MANAGEMENT OF IMPACTED TEETH

“Unveiling The Hidden”

Dr Ajin Mathew
Oral and maxillofacial surgeon
 INTRODUCTION
 The third molar has been the most widely discussed tooth in the dental
literature, and the debatable question “….. to extract or not to extract” seems
set to run into the next century. - Faiez N. Hattab, JOMS, 57: 389-391 (1999)

 Got their name ‘Wisdom teeth’ from the age during which they erupt: 17 to 25.
This is the age at which men and women become adults, and, presumably,
wiser
 DEFINITIONS
According to WHO – An impacted teeth is any tooth that is prevented from
reachimg its normal position in the mouth by tissue, bone or another tooth.

According to ARCHER – A tooth which is completely or partially unerupted

and is positioned against another tooth, bone or soft tissue so that its further
eruption is unlikely, described according to its anatomic position.

According to ANDERSON-An impacted tooth is a tooth which is prevented

from completely erupting into a normal functional position due to lack of
space, obstruction by another tooth or an abnormal eruption path.
DEFINITION

PRIMARY SECONDARY
IMPACTION
RETENTION RETENTION
• cessation of the •If no physical barrier •Cessation of
eruption of a tooth can be identified as eruption of a tooth
caused by a clinically after emergence
an explanation for the
or radiographically
cessation of eruption without a physical
detectable physical
barrier in the eruption
of a normally placed barrier in the path
path or due to an and developed tooth of eruption or as a
abnormal position of germ before result of an
the tooth. emergence. abnormal position.
Primary retention is synonymous with
-unerupted teeth
-embedded teeth
 Caused by a disturbance in the dental follicle that fails to initiate the
metabolic events responsible for bone resorption in the eruption trajectory.

Secondary retention is synonymous with

-submerged
-Halbretention
-reimpaction
-reinclusion
 Suggested causative factors include ankylosis ,Trauma, infection, disturbed
local metabolism, and genetic factors

Raghoebar GM, Boering G, Vissink A, Stegenga B: Eruption disturbanees of permanent molars: a review. J Oral Pathol Med 1991;
20: 159-66.
PRIMARY RETENTION SECONDARY RETENTION

IMPACTED
IMPACTED THIRD MOLARS
 AGENESIS OF THIRD MOLARS
 wisdom teeth many a times get impacted, exhibit extreme diminution in
size and also show agenesis as a final step towards their ultimate
disappearance from our dentition .

 19.7%-25.9% third molars shows agenesis.

 More common in females than males, in maxilla than in mandible and on

right side than left.
 CHRONOLOGY
Max.3rd molars Man. 3rd molars Max. & man.
canines

First evidence of 7-9 yr 8-10 yr 4-6 months

calcification

Crown completion 12-16 yr 12-16 yr 6 yr

Eruption 17-21 yr 17-21 yr 11-13 yr

Root completion 18-25 yr 18-25 yr 14-15 yr

If any tooth fails to erupt beyond 2 yrs of expected time, then it should be
considered unlikely to erupt.
 THEORIES OF IMPACTION
By Durbeck
1) Orthodontic theory :Growth of the jaw and movement of teeth occurs in
forward direction,so any thing that interfere with such moment will cause
an impaction (small jaw-decreased space).
--Retardation of forward growth can be due to increased bone density
which may be caused by
acute infections
fevers
severe traumas
local inflammation of periodontal tissues
--Mouth breathing habit
--Early loss of deciduous teeth
2) Phylogenic theory(nodine): use makes the organ develop better, disuse
causes slow regression of organ.
Due to changing nutritional habits of our civilization, use of large powerful
jaws have been practically eliminated. Thus, over centuries the mandible
and maxilla decreased in size leaving insufficient room for third molars
3) Mendelian theory: Heredity is most common cause. The hereditary
transmission of small jaws and large teeth from parents to siblings. This
may be important etiological factor in the occurrence of impaction.

4)Pathological theory: Chronic infections affecting an individual may bring

the condensation of osseous tissue further preventing the growth and
development of the jaws.

5)Endocrinal theory: Increase or decrease in growth hormone secretion may

affect the size of the jaws.
.
 CAUSES OF IMPACTION
Archer has classified into local and systemic causes

SYSTEMIC CAUSES
Prenata l causes -Hereditary

Postnatal causes – Rickets, anaemia, tuberculosis,

congenital syphilis,
malnutrition

Endocrinal disorders – Hypothyroidism, hypopituitarism, achondroplasia (Due to

lack of osteoclastic activity)

Hereditary linked disorders – Down syndrome, Hurlers syndrome,  Gardner’s

syndrome, Aarskog syndrome, Zimmerman-Laband syndrome and
Noonan’s syndrome, Osteopetrosis, Cleidocranial dysostosis, Cleft palate.(Due
to failure of overlying bone to resorb and to develop an eruption pathway)
 LOCAL FACTORS
Inadequate space in the dental arch for eruption – Crowding, supernumerary teeth

Inclination – Failure to upright from mesial inclination

Obstruction of tooth eruption – Irregularity in position & presence of an adjacent tooth ,

Density of the overlying & surrounding bone , Cysts & tumours, Odontomes,
Supernumerary teeth

Nonabsorbing, over retained deciduous teeth

Ankylosis of primary or permanent teeth

Dilaceration of roots(trauma)

Ectopic position of tooth bud

Non absorbing alveolar bone

 FREQUENCY OF IMPACTION
 mandibular 3rd molars
 maxillary 3rd molars
 maxillary cuspid
 mandibular bicuspids
 Maxillary bicuspids
 Mandibular canine
 maxillary central and lateral incisors
 PATHOLOGICAL SEQUELE OF
NEGLECTED THIRD MOLARS
1)Cystic like changes [radiolucent changes consistent with dentigerous cysts)

2) Internal resorption of the impacted tooth

3) Periodontal problems(periodontal ligament changes and alveolar bone loss)

4) Caries and/or resorption (tooth material loss on distal surface of second molar)

Stanley HR, Alattar M, Collett WK, Stringfellow HR Jr, Spiegel EH,Pathological sequelae of "neglected" impacted third
molars. J Oral Pathol 1988:17: 113-117.
 INDICATIONS FOR REMOVAL
“A strong indication for removal of impacted third molar
should be complemented with a strong contraindication to its
retention”

– Mercier P., Precious D., Risk and benefits of removal of impacted third molars, IJOMS
21:17, 1992.
 Prevention
Pericoronit
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Odontogen
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Considerati
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orDiseaseon
and
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 PERICORONITIS
 Pericoronitis is an acute infection
with accompanying inflammation of
gingival and contiguous soft tissues
around the crown of an incompletely
erupted tooth.
 Pericoronitis was found to be
common in vertical (23.0%) followed
by mesioangular (15.0%),
distoangular(8.0%) and horizontal
angulatio(3.0%).
 Common in females than males
 Streptococcus Viridans is the most
common facultative isolate.

The predictivity of mandibular third molar position as a risk indicator for pericoronitis
Kemal Yamalık & Süleyman Bozkaya
Clin Oral Invest (2008) 12:9–14
 CLINICAL FEATURES
 Markedly red, swollen suppurating lesion

 Marked tenderness

 Radiating pain to the ear, throat, and floor of the mouth.

 Foul taste, and an inability to close the jaws.

 Swelling of the cheek in the region of the angle of the jaw

and lymphadenitis.

 Mandibular movement is limited (Trismus).

 toxic systemic complications - fever, leukocytosis and

malaise.
 COMPLICATIONS
 pericoronal abscess.

 spread posteriorly into the oropharyngeal area and medially to the base of
the tongue, making swallowing difficult.

 Peritonsillar abscess formations, cellulities, Ludwig’s Angina are infrequent

but potential sequel of acute pericoronitis.
 DENTAL CARIES
 Mesioangular impactions were most commonly involved with caries

PERIODONTAL DISEASE

ROOT RESORPTION
Misaligned erupting teeth may resorb the roots of adjacent teeth just like
succedaneous teeth resorb the roots of primary teeth during normal eruption.

PAIN OF UNEXPLAINED ORIGIN

Odontogenic cyst and Tumors
•dentigerios cyst or keratocyst.
• Ameloblastoma

PREVENTION OF PATHOLOGICAL MANDIBULAR FRACTURES

•weakens the mandible by decreasing the cross sectional area of bone
•change in the direction of the grain of bone
•Patients with MTM are prone to angle # by 2.2 times

Impacted teeth in the line of #

Mandibular third molars as a risk factor for angle fractures: a retrospective study Rajkumar K · Ramen Sinha, Roy
Chowdhury,Chattopadhyay PK J Maxillofac Oral Surg 8(3):237–240
Impacted teeth under dental prosthesis:
 impacted tooth covered by only soft tissue or 1 or 2 mm of bone  Extract!

Facilitation of orthodontic treatment

Preparation for orthognathic surgery

Systemic health considerations

•Acts as foci of infection
•Cardiac patients with heart valve disease or valve replacement
•Organ transplant candidates

Autotransplantation

Trauma(Recurrent cheek bite)

Predisposes to premalignant and malignant diseases of oral mucosa
PROPHYLACTIC REMOVAL ?
Evidence in support of prophylactic removal of
third molars
 Glosser & Campbell - histologic abnormalities in soft tissue surrounding
impacted third molar teeth in the absence of radiographic signs of pathology.

 Wagner and colleagues extraction of third molars in young adulthood

would the incidence of mandibular angle fractures & pathologic fracture
in older age.

 Rakprasitikul - the incidence of ameloblastoma in association with the

impacted third molar - <1%

 Rionchardson and Dods concluded that most commonly the second molar
attachment levels or periodontal depths either remain unchanged or
improved after third molar extraction.

 Zachrisson- a developing mandibular third molar with insufficient space

can be one cause of late mandibular crowding.
 oral bacteria associated with periodontal disease –have risk in coronary artery
disease, stroke, renal vascular disease, diabetes, and obstetric complications
patients with periodontal attachment loss have increased levels of
biochemical markers of inflammation compared with controls.
- AAOMS Third Molars Clinical Trials

 Offenbacher and colleagues -periodontal disease and the risk of preterm

delivery.

 The incidence of nerve injuries is statistically associated with the age of the
patient.The roots of the third molars are usually not fully formed until age
21.Subsequently, extraction of third molars in the teenage years is associated
with a lower incidence of inferior alveolar nerve injury.

 Greater regenerative capacity of younger adults is associated with a greater

chance of recovery with nerve injuries
 Evidence against prophylactic removal of third
molars
 Iida and colleagues(2004) and Zhu and colleagues(2005) -reported a
significant association between removal of impacted lower mandibular
molars and mandibular condyle fractures.

 Current publications report a significant variation from 0.5% to 5% injuries

for the inferior alveolar nerve and 0.6% to 2% for the lingual nerve .If
asymptomatic impacted mandibular third molars are found to bear no future
oral or systemic health risks, it would be unnecessary to put a patient at risk
for lingual or inferior alveolar nerve injury.

 economic restraints in socioeconomically poor populations

 NICE(NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE)
GUIDELINES ON EXTRACTION OF WISDOM TEETH(2000)

 The practice of prophylactic removal of pathology-free impacted third

molars should be discontinued .

 Surgical removal of impacted third molars should be limited to patients

with evidence of pathology

 The evidence suggests that a first episode of pericoronitis, unless

particularly severe, should not be considered an indication for surgery.
Second or subsequent episodes should be considered the appropriate
indication for surgery.
CONTRAINDICATIONS FOR REMOVAL OF
IMPACTED TEETH
•Extremes of Age - Healing 
Longer recovery periods
Difficult - more densely calcified bone
Bone removal is more due to reduced PDL space
•Surgical Damage to adjacent Structures
If benefits  than complication, don’t
extract

•Compromised Medical Status

•Prosthetic considerations – Can be used as abutment
•Socioeconomic reasons
Classification systems of impacted mandibular

third molars
GEORGE WINTER’S CLASSIFICATION
Based on the relationship of the long axis of the impacted tooth in relation to the
long axis of the 2nd molar

Mesioangular – Most common type(43%) because mandibular third molars

follow an mesial inclination while eruption, least difficult to remove but most
damaging
Vertical - 2nd most common type(38%)
Horizontal - 3%
Distoangular - Most difficult to remove (6%)

Buccoangular SIGNIFICANCE - Each type of impaction has

Linguoangular some definite path of withdrawal of
Transverse the teeth.
Inverted
Mesial Angle between 10̊ & 80̊
Vertical Angle between 80̊ & 100̊
Distoangular Angle above 100̊
Horizontal Angle between 350 ̊& 10̊

Incidence of cystic changes in impacted

lower third molar Shridevi R Adaki,
Yashodadevi BK, Sujatha S, N Santana,
Rakesh N, Raghavendra Adaki
PELL & GREGORY’S CLASSIFICATION

TERMS & MEASUREMENTS USED

1. Relation of the tooth to the ascending ramus of the mandible and to the
distal surface of the 2nd molar
Shows the anterioposterior relationship of the tooth to the arch and the
amount of resistance offered by the bone of the ascending ramus that
may influence the tooth removal
CLASS I
CLASS II – Most common
CLASS III

2. Relative depth of the third molar in bone

Shows the superior inferior relationship of the tooth in relation to the
occlusal plane.
POSITION A
POSITION B – Most common
POSITION C

3.WINTER’S CLASSIFICATION
Combined ADA & AAOMS classification of procedural
terminology
Based on clinical and radiographic interpretation of the tissue overlying the
impacted teeth
07220-Soft tissue impaction
07230-Partial bony impaction
07240-Complete bony impaction
07241-Complete bony impaction with unusual surgical
complications
According to Superio-Inferior Position
of 3rd Molar
 Crown to crown

 Crown to cervix

 Crown to root
 Killey & Kay’s Classification

a) Based on angulation and position:

(Same as Winter’s classification)

b) Based on the state of eruption: - Completely erupted

- Partially erupted
- Unerupted

c) Based on roots: 1) Number of roots - Fused roots

- Two roots
- Multiple roots

2) Root pattern - Surgically favorable

- Surgically unfavorable
 G.R.OGDEN METHOD

 Compare the distance between the roots of 2nd & 3rd molars with that of 1st
& 2nd
 CLASSIFICATION OF MAXILLARY
IMPACTED THIRD MOLARS(Archer,1975)
1.According to angulation 2.According to depth of
impaction
3.The relationship of tooth to maxillary sinus :

a-sinus approximation (s.a) :

where no bone or very thin bone exist between the
impacted teeth and floor of sinus.

b-no sinus approximation (n.s.a) :

where 2 mm or more of bone exist between the
floor of sinus and impacted teeth.
 More common
 Mandibular 3rd molar impaction than maxillary 3rd molar impaction.
 In females than in males

 Among mandibular 3rd molar, mesioangular.

Class II A- Obiechina et al.
Class II B- Blondeau et al. (canada) &
Almendros-Marques et al.(spain)

• Among maxillary 3rd molars

Vertical - Quek et al
Mesioangular -Kruger et al. 
 Pre operative evaluation
 EXTRA ORAL:

 Signs of swelling & redness of the cheek.

 LN’s - enlargment & tenderness.
 Anesthesia or paraesthesia of lower lip.

 INTRA ORAL:
 Mouth opening & any evidence of trismus
 State of eruption of tooth, signs of pericoronitis
 Condition of 1st & 2nd molars
 Space present b/w 2nd M & ascending ramus
 Elasticity of oral tissues
 Size of tongue
 Radiographs
 INTRA ORAL RADIOGRAPHS
 IOPA
 Occlusal

 EXTRAORAL RADIOGRAPHS
 OPG
 Lateral cephalometric

 DIGITAL IMAGING
 CT
 CBCT

LOCALIZATION TECHNIQUES:

-Buccal object rule (SLOB)

- Magnification
-CBCT(3D)
 RADIOGRAPHIC INTERPRETATION
1.Type of impaction

2.Access - External oblique ridge

oblique & post.to third molars – good access
vertical & ant. to third molar – poor access

3. Position & depth (WAR lines)

4. Existing pathology
-Dental caries in II and III molars
-Periodontal problems
-Presence or absence of I molar
-Fused roots of II and III molars
-Any associated pathologies like cysts , odontomes.
5.Assessing the buccal / lingual obliquity
Crown – sharp & well defined –Lingual obliquity -difficult
Root apices - sharp & well defined -Buccal obliquity

6.Shape of the crown

Large square crown – difficult

7.Root pattern
WITHDRA
WAL

8. Path of withdrawal 9. Size of the follicular sac

FLAP
DESIGN

10. Texture of investing bone

 11.Relationship of Root to Canal

Related but not involving the canal

 Separated
 Adjacent
 Superimposed
Related to changes in the roots Calcification of inferior alveolar canal is
completed before the roots of 3rd molar
 Darkening of root are formed. Thus growing roots may
 Dark and bifid root
impinge upon the canal or get
 Narrowing of root
deflected. So blind elevation is not
 Deflected root
advisable.

DARKENING OF ROOT DARK & BIFID APEX NARROWING OF CANAL DEFLECTION OF ROOT
Related with changes in the canal

 Interruption of lines
 Converging canal
 Diverted canal
Age- and Gender-related Differences in the Position of the

Inferior Alveolar Nerve

(1) regardless of age, females had significantly shorter vertical distances from
the IAN to the mesial and distal apices.

(2) Females had shorter horizontal distances for total width of mandibular
bone at mesial and distal apices.

(3) the overall width of the mandibular bone decreased in both genders from
the 3rd–6th decade of life.

Age- and Gender-related Differences in the Position of the Inferior Alveolar Nerve by Using Cone Beam Computed Tomography
Jay D. Simonton, DDS, Bruno Azevedo, DDS, MS, William G. Schindler, DDS, MS,and Kenneth M. Hargreaves, DDS, PhD
INDICES OF DIFFICULTY IN
REMOVING OF 3RD MOLARS
 Scale of difficulty by YAUSA et al

Yuasa H, Kawai T, Sugiura M. Classification of surgical difficulty in extracting impacted third molars. Br
J Oral Maxillofac Surg 2002;40:26–31.
  The modified Parant scale 
was implemented to predict post-operative difficulties.
 WAR (Winter’s) Lines

The red line when extended to the inferior

edge of the radiograph should meet at 90

Red line <5mm: extraction - easy, there after every 1mm increase in depth increases
the difficulty three folds (Geoffrey Howe)& if it is >9mm then plan the surgery under
GA or LA with sedation
 The ‘‘Red Line’’ Conundrum: A Concept
Beyond Its Expiry Date?

Change of angulation of the film causes the ‘‘red-line’’ to change in length

significantly. The red-line in B is shorter by ( 30 % )than in A with a 15 change in
angulation of the film.

The ‘‘Red Line’’ Conundrum: A Concept Beyond Its Expiry Date? Sanjeev Kumar •
Mahendra P. Reddy • Lokesh Chandra • Alok Bhatnagar : JMOS 02 aug 2013
WHARFE’s ASSESSMENT by McGregor (1985)
1.WINTERS CLASSIFICTION Horizontal 2
Distoangular 3
Mesioangular 1
Vertical 0
1-30mm 0
2.HEIGHT OF MANDIBLE 31-34mm 1
35-39mm 2
1° - 50° 0
3.ANGULATION OF THIRD MOLAR 60° - 69° 1
70° -79° 2
80° - 89° 3
90°+ 4
Complex 1
4.ROOT SHAPE Favourable curvature 2
Unfavourable curvature 3
Normal 0
5.FOLLICLE Possibly enlarged 1
Enlarged 2
Space available 0
6.PATH OF EXIT Distal cusp covered 1
Mesial cusp covered 2
Both cusp covered 3
Factors that Make Surgery Less Difficult
 Mesio-angular impaction
 Class 1 ramus
 Class A depth
 Roots 1/3 – 2/3 formed (present in the younger patient)
 Fused conical roots
 Wide periodontal ligament (present in the younger patient)
 Elastic bone (present in the younger patient)
 Separated from 2nd molar
 Separated from IDN
 Soft tissue impaction
Factors that Make Surgery More Difficult
 Disto-angular impaction
 Class 3 ramus
 Class C depth
 Long thin roots (present in the older patient)
 Divergent curved roots
 Narrow periodontal ligament (present in the older patient)
 Dense, inelastic bone (present in the older patient)
 Contact with 2nd molar
 Close to IDN
 Complete bony impaction
Patient factors predicting increased difficulty of third molar removal
 Obesity
 Dense bone
 Large tongue
 Strong gag reflex
 Position of the inferior alvelolar canal
 Advanced age
 Superiorly positioned maxillary third molar
 Fractious patient
 Apical root of lower third molar in cortical bone
 Uneven anesthetic
 Atrophic mandible
 Limited surgical access
 Location of maxillary sinus

Third Molar Removal: An Overview of Indications,Imaging, Evaluation, and

Assessment of Risk Robert D. Marciani, DMD
 SURGICAL ANATOMY
 Location: lower 3rd molar is situated at the distal

end of the body of the mandible where it meets a

relatively thin ramus.

 Embedded b/w thick buccal alveolar bone

buttressed by external oblique ridge & the

narrow inner cortical plate.

 Ramus offset by 20°-Distal incision should be

curved towards buccal side.

 Thick oblique ridge

 Bone trajectories and grains

 RETROMOLAR TRIANGLE

Most prevalent types of retromolar triangles,according to Suazo et al.,2007

A. Tapering form 9.16%; B. Drop form 10.83%; C. Triangular form 80%.
•The prevalence of the RMF and RMC was 12.9%. Contents of the canal originates from
mandibular neurovascular bundle before it enters tha mandibular canal

•Neurovascular elements from the retromolar canal and foramen are distributed mainly in
the tendon of the temporalis muscle, in buccinator muscle, in the region of the alveolar
process and in the mandibular third molar, at its distal portion.

• excessive bleeding or postoperative hematomas (Azaz & Lustmann, 1973) or the post-
anesthesia of the area if the package was injured during a surgical procedure (Petruzzelli
et al., 2003).
Muscles:
• Vestibule is formed by the attachment of buccinator buccally and mylohyoid
lingually.
• Along the anterior border of the ramus - tendinous insertion of temporalis
Excessive stripping of these muscle will cause hematoma, pain and trismus.

• Lingual pouch
Arteries
 Facial artery & facial vein run in close approximation with lower 1st molar
near the anterior border of masseter.
 Mandibular vessels in retro molar triangle which supply temporalis tendon.

 Hemorrhage can occur during surgical removal of impacted tooth if distal

incision is not taken laterally towards cheek.
CLASSIFICATION OF MANDIBULAR CANAL
By NORTJE et al.,1977
Type I: Bilaterally single high mandibular canals-single high canals either
touching or within 2 mm of the apices of 1st and 2nd permanent molars.

Type II: Bilaterally single intermediate canals-single canals not fulfilling the
criteria for either high or low canals

Type III: Bilateral single low canals-single canals either touching or within
2mm of the cortical plate of the lower border of the mandible

Type IV: Variations including-asymmetry,duplications and absence of

mandibular canals
 BIFID & TRIFID MANDIBULAR CANALS
Most commonly occurs in females

During embryonic development, three separate canals fused to

form a single canal.Failure of this fusion results in bifid or trifid canals
–CHAVEZ LOMELI
 LINGUAL NERVE

•Lingual nerve lies inferior and medial to the crest of the lingual plate of
mandible with a mean position of 2.28mm(+/-0.9) below the crest & 0.58mm(+/-0.9)
Medial to crest-KIESSELBACH& CHAMBERLAIN

• In 17% of cases it lies superior to the lingual plate

INSTRUMENTS USED
 Handling The Instruments

 The scalpel is held with thumb,

middle and ring finger while the
index finger is placed on the upper
edge to help guide the scalpel.

 The scalpel should never be used

in a "stabbing" motion especially
while raising a flap.
 Surgical Management

 John Tomes (1849) – first to describe surgical access

 Steps in surgical removal

 Anesthesia
 Incision and mucoperiosteal flap
 Removal of bone
 Tooth removal
 Wound debridement
 Arrest of haemorrhage
 Wound closure
 Postoperative follow-up
 ANAESTHESIA
Mostly performed under LA

Indications of GA
When red line > 5mm
When more than two impacted teeth have to be removed at one time
Emotional liability
Fear of pain & apprehension
Medical condition requiring alleviation of anxiety
Lengthy procedure
Unco op. patient
 MUCOPERIOSTEAL FLAP
Principles of flap design
1.Incisions should avoid anatomical structures, such as major nerves or blood
vessels.

2. Incisions far enough away from the surgical area:

The wound margins should rests on sound bone

3.The base of the flap should be wider than the apex to ensure adequate blood
supply.

4.A firm pressure upon a sharp scalpel should be used so that both the mucosa
and periosteal layers of the gingiva are incised down to bone
5.Incisions are made in one operation, as extensions.
Cut the soft tissues at right angles to the surface of underlying bone.

6.The MPF should be made large enough to provide for visibility,

accessibility and adequate room for instrumentation.

7.The vertical releasing (relaxing) incision should be avoided if the horizontal

incision will provide adequate access. This is because the vertical releasing
cut
 reduces the blood supply to the flap
 and cause added discomfort

The vertical releasing incision, if needed, should be made at a line angle to

maintain the integrity of the interdental papilla.

8.Schow(1974) –Extending flap beyond EOR increases the chances of dry

socket formation
 Parts of incision
The incision having 3 parts
LIMB A: The anterior incision started from buccal
sulcus approx. at the junction of posterior and
middle third of 2nd molar, passes upwards extended
upto the distobuccal angle of the 2nd molar at the
gingival margin .

LIMB B:It was carried along the gingival crevise of

third molar extending upto the middle of exposed
distal surface of the tooth

LIMB C: Started from a point where intermediate

gingival incision ended and was carried laterally
towards cheek at mucosal depth.This arm should be
about 2 cm long.
LIMB C - not to be extended too distally
 Bleeding from buccal vessels & other arteries
 Postoperative trismus – temporalis muscle damage
 Herniation of buccal fat pad
 Damage to lingual nerve (lingual extention)

 In case of unerupted tooth ,intermediate incision is not needed.The limb A

is extended upto the middle of the distal surface of the 2nd molar

 Partly visible crown: de-epitheliazation

 FLAP DESIGNS
Envelope flap
(Two cornered flaps ) - Short
Long

Triangular flaps
(Three cornered flaps) L shaped flap
Bayonet shaped flap
Ward’s incision
Modified ward’s incision

Comma shaped incision

S shaped incision
Szmyd flap
Modified szmyd flap
Berwick’s tongue flap
Groove & Moore(1970)
 ENVELOPE FLAP
 Incision is made horizontally along the crest
of the ridge or in the buccal gingival crevice.
 Has no vertical incision.
 For shallow or superficial impactions

Advantages
Provides the broadest base and fully covers the .1
.resultant bony cavity

There is little danger of violating any major anatomical.2

.landmarks

During the procedure, the envelop flap can be .3

extended as needed; if still greater access is required
Standard incision(Ward’s incision,1968)

Ward’s incision Modified ward’s incision

 L – shaped flap
 Suits only for buccal approach
 2nd molar paramarginal Flap with vestibular
extension
 Vertical relieving incision is given at 45˚ angle to
the long axis of the 2nd molar and runs straight
anteriorly and downwards.

Bayonet – shaped flap

Distal limb
Mesial limb
Intermediate gingival incision
 Comma Incision
Designed by Nageshwar
Indications:
Total soft tissue impaction
Advantages
No part of wound lies on resultant bone defect
Less postoperative pain and swelling
 S shaped incision
Incision was made from the retromolar fossa across the external oblique ridge
curving down through the attached mucoperiosteum to run along the reflection of
the mucous membrane to the anterior border of the first permanent molar
 SZMYD FLAP MODIFIED SZMYD FLAP
 envelope flap with the incision •A vertical incision line from the distofacial
line angle of the second molar apically to the
beginning just medial to the
mucogingival line approximately 2 to 3 mm
external oblique ridge and
extending to the middle of the
distal aspect of the second molar
 sulcular incision
 VESTIBULAR TONGUE SHAPED FLAP
(Berwick,1966)

 Extende onto the buccal shelf of the mandible

 Incision line did not lie over the bony defect

created by the removal of the impacted teeth

 Its base at the distolingual aspect of the second

molar
 Groove & Moore
 A collar of tissue was preserved around the 2nd molar hence decreasing the
pocket formation

 A lingual extension of the incision allowed for exposure of the lingual

aspect as well
 Lingual flap retraction
 elevation and retraction of a lingual flap, and the placement of a retractor
(Walters-type lingual retractor )
 one can see more clearly where one is drilling, and the lingual nerve is
protected
 RETRACTION OF FLAP
A periosteal elevator is used as a retractor for small flaps and the Minnesota or
Austin retractors for large flaps.

Austi
n
Periost
Minnes
eal
ota
elevato
r
 BONE REMOVAL
Aim
1.      To remove the bone obstructing the pathway for removal of the
impacted tooth.
Types
1. By consecutive sweeping action of bur (in layers).
2. By chisel or osteotomy cut (in sections).
How much bone has to be removed?

1. Bone should be removed till we reach below the height of contour,

where we can apply the elevator.
2. Extensive bone removal can be minimized by tooth sectioning.

The surgeons should apply a handpiece load of approximately 300g

and an irrigation rate of 15mL/mL to 24mL/min (Sharon et al
Oral SUR oral Med Oral Pathol Oral Radiol Endod 1999)
 TECHNIQUES OF BONE REMOVAL
Chisel and mallet
-The chisel(Monobeveled) is a fine instrument for removing bone.
- Osteotome is bibeveled.
- Driven by hand, mallet or engine(impactor).

Bone Gauge Unibeveld Chisel Bibeveld Chisel Mallet

 BONE BURS

 Ideal length of the bur used is 7mm & diameter of 1.5mm.

 Available in many forms: crosscut fissure burs, tapered, or round.

Necklace or postage-stamp pattern

Moore & Gillbe’s Collar(BUCCAL
GUTTERING) Technique

 Conventional tech of using bur.

 Rosehead round bur no.3 is used to
create a gutter along the buccal side &
distal aspect of tooth.

 A point of elevation is created with bur.

 Amount of bone sacrificed is less.

 Can be used in old patient.

 Convenient for patient.

 Lateral trephination technique
(Bowdler Henry )
 Indicated for removal of unerupted third
molars in the age groupof 9 to 16 years.

 A modified S shaped incision is made from the

retro molar fossa across external oblique ridge.

 Such an incision leaves behind

5mmcuff of attached mucosa at the distobuccal 
region of second molar.
Chisel v/s Bur
 Split Bone / Lingual Split Technique
Sir William Kelsey Fry(1933)

INCISION VERTICAL STOP

CUT

HORIZONTAL SPLIT OF
CUT DISTOLINGUAL
BONE
REMOVAL OF
BUCCAL
& ELEVATION
DISTOLINGUAL
BONE

REMOVAL OF
CLOSURE
DISTOLINGUAL
BONE
 Tooth Sectioning
 Rationale of tooth sectioning is to create a space into which impacted tooth
can be displaced & thence removed.
Bone belongs to the
patient and the tooth
belongs to the surgeon

Indication:
Multi-rooted teeth with different lines of withdrawal
Tooth division may be done using a bur, an osteotome or tooth-splitting
forceps (tooth shear forceps).
 MESIOANGULAR IMPACTION

B. The distal aspect of the C . A small straight

crown is then sectioned from elevator is inserted into
A. buccal and distal bone are tooth. Occasionally it is the purchase point on
removed to expose crown of necessary to section the entire mesial aspect of 3rd
tooth to its cervical line. tooth into two portions rather molar, & the tooth is
than to section the distal delivered with a
portion of crown only rotational and level
motion of elevator.
HORIZONTAL IMPACTION
A. Removal of distal and
buccal underlying bone

B. The crown is sectioned

from the roots of the tooth and
is delivered from socket.

C, The roots are delivered

together or independently with a
Cryer elevator used with a
rotational motion. Saperation of
root into 2 parts - occasionally
the purchase point is made in the
root to allow the Cryer elevator
to engage it.

D, The mesial root of the

tooth is elevated in similar
fashion
 VERTICAL IMPACTION

A. When removing a B. The posterior aspect of C. A small straight no.

vertical impaction, the the crown is elevated first 301 elevator is then used
bone on the occlusal, with a Cryer elevator to lift the mesial aspect
buccal, and distal aspects inserted into a small of the tooth with a rotary
of the crown is removed, purchase point in the and levering motion.
and the tooth is sectioned distal portion of the tooth.
into
mesial and distal portions.
DISTOANGULAR IMPACTION
A. Removal of mesial & distal
boen. It is important to remember
that more distal bone must be
taken off than for a vertical or
mesioangular impaction.

B. The crown of the tooth is

sectioned off with a bur and is
delivered with straight
elevator

C, The purchase point is put into

the remaining root portion of the
tooth, and the roots are delivered by
a Cryer elevator with a wheel and-
axle
motion. If the roots diverge, it may
be necessary in some cases to split
them into independent portions
REMOVAL OF MAXILLARY THIRD MOLARS

Triangular flap Envelope flap

IMPACTED CANINES
 Theories of canine impaction

GUIDANCE Canine erupts along the root of lateral

incisors, which serve as a guide, and if
THEORY the lateral incisor is absent or
(Miller) malformed, the canine will not erupt.
 Genetic factors are primary origin of
GENETIC palatally displaced maxillary canine
and include other possibly associated
THEORY dental anomalies, such as missing or
small lateral incisor
ETIOLOGY OF CANINE IMPACTION
LOCALIZED CAUSES

Tooth size- arch length discrepancies

Failure of the primary canine root to

resorb

Prolonged retention or early loss of

primary canine

Ankylosis of permanent canine

Cyst or neoplasm
 Dilaceration of the root

Absence of maxillary lateral

incisor

Variation in timing of lateral

incisor root formation

Iatrogenic factors

Idiopathic factors
SYSTEMIC
Endocrine deficiencies

Febrile diseases

Irradiation
GENETIC
Heredity

Malposed tooth germ

Presence of alveolar cleft

 INCIDENCE
 Maxillary canine impaction occurs in approximately
2% of the population.

 More common
In females than in males
Maxillry than mandibular
Palatally placed than labially in maxilla
Labially placed than lingual in mandible
 SEQUELAE OF IMPACTED CANINE
Migration of Internal resorption
Labial or lingual or external root
neighbouring teeth
malpositioning of resorption of
and loss of arch impacted or
impacted tooth
length neighbouring tooth

Infection
Dentigerous cyst particularly with Referred pain
formation partial eruption
 CLASSIFICATION OF IMPACTED
MAXILLARY CANINE
Class I: Palatally placed maxillary canines
a)vertical,
b)Horizontal
c)Semivertical

Class II: Labialy placed maxillary canines

a)vertical
b)Horizontal
c)Semivertical

Class III: Impacted cuspid located both in

the palatal and labial bone.

Class IV: Impacted in the alveolar process

between the incisors and first premolars

Class V:impacted cuspid that are present

in an edentulous maxilla and may assume
any of the previous three classes.
 CLASSIFICATION OF IMPACTED
MANDIBULAR CANINE

Labial Aberrant
Vertical At inferior border
Oblique On the opposite side
Horizontal
 Evaluation of impacted canines
Study model • Amount of space available in dental
arch for impacted canine is assessed
analysis in model.

Morphology of • Gives clue of position of impacted

adjacent tooth tooth.

Contours of • Canine bulge present buccally or

adjacent alveolar palatally.
bone

Mobility of • Root resorption.

adjacent tooth

Failure to palpate canine bulge in buccal vestibule by 10 years

FACTORS INFLUENCING THE TREATMENT
DECISION OF AN IMPACTED CANINE
Age of patient

General
Generaldental
dentalhealth
healthand
andoral
oralhygiene
hygiene

Availability of space

Suitability of 1st premolar to replace a permanent canine

Radiographic position of canine

Patient motivation for orthodontic applainces

Presence of adequate width of attached gingiva

Involves Localization of canine
 inspection,
 palpation, and
 radiographic evaluation

PARALLAX TECHNIQUE: Two radiographs taken at different horizontal angles with the
same vertical angle.
Locates canine positioned buccally or palatally to other teeth in the arch
Combinations used :
1)Two IOPA’s taken at different horizontal angles(Clark,1909)
2)One maxillary anterior occlusal & one maxillary lateral occlusal (Southall &
Gravely,1989)
3)One IOPA & one maxillary anterior occlusal radiograph(vertical parallax,Rayne,1969)
4)One panoramic & one maxillary anterior occlusal radiograph(vertical parallax,Keur,1986)

SLOB rule- Same Lingual Opposite Buccal (or)

BOPS rule- Buccal Opposite Palatal Same (or)
BAMA rule- Buccal Always Moves Away
MAGNIFICATION:
Based on the principle of image size distortion.
For a given FSFD, objects further away from the film will be depicted more
magnified than objects closer to the film.

CBCT:
 Identify and locate the position of impacted canine accurately.
 We can assess any damage to adjacent tooth roots and amount of bone
surrounding each tooth.
 Radiographic factors in decision making
1.Angulation of the canine long axis to the upper midline

Grade I: 0-15̊
Grade II: 16-30̊
Grade III: >31̊

2.Position of the canine apex relative to the adjacent teeth

Grade I: Above the region of the canine position

Grade II: Above the first premolar region
Grade III: Above the upper second premolar region
3. Depth of impaction of canine relative to root of lateral incisor

Grade 1: Below the level of the cemento-enamel

junction (CEJ).
Grade 2: Above the CEJ, but less than halfway up
the root.
Grade 3: More than half way up the root, but less
than the full root length.
Grade 4: Above the full length of the root.

4. Mesiodistal position of the canine tip.

Grade 1: No horizontal overlap
Grade 2: Less than half the root width
Grade 3: More than half, but less than the whole root
width
Grade 4: Complete overlap of root width or more.
5.Root resorption of adjacent incisor
6.Labio-palatal position of the canine crown
MANAGEMENT OF IMPACTED CANINE
The management of impacted canine is a complex procedure requiring a
multidisciplinary approach.

(1) No treatment except monitoring

(2) Interceptive removal of primary canine

(3) Surgical removal of the impacted canine

(4) Surgical exposure with orthodontic alignment

(5) Autotransplantation of the canine

 No treatment except monitoring
 If the canine is in good position and without contact with the lateral incisor
and first premolar.

 If there is no evidence of pathology or root resorption of the adjacent teeth

 The patient refuses treatment

 If the impacted canine is severely displaced and remote from the anterior
teeth and is difficult to remove or expose
 Interceptive removal of primary canine
 If the patient is between 10 and 13 years

 The maxillary canine is not palpable

 Localization confirms a palatal position

If the canine position

does not improve over a
12-month period,
alternative treatment is
indicated.
 Surgical removal of the impacted canine

If it is ankylosed and cannot be transplanted.

If it is undergoing external or internal root resorption.

If its root is severely dilacerated.

If the impaction is severe ,e.g., the canine is lodged between the roots of the central
and lateral incisors.

If the occlusion is acceptable, with the first premolar in the position of the canine.

If there are pathologic changes (e.g., cystic formation, infection)

If the patient does not desire orthodontic treatment.

FLAP DESIGN:
canine is located buccally- Angulated flap

canine is high & buccally – Semilunar flap

 If the impacted canine is palatal

 If the both maxillary canines are impaced & planned to remove in single
sitting

 positioned transversely in the alveolus

require mucoperiosteal flaps on the palatal and labial sides
 surgical exposure with orthodontic
alignment
3 methods
(1) open surgical exposure

(2) surgical exposure with packing and delayed bonding of the

orthodontic bracket

(3) surgical exposure and bonding of orthodontic bracket

intraoperatively

GOAL: Flap designs should preserve the band of attached gingiva (2-3
mm)and should guide tooth to erupt through its natural path of
eruption
 Labial impaction of upper canine

Initial orthodontic treatment was

aimed at creating space in the
maxillary arch with fixed appliance
therapy.

Labial
impaction
Surgical exposure and orthodontic
traction.
 Open technique
• Canine crown coronal to
mucogingival junction • Excisional approach
• If the canine has correct inclination (Gingivectomy)
• Adequate amount of keratinised
gingiva is present

• Canine crown apical to

mucogingival junction • Apically positioned
flap
• When an inadequate amount of
KG is present
Apically positioned flap
 Closed eruption technique
Indicated if tooth is impacted in the centre of the alveolus or more apically near the
nasal spine

Flap is elevated

Attachment placed on impacted

tooth

Ligature or chain placed over the

attachment to activate after a week

Raised flap is repositioned in its

original location

Permit eruption of impacted

canine in normal direction
Palatal impaction of upper canine
• Crown is surgically exposed, an attachment
is bonded during the exposure, flap is
CLOSED ERUPTION sutured back, leaving a twisted ligature wire
passing through the mucosa to apply
orthodontic traction.

OPEN WINDOW • A flap is raised, bone covering crown is

ERUPTION removed, small window or fenestration is
TECHNIQUE(Trap made, orthodontic attachment is bonded and
door approach) flap is sutured in to place.
Closed eruption
Methods of applying traction

Ligature wire Rubber bans

Ballista springs

Elastic chains

TMA sectional arch wire Eyelet attachment

IN NUT SHELL
 Debridement of Wound & Closure

 Thorough debridement of the socket by Periapical curettage.

 Smoothening of sharp bony margins by Bone file / burs.

 Thorough irrigation of the socket Betadine solution + Saline .

 Initial wound closure is achieved by placing 1stsuture just distal to 2ndmolar,

sufficient number of sutures to get a proper closure.

 Post Operative Instructions

the incidence of dry socket can be reduced significantly by using 0.2%

chlorhexidne gluconate mouth rinse perioperatively (twice daily, 1 day
before and 7 days after surgical extraction.
 Complications
Intra Operative
1. During incision
a. Injury to facial artery
b. Injury to lingual nerve
c. Hemorrhage – careful history

2. During bone removal

a. Damage to second molar
b. Slipping of bur into soft tissue & causing injury
c. Extra oral/ mucosal burns
d. Fracture of the mandible when using chisel & mallet
e. Subcutaneous emphysema

3. During elevation or tooth removal

a. Luxation of neighbouring tooth/ fractured restoration
b. Soft tissue injury due to slipping of elevator
c.  Injury to inferior alveolar neurovascular bundle
d. Fracture of mandible
e. Forcing tooth root into submandibular space or inferior
alveolar nerve canal
f. Breakage of instruments
g. TMJ Dislocation – careful history
 Post-operative Complications
Immediate

- Hemorrhage
- Pain
- Edema
- Drug reaction
Delayed

- Alveolitis
- Infection
- Trismus
 Hemorrhage
 Use good surgical technique, minimize trauma, avoid tears of flaps.

 Most effective measure to achieve hemostatis is via moist gauze pressure

over wound.

 Application of topical thrombin on Gelfoam into socket and oversuturing.

 Other hemostatics: oxidized cellulose (Oxycel or Surgicel), microfibriller

collagen(Avitene).

 Patients with acquired or congenital coagulopathy may need blood product

replacement.
 NERVE INJURIES
 0.6-5% of all the third molar surgeries are involved with nerve damages of
which 0.2% are irreversible

 IAN: immediate disturbance - 4-5% (1.3-7.8%)

permanent disturbances - <1% (0-2.2%)
 Lingual N: immediate - 0.2-22%
permanent - 0-2%

 96% IAN injuries show spontaneous recovery within 9 months, better than
lingual nerve which is about 87%

 Beyond 2yrs recovery is unlikely

IANI-RISK REDUCING PROCEDURES
Coronectomy – oral surgery’s answer to modern

day conservative dentistry

 A method of removing the crown of a tooth but leaving the roots
untouched, which may be intimately related with the inferior alveolar nerve,
so that the possibility of nerve injury is reduced.
 first proposed in 1984 by Ecuyer and Debien.
 Also known as intentional partial odontoectomy, partial root removal and
deliberate vital root retention

BASIS FOR CORONECTOMY

It is common practice for broken fragments of the root of vital teeth to be left
in place and most heal uneventfully.

 Renton et al.and Leung et al. (randomised clinical trial), Hatano et al. (case
control study) and O’Riordan (retrospective study) provided evidence that
coronectomy decreases the risk of IDNI when compared to traditional
extraction of MTMs
RADIOGRAPHIC SIGNS INDICATING PROXIMITY TO IAN

DEVIATION OF THE CANAL PERIAPICAL RADIOLUCENT AREA

NARROWING OF THE CANAL NARROWING OF ROOT

DARKENING OF ROOTS CURVING OF ROOTS

LOSS OF LAMINA DURA OF CANAL

PROCEDURE

A Walters-type lingual retractor with appropriate

periosteal elevators to retract the lingual flap.

A and B) Models show lingual

retractor in place to demonstrate that
the shape of the lingual retractor fits
the lingual contours of the mandible.

The lip engages the

internal oblique ridge and prevents the
retractor from passing too far
inferiorly.
Coronectomy:A, cutting crown below cement-enamel junction (arrow);
B, trimming cutted surface to less than 3 to 4 mm below alveolar crest.
FATE AFTER CORONECTOMY
 Bone formation over the retained root fragment.

 In all cases the root fragments move into a safer position with regard to the
nerve and it can be envisaged that should removal become necessary the
nerve would not then be at high risk.

 Root migration is more in distoangular impactions and in older individuals

 Dry socket can be treated in the conventional manner with irrigation and
dressing, if it occurs.

 There does not appear to be any need to treat the exposed pulp of the tooth.
PREOPERATIVELY 1 WEEK POSTOPERATIVELY

36 MONTHS POSTOPERATIVELY
CASES TO AVOID
 Teeth with associated infection, particularly infection involving the root
portion
 Teeth that are mobile
 Teeth that are horizontally impacted along the course of the inferior alveolar
nerve

DRAWBACKS OF CORONECTOMY
 Root walk out during surgery(FAILED CORONECTOMY)
 deep periodontal pockets on the distal of the second molar,
 delayed postoperative root migration with the possible need of a second
procedure
 postoperative pain
 dry socket
 infection
RESISTANCE TO THE ACCEPTANCE BECAUSE

 concern about leaving a large section of root in the mandible.

 Retained root may develop a radicular cyst leading to further surgery and
morbidity.

 post-operative infections

 root eruption leading to reoperation

BUT...
 MODIFIED AND GRAFTED CORONECTOMY

GOALS
 To decrease the incidence of
intraoperative root walkout.
 To minimize the potential and/or
preexisting periodontal pockets distal to
the second molar
 To decrease the risk of delayed root
migration with the possible need for a
second surgical procedure

PROCEDURE
 An initial vertical cut with a #703 cross
cut fissure carbide FG bur, 2.1mm
diameter was made above the CEJ and
oriented at a 20∘ angle to the distal root
of the second molar
 After the removal of the first
fragment, rest seats were created
in the root portion at each of the
subsequent steps

 Clearance is achieved between 2nd

and 3rd molars.

 A resorbable hydroxyapatite (HA)

graft was placed into the bleeding
site and no membrane was used.

23 month follow up showing healing

Postoperative radiograph after the right Three months after odontectomy. The third
mandibular third molar was surgically molar moved mesially. However, the mesial
sectioned. The space distal to the second root was still in contact with the alveolar
molar would allow mesial migration of canal. A second sectioning was required.
the impacted tooth.
Postoperative radiograph after second Periapical radiograph obtained 2 months
sectioning of the right mandibular third molar. after second sectioning. At that time, the
A pulpotomy has been performed. roots were away from the alveolar canal, and
More space was created distal to the right a riskless extraction could be scheduled.
mandibular second Molar to allow further
migration
 ORTHODONTIC EXTRUSION
•Risk of direct trauma to IAN is eliminated

•A potential problem with this technique is soft

tissue damage from impingement on the
mucosa of the cheek and the gingva.

•Difficult in working in this area because the

action of the masseter muscle leads to cheek
compression against the orthodontic appliances

• no value in case of ankylosed teeth.

•It is time consuming and not always successful

 PERICORONAL OSTECTOMY
The removal of the overlying bone to allow for the tooth to erupt away from the IAN,
in cases of incomplete root formation in younger patients 14 to 18 years old
 ACCIDENTAL DISPLACEMENT OF THIRD MOLARS

CAUSES
 Excessive apical force during the use of elevators .

 incorrect surgical technique.

 Maxillary third molars have only a thin layer of bone posteriorly separating
them from the infratemporal space and anteriorly separating them from the
maxillary sinus.

 In mandibular third molar, the thinness of the lingual cortical bone

predisposes to displacement in a lingual direction.

 Distolingual angulation of the tooth predisposes to the displacement.

TREATMENT RECOMMENDATIONS
 DISPLACEMENT INTO MAXILLARY SINUS

patient complains of mild pain and heaviness in the left maxillary sinus area and the left
maxillary sinus was tender on palpation. maxillary sinus was exposed through a
Caldwell-Luc approach. The sinus was irrigated with sterile saline solution under pressure
and the tooth was removed only by negative pressure of the suction pump
DISPLACEMENT INTO PTERYGOPALATINE FOSSA

•classical maxillary third molar surgery flap design was performed

•Upon the reflection of the flap the pathway of the displaced third molar has been
revealed as the posterior aspect of maxillary sinus area was open to site.
•Extending through the posterior wall of maxillary sinus and with careful exploring
the tooth was reached and exposed with a straight elevator.
 DISPLACEMENT INTO BUCCAL SPACE

CT image of the case depicting the 3D CT image of the displaced maxillary third
displaced tooth between the molar seen as localized obliquely in front of the
buccinator and masseter muscle in the anterior border of the ramus of the mandible in
buccal space.. the buccopalatine direction.
 DISPLACEMENT INTO LATERAL PHARYNGEAL SPACE

Panoramic radiograph showing displaced Axial CT scan showing upper left third
upper left third molar medial to molar in lateral pharyngeal space.
mandibular ramus
Incision over glossopalatine arch. The tooth crown is visible after dissection
The dotted line shows the bulge created by of the surrounding fibrous capsule.
the underlying tooth crown.
 Displacement into submandibular space

•A lingual mucoperiosteal flap was raised in the 48 region after making

an incision from the medial aspect of anterior border of the mandibular
ramus and extending upto the lingual gingival sulcus of the mandibular
right first premolar tooth.

•Blunt dissection was carried out medial to the third molar socket to
reach the mylohyoid muscle.

•The tooth was located inferior to the muscle.

Displacement in pterygomandibular space
 DRY SOCKET
DEFINITION
“postoperative pain in and around the
extraction site, which increases in severity
at any time between 1 and 3 days after the
extraction accompanied by a partially or
totally disintegrated blood clot within the
alveolar socket with or without halitosis.”

.
I R. Blum: Contemporary views on dry socket (alveolar osteitis): a clinical appraisalof standardization, aetiopathog
enesis and management: a critical review. Int. J. Oral Maxillofac. Surg. 2002; 31: 309–317
First described by CRAWFORD

SYNONYMS
 alveolar osteitis(AO)
 alveolitis
 localized osteitis
 alveolitis sicca dolorosa
 localized alveolar osteitis
 fibrinolytic alveolitis
 septic socket
 necrotic socket
 alveolalgia
 ONSET AND DURATION
 Mostly 1-3 days after extraction

 Unlikely –before first operative day

Because the blood contains anti-plasmin that must be
consumed before clot disintegration can take place.

 The duration of AO varies depending on the severity of disease ,but it

usually ranges from 5-10 days

 The incidence of alveolitis was 2.7 times greater among females than
among males
 SIGNS AND SYMPTOMS

 The denuded alveolar bone ma be painful and tender

 Some patients may also complain of intense continuous pain radiating to

the ipsilateral ear, temporal region or the eye

 Regional lymphadenopathy(occasionally)

 Unpleasant taste(occasionally)

 Trismus
 ETIOLOGY
 Multifactorial in origin
Suggested factors include
-Oral micro organisms(Trepanoma denticola)

-Difficulty and trauma during surgery

-Roots or bone fragments remaining in the wound

-Excessive irrigation or curettage of the alveolous after extraction

-Physical dislodgement of the clot

-Local blood perfusion and anaesthesia

-Oral contraceptives-estrogens, like pyrogens, will activate the fibrinolytic system

indirectly

-Smoking
 RISK FACTORS
 Previous experience of AO

 Deeply impacted mandibular third molar (risk factor is directly
proportional to increasing severity of impaction)

 Poor oral hygiene of patient

 Active or recent history of acute ulcerative gingivitis or pericoronitis
associated with the tooth to be extracted

 Smoking (especially >20 cigarettes per
day)

 Use of oral contraceptives

 Immunocompromised individuals
 PATHOGENESIS
BIRN FIBRINOLYTIC THEORY
 NON-PHARMACOLOGICAL MEASURES
 Use of good quality current preoperative radiographs

 Careful planning of the surgery

 Use of good surgical principles

 Extractions should be performed with minimum amount of trauma and
maximum amount of care

 Confirm presence of blood clot subsequent to extraction (if absent,
scrape alveolar walls gently)

 Wherever possible preoperative oralhygiene measures to reduce plaque leve
ls to a minimum should be instituted
 Encourage the patient (again) to stop (or)limit smoking in the immediate
postoperative period

 Advise patient to avoid vigorous mouthrinsing for the first 24 h post extract
ion&to use gentle toothbrushing in theimmediate postoperative period

 For patients taking oral contraceptives
extractions should ideally be performed during days 23 through 28 of the
menstrual cycle

 Comprehensive pre- and postoperative verbal instructions should be
supplemented with written advice to ensure maximum compliance
 PHARMACOLOGICAL MEASURES
 Antibacterial agents

 Antiseptic agents and lavage- Chlorhexidine

 Antifibrinolytic agents- Para hydroxybenzoic acid(PHBA)

 Steroid anti-inflammatory agents- polylactic acid

 Obtundant dressings

 Clot supporting agents

 SURGICAL MANAGEMENT
 Under block aneasthesia

 The clot devoided socket is thoroughly curetted, both from the floor of the
socket as well as from the bony walls

 The sharp margins were trimmed & rounded

 Any foreign bodies if present were thoroughly removed

 The detached gingival margins were also scraped

 The desired medications and precautions

 CONCLUSION

Many advantages
Few disadvantages
Stick to protocol
Surer to have a good
result……
 References
 Textbook of oral and maxillofacial surgery- NEELIMA MALIK

 Textbook of oral and maxillofacial surgery- B SRINIVASAN

 Oral and maxillofacial surgery - FONSECA volume I

 Oral and maxillofacial surgery – LASKIN volume II

 A Novel Surgical Approach to Impacted Mandibular Third Molars to

Reduce the Risk of Paresthesia: A Case Series Luca Landi, DDS, CAGS,
Paolo Francesco Manicone, DDS,Stefano Piccinelli, DDS,Alessandro
Raia, DDS, and Roberto Raia, DDS
THANK YOU