removed
horizontal angulation associated with these impactions.
and the space left in the region of canine, if cannot be
In case where spontaneous eruption of the tooth is not
orthodontically closed or if patient denies a prosthetic
expected as in oblique position of the tooth and
appliance it could be closed with a lateral segmental
completely formed root apex, orthodontic traction of the
osteotomy and sagittal advancement. Post surgical
tooth may be required to bring it into occlusion. minimal orthodontic intervention could close the residual
When there is insufficient space for alignment of the defect or step deformity. A re-contouring of premolar
canine, extraction of the lateral incisor or first premolar could be considered to have the canine look.
tooth may be required, or space should be gained by the
orthodontic movement of these and other teeth.
Surgical Repositioning/Autotransplantation
Surgical Removal of the Impacted Tooth Impacted, malpositioned canines with a favorable root
pattern (without hooks or sharp curves) can be tried to
Teeth in an unfavorable position which are likely to create be transplanted in the dental arch. This is done utilizing
problems in the future, are best removed at an early stage. the socket of deciduous canine or first premolar,
When a patient is not willing for or cannot afford depending on the space available.
orthodontic treatment, even teeth in a favorable position Table 18.1 shows the summary of eruption activating
may have to be sacrificed. procedures/intervention for developing permanent

canines. The same procedures are applicable for
developing permanent incisors and premolars also.
Surgical Removal of the Impacted Tooth
with Orthodontic Space Closure Table 18.1: Eruption activating procedures for permanent
In case of an unfavorable canine and if patient doesn't Eruption stage Intervention

want to spend extra time for orthodontic traction along 1 Intraosseous stage a. Primary tooth removal
with an indicated case of first premolar extraction, this b. Primary tooth + bone removal
approach could be tried. Instead of first premolar to be c. Primary tooth + bone removal
extracted on the impacted side the canines could be + coronal follicle removal,
exposure site kept open
removed and space could be closed orthodontically. Later
d. Surgical repositioning
on the first premolar could be shaped to resemble canine. e. Space augmentation
When the ipsilateral first premolar and lateral incisor are f. Removal of obstacles to
suitably positioned the planned and timely removal of eruption
an unerupted labially placed maxillary canine may 2 Mucosal stage a. Mucosa removal
produce an acceptable aesthetic result and minimize the b. Space augmentation
3 Preocclusal stage a. Orthodontics
length of time of orthodontic treatment.
b. Space augmentation
Surgical Removal of Impacted Tooth

REFERENCES
with Prosthetic Replacement
1. Kurol J, Ericson S, Andreasen JO. The impacted maxillary
This could be tried in an unfavorable canine with no need
canine. In: (Editor): Andreason JO, Textbook and Colour
for otherwise extraction correction. Also in cases where
Atlas of Tooth Impaction. Munksgaard, Copenhagen
patient is not willing for the long process of orthodontic 1997;124-64.
traction. After proper healing a removable or fixed 2. Kuftinec MM, Stom D, Shapira Y. The impacted maxillary
prosthesis could be given. A single tooth implant also canine II. Clinical approaches and solutions. Journal of
could be a good option. Dentistry for Children 1995; 52, 325-40.
19
Surgical Exposure of Impacted
Maxillary Canine
The conventional treatment option for impacted canine the safest in dental outpatient setting. However, with the
is exposure and orthodontic alignment. change in the social set up, changing out looks of the
Factors' influencing the prognosis—The prognosis patient as well as the surgeon and the availability of
for alignment is dependent on a number of factors which modern equipments, medicines and techniques general
include the age of the patient, spacing/crowding and anesthesia has become more popular than earlier times.
the vertical, anteroposterior, and transverse position of Another choice is local anesthesia supplemented with
the canine crown and root. If the inclination of the canine intravenous sedation but requires monitoring facilities.
in relation to the midline is greater than 45 degrees then
the prognosis for alignment worsens. The closer the PROCEDURE
tooth is to the midline the poorer the prognosis. For
successful alignment, the root should be neither a. Palatally positioned canine
ankylosed nor dilacerated. The further the canine needs The position of the crown of the tooth is determined with
to be moved, the poorer the prognosis for a successful the help of radiographs, and a cruciform incision is made
outcome. Similarly as with all orthodontic treatment co- with its center over the estimated position of the crown
operation and motivation of the patient is supreme. The of the buried tooth. The flaps (on four sides) are raised to
general dental health should be excellent since the expose the tooth crown. And once completely exposed,
treatment time in these cases is often prolonged. It is the flaps are excised. Resultant hemorrhage can usually
generally agreed that the optimum time for alignment be controlled by pressure. The bone over and surrounding
is adolescence. the crown of the tooth is removed in such a way that the
As for any surgical procedure, proper history of the crown will be left lying in a saucer-shaped bony cavity,
patient should be taken, including the general medical without any sharp ledge of bone at the edges. A pack is
history. inserted to prevent the soft tissues growing over the
Local examination should emphasize on any bulge exposed tooth. The pack can be perio pack or roller gauze
labially or palatally, which might give a clue to the impregnated with iodoform or antibiotics, which can be
position of the tooth. sutured into place (Figs 19.1A to 19.2I).
Radiographs are taken to confirm the position of the Surgical exposure of palatally impacted canine by
impacted tooth and its relationship to the adjacent teeth. excision of overlying mucoperiosteum (Figs 19.2 A to I):
Necessary hematological examinations should be done Case report: A 12-year-old girl reported with
prior to anesthetic assessment. complaints of unerupted right upper canine and excessive
Choice of anesthesia: Local anesthesia is sufficient in spacing of upper anterior teeth. Intraoral examination
almost all cases of this minor surgical procedure and is showed retained deciduous right upper canine and
Figs 19.1A to D: Schematic diagram showing exposure of impacted canine in the palate. (A) Position of the crown of the canine is localized by
clinical examination and with the help of radiographs, (B) Incision, (C) Excision of the overlying flap and exposure of the crown, (D) Debridement
and insertion of the pack
impacted upper permanent canine (13) and missing premolar on the involved side to the canine on the other
upper laterals (Figs 19.2A and B). Periapical X-ray showed side, after placing an incision around the neck of the teeth.
that impacted 13 is in a favorable position for orthodontic The crown of the impacted tooth is then exposed by
eruption (Fig. 19.2C). Under local anesthesia, excision of removal of sufficient amount of bone. The part of the
the overlying mucoperiosteum was done to expose the mucoperiosteum overlying the crown is excised with a
impacted 13 (Figs 19.2D and E). Retained deciduous scalpel. The flap is then repositioned and sutured back
canine was also extracted (Fig. 19.2F). Zinc oxide eugenol into place. A pack is placed as explained before (Figs 19.3
pack was placed to cover the raw area (Fig. 19.2G). After A to I).
10 days when the healing has completed, brackets were
fixed to the maxillary teeth (Fig. 19.2H). Arch wire was b. Labially positioned canines
then applied to the maxillary arch and impacted 13 Depending upon the depth and position of the impacted
connected to arch wire (Fig. 19.2 I). tooth anyone of the following three methods can be
Surgical exposure of palatally impacted canine by employed to expose the crown:
creating a window (Figs 19.3 A to I): • Creating a surgical window/Gingivectomy
In cases where the crown of the tooth cannot be • Closed eruption technique
localized, the palatal mucoperiosteal flap is reflected from • Apically positioned flap
Surgical Exposure of Impacted Maxillary Canine 187
Figs 19.2 A to D: (A) Intraoral view of the patient showing retained deciduous right upper canine, impacted permanent canine (13) and missing
upper laterals, (B) Palatal view showing bulge of impacted 13, (C) Periapical X-ray showing impacted 13, (D) Incision marked to expose
impacted 13
A. Creating a surgical window/Gingivectomy (Figs 19.4 obstruction is removed, and in such instances
A to C): If the tooth is situated just beneath the gingiva, orthodontic treatment may not be required. A
simple excision of the overlying soft tissue is enough gingivectomy procedure is indicated when one half
to expose the crown. to 2/3 of the crown can be uncovered leaving at least
A surgical window or gingivectomy is suggested 3 mm of gingival collar. In most instances, the tip of
for shallow, labially positioned maxillary canine the impacted tooth is near the cemento-enamel junction
impactions close to the alveolar crest or when a broad of the adjacent tooth. This technique is simple but it
band of keratinized tissue is present. Implementing sacrifices attached gingiva (Kokich et al, 1993).1
the window approach involves resecting a full
thickness flap and then repositioning the flap back with B. Closed eruption technique ( Figs 19.5A to F): A closed
a fenestration being opened in the area of the crown. eruption technique is indicated if the tooth is impacted
The tooth may erupt normally once the soft tissue in the middle of the alveolus, near the nasal spine, high
Figs 19.2 E to H: (E) Overlying mucoperiosteum being excised, (F) Mucoperiosteum excised and retained deciduous tooth removed, (G) Zinc
oxide eugenol pack placed to cover the raw area, (H) After 10 days when the healing has completed, brackets were fixed to the maxillary teeth
Fig. 19.2 I: Arch wire applied and impacted 13 connected to the arch wire using ligature wire.
An elastic thread also can be used instead of a ligature wire
Figs 19.3 A to D: Surgical exposure of palatally impacted canine by creating a window - (A) Intraoral view of the patient showing retained
deciduous left upper canine (yellow arrow) and impacted permanent canine, (B) Palatal view showing impacted 23 (black oval), (C) OPG showing
impacted 23 (yellow oval), (D) Periapical X-ray showing impacted 23
in the vestibule or in the palate (Vermette et al, 1995).2 Apically positioned flap (Figs 19.6 and 19.7): If the
A flap is first reflected over the area of the impacted cervical part of the crown of the impacted tooth is not
tooth (Fig. 19.5B). The crown is then exposed (Fig. within the attached gingiva, removal of the soft tissue
19.5C) after removal of the overlying bone if necessary. by gingivectomy can lead to loss of attached gingiva.
An orthodontic bracket is bonded to it. A traction wire Later on this can cause periodontal problems. In such
is connected to the bracket. The flap is closed over the a case an apically repositioned flap is advisable.
crown, exposing only the traction wire to the oral This technique is indicated when the tooth is apical
cavity (Fig. 19.5D). Adequate time is given for the or lateral to the edentulous area but is used primarily
initial healing of the flap. Later the traction wire is for labial impactions due to the inability to apically
connected to an arch wire and optimal force needed reposition the palatal tissue. The flap is designed so
to erupt the impacted tooth is exerted (Fig. 19.5E). that there are vertical incisions adjacent to the distal
Figure 19.5F shows the final position of the canine in aspect of the lateral incisor and the mesial side of the
the arch. Disadvantages of this technique include that first premolar and a horizontal incision connecting the
once the flap is closed, direct inspection of the tooth is two (Fig. 19.6A). Next, the crown of the impacted tooth
impossible. Moreover, it is difficult to isolate the area is located and the flap is secured back into place
and studies have shown a longer eruption time apically so that the crown remains exposed in the oral
compared to procedures used in open techniques. cavity (Fig. 19.6B).
Figs 19.3 E to H: (E) Mucoperiosteum reflected to expose the incisal tip of impacted canine, (F) Bone surrounding the crown of impacted 23
removed to expose the crown fully, (G) A window created in the flap after excising an oval piece of tissue to accommodate the crown of 23, (H)
Flap replaced back and sutured in position. Note the crown of impacted 23 protruding through the window in the flap
Fig. 19.3 I: Raw area of the mucoperiosteum covered with zinc oxide eugenol pack
Figs 19.4 A to C: Steps in creating a surgical window / gingivectomy - (A) Labial bulge of the canine, (B) Gingivectomy performed,
(C) Bracket fixed to the exposed canine crown and traction wire attached to the arch wire
Figs 19.5 A to F: (A) Palatal view showing edentulous space between the lateral incisor and first premolar tooth, (B) Reflection of mucoperiosteal
flap, (C) Bone overlying the tooth removed to expose the crown, (D) Traction wire connected to the orthodontic bracket bonded to the impacted tooth,
(E) Labial view showing traction wire connected to the arch wire, (F) Final position of the canine in the arch
Figs 19.6 A and B: Schematic diagram of apically positioned flap for exposure of
a labially positioned crown. (A) Incision, (B) Suturing
Figs 19.7 A to D: Surgical steps in developing an apically positioned flap. (A) Intraoral view of the patient showing missing lateral and
impacted left upper canine, (B) Incision marked, (C) Flap reflected, (D) Suturing completed to secure the flap apically
If necessary, a bracket ( Fig. 19.7 E) can then be placed orthodontic arch wire with ligatures or elastics to apply
on the erupting tooth to orthodontically guide it into the necessary traction. One of the drawbacks of this
position (Jarjoura et al, 2002).3 This is a quick and simple method is the difficulty in maintaining an absolutely dry
procedure that allows accurate control and helps to crown surface within the surgical field, for proper etching
maintain the mucogingival complex. However, this and bonding of the bracket.
technique cannot be used when the tooth is positioned Studies by Quirynen et al (2000)4 has shown that
high in the palate. orthodontic extrusion of impacted front teeth does not
Whatever be the position of the tooth, care is taken jeopardize their periodontal health. This procedure
to remove the bone over the crown without leaving any appears to be a satisfactory alternative to extraction and/
ledge of unsupported bone. Chisel and mallet are or transplantation. In any surgical procedure, the manner
preferred for bone removal as it minimizes the chance of in which the soft tissue is handled ultimately affects the
damage to the crown of the tooth. When bur has to be results of the treatment. Potential complications involving
used, utmost care should be taken as it can easily damage the soft tissue include attachment loss, recession, and
the crown surface. gingival inflammation. Vertical relapse, intrusion of
adjacent teeth, root resorption and debonding of brackets
Aids for Orthodontic Eruption are other complications that may occur from impacted
As mentioned earlier, some times orthodontic alignment maxillary canine treatment. Furthermore, studies have
of the impacted tooth may be required. Simple exposure shown that ankylosed teeth can cause adjacent teeth to
of the crown and leaving it as such can lead to in growth tip in the space provided by the impaction. More details
of soft tissues to cover the crown again. So to start on aids for orthodontic eruption are given in the next
orthodontic treatment, re exposure may be required. To chapter (Chapter 20).
avoid this, at the time of exposure initially any attaching
device can be fitted on to the exposed crown, which can
Surgical Eruption of Upper Incisors
later be utilized for orthodontic traction. These devices
include placement of a metal crown, stainless steel In cases where the root of the tooth is not fully formed
traction wire, cementation of preformed orthodontic band and when the position of the tooth is at a near normal
or drilling a hole in the crown and insertion of a threaded position, surgical exposure (excision of the overlying
pin. A simple method is to do a direct bonding of a special gingiva) alone is sufficient to promote the eruption of the
orthodontic bracket with a gold chain attached to it. The
unerupted tooth. However, in cases where the root of
gold chain will be visible outside even if soft tissue grows
the impacted tooth has been fully formed, the tooth lacks
to cover the crown and it can later be attached to the
its inherent potential to erupt and in such instances
orthodontic guidance will be required to facilitate
eruption. Figures 19.8 A to I shows the steps in the surgical
eruption of an unerupted central incisor tooth in a twelve
year-old boy.
Surgical orthodontic management of impacted
incisors (Figs 19.9 A and B): The procedure is similar to
that applied for the management of impacted canines.
Case report (Figs 19.10 A to D): The following case
report illustrates the steps involved in the procedure of
employing removable orthodontics for incisor guidance.
A nine-year-old boy reported complaining of unerupted
upper central incisors (Fig. 19.10 A). A diagnosis of
Fig. 19.7 E: Orthodontic bracket fixed and then impacted upper centrals was made. The diagnosis was
connected to the arch wire confirmed with periapical X-ray. Under local anesthesia
Figs 19.8 A to I: Steps in the surgical eruption of upper central incisor. (A) Intraoral labial view of the patient showing impacted 21,
(B) Palatal view, (C) OPG of the patient showing impacted 21 (yellow arrow). Note the incompletely formed root of the tooth, (D) Incision marked,
(E and F) Incision deepened with surgical blade and overlying gingiva removed. Alternatively electrocautery may be employed to excise the
gingiva, (G) Crown of the tooth fully exposed, (H) Surgical site covered with zinc oxide eugenol paste, (I) Healed surgical site after two weeks
Figs 19.9 A and B: Schematic diagram showing the type of incision (A) to expose the crown and
(B) the closure method after fixing the bracket and attaching the traction chain
Figs 19.10A to D: Orthodontic eruption of impacted upper incisor using removable orthodontics. - (A) Intra oral view showing impacted 11 and 21,
(B) Surgical exposure of impacted teeth, (C) Brackets bonded to the teeth and traction chain attached to the brackets, (D) Removable appliance
fabricated for use in the case
the impacted teeth were surgically exposed (Fig. 19.10 Management of impacted canines / premolars with
B). Brackets were then bonded to the impacted teeth. associated eruption cyst: Impacted canines or premolars
Traction chain was tied to the brackets (Fig. 19.10 C). Tip may be associated with dentigerous cyst or eruption cyst
of the traction chain was kept out side the wound. The in children. The conventional method of management is
wound was then sutured. After the wound has healed enucleation of the cyst along with the removal of
using the traction chain orthodontic force was applied associated teeth. However, in cases where the cyst is small
using removable appliance (Fig. 19.10 D) to guide the or if the impacted tooth associated with the cyst is in a
tooth into position. favorable position to erupt, marsupialization can be tried
Orthodontic eruption of impacted upper incisor to permit the eruption of the tooth into a functional
using fixed orthodontics (Figs 19.11A to D): position. This is especially applicable in case of growing
Complications of orthodontic treatment: Orthodon- children where the root formation is incomplete and bone
tic treatment is not without risks. This includes root formation is very rapid. Figures 19.12 A to D illustrates
resorption, decalcification, periodontal problems, canine the technique in case of an impacted premolar associated
ankylosis and failure to complete treatment. with an eruption cyst in a seven-year-old child.
Figs 19.11 A to D: Orthodontic eruption of impacted upper incisor using fixed orthodontics. (A) Periapical X-ray showing impacted right upper
central incisor, (B) Impacted right upper central incisor 2 months after surgical orthodontic eruption, (C) Orthodontic eruption completed, (D)
Appliance removed after completion of treatment
If the impacted canine is associated with a large PNS radiograph showed opacity of left maxillary
cyst and the patient's age is above the growth period it antrum with impacted canine tooth suggestive of a
may not be possible to marsupialize the cyst so as to dentigerous cyst (Fig. 19.13 B, yellow circle). OPG
permit the eruption of the canine. The following figure showed impacted 23 placed very much superiorly (Fig.
(Figs 19.13 A to C) illustrates this point. A patient aged 19.13 C, yellow arrow). The cyst was enucleated under
20 years reported with unerupted left upper canine and general anesthesia along with the removal of impacted
displaced lateral incisor (Fig. 19.13 A, black arrow). canine.
Figs 19.12 A to D: Marsupialization

of an eruption cyst associated with
an impacted lower premolar tooth.
(A) Bulge seen in the area of erup-
tion cyst associated with impacted
35 (black arrow), (B) OPG showing
eruption cyst in relation to 35 (black
arrow), (C) Marsupialization com-
pleted. Note the erupting 35 (yellow
arrow), (D) Cavity covered with ZOE
paste for a week to prevent entry of
food. The pack will be removed a
week later with instruction to keep
the area clean to permit the erup-
tion of impacted 35
Figs 19.13 A to C: Management of

maxillary impacted canine with
dentigerous cyst (A) Intraoral view
of the patient showing unerupted left
upper canine and displaced lateral
incisor (black arrow), (B) PNS
radiograph showing opacity of left
maxillary antrum with impacted
canine (yellow circle), (C) OPG
showing impacted canine placed
superiorly in the maxilla
REFERENCES 3. Jarjoura K, Crespo P, Fine JB. Maxillary canine impactions:

orthodontic and surgical management. Compendium of
1. Kokich VG, Mathews DP. Surgical and orthodontic Continuing Education in Dentistry 2002; 23(1):23-26.
management of impacted teeth. Dent Clin North Am 1993; 4. Quirynen Marc, Heij Danny G. Op, Adriansens Annelies,
37(2):181-204. Opdebeeck Heidi M., Steenberghe Daniel van. Periodontal
2. Vermette ME, Kokich VG, Kennedy DB. Uncovering health of orthodontically extruded impacted teeth. A split-
labially impacted teeth: apically positioned flap and closed- mouth, long-term clinical evaluation. J Periodontology
eruption techniques. Angle Orthod 1995;65(1):23-32. 2000; 71(11)1708-14.
20 Orthodontic Eruption
of Impacted Canine
An impacted canine should be given an opportunity to Step 4 Locate the root apex of the impacted canine
erupt into the oral cavity and serve its role as cornerstone using radiograph (IOPA) and determine the
of dental arch. Hence, the possibility of orthodontic root apex if the canine would have been
repositioning of impacted canine should be explored normally erupted. Assess the difference in root
before undertaking surgical removal of such tooth. apex location, the more it is deviated from the
If the decision of the clinician is to undertake an ideal apex mesially or distally the more difficult
orthodontic traction of canine after surgical exposure it will be to position. If the apex of the impacted
the following points have to be considered before tooth is close to the ideal apical position of the
attempting it. canine, it will be easier to position orthodon-
Factors to be considered before attempting surgical tically. An assessment regarding the horizontal
orthodontic management of impacted canine are: position also should be considered. Also if the
1. Favorably impacted canine. incisal tip is displaced mesially more than the
2. Good patient cooperation for the long orthodontic and long axis of the lateral incisor it is again difficult
surgical approach. to position.
3. No associated medical problems.
4. Good interdisciplinary support. Canines favorable for orthodontic eruption
• Labially positioned canines.
• Root apex close to the normal apex.
Determining the Favorability of an Impacted • Incisal tip not displaced too much.
Canine for Orthodontic Treatment • Good patient cooperation.
Step 1 Assess whether the impaction is unilateral or Recently three-dimensional CT scans (Ericson S et al,
bilateral. 1988)1 have been used to precisely locate the impacted
Step 2 Clinically palpate for the buccal or the palatal canine. They described the use of high-resolution
bulge. If there is no bulge it might be in a mid computed tomography (CT) in the diagnosis of both the
alveolar position. location and extent of root resorption of permanent
Step 3 Proper radiographs to confirm the bucco- incisors due to ectopic eruption of the maxillary canine.
lingual position and mesiodistal angulation The CT image proved to be superior and more
should be made. Radiographic localization is information was obtained than when conventional
described in Chapter 2. Intraoral periapical radiographic methods, including polytomography were
radiograph (IOPA) and occlusal radiograph are used. Although CT is an expensive method, it is not time-
invaluable aids in deciding the exact position consuming or complicated. (Refer Chapter 2 for more
of the impacted canine. details regarding use of CT scan).
Utilizing all the above diagnostic criteria the clinician Orthodontic Treatment Planning
should develop a mental picture about the possible
placement of canine three dimensionally within the bone a. Evaluate the space requirement for canine: This can be
(almost similar to a 3D CT reconstruction image). done by utilizing the mesiodistal width of the
Bilateral, palatally placed and unfavorably angulated contralateral canine. Radiographs usually made of
canines are usually difficult to position orthodontically paralleling technique may be used in some cases
but not impossible. Cost effort benefit analysis should be especially for non rotated normally inclined canines.
done before orthodontically attempting to position these b. Measures to gain additional space: Retained deciduous
teeth. canines if present, might have maintained some space.
Calculate any space that is present or possible means
to gain it. Remember to create some extra space
Good Patient Cooperation
because there is every possibility to lose some space
Good patient cooperation (Becker A, 1998)2 is the key to during the repositioning process.
success in surgical orthodontic positioning of impacted Also determine whether additional extractions of
canine. The treatment time can vary depending on the premolars are required for correction of proclination
placement and angulation of the impacted tooth. At times along with impacted teeth, which should be based on
there can be bond failure during traction which may need facial aesthetics and occlusion status.
further surgical opening and reattachment. The extra time

required should be explained to the patient. Orthodontic treatment planning
• Space requirement
• Space gaining measures

Associated Medical Problems • Anchorage reinforcement
• Planning for correction of associated orthodontic
This aspect should be assessed as with any surgical case problems.
and necessary precautions should be taken to avoid
complications. A risk benefit analysis should be made c. Anchorage planning/reinforcement: Good anchorage
before attempting the surgical orthodontic positioning. source is very essential for successful positioning of
If it is difficult to position the canine considering the canines (Becker A, 1998).2 The more unfavorable the
medical condition, an alternative approach like surgical tooth is, more the anchorage is needed. Unwanted
removal and replacement with prosthesis or leaving in
movements of adjacent teeth should be expected and
its place may be considered.
necessary steps to reinforce anchorage are essential.
Bilateral, palatally placed and unfavorably angulated canines In case of bilateral impacted canines the anchorage
are usually difficult to position orthodontically requirement is more. A transpalatal arch or Nance
palatal button may be considered to reinforce the molar
anchorage. A molar distalization appliance could be
Good Interdisciplinary Support considered to distalize the molar to create additional
space in a non extraction case (Fig. 20.1).
The need for surgical opening with minimal trauma and
d. Planning for correction of associated orthodontic
at the same time with maximum visibility and accessi-
problems: If the patient has associated problems like
bility for bonding will need the service of an oral surgeon.
proclination or crowding along with impacted
Efficient orthodontic bonding, traction with directional
control and precise aesthetic positioning may need the tooth, the question of which one to be carried out
help of an orthodontist. Radiographic localization needs first will put the clinician in a dilemma. Waiting to
the support of a radiologist. Final gingival aesthetics may complete one and then go for the other problems
be enhanced by a cosmetic periodontist. Hence, all the will unnecessarily increase the total treatment time.
concerned specialist should work in unison for the Here the clinician's wisdom should be applied to
successful orthodontic management of an impacted carryout the entire process in a clinically justifiable
canine. short period.
Orthodontic Eruption of Impacted Canine 201
Attachments
The placement of orthodontic attachment on the correct
buccal side of the tooth crown is another important aspect
in the interdisciplinary management of the impacted
canine. Bonding an attachment to the crown could be
performed either during the surgical opening (Becker
et al, 1975)3 or can be performed several days or weeks
later, i.e. an open method. Both have its advantages and
disadvantages as detailed below. In a closed eruption or
a full flap closure method, the attachment should be
bonded on the same appointment.
Fig. 20.1: Creating space for canine positioning using intraoral
molar distalization appliance Advantage of Bonding on the Same
Appointment
Orthodontic Treatment Strategy
a. A closed method of eruption which is superior to the
The aims of orthodontic treatment for an impacted tooth open method could be carried out.
are: b. Bond strength is found to be superior as the newly

1. Provide a secure attachment on the crown to apply exposed tooth is covered only with the enamel cuticle
adequate force for its eruption. which is only one micron thick and could be easily
2. Allow the tooth to erupt through the keratinized removed by the application of the orthophosphoric
mucosa.2 acid used for etching.(Becker et al 1996).4
3. Precisely position the tooth in the arch without c. Healing could be achieved by primary intention.
compromising periodontal aesthetics.
One of the main disadvantages of bonding at the
The opening of space in the arch may initiate the
same appointment is the problem of moisture control
movement of an unimpeded impacted tooth.2 By the time
during bonding.
the space is adequate and the arrangement for surgery
have been made, a new periapical radiograph may show
a more positive change and often the clinician feels the Advantages of Bonding in a Second Visit
tooth may erupt spontaneously.2 If it erupts by its own it
a. Dry field could be easily achieved, which is very critical
is well and good, but if the eruption process is slow it is
for bond strength.
better to intervene surgically and initiate orthodontic
b. Appointment can be scheduled as per the doctor's will
traction. and the long process of surgical opening and bonding
The placement of orthodontic appliance carries some at same visit could be avoided.
amount of risk to the tooth in terms of caries and The disadvantages of bonding in a second visit are:
periodontal problems. Every clinician should aim and a. After few days of exposure of the tooth to oral
attempt to finish the treatment in the shortest time frame environment there is plaque and food debris accumu-
to avoid this risk factor. When orthodontic treatment has lation on the crown. This needs to be removed prior to
created enough space to accommodate the impacted bonding by polishing with rubber cup and pumice
tooth, surgical procedures to remove any associated paste. If the opening is not wide enough adequate
pathology as well as to initiate traction are to be cleansing is difficult.
undertaken simultaneously. If the pathology associated b. The edematous tissue may bleed which can result in
is a cyst or a space occupying lesion it may have to be poor bond strength.
treated initially and sufficient time should be given for c. The surgeon needs to create a wide opening to prevent
healing and new bone formation. Here orthodontic strap the spontaneous closure and to facilitate polishing,
up could be delayed to reduce the risk of periodontal which can affect the future periodontal health and
damage. aesthetics.
was analyzed by radiographic method a live direct

visualization can only give the accurate picture of the
tooth. The point of bonding and direction of force
application should be assessed. As far as possible the
attachment should be bonded on the mid buccal position
and light continuous force should be applied along the
long axis of the crown. If the mid buccal position is not
accessible an alternate location could be selected. The
treatment time will be increased in the latter case as the
attachment needs repositioning for dental rotation and
axial inclination correction. In case of palatally impacted
Fig. 20.2A: Armamentarium used for orthodontic bonding
teeth, bonding can be done on the palatal aspect initially
and the force is redirected appropriately for its eruption
through the keratinized area.
Detailed description regarding surgical exposure is
given in Chapter 4.
Once the location of the attachment and type of
attachment is finalized bonding can be started. (Figs 20.3
A to H).
Hemostasis
A dry field is of utmost importance for successful
bonding. After raising the flap it should be retracted
sufficiently. Bleeding can be arrested by means of a
pressure pack. Further oozing from the bone margins may
Fig. 20.2B: Begg's bracket with custom made traction
chain and ligature wire twisted necessitate additional pack for some more time or use of
bone wax.2 Use of electrocautery will control soft tissue
bleeding. Adequate suction and proper illumination is
Armamentarium for Successful Bonding
very essential as with any case of surgery. A fine suction
(Figs 20.2A and B)
is highly useful during the process of bonding to maintain
1. The selected attachment with ligature tie. a dry field.
2. Reverse action tweezer. If the bonding is done immediately after raising
3. Orthodontic adhesive system comprising of surgical flap polishing with pumice paste is not required.
phosphoric acid gel, bonding agent (if required as per After proper drying with fine suction tip, 37%
the manufacture's specification), and applicator tips. orthophosphoric acid etching gel should be applied with
4. Polishing cup and pumice paste. an applicator tip over the area to be bonded for 30
5. Ligature director. seconds. Acid solutions should not be used as the area of
6. Artery forceps. application cannot be controlled (Kokich, 1993).5 Care
7. Elastic thread or chain depending on the mode of force should be taken to prevent acid from contacting the
application. cemento-enamel junction. After 30 seconds the acid is
drawn through a fine suction tip until the surface is dried.
Procedure of Bonding A syringe loaded with saline can be used to wash out all
(in the same visit approach) the residual etchant. After this, rinsing with distilled
water using a syringe could be done to prevent the salts
After the flap is raised, the impacted tooth which is now of saline from accumulating on the etched surface. Drying
visible in the oral cavity should be carefully inspected is usually done with the suction alone until the
for the position, angulation and rotation. Even though it characteristic 'chalky white' appearance is achieved.2 If
Figs 20.3 A to D: Steps in bonding: (A) Preoperative intraoral photograph showing unerupted right upper canine, (B) Periapical X-ray showing the
crown position and angulation of the impacted canine three months after removal of first premolar, (C) Raising the flap to expose the impacted
tooth, (D) Etching gel application after isolation and hemostasis
required drying with gentle air from the three way bond is critical to the bond strength. Holding with an
syringe could be done carefully. instrument like tweezer or artery forceps should be
Now the tooth is ready for bonding. Light activated avoided. Instead a ligature director or the reverse end of
or chemically cured adhesives may be used. A thin layer a reverse action tweezer could be used to apply some
of primer is coated over the etched surface. A reverse pressure and its removal will not produce any jolting of
action tweezer is used to hold the bracket or eyelet used the attachment.2
for bonding. The ligature wire should be passed through The bracket should be left in place for a few minutes
the bracket and the remaining wire is twisted to form an for the complete bonding and isolation should be
extension from the attachment base. The wire should maintained during this period. After this it could be tested
swing from the bracket. for strength and suturing could be done. The free end of
A layer of primer is applied over the base of the the extension from the bracket is placed in such a way
bracket and adequate amount of composite is applied that it should exert force along the long axis of the tooth;
over the base which is carried to the tooth surface and usually the wire is directed through the alveolar crest. In
left in place for some time. Continuous pressure certain cases, especially in palatal canines if the tooth is
application until it sets is unnecessary. It is better to leave angulated in such a way that the force application along
the bracket in place after correct positioning and an initial long axis is not possible or detrimental to the root of other
pressure application to squeeze out the excess adhesive. teeth, the direction should be initially altered.2 A pin hole
Avoiding disturbance during the initial crystallization of could be placed in the appropriate location of the flap
Figs 20.3 E to H: Steps in bonding contd: (E) Curing light applied after placement of bracket with ligature tie for traction, (F) Bonded
attachment after curing, (G) Postoperative view after 1 week, (H) After placement of arch wire
and wire is extended into the oral cavity through this bonding surface to the tooth. Conventional brackets are
hole which is attached to appropriate spring for traction. designed to bond on the mid buccal surface. If it is used
on any other surface the adaptability is poor. Hence in
Essentials of orthodontic bonding other areas a custom made attachment should be
• Adequate exposure and hemorrhage control developed which can perfectly adapt to the surface. Using
• Isolation with cheek retractor, tongue guard, cotton and
an eyelet welded on a mesh base is a good option.
suction.
• Etching with phosphoric acid gel
• Drying Various Attachments
• Application of primer and curing
• Placement of attachment with adhesive and curing. 1. Bonded attachments: This include: (a) bondable
traction chain, (b) conventional bondable bracket and
It is better to apply force in the same visit itself, as (c) bondable lingual button
subsequent manipulation later after a few days will be a. Traction chain: Orthodontic traction chains with
painful. The reliability of the bonding procedure in the bondable base are available. Bonding bases with
above described pattern is found to be high (Becker et al, gold chains were used initially. To the holes of the
1996).4 This depends on the creation of a moisture free chain the arch wire can be ligated either by ligature
area developed for bonding, avoidance of disturbance in wire or elastic thread. As the tooth moves down
the initial crystallization process and adaptability of the the chain is activated by re-ligation. This type of
an attachment could be made in an average

practice by using a bondable Begg's bracket or a
Tip edge bracket with small circular rings made
of 0.6 mm stainless steel wire which resembles like
a chain (Fig. 20.2B).
b. Conventional bondable bracket: Conventional
bondable bracket is the most widely used
attachment mode for traction. It is best suited if
the midbuccal surface is accessible, since most
preadjusted brackets are designed for this position.
Contoured Begg's bracket could be used on the
buccal side. Contour can be altered to some extent
by manipulation with How's plier. If the closed
method is to be used then the ligature wire should
be used to tie to the bracket or passed through the
bracket for attachment to the arch wire. Usually
the ligature wire should be passed through the slot
in a Begg's bracket or tied around the wings of
edgewise bracket. Then this ligature wire is Fig. 20.5: Lasso wire wrapped around the cervical
twisted with an artery forceps to form a twisted
aspect of canine for traction

wire. The connection between the bracket and the
twisted wire should be free enough to permit free Twisted ligature wire tie could be made for
swinging of the bracket i.e. it should not be too bonding in closed eruption cases also.
rigid. This will avoid undue pressure on the 2. Lasso Wire
bracket during bonding. While making the twisted In the years prior to 1960s a lasso wire (Fig. 20.5) twisted
wire small circles could be incorporated by placing around the neck of the canine had been employed widely.
a round wire or a micromotor bur in between to The wire is engaged at the cemento enamel junction and
resemble a traction chain (Fig. 20.2B). This will help this will result in irritation of the gingiva and prevent
to tie elastics for activation. reattachment of the healing tissues in this vital area.
c. Bondable lingual buttons (Fig. 20.4) also could be Studies have shown that this method can result in external
used for attachment to the tooth especially in cases resorption and ankylosis (Shapira and Kuftinec, 1981)6
where the canines are left open. To this, later elastic of the impacted canine. Since many other good
chains or threads could be tied for activation. alternatives are available this method is seldom
followed now.
3. Stainless Steel Crowns
Sometimes a stainless steel crown of appropriate size
could be cemented to the crown especially to molars and
premolars after surgical exposure. Orthodontic traction
could be placed to the soldered attachments. This
procedure can avoid bonding at the site of surgical
exposure and immediate traction force could be placed.
Various attachments for canine traction

1. Bonded attachments 3. Cemented crowns
a. traction chains 4. Threaded pins
b. brackets 5. Orthodontic bands
c. buttons
Fig. 20.4: Bonded button in place after surgical 2. Lasso wire
exposure with traction applied
accessible for bonding or in cases where there is repeated

bond failure. Traction force application without fear could
be applied at each visit for orthodontic positioning, since
many clinicians have the fear of bonding breakage. Later
the hole could be closed with composite resin. Once the
tooth is accessible for bonding, orthodontic bracket
should be bonded.
Principles of Orthodontic Traction

Orthodontic canine traction is best treated with any of
the fixed appliance systems. At the age at which an
impacted canine is detected and treated, a full
compliment of teeth with the exception of third molar is
invariably present. Accordingly a fully multibracketed
appliance should be normally placed and the initial
process of leveling and alignment with bite correction
should be performed. Sufficient space should be opened

Fig. 20.6: Treaded pin
up for accommodating the impacted canines. Retained
4. Threaded Pins deciduous counterpart could be used as a good space

maintainer until the surgical exposure. If it is removed
Threaded pins (Fig. 20.6) that are usually used for early the bone gets hardened and affects the traction
retention of amalgam restoration can be threaded to the process adversely. Preadjusted edgewise appliance
impacted tooth and traction force can be applied. (Becker provides better three dimensional control of the teeth than
and Zilberman, 1978).7 The obvious disadvantage of this a Begg's appliance.
method is that it is a dentally invasive method which Orthodontic extrusion is one of the tooth movements
requires a restoration later. Also since the long axis of a which require very light and continuous force. 35-60
tooth cannot be exactly determined during exposure, the grams (Proffit WR, 2000)8 is the ideal force suggested for
pin can reach the pulp as the chamber is usually large in extrusion. A good guide will be one mm of extrusion per
an impacted unerupted tooth. month. Force should be directed along the long axis of
the tooth. A tooth with altered axial inclination should
5. Orthodontic Bands have the force directed accordingly to avoid damage to
the roots of adjacent teeth. Force should be redirected
Placement of preformed orthodontic bands to the crown later after the initial unlocking of the roots.
is another option. This requires wide clearance of bone
for the exact placement of band with out contamination • Orthodontic extrusion requires very light and continuous
with blood while cementing. With the introduction of acid force.
• 35-60 grams is the ideal force at the rate of one mm per
etch bonding this method has become obsolete.
month.
• Force is directed along the long axis of the tooth.
6. Through and Through Hole at the
Tip of Canine
Orthodontic Springs
This is another approach in which a through and through
hole is drilled close to the incisal edge and a ligature is An orthodontic spring could be designed for affecting
passed through it for applying traction. The disadvantage the traction by the clinician himself. A number of designs
is that it is dentally invasive and requires a restoration are available in the literature. Ballista spring (Jacoby H,
later. This could be tried in canines which are not 1979)9 is one example. Usually springs are made of
Orthodontic traction
• Traction force applied at the same appointment itself is
better.
Traction can be done with:
• Auxiliary springs made of flexible wire
• Niti closed coil springs
• Elastic threads and chains
• Magnets.
Elastic Traction
Fig. 20.7: Auxiliary wire spring for canine alignment
After bonding of the attachment to the tooth, sufficient
traction force could be generated by elastic ligation
(Fig. 20.9) to the arch wire. Elastic threads are
conventionally used to tie the end of the traction chain to
the arch wire. Care should be taken to prevent loosening
of the elastic after tying. Small segment of elastic chains
also could be used as force generating unit. One

disadvantage with elastic ligation is the rapid rate of force
decay. Force level reduces considerably after two to three

weeks (Lu TC et al, 1993) 10 and hence frequent
reactivation is necessary.
Elastic threads, chain (Figs 20.10 to 20.12) or module
with a flexible arch wire, when deflected with ligation
provide good power source. Alternatively nickel titanium
closed coil springs or flexible wire with incorporated
loops may also be used to deliver force to the impacted
canine.
Figs 20.8A and B: Palatal spring for the canine alignment
accessory wire with good flexibility (Fig. 20.7) and are

placed in concert with the main arch wire. Care should
be taken so that the line of action of the spring should be
in the desired direction. (Figs 20.8A and B). Fig. 20.9: Elastic traction in place
Anchorage
Orthodontic canine traction requires good anchorage and
all means to reinforce anchorage like transpalatal arch,
lingual arch and Nance palatal arch should be considered.
Prior to application of traction force on canine the arch
wire should be of thicker gauge to avoid undue tooth
movement of the adjacent teeth. (Kokich and Mathews
DP, 1993).5 Usually when canine is extruded down,
adjacent laterals and premolars will have an intrusive
effect, which could be prevented by thick wire, especially
full slot rectangular wires in straight wire technique.
Teeth located on both sides of the space for future canine
should be tied to the adjacent teeth with closed figure of
eight ligature wire to prevent space closing. Open or
closed coil spring could be placed accordingly to maintain
or gain space between teeth for canine. Smaller gauge
Fig. 20.10: Elastic chain and elastic thread auxiliary Niti wire can be placed over the heavier wire to
exert lighter force.
Implants for Canine Traction

Cortically stabilized implants are now gaining popularity

among orthodontists for various orthodontic needs. It can
be utilized for effecting canine traction, especially a
resistant canine with out compromising the anchorage.
The use of osseointegrated implants in adult patient will
provide absolute anchorage (Roberts et al, 1984).11
Removable Orthodontic Appliance

Although fixed appliance is the appliance of choice for
the orthodontic traction at times a removable appliance
Fig. 20.11: Elastic chain applied for labial positioning of canine could be used in selected cases. If a removable appliance
Fig. 20.12: Elastic thread applied for canine alignment

is found sufficient, it should have attachment hooks for Prevention of Canine Impaction
the placement of elastics and a good number of clasps
for retention. Stops should be placed for laterals and Development of permanent canine begins at 4-5 months
premolars to prevent drifting. Traction chains cannot be after birth. Crown is completed by 6-7 years. Eruption of
used with removable appliance. Always an open the upper canine is at 11-13 years and lower canine at 10-
approach is preferred where the superficially impacted 12 years. This shows racial and sexual variations. Root
tooth is opened and a bracket with hook is bonded. The formation is completed at 13-15 years for the upper and
hook on the removable plate is positioned in such a way 12-14 years for the lower. It is the last tooth to erupt in
that the line of force is in the desirable direction and there the anterior segment of the arch. Clinically one should
is no occlusal disturbance. Care should be taken by the be watchful from the dental age of 8 or 9 years for the
patient while placing and removing the elastics not to eruption of permanent canines especially in patients with
dislodge the attachment bonded to the tooth. The elastic a family history of small or peg-shaped laterals,
should not impinge on the mucosa. Regular cleansing of congenitally missing laterals and impacted canines.
the appliance and proper oral hygiene maintenance Normally erupting canines should be palpable in the
should be recommended. buccal sulcus as a firm bulge at about 12-18 months before
eruption. At the age of 10 years if the canine prominence
is not felt or if there is any asymmetry while palpating
Magnets for Correction of Canine Impaction
left and right side cuspid regions labially, appropriate
The introduction of lanthanide alloys has provided the radiograph should be taken to rule out the possibility of
possibility of applying suitable force for the traction of impaction.
impacted canines using magnets as described by Sandler

et al (1989)12 and also by Vardimon (1993)13 (Fig. 20.13). Prevention of canine impaction
The attracting force between two magnets is inversely • Prevention is better than cure.
• Careful watching of the developing laterals and
proportional to the square of the distance between them.
canines.
So the magnets should be positioned very close to each
• Necessary radiographs especially in patients with family
other for sufficient force. A grossly displaced tooth may
history of impacted canines, missing laterals, or with
require that the appliance magnet may be repositioned abnormal shape and size of lateral incisors.
from time to time, in line with the progress of the tooth.
The greatest disadvantage of using magnets is its corrosion Ericson and Kurol (1988)1 in a landmark study had
as reported by Rygh (1993)14 and Darendelier et al (1994).15 reported that extraction of primary cuspid can prevent
It can be concluded that the use of magnets offers no better palatal impaction of permanent canine provided normal
advantage over the conventional traction process. space condition is present and there is no radiographic
evidence of incisor root resorption. In cases of crowding,
extraction of primary canine alone may not resolve the
problem; rather additional arch expansion or other means
of gaining space is required. A marked difference in the
eruption of canine between the two sides, maxillary
lateral incisor which is late in eruption and is unusually
proclined are a few warning signs of maxillary canine
impaction.
Conclusion
This chapter has focused on the sequential management
of impacted maxillary canine by surgical orthodontic
Fig. 20.13: Embedded magnet in removable appliance approach. The principle of management of other
impacted teeth are also essentially the same with minor 6. Shapira Y, Kuftinec MM. Treatment of impacted cuspids:
differences. A wise clinician should consider many factors the hazard lasso. Angle Orthod 1981;51:203-07.
before taking up a decision regarding the management 7. Becker A, Zilberman Y. The palatally impacted canine: a
of an impacted tooth. Patient perception should get new approach to its treatment. Am J Orthod 1978;74:
appropriate consideration in the treatment plan. A team 422-29.
approach is essential in the ideal surgical orthodontic 8. Proffit WR. Contemporary Orthodontics, Third edition,
management of an impacted canine tooth. Mosby Inc. USA 2000.
9. Jacoby H. The ballista spring system for impacted teeth.
Am J Orthod 1979; 75: 143-51.
REFERENCES 10. Lu TC. Wang WN, Tarng TH, Chen JW. Force decay of
elastomeric chain - a serial study, Part - 2, Am J Orthod
1. Ericson S, Kurol J. CT Diagnosis of ectopically erupting
1993;104:373-77.
canines. Case report. Eur J Orthod 1988;10:115-20.
2. Becker A. The orthodontic treatment of impacted teeth, 11. Roberts WE, Smith RK, Zilbermann Y, et al. Osseous
Martin Dunitz, London 1998. adaptation to continuous loading of rigid endosseous
3. Becker A, Zilberman YA. Combined fixed removable implants. Am J Orthod 1984;86:95-111.
approach to the treatment of impacted maxillary canines. 12. Sandler PJ, Meghji S, Murray AM, et al. Magnets and
J Clin Orthod 1975; 9:162-69. Orthodontics. Br J Orthod 1989;16:243-49.
4. Becker A, Shpack N, Shteyer A. Attachment bonding to 13. Vardimon AD. The use of magnets in orthodontic therapy:
impacted teeth at the time of surgical exposure. Eur J Panel discussion. Eur J Orthod 1993;15:421-24.
Orthod 1996;18:457-64. 14. Rygh P. The use of magnets in orthodontic therapy: Panel
5. Kokich VG, Mathews DP. Surgical and orthodontic discussion. Eur J Orthod 1993;15:421-24.
management of impacted teeth. Dent Clin N Am 1993; 15. Darendelier MA, Friedli JM. Treatment of an impacted
37:181-204. canine with magnets. J Clin Orthod 1994;28:639-43.
21 Surgical Removal of Palatally
Impacted Maxillary Canine
Impacted maxillary canines which are in an unfavorable Factors Complicating the Removal of
position to bring into normal occlusion should be Impacted Maxillary Canine
removed earlier rather than later as the difficulty for

removal increases with age and also as the damage done Due to the close proximity of impacted maxillary canine
by the tooth to the adjacent structures can be minimized. to the adjacent central incisor, lateral incisor and premolar
there is a danger of injury to these teeth. Injury to the

above teeth can occur either during bone removal, or
Indications for Removal during sectioning or during elevation of the impacted
cuspid.
1. Change in position of adjacent teeth due to the
In the majority of cases the impacted canine is
impacted tooth in unfavorable position
separated from the maxillary sinus and nasal cavity by a
2. Resorption of roots of adjacent teeth.
thin plate of bone (Fig. 21.1). Rarely this bone may be
3. Associated pathology, like formation of a dentigerous
cyst.
4. Teeth in the alveolar cleft in cleft palate patients, if the
tooth cannot be aligned orthodontically after bone
grafting.
5. Impacted tooth in edentulous patient.
6. Neurological symptoms like pain.
7. Prior to orthodontic treatment if it can hinder the
movement of other teeth.
8. Lack of motivation of the patient or lack of facilities
for orthodontic alignment.
In cases where the primary canine is left following
extraction of the permanent successor it is not possible to
predict how long the primary canine will remain intact.
Little research has been carried out on this aspect. In the
event of the primary canine becoming unsightly or being
Fig. 21.1: Surgical anatomy of maxillary canine area. Note the close
lost it could be replaced with fixed or removable pros- relationship of the root of the impacted canine to the floor of the maxillary
thesis. sinus and nose
absent. Hence, in such cases there is a possibility of If the cuspids are impacted bilaterally and are close
pushing the impacted tooth or the sectioned root into the to the midline, the incision should always extend from
maxillary sinus. It is also not uncommon to have the the first premolar on one side to the first premolar of
possibility of creating an oro antral communication and the opposite side (Figs 21.3A to 21.4K). This is
the resultant postoperative nasal bleeding even if the important because if a double flap is elevated to avoid
tooth has been removed successfully. Postoperative injury to nasopalatine neurovascular bundle, the
infection of the maxillary sinus can be avoided in such tissues left in the midline is easily traumatized and
cases by following strict asepsis. sloughs eventually. By elevating a single palatal flap
Most impacted maxillary canine roots have a sloughing is avoided and at the same time there is
pronounced curvature at the apical third of the root. Very adequate visualization. The only problem encountered
often this is not visible in the radiographs. In cases where is brisk hemorrhage from the nasopalatine vessels
resistance is encountered in the removal of a tooth or a which can be controlled by pressure pack or by
sectioned root which is otherwise adequately mobilized, electrocautery.
the possibility of extreme root curvature should be b. Instead of placing the incision in the gingival sulcus,
thought of. Removal of a fractured apical third of the root an incision can be made above the attached gingiva,
is a difficult procedure. leaving at last 0.5 cm of it. This incision is not
As the age advances, the bone becomes more commonly employed.
sclerosed and its removal especially that of the palatal
c. If the tooth is only on one side, instead of carrying the

bone becomes more difficult. This in turn prolongs the incision over to the opposite side, a vertical incision
operative time as well as increases the possibility of can be given in the mid palate (Figs 21.5A to 21.6N).
development of complications both intra operatively and However in such cases suturing after the procedure
post operatively. Hence it is always ideal to remove may be difficult and the chance of traumatisation of the
impacted canine at a younger age when the bone is more flap is more in the last two methods, especially for the
elastic. Asymptomatic impacted canine in older beginners.
individuals may be left as such with periodic review. The mucoperiosteal flap is reflected to expose the
palatal bone and the tooth. The nasopalatine vessels and
Choice of Anesthesia nerve can be divided if needed for sufficient exposure
and firm pressure is usually sufficient to stop the bleeding.
The surgery can be done under local or general anesthesia
The crown of the tooth may sometimes be visible, or
or under local anesthesia with intravenous sedation.
a bulge may be felt. Bone is removed around the area
Like in any other surgical procedure, a proper history
with a chisel or bur or using both, taking care not to
has to be taken. Clinical and radiographic examination is
damage the roots of the adjacent teeth. Once sufficient
then done and the position of the tooth localized.
bone is removed, a groove is made on the mesial side.
An elevator is introduced in the groove and the tooth is
Procedure luxated. Once the crown moves out, it can be grasped
The patient should be in a reclining position with the head with an upper anterior or premolar forceps and removed.
bend back, which helps in direct vision of the palate. A certain amount of torsion may be needed to disengage
the apex of the root which is often curved.
If the tooth is resistant to elevation, more bone is
Approaches
removed to enlarge the opening. If there is still obstruction
a. The usual approach is by using a mucoperiosteal flap to the movement of the crown, the tooth may need to be
reflected following an incision along the gingival sulci sectioned (odontotomy). This is accomplished with a
on the palatal side. The incision starts from the first straight fissure bur. The crown portion is first removed.
premolar on the same side and extends up to the lateral Some amount of the remaining root should be visible and
incisor or up to the pre molar of the opposite side if not, bone is removed to expose the root. A bur hole is
depending upon the position of the impacted tooth placed in the root close to the bony margin and the root
(Figs 21.2 A to F). is elevated into the space created by removal of the crown
Surgical Removal of Palatally Impacted Maxillary Canine 213
Figs 21.2 A to F: Schematic diagram showing steps in the surgical removal of palatally positioned impacted maxillary canine (A) Incision, (B)
Reflection of the flap, (C) Removal of bone to expose the crown, (D) Sectioning of the crown, (E) Removal of the root, (F) Suturing of the flap
Figs 21.3 A and B: Palatal flap elevation for exposure of bilaterally impacted palatally positioned canine. (A) Flap outlined from second premolar
on one side to the second premolar of the opposite side, (B) After reflection of the mucoperiosteal flap multiple drill holes are placed in the bone
overlying the crown. These drill holes are then connected together to remove the bone thereby exposing the crown
by using a gauze pack for an hour or two. The gauze

pack is held in position by the pressure from the dorsum
of the tongue. Healing follows without any complications.

Use of a prefabricated clear acrylic plate covering the
palate postoperatively may help to reduce the chance of
hematoma formation.
Removal of bilateral palatally impacted canine by
elevating a full palatal flap and tooth sectioning:
Case report (Figs 21.4 A to K): An 18-year-old boy
reported with diastema between upper centrals and
unerupted canine teeth (Fig. 21.4 A).Occlusal X-ray and
OPG revealed bilaterally impacted canine in the maxilla
with their crowns closely related to the roots of the central
incisors (Figs 21. 4 B and C). Impacted teeth could not be
palpated on the labial side. However, there was a mild
swelling on the palatal aspect suggesting the presence of
impacted teeth on the palatal aspect. Considering the
position of impacted tooth in the palatal aspect, the
procedure was planned under general anesthesia with
Figs 21.4 A to C: Steps in the surgical removal of palatally impacted endotracheal intubation. Incision was given along the
canines (A) Intraoral view of the patient, (B) Occlusal X-ray of maxilla
showing bilaterally impacted canines, (C) OPG of the patient showing palatal gingival margin from 16 to 26 (Fig. 21.4 D).
bilaterally impacted canines Mucoperiosteum was reflected (Fig. 21.4 E). The bone
overlying the impacted teeth was removed using bur
portion. along with profuse saline irrigation to expose the crown
Thorough debridement is done taking care to remove of the impacted tooth (Fig. 21.4 F). Care was taken not to
the tooth follicle by curettage and to remove the bone injure the roots of the adjacent teeth. The crown was then
debris with saline irrigation. The flap is replaced and sectioned (odontotomy) using a fissure bur and removed
sutured into position. Once the mucoperiosteum is (Fig. 21.4 G). Using an elevator, the root was elevated
sutured back, it is held in contact with the palatal bone into the space created by removal of the crown portion.
Figs 21.4 D to G: (D) Incision along the gingival margin in the palatal mucoperiosteum, (E) Mucoperiosteum reflected to expose the
bone overlying the impacted canines, (F) Bone overlying the canines removed to expose the crown, (G) Sectioning of the crown
Figs 21.4 H to K: (H) Socket after the removal of impacted canines, (I) Excised canines,
(J) Suturing complete-view from the palatal aspect, (K) View from the labial aspect
The root was then removed (Fig. 21.4 H). Both the teeth anesthesia. Incision was placed along the palatal gingival
were removed in a similar fashion (Fig. 21.4 I). The wound margin from 15 to 21 region with a vertical incision in
was then debrided, irrigated and closed with 3-0 black the palate in the region of 21 (Fig. 21.6 E). Mucoperiosteum
silk interdental sutures (Figs 21.4 J and K). was reflected (Fig. 21.6 F) and it was held in position using
Removal of palatally impacted canine (unilateral) by a 'stay suture' (black arrow). The bone overlying the
elevating a palatal flap with vertical incision: impacted tooth was removed using bur with profuse saline
Case report (Figs 21.6A to N): A 14-year-old boy irrigation to expose the crown of the impacted tooth. Care
reported with complaints of deformed right upper lateral was taken not to injure the roots of the adjacent teeth. A
incisor and unerupted canine tooth (Figs 21.6A and B). trough (black arrow) was made around the crown of the
There was projection of the impacted canine on the palatal impacted tooth (Figs 21.6 G) for placement of an elevator
side with the crown tip visible (Fig. 21.6 C). Periapical X- and for mobilizing the tooth. The tooth was slowly luxated
ray revealed impacted right maxillary canine with its using an elevator(Figs 21.6 H and I) and removed in one
crown closely related to the roots of the central incisor piece (Fig. 21.6 J).The wound was then debrided and
(Fig. 21.6 D). Orthodontic consultation was done to assess irrigated with normal saline(Fig. 21.6 K). Closure was done
the feasibility of orthodontic guidance of the impacted with 3-0 black silk interdental sutures and two sutures for
tooth. Considering the unfavorable position of the vertical incision in the palate (Fig. 21.6 L).
impacted tooth for orthodontic positioning, surgical As discussed in Chapter 17, CT scans are extremely
removal of the impacted tooth was advised by the useful in the localization of maxillary canines and to
orthodontist. The procedure was planned under local decide the type of surgical approach to be employed to
Figs 21.5A to F: Schematic diagram showing removal of palatally impacted canine by elevating a palatal flap with vertical incision. (A) Incision
made around the neck of the teeth from the region of the second premolar to the midline followed by a midline incision in the palate, (B)
Mucoperiosteum reflected, (C) Drill holes made around the crown of the impacted tooth, (D) Opening enlarged to fully expose the crown, (E) Tooth
elevated using elevator, (F) Closure of the flap using interdental sutures and sutures in the midline of the palate
Figs 21.6 A to D: Steps in the

surgical removal of a palatally
impacted canine (A) Intraoral view
from the right lateral aspect
showing spacing between 12 and
14, (B) Intraoral frontal view
showing deformed 12, (C) Palatal
view showing impacted 13 with the
crown tip visible, (D) Periapical X-

ray with impacted 13 and its cusp
tip close to the root of 11
Figs 21.6 E to H: (E) Incision along the gingival margin from 15 to 21 with vertical incision in the palate, (F) Mucoperiosteum reflected and held in
place using 'stay suture' (black arrow), (G) Bone overlying the crown removed to expose it and a trough created around the crown (black arrow),
(H) Elevator placed in the trough to luxate the tooth
Figs 21.6 I to L: (I) Impacted tooth luxated out of the socket, (J) Tooth removed in one piece,
(K) Debridement of the socket, (L) Suturing completed
Figs 21.6 M and N: Postoperative appearance two weeks later. (M) Intraoral frontal view,
(N) Palatal view. Note the well healed palatal wound
Figs 21.7 A to D: (A) Intraoral view showing spacing between the upper centrals and unerupted maxillary canines. There is no labial bulge
indicating the position of impacted 13 and 23, (B) Palatal view showing unerupted canines and retained deciduous canine root on the right side.
No palatal bulge can be seen indicating the location of the impacted teeth, (C) OPG demonstrating impacted canines (yellow circle and yellow
arrow), (D) Occlusal view showing impacted 13 and 23
Figs 21.7 E to I: (E) Axial CT showing impacted 13 and 23 (yellow arrows). Note that the crowns of impacted canines are more palatally placed
compared to the roots of the incisors, (F) Coronal CT scan at the level of normal position of the canines. Note that the impacted canines are
obliquely placed, (G) Coronal CT scan at the level of premolars. Note the relationship of the roots of the canine to the nasal floor and the deficient
palatal plate in the region of cusps of impacted canines, (H) Sagittal CT through the region of 13. Note the palatal position of impacted 13 in
relation to the root of 12, (I) Sagittal CT through the region of 23. Note the palatal position of impacted 23 in relation to the root of 22
Figs 21.7J to L: (J) Mucoperiosteum reflected and the overlying bone removed to expose the crowns of impacted 13 and 14 (yellow arrows),
(K) The impacted teeth were removed by sectioning and the surgical site before closure, (L) Suturing completed with interdental 3-0 sutures
remove the tooth i.e. the labial approach or the palatal incisors (Figs 21.7 E to I). Considering the position of the
approach when the bulge of the impacted tooth cannot impacted tooth in the palatal aspect, the procedure was
be felt on either side. The following is the report of a case
planned under local anesthesia. Incision was given along
in which the CT scan was useful in confirming the palatal
the palatal gingival margin from 16 to 26. Mucoperiosteum
position of bilaterally impacted maxillary canines. The
surgical removal of the impacted teeth was done under was reflected. The bone overlying the impacted tooth was
local anesthesia via palatal approach. removed using bur with profuse saline irrigation to expose
Case report: (Figs 21.7 A to L): A 16-year-old girl the crown of the impacted tooth (Fig. 21.7 J). Care was
reported with complaints of unerupted permanent canines taken not to injure the roots of the adjacent teeth. The crown
in the maxilla (Figs 21.7 A and B). Occlusal X-ray and OPG was then sectioned (odontotomy) using a fissure bur and
revealed bilaterally impacted canines in the maxilla with removed. Using an elevator, the root was elevated into
their crowns closely related to the roots of the central
the space created by the removal of the crown portion.
incisors(Figs 21.7 C and D). The impacted teeth could not
The root was then removed (Fig. 21.7 K). Both the teeth
be palpated on the labial side or on the palatal side. Hence
a CT scan was taken to locate the position of impacted were removed in a similar fashion. The wound was then
teeth in the axial, coronal and sagittal planes. The scans debrided, irrigated and closed with 3-0 black silk
revealed that the canines were lying palatal to the upper interdental sutures (Fig. 21.7 L).
22 Removal of Labially Positioned
Impacted Maxillary Canine
The patient is best placed in a sitting or semi-reclining prominence of the crown with a chisel or bur or both (Fig.
position. 22.2B). This is enlarged to expose the whole crown, taking
care not to damage the roots of the adjacent teeth. An

elevator can then be inserted to mobilize the tooth (Fig.
Incision
22.2C).
A semilunar incision (Fig. 22.1A) is sufficient for good If there is resistance, expose the root of the tooth and
exposure, but proper localization of the position of the then try to elevate. The elevator should not rest on the
tooth is important to make sure there will be sufficient adjacent teeth; rather the cortical plate is used as the
bone to support the wound edges after the procedure. fulcrum.
The lower part of the incision should not come closer than If there is still resistance, division of the tooth should
0.5 cm from the gingival margin. be considered (Fig. 22.2D). Dividing the tooth into two
For the beginners, a standard triangular (2 sided) or or three parts will help in the easy removal of the
trapezoidal (3 sided) flap with a broad base and incision fragments. The middle piece can be removed first, and
along the gingival sulcus may be better for easy handling the resultant space can be utilized for elevating the
(Fig. 22.1B). remaining two fragments.
(A) Semi-lunar incision, (B) Trapezoidal (3 sided)
The area is thoroughly debrided and follicle
incision
remaining if any is removed. The flap is repositioned and
sutured into place.
Operative Procedure
The mucoperiosteum is reflected to expose the bone and Removal of Maxillary Canine without
the bulge of the tooth. A window is cut over the Tooth Sectioning
In carefully selected cases, the impacted maxillary canine

can be removed without tooth sectioning. The procedure
can be performed much faster with minimum post
operative morbidity. Cases with the following clinical and
radiographic features may be considered for surgical
removal without tooth sectioning:
1. The crown of the impacted canine can be appreciated
by the presence of a swelling of the labial gingiva.
Figs 22.1A and B: Incisions for removal of labially placed canine 2. Crown of the impacted tooth can be easily palpated.
trapezoidal mucoperiosteal flap was raised on the labial

side. Bone covering the crown of the impacted tooth was
found to be very thin (Fig. 22.3 D-yellow circle). It was
removed using the sharp tip of a #9 Molt periosteal
elevator (Fig. 22.3E). (Alternatively, the overlying bone
can be removed using bur also). After adequate exposure
of the crown, the tooth was elevated out of the socket
with the sharp tip of an elevator using the labial cortical
plate as the fulcrum (Figs 22.3F and G). The follicle
surrounding the crown of the impacted canine was also
removed. Following thorough debridement (Fig. 22.3 H),
the flap was replaced back and sutured (Figs 22.3I and J).
Figure 22.3 K shows the impacted canine and the follicle.
The postoperative period was uneventful and sutures
were removed on the seventh postoperative day (Fig.
22.3L).
Figs 22.2A to F: Schematic diagram showing surgical removal of labially
impacted maxillary canine. (A) Impacted left maxillary canine. Note the However in majority of cases, when the tooth is
deeply impacted, sectioning of the impacted tooth into
relationship of the cuspid to the roots of the adjacent teeth, nasal cavity
and maxillary sinus. (B) Drill holes placed in the cortical plate overlying two or three pieces may have to be done to facilitate its
the crown so as to expose the crown, (C) After the full exposure of the
removal as shown in the subsequent case reports.
crown elevator is applied beneath the crown to mobilize the tooth, (D) If
the tooth is resistant to elevation, the crown is sectioned using bur and Step by step procedure for the removal of labially
it is removed, (E) Cavity created following removal of crown, (F) The
impacted canine by tooth sectioning (Incision in the
root is moved into the space created by the removal of the crown and it
is then removed sulcus):
Case report (Figs 22.4A to H): A 52-year-old man
3. Presence of a radiolucency around the crown of the reported with complaints of recurrent pain in right upper
impacted tooth suggestive of a large follicular sac. buccal sulcus. On clinical examination, the left upper
4. Incompletely formed root of canine seen in the X-ray. quadrant was found to be edentulous and there was a
5. Vertical or semi-vertical position of the tooth. bridge on the right upper quadrant. An OPG (Fig. 22.4A)
6. Patient in the 12-15 years age group when the bone is revealed an impacted right upper canine high up in the
more elastic. alveolus (yellow oval) above the roots of the right upper
The following is the case report of a patient in which central and lateral incisors. The tip of the root was found
a labially positioned impacted maxillary canine was to be curved and in close approximation to the right
removed without tooth sectioning (Figs 22.3A to L). maxillary sinus. After relevant investigation and
Case report (Figs 22.3A to L): A 14-year-old girl discussion with the patient the procedure was planned
reported to her dental practitioner with complaints of under local anesthesia. Considering the high position of
proclination of left upper lateral incisor and unerupted the impacted tooth, an incision was given in the sulcus,
upper canine. On examination there was proclination of from 15 to 21 region (some what similar to the incision
22 and 23 was impacted (Figs 22.3A and B). The swelling given for Caldwell Luc operation). This is because a semi-
of the crown of impacted 23 was visible as well as it could lunar incision or the reflection of a trapezoidal flap will
be palpated (Fig. 22.3 A- yellow oval) on the labial side necessitate a significant amount of flap reflection to reach
near the region of the root of 22. Intraoral periapical X- the vicinity of the impacted canine. The mucoperiosteal
ray showed impacted 23 in a semi vertical position. The flap was then elevated to expose the bone overlying the
root was incompletely formed (Fig. 22.3 C- yellow arrow)) impacted tooth. The bone overlying the impacted tooth
and there was a radiolucency (Fig. 22.3 C -yellow circle) was removed using bur with profuse saline irrigation to
surrounding the crown suggestive of a follicular sac. Since expose the crown of the impacted tooth (Fig. 22.4B). Care
there was no adequate space for orthodontic eruption of was taken not to injure the roots of the adjacent teeth.
impacted 23, its surgical removal was planned. The The crown was then sectioned (odontotomy) using a
procedure was performed under local anesthesia. A fissure bur (Fig. 22.4C). The sectioned crown was
Removal of Labially Positioned Impacted Maxillary Canine 223
Figs 22.3A to D: Steps in the

surgical removal of a labially
positioned impacted maxillary
canine without tooth division- (A)
Intraoral view of the patient
showing proclination of 22 and
missing 23. Bulge in the mucosa
indicating the crown of impacted 23
is marked as yellow oval, (B)
Palatal view showing slight
proclination of 22 due to the
pressure effect of impacted 23, (C)
Periapical X-ray showing impacted
23. Note the incompletely formed
root of 23 (yellow arrow) and the
follicular sac surrounding the crown

(yellow circle), (D) A trapezoidal
mucoperio-steal flap elevated.

Note the thin bone covering the
crown of the impacted canine
(yellow circle)
Figs 22.3E to H: (E) Exposure of

the crown by the removal of over-
lying bone, (F) Tooth elevated us-
ing an elevator, (G) Use of buccal
cortical plate as the fulcrum for the
elevator, (H) Socket after debride-
ment
Figs 22.3I to L: (I) Suturing

completed - view from the labial
aspect, (J) View from the palatal
aspect, (K) Specimen of the tooth
and attached follicle. Note the

incompletely formed apex of the
tooth, (L) Intra oral view on the
seventh post operative day after

suture removal

surgical removal of labially
impacted maxillary canine- (A)
OPG showing impacted right upper
canine (yellow oval), (B) Overlying
bone removed to expose the
crown, (C) Crown sectioned,
(D) Sectioned crown removed
Figs 22.4E to H: (E) Root pushed

into the space occupied by the

crown, (F) Socket after removal of
the root, (G) Specimen after
removal. Note the curvature of the

root tip. (H) Suturing completed
removed (Fig. 22.4D). Using an elevator, the root was impacted tooth (Fig. 22.5D). The bone overlying the
elevated into the space created by the removal of the impacted tooth was removed using bur with profuse
crown portion (Fig. 22.4E). The root was then removed saline irrigation to expose the crown of the tooth (Figs
(Fig. 22.4F). The root was found be sharply curved at the 22.5E and F). Care was taken not to injure the roots of the
apex (Fig. 22.4G) as noted in the OPG. Involvement of adjacent teeth. The crown was then sectioned
the maxillary sinus and the possibility for the (odontotomy) using a # 703 fissure bur (Figs 22.5G and
development of an oro-antral communication was H). The sectioned crown was removed (Fig. 22.5 I). Using
evaluated by asking the patient to blow the nose. No an elevator, the root was pushed into the space created
bubbling of air was found in the wound. More over, there by the removal of the crown (Fig. 22.5 J). The root was
was no associated nasal bleeding. The wound was then then removed. The wound was then debrided, irrigated
debrided, irrigated and closed with 3-0 black silk sutures with normal saline (Fig. 22.5K) and closed with 3-0 black
(Fig. 22.4H). silk interdental sutures (Fig. 22.5L). A pressure bandage
Step by step procedure for the removal of labially was applied using adhesive plaster to reduce the post
impacted canine by tooth sectioning (Trapezoidal operative edema (Fig. 22.5M).
incision)
Case report (Figs 22.5A to M)- A 15-year-old girl Removal of Maxillary Canine in an
reported with complaints of retained deciduous left upper Intermediate Position
canine and spacing of upper anterior teeth (Figs 22.5A
and B). Maxillary occlusal X-ray (Fig. 22.5 C) revealed an This may require reflection of flap both labially and
impacted left upper canine. After relevant investigation palatally and the incisions are designed based on the
the procedure was planned under local anesthesia. A location of the tooth. If the canine is wedged between the
trapezoidal incision was given and a mucoperiosteal flap adjacent teeth, it may need to be sectioned. When there
was then elevated to expose the bone overlying the is bone overlying the crown, it is first removed on the

surgical removal of labially
impacted maxillary canine- (A)
Intraoral view of the patient
showing retained deciduous left
upper canine, (B) Palatal view
showing slight proclination of 22

due to pressure effect of impacted
23, (C) Occlusal X-ray showing
impacted 23, (D) Mucoperiosteal

flap elevated
Figs 22.5E to H: (E) Removal of

bone overlying the impacted tooth
started, (F) Crown fully exposed,
(G) Crown sectioned using # 703
fissure bur, (H) Crown fully
sectioned
Figs 22.5 I to L: (I) Sectioned

crown being removed, (J) Root
being pushed into the space

created by the removal of the crown
portion, (K) Socket following
removal of the root and after

debridement, (L) Suturing
completed
Impacted Maxillary Canine with Root on the

Labial Side and Crown on the Palatal Side
The impacted maxillary canine can assume unusual

position with the root on the labial side and the crown on
the palatal side or vice versa. The removal of such
impactions are more difficult and time consuming since
the tooth has to be approached from both the labial and
palatal sides. More over there is a higher possibility of
causing injury to the adjacent teeth during the procedure.
CBCT or CT scan is extremely useful in such cases to
localize the impacted tooth. Figures 22.7 A to H show the
steps schematically in the surgical removal of an impacted
canine with the root on the labial side and crown on the
Fig. 22.5 M: Pressure dressing applied using adhesive plaster palatal aspect.
side towards which the tooth is pointing. Bone removal Teeth in Abnormal Positions
may be required on the opposite side also. Use of CT scan Maxillary canines can sometimes be present in abnormal
or Cone beam CT (CBCT) is extremely helpful in positions like infra orbital rim, maxillary antral wall or
managing such cases. Figures 22.6A to F show the nasal wall. The incision and procedure for their removal
usefulness of CT in locating the position of canine. vary depending on the exact position of the tooth.
Figs 22.6 A to F: Usefulness of CT in locating the intermediate position of impacted maxillary canine. (A) Occlusal X-ray of an 18-year-old young
man who reported with unerupted 23. The patient gave a history of endodontic treatment of 21 an year back. Impacted 23 could not be palpated
on the buccal or palatal aspect. (B) Coronal CT scan image showing the crown of the impacted canine above the roots of central incisor teeth, (C)
Axial CT scan image showing crown tip of impacted canine crossing the midline and lying just below the level of anterior nasal spine. The position
of the impacted tooth is at the mid alveolar region rather than either to the buccal or palatal side. (D) Axial CT scan image showing slight curvature
of the root tip. The impacted canine was removed through a labial approach under local anesthesia by sectioning of the crown. (E) Removed tooth
showing extreme curvature of the root which was not evident in the occlusal X-ray, but visible to some extent in the CT scan. (F) Postoperative
occlusal X-ray showing no damage to the roots of the adjacent teeth
Whatever may be the position of the tooth, if there is maxillary canines. The following are the specific
any cyst associated with the tooth, the cyst lining has to complications:
be completely removed along with the tooth and a. Nasal or antral perforation: This can be avoided with
subjected to histopathological examination. proper care during reflection of the flap, bone removal
and application of elevators. Even if small perforations
occur, they are covered by the flap when it is replaced,
Complications of Removal of Maxillary Canines
and heal without any problem. But strict aseptic
All possible complications with regard to the surgical technique should be followed; otherwise infection may
removal of teeth can also occur following the removal of be introduced into the maxillary sinus.
usually stops after a few minutes. Apart from tight

suturing no other precaution is usually necessary.
Patient should be cautioned against possible nasal
bleeding in the post operative period. Should this
occur, there is no reason to alarm and no attempt is
made to blow the nose. Rather the blood may be gently
wiped away and lie down with the head raised over a
pillow. In case of persistent hemorrhage, the doctor
may be contacted.
b. Displacement of canine/ root into the antrum: Care
should be taken during elevating the impacted canine
or its root to avoid pushing it into the antrum. Should
Figs 22.7 A to D: Schematic diagram showing the steps in the in the
this occur the removal of the displaced tooth/root may
surgical removal of impacted maxillary canine with root on the labial
side and crown on the palatal side. (A) Outline of the impacted canine have to be done by a Caldwell Luc approach.
and its relation to the roots of the adjacent tooth. Note the semilunar c. Hemorrhage: Troublesome hemorrhage can occur if
incision marked, (B) Outline of the crown of the impacted canine on the
palatal aspect, (C) Mucoperiosteum reflected on the buccal side
greater palatine or nasopalatine vessels are severed.
overlying the bone to be removed and the root of the impacted tooth Firm pressure is usually sufficient to stop the bleeding,
but cautery or ligation may be required if this does
sectioned. An elevator is being used to dislodge the root, (D) Empty

socket after removal of the root
not help.
d. Damage to adjacent teeth: Exact position of the
impacted tooth in relation to the adjacent teeth should

be confirmed prior to surgery and care should be taken
while removing the bone, not to damage the roots of
the adjacent teeth. While applying elevators, fingers
should be kept on the labial surface of the adjacent
teeth to assess their mobility and to prevent their
subluxation or avulsion. There may be mild mobility
of the adjacent teeth after the procedures, which will
usually become firm in a short while. However if there
is marked mobility, such teeth should be splinted and
later evaluated for viatality.
e. Fracture of apical third of the impacted tooth: If the
canine develops with its apex close to the antral or
nasal floor, a 90° deflection of the apex or a sharp
curvature of the apex may occur. This curvature will
result in resistance against tooth removal. In such an
instance any one of the following two approaches can
be used:
Figs 22.7 E to H: (E) Palatal flap is outlined and reflected. Bone covering
the crown of the impacted tooth is removed using bur. (F) Using a blunt 1. Deliberately fracture the apical portion from the
instrument placed in the socket of the tooth on the buccal side, pressure reminder of the tooth and then retrieve it. This is done
is exerted on the cut end of the crown (see black arrow) to push the using a thin elevator, excavator or a root canal file. If
crown palatally, (G) Empty socket on the palatal side after removal of
the crown, (H) Flap is replaced back and suturing completed the attempt to remove the apical portion is futile, it
may be left in situ rather than inadvertently push it
into the maxillary antrum
A nasal perforation may occur in those cases where 2. Uncover the major part of the root. Here the root is
the apex is positioned close to the lateral wall or floor removed in one piece. This may be a better choice than
of the nasal cavity. This results in nasal bleeding, which the former one.
23 Management of Impacted
Mandibular Canine
Mandibular canines are much less frequently impacted treatment. The retained primary may be permitted to
than the maxillary canines. continue for an extended period. However, the
Most mandibular canines are found in a labial impacted tooth should be periodically reviewed to
position. But sometimes they can be in the mental assess the development of pathologic changes.
protuberance area or lying transversely at the lower 2. Exposure and orthodontic repositioning: This can be
border of mandible. They can migrate to the opposite side considered if there is adequate space for the
of the mandible, i.e. transposition of canine (Figs 23.1A accommodation of the tooth in the arch and if the
and B, 23.2A and B). Such teeth maintain their original angulation of the tooth is favorable, i.e. deviation of
innervation and this fact has to be considered when the long axis of the tooth is not excessive. The treatment
removing them under local anesthesia. is carried out in the same manner as for the maxillary
Patients with impacted mandibular canine also canine.
presents with symptoms comparable to that of impacted 3. Surgical repositioning: This may be considered as an
maxillary canine like retained deciduous teeth, alternative treatment option if exposure and
proclination/displacement of adjacent incisors orthodontic repositioning is not possible. The optimal
(Figs 23.3A and B) or clinical features associated with cyst time for surgical repositioning appears to be before
formation (Figs 23.4A and B). Impacted canines may the root formation is complete, i.e. when the apical
remain symptom free and are then discovered foramen is still wide open. In such cases pulpal
accidentally in a routine radiograph or while investigating revascularization and periodontal healing are very
for other diseases (Figs 23.5). It may sometimes lead to predictable. With further root development, the tooth
recurrent pain and infection (Figs 23.6A and B). may require endodontic treatment.
4. Surgical removal of the tooth: The following are the
indications for the removal of impacted mandibular
Treatment
canine:
The following treatment options should be considered a. Evidence of pathology around the tooth, e.g.
in the management of impacted mandibular canine: follicular cyst, tumor.
1. Observation: In many cases this modality is acceptable b. Close proximity of the follicle to the marginal
if indications for removal do not exist like periodontium of the adjacent tooth.
impingement on adjacent tooth, development of c. Orthodontic need to move adjacent tooth into the
follicular cyst or as a part of the planned orthodontic area.
Management of Impacted Mandibular Canine 231
Figs 23.1A and B: Transposition of 33 to the midline. (A) Intraoral view, (B) Occlusal X-ray of the patient
Figs 23.2A and B: Transposition of both lower canines. (A) Clinical appearance of the patient,
(B) OPG of the patient showing transposed canines (yellow arrows)
Figs 23.3A and B: Impacted canines causing displacement of lower anterior teeth.
(A) Proclination of lower incisor teeth, (B) OPG of the patient showing both lower canines impacted
Figs 23.4A and B: Impacted canine associated with dentigerous cyst of mandible (A) Operative appearance showing impacted canine and
incisor associated with cyst, (B) OPG of the same patient showing impacted canine and lateral incisor with radiolucent lesion of mandible
Fig. 23.5: Impacted mandibular canines (bilateral) and impacted right maxillary canine in a 52-year-old man. The impacted teeth had
remained symptom-free during these years when it was discovered accidentally while investigating for chronic periodontitis
Figs 23.6A and B: (A) Patient aged 73 years reported with swelling of the right side of the face. He was using complete denture for
the last 15 years, (B) OPG of the patient showing impacted 43 and 44 (yellow arrows). Both the teeth were surgically removed
Surgical Anatomy (Fig. 23.7) may require an extraoral incision and dissection for
proper exposure. Bone removal is done with burs and
Compared to maxillary canine the bone encasing the chisel and the tooth can be removed by simple elevation
mandibular canine is thick. The lingual cortical bone in or after sectioning.
the mandibular canine region is very thick, whereas the
buccal bone is rather thin. The impacted mandibular
canines are often located mesial or distal to the canine
region. Surgical access to the tooth is obtained by raising
a buccal flap. A lingual flap is seldom raised due to
insufficient access and marked postoperative morbidity
associated with it. While raising the buccal flap, the
insertion of mentalis and incisive muscle is severed. The
incisive muscle is inserted at the height of the canine
alveolus while the mentalis arises from the mental fossa.
Removal of Mandibular Canine (Figs 23.8 A to H)

A standard trapezoidal (3 sided) flap or a horizontal
incision below the attached gingiva can be used to expose

the tooth. A tooth close to the lower border of mandible Fig. 23.7: Surgical anatomy of mandibular canine area
Figs 23.8A to H: Schematic

diagram showing steps in the
surgical removal of impacted
mandibular canine. (A) Incision
to raise a trapezoidal flap, (B)
Mucoperiosteal flap reflected
and the bone overlying the
crown removed using bur and
chisel, (C).Crown of impacted
canine exposed, (D). Elevators
applied in an attempt to luxate
the tooth. If unsuccessful, (E)
Tooth division is performed
using bur, (F) Crown removed
and more of the root exposed
to create a purchase point on
the root using bur, (G) Root
removed using an elevator
applied at the purchase point,
(H) Closure of the incision
Case report A 16-year-old girl was advised surgical leading to loosening of the tooth. If this happens, the
removal of impacted 33 before starting orthodontic involved tooth should be splinted to the adjacent tooth.
treatment. The following is the surgical steps (Figs 23.9 2. Mental nerve injury—This can happen if the distal
A to L): vertical incision is carried too far backwards and
inferiorly.
Complications of Surgical Removal Removal of Impacted Mandibular Canine
The following complications may occur during the in an Edentulous Patient
procedure: The technique of removal is essentially the same with
1. Accidental injury to adjacent tooth—During bone some modifications and additional precautions. The
removal to expose the impacted canine damage to the incision is often given on the crest of the alveolar ridge if
supporting bone of the lateral incisor may occur the tooth is closer to the ridge. If it is closer to the inferior
Figs 23.9 A to D: Steps in the surgical removal of impacted left mandibular canine- (A) Impacted 33 transposed to midline. Projection of impacted
canine marked by dotted black oval, (B) Periapical X-ray showing impacted left lower canine transposed to region of 41 and 31, (C) Incision given
and mucoperiosteum reflected, (D) Bone overlying the crown removed to expose the crown
Figs 23.9E to H: (E) Crown sectioned, (F) Sectioned crown removed, (G) Root moved into the space previously occupied
by the crown, (H) Root removed. Socket debrided and saline irrigation done
Figs 23.9I to L: (I) Suturing completed, (J) Specimen of the tooth (note sectioned area marked with yellow line and follicle with yellow oval),
(K) Pressure bandage applied using adhesive plaster to reduce the edema, (L) Postoperative appearance two weeks later with lower arch
wire placed
Figs 23.10A to C: Steps in the surgical removal of impacted left mandibular canine. (A) OPG showing impacted 33 transposed to the midline with
associated radiolucency (yellow oval), (B) Intraoral view showing a sinus opening in the lower labial sulcus (yellow arrow), (C) Incision marked
Figs 23.10D to G: (D) Incision deepened and reflection of mucoperiosteum started, (E) Mucoperiosteum reflected to expose the crown tip of
impacted 33 (yellow arrow), (F) Bone around the crown removed using bur to expose the crown fully (yellow arrow), (G) Crown mobilized using
an elevator
Figs 23.10H to K: (H) Removal of the tooth using forceps. This was followed by the curettage of associated granulation tissue, (I) Specimen of the
tooth with the soft tissue removed by curettage. The soft tissue was sent for histopathological examination, (J) Socket following debridement, (K)
Suturing completed
border, an incision in the sulcus should be considered. The following is the case report of surgical removal
As in the case of impacted mandibular third molar due of impacted left mandibular canine transposed to
to the extreme resorption of the alveolar ridge and midline in a 56-year-old man (Figs 23.10A to K). The
sclerosis of bone in the old age, use of excessive force patient reported with recurrent swelling of the sub
should be avoided to prevent fracture of mandible. mental region of two years duration associated with
Moreover, there may be pathology associated with the occasional intraoral pus discharge. He was wearing
impacted canine which also has to be looked into which complete denture for the last seven years. He gave a
further weakens the mandible. Any associated systemic history of treatment for hypertension for the last three
disease contraindicating the surgery has to be considered years and the disease was well controlled with
during the planning stage. medication.
24 Surgical Repositioning/
Autotransplantation
Impacted or malpositioned canines with a favorable root Case report: An 18-year-old girl reported with
pattern (without hooks or sharp curves) can be tried for complaints of retained left upper deciduous canine and
unerupted permanent canine (Fig. 24.1A). Intraoral
transplantation in the dental arch. This is done utilizing

the socket of deciduous canine or first premolar, depen- periapical X-ray showed retained left maxillary canine
ding on the space available. and impacted 23 (Fig. 24.1B). Surgical removal of 23 was
The prognosis for auto transplantation of impacted planned under local anesthesia. The patient was informed
canines in adults is poor (Moos,1974). Periodontal healing regarding the option of reimplantation of 23 following
without any root resorption varied between authors from its removal. The patient readily agreed for the procedure.
25 to 85 percent. At a later stage of development the root After raising a mucoperiosteal flap (Figs 24.1C and D)
is fully completed and the chance for pulpal and the retained deciduous canine was removed. The
periodontal healing is reduced. The optimal development impacted 23 was exposed by removing the overlying bone
stage for autotransplantation is when the root is 50-75 (Fig. 24.1E). The impacted tooth was mobilized and then
removed (Figs 24.1F and G). The socket of deciduous
percent formed. In light of good prognosis for auto-
canine and permanent canine was debrided and 23 was
transplantation of premolars documented by Andreasen
tried for fit (Figs 24.1H and I ). To fill the area of bone loss
(1992)1 canine transplantation should be planned as early
artificial bone substitute ('Periobone- G') was considered
as possible.
(Fig. 24.1J). The bone defect was slowly filled using the
bone substitute as per the manufacturer's direction (Figs
Autotransplantation could be 24.1K and L). Suturing was completed (Fig. 24.1M) and a
Recommended When previously fabricated splint was cemented to immobilize
the reimplanted tooth and to relieve it from occlusal forces
Interceptive measures are inappropriate or have failed. (Fig. 24.1N). Healing was normal and the sutures were
The degree of malposition is too great to make removed on the tenth postoperative day. Postoperative
orthodontic alignment feasible. X -ray was taken (Fig. 24.1O). It was an interesting finding
Adequate space is available for canine. in the postoperative X-ray of an additional impacted tooth
The prognosis is good for the tooth to be transplanted in the same region (marked as yellow oval) which was
and it can be removed atraumatically. not visible in the preoperative radiograph. Root canal
There is no evidence of ankylosis of canine. treatment was then completed for the transplanted tooth
However even in experienced hands, it can fail and on the 14th day (Fig 24.1P). The patient was regularly
there could be rejection, resorption, or ankylosis of the followed up. The splint was removed eight weeks later.
transplanted tooth. The procedure of transplantation is Figure 24.1Q shows the reimplanted tooth in good
described in the following case report. functional occlusion.
Surgical Repositioning/Autotransplantation 239

surgical reimplantation of
impacted maxillary canine
tooth: (A) Intraoral photograph
of the patient showing
retained left upper deciduous

canine (yellow arrow), (B)
Periapical X-ray showing
impacted 23, (C) Incision

marked, (D) Mucoperiosteal
flap reflected and retracted
Figs 24.1E to H: (E) Retained

deciduous canine extracted
and overlying bone removed
to expose impacted 23 (yellow
oval), (F) Adequate bone
removed to mobilize 23,
(G) Impacted 23 removed,
(H) Socket after removal of 23
Figs 24.1I to L: (I) Canine

tried for fit in the socket,
(J) Packing of artificial bone

substitute 'Periobone -G'
used, (K) 'Periobone -G'
placed in the socket,

(L) Canine tooth reimplanted
and additional amount of
'Periobone -G'placed
Figs 24.1M to Q: (M) Suturing

completed, (N) Splint cemen-
ted to immobilize the reim-
planted tooth and to relieve it
from occlusal forces, (O)
Postoperative X-ray taken on
the 10th day. It was an
interesting finding in the post-
operative X-ray of an addi-
tional impacted tooth in the
same region (yellow oval)
which was not visible in the
preoperative radiograph,
(P) Radiograph showing root
canal treatment of reimplanted
23 completed, (Q) Reimplan-
ted tooth in good functional
occlusion 8 weeks later
(yellow arrow) after removal of
the splint
REFERENCE
1. Andreasen JO. Atlas of Replantation and Transplantation of Teeth. Mediglobe SA, Fribourg 1992.
25 Unerupted and Impacted
Supernumerary Teeth
Supernumerary teeth, especially mesiodens may be obstruct orthodontic tooth movement or may be
indicated for extraction as they can prevent the eruption associated with cyst formation.
of normal dentition, or cause malposition of teeth Multiple supernumerary teeth may be associated
(Figs 25.1A to D), produce diastema (Figs 25.2A to C), or with odontome (Figs 25.3A and B).
Figs 25.1A to D: Supernumerary teeth in the palate in a nine year old boy (A) Hard selling in the palate,
(B) Intraoral view showing that 11 and 21 have erupted, but 12 and 22 are unerupted, (C) Occlusal X-ray
showing two impacted supernumerary teeth in the palate, (D) Impacted supernumeraries removed surgically
Figs 25.2A to C: Mesiodens causing diastema in a 10-year-old girl

(A) Partial eruption of 11 and diastema, (B) Periapical X-ray of the same Figs 25.5A and B: (A) Impacted 11 erupting labially (black arrow
patient showing impacted mesiodens in inverted position (yellow arrow) indicating the bulge), (B) Periapical X-ray of the patient showing
and erupting 23. Removal of mesiodens was necessary to facilitate dilacerated 11
space closure between the centrals and to promote eruption of 23,
(C) Mesiodens surgically removed
Operative Procedure
Localization and the surgical removal of impacted
supernumerary is similar to that of maxillary canine. As
for the maxillary canine tooth, the position of the

supernumerary tooth is first localized clinically and
radiographically. A mucoperiosteal flap is then designed
and elevated, bone removal is done with burs and the

tooth is then exposed and removed.
Other teeth in the dental arch like the incisors (Figs
25.4 to 25.6) or premolars (Fig. 25.7) can also get impacted
Figs 25.3A and B: Impacted supernumerary teeth associated with either due to systemic or local factors. The flap design
odontome (A) IOPA X-ray showing multiple impacted supernumerary
teeth associated with odontome in the upper incisor region, for their removal depends on the position of the teeth.
(B) Supernumerary teeth removed at the time of surgery But the basic principles of removal remain the same.
Impacted upper central incisors are frequently
dilacerated, which makes their removal difficult (Figs 25.4
and 25.5).
Impacted incisors will also prevent the eruption of
adjacent teeth (Figs 25.6A and B).
SUMMARY
The management of impacted supernumerary teeth

requires good clinical skills and observation from the part
Figs 25.4A and B: (A) Dilacerted 11 in a 10 years boy erupting palatally, of the dental surgeon. Any tooth missing in the dental
(B) Periapical X-ray of the above patient showing dilacerated 11 arch even after its normal time of eruption should compel
Unerupted and Impacted Supernumerary Teeth 243
Fig. 25.7: Impacted lower premolar, the root of which is reaching up to

the inferior border of mandible. Possible fracture of the mandible should
be anticipated if excessive bone removal is done
the dental surgeon to investigate. Management of

impacted teeth is not difficult and the basic principles of
surgery followed are the same for all the teeth. Time
should be spent to evaluate the case, arrive at a proper
diagnosis and those which need expert management
should be referred. In formulating a treatment plan close
association of the general dental surgeon with the oral
Figs 25.6A and B: (A) Unerupted 21, 22 and 23 in an 11-year-old boy,
(B) OPG of the patient showing supernumerary (yellow oval) preventing
and maxillofacial surgeon, orthodontist and pedodontist
eruption of 21 and 23 (yellow arrows). 22 is missing is required.
Index
A diagnosis and management of Etiology of canine impaction 164
nerve injury 145 Evolution theory 11
Advantage of bonding 201 indication for trigeminal nerve antagonistic view to evolution
on same appointment 201 microsurgery 146 theory 11
in a second visit 201 infections of delayed onset 137 Extraction of deciduous canine 182
CBCT scanner over regular lingual nerve injury 141 Extraoral examination 42
medical CT scanner 56 management 145
Aids for orthodontic eruption 193 outcome of trigeminal nerve F
Anchorage 208 microsurgery 147
Angulation of tooth 101 post surgical sequelae and Facial artery and vein 31
Antagonistic view to evolution theory 11 complications 130 Factors complicating removal of
Antibiotics 115 prevention of lingual nerve injury impacted maxillary canine 211
Armamentarium for successful 143
bonding 202 procedure of trigeminal microsurgery G
Assessment of risk 58 146

Contraindications General principle 59
Associated medical problems 200
for removal of impacted tooth 24 Good interdisciplinary support 200

Attachments 201
to partial odontectomy 96 Good patient cooperation 200
Autotransplantation 238
Controversies on prophylactic removal of
third molars 8 H
B
CT evaluation 52
Hemostasis 202
Bleeding 114
D History taking 40
Bone
removal 74 Debridement 82
trajectories of mandible 33 I
Determining degree of difficulty of
Burden on health care delivery 8 removal 104 Identification of risk factors 22
Determining favorability of an Immediately following surgery 114
C impacted canine for Impacted maxillary canine 227
Choice of anesthesia 72, 212 orthodontic treatment 199 with root on labial side and crown
Classification Development and eruption pattern 163 on palatal side 227
Diagnosis and management of nerve Implants for canine traction 208
impacted mandibular third molar 35
injury 145 Implication of lingual nerve anatomy 32
impacted maxillary canines 166
Diagnostic criteria 22 in surgical technique 32
Clinical examination 40, 169
Diet 116 Incidence and epidemiology 163
Clinical neurosensory testing 141
Drug therapy 117 Incidence of impaction 6
Combining steroids and nsaids 121
combining steroids and NSAIDS 121 Incision 221
Complications Incision and designing flap 73
during surgery of impacted use of analgesics 121
Indications for
maxillary third molar 109 use of antibiotics 117
removal 102, 211
during surgical procedure 123 use of anti-inflammatory drugs
maxillary third molar 102
removal of maxillary canines 228 and steroids 119
surgical management 25
surgical removal 234 use of non-steroidal anti-inflam-
trigeminal nerve microsurgery 146
Complications of impaction surgery 123 matory drugs (NSAIDS) 120
Infections of delayed onset 137
classification 140 Informed consent 59
clinical neurosensory testing 141
E
Instrument tray set-up 62
complications during surgical Ectopic teeth and unusual cases 153 use of operating loupe in third
procedure 123 Elastic traction 207 molar surgery 70
Intentional therapeutic agenesis of Methods for removal of impacted associated medical problems 200
tooth 157 lower third molar 88 attachments 201
Interpretation of periapical x-ray 45 contraindications to partial determining favorability of an
Intraoral examination 42 odontectomy 96 impacted canine for
modification of lingual split orthodontic treatment 199
L technique 94 elastic traction 207
steps in surgical procedure 91 good interdisciplinary support 200
Lingual nerve 31, 141
surgical steps 94 good patient cooperation 200
Lingual plate 33
Modalities of management of hemostasis 202
Local contraindications for removal 103
impacted canine 182
Localization of impacted canine 169 implants for canine traction 208
extraction of deciduous canine 182
clinical examination 169 indications for removal 211
no treatment—leave tooth in situ
magnification 171 magnets for correction of canine
183
parallax 171 impaction 209
surgical exposure and orthodon- orthodontic bands 206
points to be noted from
radiograph 173 tically assisted eruption 183 orthodontic springs 206
Locating lingual nerve 56 surgical exposure of tooth 183 orthodontic treatment planning 200
Long buccal nerve 33 surgical removal orthodontic treatment strategy 201
prosthetic replacement 184 prevention of canine impaction 209
M impacted tooth 184 principles of orthodontic traction

impacted tooth with ortho- 206
Magnets for correction of canine dontic space closure 184 procedure of bonding 202
impaction 209 posterior segmental osteotomy removable orthodontic appliance

Magnification 171 184 208
Management surgical repositioning/autotrans- threaded pins 206
complications of surgical removal plantation 184 through and through hole at tip
234 Modifications of canine 206
impacted mandibular canine 230 lingual split technique 94 various attachments 204
impacted tooth 6 removal of impacted tooth 77 Orthodontic springs 206
removal Musculature 34 Orthodontic treatment 200
impacted mandibular canine 234 Mylohyoid nerve 33 planning 200
edentulous patient 234 strategy 201
mandibular canine 233 Outcome of trigeminal nerve micro-
N
surgical anatomy 233 surgery 147
treatment 230 Nature of roots 102
Mandibular third molar 29 Neurovascular bundle 30
P
bone trajectories of mandible 33
classification of impacted O Pain 115
mandibular third molar 35 Palpation of anatomical landmarks 72
Obstruction of eruption pathway 5
facial artery and vein 31 Obtaining consent 60 Parallax 171
implication of lingual nerve anatomy Operative procedure 71, 221, 242 Patient positioning 71
in surgical technique 32 Oral hygiene 116 bone removal 74
lingual nerve 31 Orthodontic bands 206 choice of anesthesia 72
lingual plate 33 Orthodontic eruption of impacted canine debridement 82
long buccal nerve 33 199 incision and designing flap 73
maxillary third molar 34 advantage of bonding on same modifications for removal of
musculature 34 appointment 201 impacted tooth 77
mylohyoid nerve 33 advantages of bonding in a second palpation of anatomical landmarks
neurovascular bundle 30 visit 201 72
retromolar triangle 30 anchorage 208 sectioning and tooth delivery 76
Maxillary third molar 34 armamentarium for successful summary of surgical procedure 86
Medical evaluation form 41 bonding 202 wound closure 82
Index 247
Patient risk factors 58 significance of medical evaluation 42 operative procedure 221

Pell and gregory classification 101 social risk factors 59 teeth in abnormal positions 227
Pericoronitis 22 steps in CT evaluation 55 Retromolar triangle 30
Perioperative drug therapy 122 surgical team risk factors 59 Role of diet 12
use 122 types of consent 60 Role of genetics 12
analgesics 122 Prevention contraindications for removal of
antibiotics 122 canine impaction 209 impacted tooth 24
steroids 122 lingual nerve injury 143 diagnostic criteria 22
Post surgical sequelae and complications management 110 identification of risk factors 22
130 Principles of orthodontic traction 206 indications for surgical management
Postoperative care 114 Procedure of 25
activity 116 bonding 202 pericoronitis 22
antibiotics 115 trigeminal microsurgery 146 predicting eruption/impaction of
bleeding 114 mandibular third molars 27
diet 116 R removal of asymptomatic impacted
immediately following surgery 114 third molars 24
Radiographic examination 103
oral hygiene 116 role of diet 12
Radiography of impacted mandibular
pain 115 treatment 23
third molar 43
smoking 116
Recent advances and future of third

stiffness of jaw 116 S
molars 157
surgical removal of impacted tooth
classification of impacted maxillary Sectioning and tooth delivery 76
116
canines 166 Sequelae of canine impaction 166
suture removal 116
development and eruption pattern Significance of medical evaluation 42
swelling 114
163 Smoking 116
temperature 115
etiology of canine impaction 164 Social risk factors 59
trismus 116
incidence and epidemiology 163 State of eruption 101
Postoperative care and instructions 114
intentional therapeutic agenesis of Steps in CT evaluation 55
Predicting eruption/impaction of
tooth 157 Steps in surgical procedure 91
mandibular third molars 27
sequelae of canine impaction 166 Stiffness of jaw 116
Preoperative evaluation of difficulty of Summary of surgical procedure 86
unerupted and impacted third molars
removal 57 Surgical anatomy 29, 104, 233
159
Preoperative planning 40 Surgical eruption of upper incisors 193
Relationship of impacted maxillary third
advantages of CBCT scanner over Surgical exposure and orthodontically
regular medical CT scanner 56 molar to maxillary sinus 102
Removable orthodontic appliance 208 assisted eruption 183
assessment of risk 58 Surgical exposure of impacted maxillary
clinical examination 40 Removal of
canine 185
CT evaluation 52 asymptomatic impacted third molars
aids for orthodontic eruption 193
extraoral examination 42 24
procedure 185
general principle 59 impacted mandibular canine 234
surgical eruption of upper incisors
history taking 40 edentulous patient 234
193
informed consent 59 impacted maxillary canine 227
Surgical exposure of tooth 183
interpretation of periapical x-ray 45 crown on palatal side 227 Surgical removal of impacted maxillary
intraoral examination 42 with root on labial side 227 third molar 101
locating lingual nerve 56 incision 221 angulation of tooth 101
medical evaluation form 41 labially positioned impacted complications during surgery of
obtaining consent 60 maxillary canine 221 impacted maxillary third
patient risk factors 58 mandibular canine 233 molar 109
preoperative evaluation of difficulty maxillary canine determining degree of difficulty of
of removal 57 intermediate position 225 removal 104
radiography of impacted mandibular maxillary canine without tooth indications for removal of maxillary
third molar 43 sectioning 221 third molar 102
local contraindications for removal autotransplantation 238 Treatment 23, 230

103 Surgical repositioning/autotrans- Trismus 116
nature of roots 102 plantation 184 Types of consent 60
pell and gregory classification 101 Surgical steps 94
prevention and management 110 Surgical team risk factors 59 U
radiographic examination 103 Suture removal 116
Unerupted and impacted supernumerary
relationship of impacted maxillary Swelling 114
teeth 241
third molar to maxillary sinus
T operative procedure 242
102
Unerupted and impacted third molars
state of eruption 101 Teeth in abnormal positions 227 159
surgical anatomy 104 Temperature 115 Use of analgesics 121,122
Surgical removal of impacted tooth Terminology 4 Use of antibiotics 117,122
116, 184 Threaded pins 206 Use of anti-inflammatory drugs and
Surgical removal of palatally impacted Through and through hole at tip of canine
steroids 119
maxillary canine 211 206
Use of non-steroidal anti-inflammatory
approaches 212 Tooth eruption 4
drugs (nsaids) 120
choice of anesthesia 212 burden on health care delivery 8
Use of operating loupe in third molar
factors complicating removal of controversies on prophylactic
surgery 70
impacted maxillary canine removal of third molars 8
Use of steroids 122

211 incidence of impaction 6
procedure 212 management of impacted tooth 6
W
Surgical repositioning/autotrans- obstruction of eruption pathway 5

plantation 238 terminology 4 Wound closure 82

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For Personal Use Only

Library of School of Dentistry, TUMS

K George Varghese MDS DSS (Vienna)

Department of Oral and Maxillofacial Surgery

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

• Kochi, Phone: +91-484-2395740, e-mail: kochi@jaypeebrothers.com

• Lucknow, Phone: +91-522-3040554, e-mail: lucknow@jaypeebrothers.com

A Practical Guide to the Management of Impacted Teeth

First Edition: 2010

Typeset at JPBMP typesetting unit

to my students who gave me the impetus for learning

and to my colleagues who provided me with support

encouragement to accomplish this endeavor.

SECTION 1: MANAGEMENT OF IMPACTED THIRD MOLAR

9. Other Methods for Removal of Impacted Lower Third Molar ............................................................................. 88

11. Postoperative Care and Instructions ....................................................................................................................... 114

SECTION 2: MANAGEMENT OF IMPACTED CANINE

Index ............................................................................................................................................................................. 245

Management of Impacted Third Molar

Chapter 3 Why do We Remove Impacted Teeth?

TOOTH ERUPTION mechanisms/theory explaining eruption and the

5. Occlusal stage completely erupting into a normal functional position.

Fig. 1.1: Schematic diagram showing different stages of eruption of tooth

Eruption stage Eruption mechanism/ Structures resisting

Bone formation Mastication

teeth were found in the maxilla and 534 (56.81%) in the

part of the jaws (44 in the maxilla and 7 in the mandible)

1 Intraosseous stage a. Mucosa + bone removal

removal of unerupted teeth prophylactically seems as Summary

The third molars are often labelled vestigial (of use

1. Nodine AM. Aberrant teeth, their history, causes and

second and first molars. One third of the study population

impacted tooth with the root closely related to mandibular canal

associated with periodontal disease has been implicated

Fig.3.2: Horizontally impacted 38 with dental caries

the second molar and later on leads to pulpo periodontal

develop in many cases and this also happens to be the

resulting in the narrow contacts of the lower incisors

of this hypothesis and the following statements can

Fig. 3.8: OPG showing impacted 37 and 38 (yellow circle) associated

plates and screws. Erupted maxillary third molars that

Fig. 3.9: OPG showing impacted 37 associated with extensive

Figs 3.7 A to D: (A) Intra-oral photo of an 18-year-old young man with

Olson et al (2000)2 reported an unusual odontogenic

Sometimes it may be during a routine radiographic

visible in oral cavity.

8. Resorption of root of adjacent tooth: Once the root

Since pericoronitis is the commonest indication for

Pericoronitis is the inflammation of the soft tissues

present as a recurrent condition requiring multiple

• Erythema. The following should be considered after resolution of

history, physical examination and laboratory

• Caries: removal should be considered when there is 1996;47(4):43-7.

Predicting the Eruption/Impaction

prediction in the overlay was the intersection of a REFERENCES