THIS PRESENTATION BASED ON INTRODUCTION OF IMPACTED TOOTH AND TREATMENT OF MANDIBULAR IMPACTED TOOTH AND COMPLICATIONS OF ITS

1. Guided by:
Dr. Sunil Sharma
PRESENTER
Dr. Ashish Soni

2. CONTENTS
 INTRODUCTION
 DEFINITIONS
 ORDER OF FREQUENCY OF IMPACTED TEETH
 ETIOLOGY
 PROBLEMS DUE TO RETAINED IMPACTED TEETH
 INDICATIONS FOR REMOVAL
 CONTRAINDICATIONS FOR REMOVAL
 IMPACTED 3RD MOLARS
• SURGICAL ANATOMY
• CLASSIFICATION
• PRE-OP ASSESSMENT

3. PRE-OP MANAGEMENT OF IMPACTED TEETH
SURGICAL TECHNIQUES
 SURGICAL SIDE-EFFECTS AND COMPLICATIONS
 REFERENCES

5. DEFINITIONS
 IMPACTED TOOTH : 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. (Archer)
 MALPOSED TOOTH : A tooth, unerupted or erupted, which is in an
abnormal position in the maxilla or mandible.
 UNERUPTED TOOTH : A tooth not having perforated the oral mucosa.
 ANKYLOSED TOOTH : When the cementum of the tooth is fused to the
alveolar bone and there is no periodontal ligament in between, a tooth is
considered to be ankylosed.
 SUBMERGED TOOTH : A decidous tooth which is ankylosed , prevents
their exfoliation and subsequent replacement by permanent tooth. After the
adjacent permanent tooth have erupted, the ankylosed tooth appears to have
submerged below the level of other teeth.

6. ORDER OF FREQUENCY OF
IMPACTED TEETH
 Maxillary 3rd Ms
 Mandibular 3rd Ms
 Maxillary cuspids
 Mandibular bicuspids
 Mandibular cuspids
 Maxillary bicuspids
 Maxillary central incisors
 Maxillary lateral incisors
According to Archer

7. ETIOLOGY

8.  THEORIES OF IMPACTION
According to DURBECK, causes can be discussed
under 5 separate theories:
 Orthodontic theory
 Phylogenic theory
 Mendelian theory
 Pathological theory
 Endocrinal theory

9. Orthodontic theory
The normal growth of the jaws and movement of teeth is in a forward
direction and anything interfering with such development will cause an
impaction of teeth.
 Dense bone and many pathologic conditions like acute infections,
fever, severe trauma ,malocclusion ,inflammation of the periodontal
membrane etc which can cause increased bone density - retards
such forward growth of the jaws
 Constant mouth breathing - contracted arches. Thus leaving
insufficient room for erupting M3.
 Early loss of deciduous teeth - arrested development of teeth,
resulting in impactions.

10. Phylogenic theory
 Nature tries to eliminate that what is not used, and our civilization
with its changing nutritional habits has practically eliminated the
human need for large powerful jaws.
 As a result, the size of jaws has decreased - abnormal position of M3
leading to impaction
Mendelian theory
 Heredity – such as transmission of small jaws from parent and large
teeth from the other parent– may be an important etiologic factor in
impactions

11. Pathological theory
 Chronic infections affecting an individual may bring the
condensation of osseous tissue further preventing the growth and
development of the jaws.
Endocrinal theory
 Increase or decrease in growth hormone secretion may affect the
size of the jaws

12.  LOCAL CAUSES
Berger lists the following local causes of impaction :
 Irregularity in the position and presence of an adjacent
tooth.
 Density of the overlying or surrounding bone.
 Long – continued chronic inflammation with resultant
increase in density of the overlying mucous membrane.

13.  Lack of space due to underdeveloped jaws.
 Unduly long retention of the primary teeth.
 Premature loss of the primary teeth.
 Acquired diseases, such as necrosis due to infection or
abscesses and inflammatory changes in the bone due to
exanthematous diseases in children.

14.  SYSTEMIC CAUSES
 Prenatal causes
 Heredity
 Postnatal causes
 Rickets
 Anemia
 Congenital syphilis
 Endocrine dysfunctions
 Malnutrition

15.  Rare conditions
Cleidocranial dysostosis
Oxycephaly
Achondroplasia
Cleft palate

16. PROBLEMS DUE
TO RETAINED
IMPACTED
TEETH

17.  Fascial space infections
 Infections arising from M3 may be
spread through various tissue planes:
 Pterygomandibular space
 Lateral pharyngeal space
 Retropharyngeal space
 RISK OF CYST & TUMOR DEVELOPMENT
 Most common age : 20- 25 years.
 Incidence of dentigerous cyst- 1.6% (KEITH,1973)
 Incidence of cyst formation-2.31%(Guven et al,2000)
 Incidence of ameloblastoma – 0.14- 2 %(Shear,1978)

18.  Dental caries
 Pain
 Risk of mandibular fracture:
 Trismus.
 Chronic cheek biting.
 Resorption of adjacent tooth.
 Other complications :
 Ears - Ringing, singing or buzzing sound
 Eye - dimness of vision, blindness, iritis, pain simulating that
of glaucoma

19. INDICATIONS FOR REMOVAL
 Any symptomatic wisdom tooth
 Grossly decayed 3rd molars
 Periodontal disease
 Dentigerous cyst formation or other related oral pathology
 External resorption of 3rd molar or of 2nd molar
 Infection.
 Non restorable dental caries.
 Interference with orthodontic treatment.
 Presence of impacted tooth in the line of jaw fracture.
 Persistent pain of unknown origin.
 Pre-irradiation.
 Resorption of adjacent teeth.
 Proceeding fabrication of adjacent restorative crowns and dentures.
 Removal of 3rd molar prior to orthognathic surgery

20. Contraindications for removal of impacted
teeth
 Possible Damage to Adjacent Structures
 If the removal of an asymptomatic impaction is likely to result in
the loss of adjacent teeth, damage to the vital structures like
neurovascular bundle, the tooth should be left in place.
 Compromised Physical Status
 One of the most significant factors to be considered when
removing of an impacted tooth is the patient's physical condition
and life expectancy. Surgical removal is contra indicated if the
patient is not fit to undergo minor oral surgical procedure.

21.  Prosthetic consideration
Sometimes, partially erupted tooth has to be retained
since such a tooth could be utilized as an abutment for a
fixed partial denture.
 Availability of adequate space:
If adequate space is available for the eruption of the
unerupted tooth, it is better to retain it.
 Socioeconomic reasons:
The patient may not be willing for removal due to fear
or socioeconomic reasons.

22. Local factors
 Radiotherapy
 Teeth in close proximity to tumour
 Acute gingivitis
Systemic factors
 Uncontrolled diabetes
 Pregnancy
 Underlying bleeding disorders
 Cardiac conditions
 Patients on anticoagulants,steroids,etc.

23. IMPACTED MANDIBULAR 3rd MOLARS

24. Surgical anatomy
 The main external osseous features of the
mandibular first and second molar region
are
 the very thick roll of convex lateral bone
extending from the crest of the alveolus to
the base of the mandible and
 On the medial (lingual) aspect the alveolar
process area declines in height as it passes
posteriorly, and it is convex with a thick roll
of cortical bone.
 The mylohyoid ridge continues posteriorly in
an upward sweep toward the third molar
region. Below the mylohyoid ridge there is
usually a concavity in the medial aspect of
the mandible, the submandibular fossa.
However, normal variations of the anatomy
below the mylohyoid ridge include the
area’s being convex rather than concave.

25. The Retromolar Triangle
 Behind the third molar is a depressed
roughened area on the upper surface of the
mandible which is bounded by the lingual
and buccal crests of the alveolar ridge this is
the retromolar triangle.
 Lying lateral to the retromolar triangle is a
shallow, hollow depression, the retromolar
fossa, which is bounded by the anterior
border of the ascending ramus and the
temporal crest.
 The retromolar triangle is the site for initial
surgical procedures to remove the usual
impacted mandibular third molars.

26. Retromolar canal and foramen
 It is a rare anatomic variation, found In the
retromolar triangle through which emerges
branches of the mandibular vessels
 According to Schejtman, Devoto and Arias
(1967), are distributed over the temporalis
tendon, buccinator and adjacent alveolus.
 Contents of this canal originates from
mandibular neurovascular bundle.
 Anderson et al. (1991) – innervate and supply
temporalis M, part of buccinator M,
retromolar trigone.
 Although these are small vessels a brisk
hemorrhage can occur during the surgical
exposure of the third molar region if the
distal incision is carried up the ramus and not
taken laterally towards the cheek.

27. Inferior Alveolar canal
 The inferior alveolar
canal may be present as a
single cortical bony tube
that can be in various
locations lateral to,
medial to, inferior to, and,
possibly, through the roots
of the mandibular teeth.
 Instead of a single canal,
multiple tubes may be
present, carrying nerves
and vessels to single teeth
or to groups of teeth and
to the mental foramen.
Various routes and patterns of IAN.

28. Lingual Nerve
 The lingual nerve may be hidden beneath or in the mucosa lateral to the
location of a mandibular third molar near the crest in an abnormal,
superior position.

29. Variations in lingual nerve: from the crest of the lingual
bone to the floor of the mouth
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30. Classification suggested by Pell &
Gregory(1933), which includes portion of
George B Winter’s classification(1926) :
A. Availability of space between 2 nd molar and
ramus of the mandible (horizontal plane):
Class I
There is sufficient space between the ramus of the
mandible & the distal side of the second molar for the
accommodation of the mesiodistal diameter of the crown of
the third molar.

31. Class II
The space between the ramus of the mandible & the distal
side of the second molar is less than the mesiodistal
diameter of the crown of the third molar.

32. Class III
Complete or most of the third molar is located within the
ramus.

33.  B. Relative depth of the 3rd molar in bone (vertical
plane):
Position A
The highest portion of the tooth is on a level with or above the
occlusal plane.
Position B
The highest portion of the tooth is below the occlusal plane, but above
the cervical line of the second molar.
Position C
The highest portion of the tooth is below the cervical line of the
second molar.

34.  C. Long axis of the impacted tooth in relation to the long
axis of the 2nd molar (angulation ; Winter’s
classification):
1. Vertical.
2. Horizontal.
3. Inverted.
4. Mesioangular.
5. Distoangular.
6. Buccoangular.
7. Linguoangular.

35. G.R.OGDEN METHOD
A simple method of
determining the type of
impaction involves
comparing the distance
between the roots of 3rd
and 2nd molars , with the
distance between the roots
of the 2nd and 1st molars .
a>b : mesioangular
a=b: vertical
a<b: distoangular

36. Class I position A Horizontal Class I position B Vertical
Class II position A Vertical Class II position B Distoangular

37. AAOMS classsification of procedural
terminology :
 Based on the operation performed to remove an
impacted tooth.
 It relates directly to abnormal physical findings of
other classifications.

38. ADA code on procedures and nomenclature:
 The American Dental Association (ADA) Code
describes the amount of soft and hard tissues over the
coronal surface of an impacted tooth.
 These are described as: soft tissue impactions, partial
bony impactions, completely bony impactions, and
completely bony impactions with unusual surgical
complications.

39. Combined ADA and AAOMS classifications :
The AAOMS published the ADA coding with explanations
from the AAOMS procedural terminology, in parentheses, as
follows:
 07220 : Removal of impacted tooth – (overlying) soft tissue
(Impaction that requires incision of overlying soft tissue and
the removal of the tooth).
 07230 : Removal of impacted tooth – partially bony
impacted (Impaction that requires incision of overlying soft
tissue, elevation of a flap, and either removal of bone and tooth
or sectioning and removal of tooth.

40.  07240 : Removal of impacted tooth – completely bony
(Impaction that requires incision of overlying soft tissue,
elevation of a flap, removal of bone, and sectioning of tooth
for removal).
 07241 : Removal of impacted tooth – completely bony, with
unusual surgical complications (Impaction that requires
incision of overlying soft tissue, elevation of a flap, removal of
bone, sectioning of the tooth for removal, and/or presents
unusual difficulties and circumstances.

41. PRE-OP ASSESSMENT
 HISTORY
chief complaint
history of presenting complaint
medical history
social history
 EXAMINATION
clinical
radiographs
 DECISION
diagnosis
treatment planning

42.  HISTORY
Pain and infection associated with partially erupted
teeth.
Many impacted or displaced teeth are unerupted and
asymptomatic - incidental finding following
radiographic examination.
Occasionally, unerupted wisdom teeth, in the absence
of any obvious infection, can give rise to discomfort .
 It is important to exclude other possible causes such
as TMJ pain and pulpitis / periapical abscess from
another tooth

43. CLINICAL EXAMINATION
 Compliant : Pain, exclude other causes such as TMJ
disorder, pulpitis/abscess of other teeth.
 Previous medical history.
 Dental history.
 Extraoral features.
 Intraoral features.

44.  RADIOGRAPHIC EVALUATION
1. To study the relation with adjoining tooth.
2. To study the configuration of the roots &
status of the crown.
3. To know the buccoversion or linguoversion
of Impacted tooth.
4. Shadow of the external oblique ridge.
 If vertical & anterior to the Impacted
tooth – Poor access.
 If oblique & posterior to the Impacted
tooth—Good access.

45.  PERIAPICAL X-RAYS
FRANK’S TUBE SHIFT TECHNIQUE

46. RELATIONSHIP OF INFERIOR ALVEOLAR NERVE TO
THE ROOTS OF THE THIRD MOLAR. (HOWE&
POYTON;1960)
Darkening of root Deflection of root Narrowing of root Dark & Bifid apex

47. Interruption of white Narrowing of canal Diversion of canal
line of canal

48.  OPG
 Conventional tomography
 Facial x-rays
lateral oblique views
 CT
 Other imaging techniques
xeroradiography
dentascans
intra-oral cameras
magnetic resonance imaging

49.  Uses of radiographs:
 To determine the type of impaction
 Access: the inclination of the external oblique ridge,
represented by the radio opaque line.
 Existing pathology
 Crown of the impacted tooth : large bulbous crown with
prominent cusps may present difficulty in smooth delivery.

50. Roots of the impacted tooth
 Position and root pattern of the impacted as well as the adjacent
tooth may create difficulty while removing the impacted tooth.
These are also the factors which determine the point of application
and line of withdrawal.
 Radiograph must be carefully examined with reference with the
following factors :
 Fused or separate roots
 Number of roots
 Configuration of the roots
 If curved, is curvature favorable or unfavorable ?
 Long and slender or short and stout roots.
 Convergent or divergent

51.  Length
 The ideal time to remove the impacted teeth is when the root is
two-thirds formed. In this stage, the roots will blunt and removal
is very easy.
 If the tooth is not removed during the formative stage and the entire length of
the root develops, the possibility increases for abnormal root morphology and
for fracture of the root tips during extraction.
 Not indicated
When the root is one-third formed, as the tooth tends roll in its
crypt like ball in a socket, which prevents easy elevation.

52.  The fused, conical roots are easier to remove than widely separated
roots.
 Severely curved or dilacerated roots are more difficult to remove
than straight or slightly curved roots. Convergent roots are
comparatively easier to remove than the divergent roots.
 The total width of the roots in the mesiodistal direction should be
compared with the width of the tooth at the cervical line.
 If the root width is greater, the extraction will be more difficult.
More bone must be removed or the tooth must be sectioned
before extraction.

53. Bone texture
 Bone is cancellous and elastic in the younger age group, while it tends to
become dense and sclerosed as the age advances.
 The texture of the bone can be gained by noting the size of the cancellous
spaces and the density of the bone encircling them in the radiographs.
 Spaces are large and bone structure fine- elastic bone.
 Spaces are small and bone shadow dense- sclerotic bone.
 In patients of younger age - The bone is less dense, is more likely to be
pliable, and expands and bends some what, which allows the socket to be
expanded by elevators or by luxation forces applied. The bone is easier to
cut with a dental drill and can be removed more rapidly than denser
bone.
 Patients who are older have denser bone and thus decreased flexibility
and ability to expand. So it is not possible to expand the bony socket. It
becomes more difficult to remove with a dental drill, and the bone
removal process takes longer.

54. HOWES TECHNIQUE TO PREVENT
INFERIOR ALVEOLAR NERVE DAMAGE

55. ARCHER’S MODIFICATION TO PREVENT
INFERIOR ALVEOLAR NERVE DAMAGE

56. Assessment of difficulty for
removal of impacted third
molar

57. ASSESSMENT OF POSITION &DEPTH
WINTER’S LINES OR WAR LINES
 WHITE LINE
 It corresponds to the occlusal plane.
 It indicates the difference in occlusal level of second & third
molars.

58.  AMBER LINE.
 Crest of the interdental septum
 This line denotes the alveolar bone covering
the impacted tooth & the portion of the tooth
not covered by the bone.

59.  RED LINE.
 It indicates the amount of bone that will have
to be removed before elevation i.e. the depth
of tooth in bone & the difficulty encountered
in removing the tooth.
 Length more than 5mm - extraction is
difficult.
 Every additional millimeter renders the
removal of the Impacted tooth 3 times more
difficult.

60. FACTORS RESPONSIBLE FOR INCREASING
THE DIFFICULTY SCORE FOR REMOVAL OF
IMPACTED 3rd MOLARS
1. Difficult access to the operative field:
a. Small orbicularis oris muscle.
b. Inability to open mouth wide enough.
c. Trismus.
d. OSMF.
e. Macroglossia.

61. 2. As per the angulation.
3. As per the depth.
4. As per the space available for the eruption.
5. Dilacerated roots.
6. Hypercementosis.
7. Extremely dense bone.
8. Proximity to mandibular canal.
9. Ankylosed impacted tooth.
10. Large bulbous crown.
11. Long slender roots.

62. DIFFICULTY INDEX FOR REMOVAL
OF IMPACTED LOWER 3rd MOLARS
Pederson’s Scale
 Relation with ramus and available space
 Class I – 1
 Class II – 2
 Class III- 3
 Position Of Molar
 Mesioangular - 1
 Horizontal – 2
 Vertical - 3
 Distoangular - 4

63.  Relative depth
 Position A - 1
 Position B - 2
 Position C - 3
 Difficulty score Total
 Relatively difficult: 3-4
 Moderately difficult: 5-6
 Very Difficult : 7-10

64. WHARFE’S ASSESSMENT
1. Winter's classification
Horizontal 2
Distoangular 2
Mesioangular 1
Vertical 0
2. Height of mandible
1-30mm 0
31-34mm 1
35-39mm 2

65. 3.Angulation of 3rd molar
1- 59° 0
60 -69° 1
70 -79° 2
80 -89° 3
90° & above 4
4. Root shape- Root development
Favourable curve 1
Unfavourable curve 2
Complex 3

66. 5.Follicle
Normal 0
Possibly enlarged 1
Enlarged 2
6. Path of exit
Space available 0
Distal cusp covered 1
Mesial cusp covered 2
Both covered 3
TOTAL SCORE 33

67. SURGICAL TECHNIQUE
 GENERAL PRINCIPLES FOR SURGICAL TECHNIQUE OF
IMPACTION REMOVAL
.
 Reflect mucoperiosteal flap to obtain good visual
access.
 Remove labial bone with high speed surgical drill
using round or cross-cut but.
 Expose crown of impaction upto CEJ and make room
to allow for elevator placement.
 Attempt to gently evaluate for motility with elevator.
 Section crown with high-speed surgical handpiece.
Care should be taken to protect the lingual soft tissue
and depth of surgical cut should not be too much.

68.  Straight elevator should be used to separate
crown from tooth.
 Deliver roots with root tip elevators or crane pick.
 Inspect bony crypt for loose debris and any
bleeding problems and smooth bone margins with
bone file.
 Carefully remove follicular soft tissue and tease it
out from surrounding mucosa.
 Copious irrigation of socket and beneath soft
tissue

69.  Reapproximate soft tissue flap and close with 3-0 or
4-0 chromic or black silk sutures.
 Consider intraoral injection of steroids if extensive
bone surgery has been performed. 4mg of
dexamethasone can be injected into masseter
muscle on each side
 Evaluate for post surgical bleeding prior to discharge.
flap prior to closure.

70. BUCCAL VS LINGUAL APPROACH
Criteria Buccal Lingual
Access Relatively easy in the conscious patient Relatively difficult in the conscious patient
Instruments Chisel and mallet or bur Only chisel and mallet
Procedure Tedious Easy
Operating time Time consuming Less time consuming
Technique Easy to perform, hence traditionally popular Technically difficult, hence not popular among
all dental surgeons
Bone removal Thick buccal plate Thin lingual plate
Postoperative pain Less More due to the damage of lingual periosteum
Postoperative edema Obviously more Less
Dry socket Incidence is high due to the damage of external
oblique ridge
Incidence is negligible since socket is
eliminated.

71. INCISIONS AND FLAP
DESIGNS

72. Parts of incision  The incision having three parts:
 Limb A: The anterior incision started from a
point about 6.4 mm down in the buccal
sulcus approximately at the junction of
posterior and middle third of the second
molar, passes upwards extended upto the
distobuccal angel of the second molar at
the gingival margin for a distance of 1-2cm.
 Limb B: It was carried along the gingival
crevice of the 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 the cheek at
mucosal depth. This arm should be about
25.4 mm long.
 In case of unerupted tooth when
intermediate gingival incision was not
needed. Then limb' A' was extended upto
the middle of the distal surface of the
second molar.

73. FLAPS - Principles
 The base of the flap must be broader than the free margin to preserve an adequate
blood supply.
 Must be of adequate size - sufficient soft tissue reflection - provide necessary
visualization of the area.
 The flap should be a full-thickness mucoperiosteal flap.
 The incisions must be made over intact bone
 Should be designed to avoid injury to local vital structures in the area of the
surgery.
 When making incisions in the posterior mandible, especially in the region of the
third molar, incisions should be well away from the lingual aspect of the mandible.
In this area the lingual nerve may be closely adherent to the lingual aspect of the
mandible, and incisions in this area may result in the severing of that nerve, with
consequent prolonged temporary or perma­nent
anesthesia of the tongue.
 Vertical-releasing incisions should cross the free gingival margin at the line angle
of a tooth and should not be directly on the facial aspect of the tooth nor directly
in the papilla . Incisions that cross the free margin of the gingiva directly over the
facial aspect of the tooth do not heal properly because of tension and result in
defect in the attached gingiva.

74. Flap designs
The different types of flaps used are:
 L- shaped flap: suits only the buccal approach
since it is difficult to raise a lingual flap from this
approach. The posterior limb of the incision
extends from a point just lateral to the ascending
ramus of the mandible into the sulcus. It passes
disto-lateral periodontium by avoiding or
including it -depending upon the proximity of the
third molar with the second molar. The junction
between the limbs may be curved and incision
made in one sweep or it may be angled.
 Bayonet flap: This incision has three parts:
distal or posterior, intermediate or gingival, and
an anterior part. The posterior part of the incision
goes round the gingival margin of the second and
even the first molar, before turning into the sulcus.

75.  Envelop flap: Extends from the
mesial papilla of the mandibular
first molar and passes around the
neck of the teeth to the disto
buccal line angle of the second
molar. Now the incision line
extends posteriorly and laterally
upto the anterior border of the
mandible. Its anterior extension is
directly proportional to the depth
at which the impacted tooth is
present- deeper the tooth, longer
the ant extension
 Adv- Easier to close and heal
better .

76.  Triangular flap
 This flap is the result of an L-shaped incision with a
horizontal incision made along the gingival sulcus
and a vertical or oblique incision. The vertical
incision begins approximately at the vestibular fold
and extends to the interdental papilla of the
gingiva. The triangular flap is performed labially or
buccally on both jaws and is indicated in the
surgical removal of root tips, small cysts, and
apicoectomies.
 Advantages. Ensures an adequate blood supply,
satisfactory visualization, very good stability and
reapproximation; it is easily modified with a small
releasing incision, or an additional vertical incision,
or even lengthening of the horizontal incision.
 Disadvantages. Limited access to long roots,
tension is created when the flap is held with a
retractor, and it causes a defect in the attached
gingiva.

77. Design of disto lingually based flap by buccal
Comma incision
 The incision - a point below the second molar,
smoothly curved up to meet the gingival crest at the
distobuccal line angle of the second molar. The
incision is continued as a crevicular incision around
the distal aspect of the second molar.
 This comma-shaped incision allows reflection of a
distolingually based flap adequately exposing the
entire third molar area.
 The incision and flap design seems best suited to
cases in which the third molar is completely
covered with soft tissues. In cases in which part of
the impacted tooth is visible in the mouth, a small
modification is made.
 After the incision , a second incision is made from
the distobuccal point on the exposed portion of the
third molar to join the first incision approximately
midway down . This allows excision of a triangular
gingival flap.

78. Wards incision
WARDS INCISION MODIFIED WARDS INCISION
Sir TG Ward 1968, made some modification of the incision. The anterior line of the
incision runs from the distal aspect of the second molar curving ,downward and forward
to the level of the apex of the distal root of the first molar. This second type of incision is
used when a linguoverted tooth impaction is present. The posterior part of the incision is
the same but the anterior part commences as the junction of the anterior and middle
thirds of the second molar and runs down to the apex of the distal root of the first molar.

79. Reflection of flap
 Reflection of the flap begins at the papilla. The end of the Woodson
elevator or the no. 9 periosteal elevator begins a reflection. The
sharp end is slipped underneath the papilla in the area of the
incision and turned laterally to pry the papilla away from the
underlying bone. This technique is used along the entire extent of
the free gingival incision.
 Once the flap reflection is started, the broad end of the periosteal
elevator is inserted at the middle corner of the flap, and the
dissection is carried out with a pushing stroke, posteriorly and
apically. This facilitates the rapid and atraumatic reflection the soft
tissue flap.

80. BONE REMOVAL
Aim:
1. To expose the crown by removing the bone
overlying it.
2. 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.

81. CHISEL VS BUR
Sl.No Criteria. Chisel&Mallet Bur
1. Technique Difficult Easy.
2. Controll over bone cutting Uncontrolled Controlled.
3. Patient acceptance. Not tolerated in
L.A.
Well tolerated in
L.A.
4. Healing of bone. Good Delayed Healing
5. Postoperative edema Less More.
6. Dry socket. Less. More.
7. Postoperative Infection. Less. More.

82. TTEECCHHNNIIQQUUEESS FFOORR RREEMMOOVVAALL OOFF
DDIIFFFFEERREENNTT TTYYPPEESS OOFF MMAANNDDIIBBUULLAARR
33rrdd MMOOLLAARR IIMMPPAACCTTIIOONNSS

83. Bur technique
 Most surgeons prefer to use a hand piece with adequate speed and high torque to
remove the overlying bone.
 The size of the bur used for the removal of the bone removal :
 Ideal length – 7mm; diameter – 1.5mm.
 Large rose head bur (size 12) or fissure bur (no.7) used for gross bone removal.
 The bur should rotate in correct direction and at maximum speed.
 Cutting instruments that induce air should not be used.
 Handpiece should not rest on the tissues of the cheek and lips to avoid burning.
 The crown of the impacted tooth should be exposed (CEJ) by removal of surrounding
bone:
 mesially – to create a point of application
 Buccaly – cutting a trough or gutter around the tooth to the root furcation.
 Distolingually – lingual plate should not be breached to protect the lingual
nerve.

84.  Copious amount of normal saline is irrigated to avoid thermal
necrosis of bone.
 To keep the operator field clean an efficient suction should be
used.
 In the mesial side adequate bone must be removed so that the
elevator stands up an angle of 45° to the mandible without any
support.

85. MOORE/GILLBE COLLAR
TECHNIQUE
 A mucoperiosted flap of standard
design is elevated exposing the
underlying bone.
 A rose-head bur (no.3) is used to
create a ‘gutter’ along the buccal side
and distal surface of the tooth.
 The lingual soft tissue s/b protected
with a periosteal elevator during the
removal of the distolingual spur of
bone

86. A mesial point of application is created with
the bur, and a straight elevator is used to
deliver the tooth.
After delivery of the tooth has been effected,
the sharp bone edges are smoothed with a
vulcanite bur, and the cavity is irrigated.
The wound is closed with sutures or the
buccal flap is tucked into the cavity and held
against the bone with a pom-pom soaked in
Whitehead’s varnish.

87. Chiesel technique
 When using chisel - the mandible should be adequately supported.
 The mallet is used with a loose, free-swinging wrist motion that gives
maximum speed to head of the mallet without introducing the weight of the
arm or body into the blow. To plane bone with a chisel, the bevel have to be
turned towards the bone. To penetrate the bone, turn the bevel away from the
bone.
 To restrict the bony cut to the desired extent a vertical limiting cut is made by
placing a 3 mm or 5 mm chisel vertically at the distal aspect of the II molar
with the bevel facing posteriorly.
 Its approximate height is 5-6 mm. Then the chisel is placed at an angle of 45°
at the lower edge of the limiting cut in an oblique direction.
 This will result in the removal of a triangular piece of buccal plate distal to the
II molar.If necessary, bony cut can be enlarged to uncover the impacted tooth
to the desired level.
 Finally.distal bone must be removed so that when the tooth is elevated, there is
no obstruction at the distobuccal aspect.

88. Irrigation
 The surgeons should apply a handpiece load of approximately 300g and an
irrigation rate of 15 mL/min (for intermittent drip) to 24 mL/min (for continuous
flow).
 The various solutions which can be used as irrigants are:
 Saline
 Sterile water
 Ringer’s lactate.
 1% povidone iodine
 The irrigation cools the bur and prevents bone-damaging heat buildup. The
irrigation also increases the efficiency of the bur by washing away bone chips from
the flutes of the bur and by providing a certain amount of lubrication.
 A large plastic syringe with a blunt I8-gauge needle is used for irrigation
purposes. The needle should be blunt and smooth so that it does not damage soft
tissue, and it should be angled for more efficient direction of the irrigating stream

89. SSeeccttiioonniinngg ooff tthhee ttooootthh
Bone belongs to the patient and the tooth belongs to
the surgeon.
This implies the tooth division technique.
 Pell and Gregory stated the following advantages
of splitting technique:
Amount of bone to be removed is reduced. The time of
operation is reduced.
The field of operation is small and therefore damage to
adjacent teeth and bone is reduced.
Risk of jaw fracture is reduced.
Risk of damage to the inferior alveolar nerve is reduced

90. Sectioning of the tooth
 Sectioning of a tooth can be carried out with a bur or with an osteotome
 Sectioning of teeth with a bur is safe and technically easy, whereas the osteotome
technique is quicker but more hazardous.
 If bur is used it should be the fissure type, and about size No.8, but a surgical pattern
with a longer cutting surface. A tapered fissure bur is less likely to jam or break than
the standard crosscut bur during the process of cutting either bone or tooth substance.
 If an osteotome is used for tooth division it should be about 6.4 mm (1/4 in) in width and
have a handle of about 17.5cm (7 in) in length.
 When splitting a tooth longitudinally through the root bifurcation the osteotome
blade should be placed in the buccal anatomical groove between the mesial and distal
coronal cusps at an angle of 450 to the vertical axis of the tooth.

91. Mesioangular impaction

92. Horizontal impaction

93. Vertical impaction

94. Distoangular impaction

95. Lingual split bone technique
(Kelsey Fry , T. Ward)
 Useful- removal of deeply positioned
horizontal distoangular impactions
(Rud, 1970).
 First, a vertical stop cut about 5 mm in
height is made with a 3 mm width chisel
in the buccal cortex immediately distal
to the second molar.
 A second vertical stop cut will be made
about 4 mm disto-buccal to the third
molar crown.
 The two cuts will then be joined, and the
buccal plate covering the crown will be
removed

96.  The distolingual bone is now
fractured inward by placing the
chisel at an angle of 45° to the
bone surface and pointing in the
direction of second premolar on
the contralateral side.
 The cutting edge of the chisel is
kept parallel to the external oblique
ridge and a few light taps are given
with the mallet which separates the
lingual plate from the alveolar
bone.
 The "peninsula" of bone which
then remains distal to the tooth
and between the buccal and
lingual cuts js excised.

97.  care must be taken that the cutting
edge of the chisel is not held parallel to
the internal oblique ridge as this may
lead to the extension of the lingual split
to the coronoid process.
 A sharp, pointed, fine-bladed straight
elevator is then applied to displace the
tooth upward and backward out of its
socket.
 As the tooth moves,backward, the
fractured lingual plate is displaced
from its path of withdrawal, thus
facilitating delivery of the tooth.
 The fractured lingual plate is then
lifted from the wound, thus completing
the saucerization of the bony cavity..

98. ADVANTAGES
Faster tooth removal.
Less risk of inferior alveolar nerve damage.
Reduces the size of residual blood clot by means of saucerization
of the socket .
Decreased risk of damage to the periodontium of the second
molar.
Decreased risk of socket healing problems.
DRAWBACKS
Risk of damage to the lingual nerve. The incidence of lingual nerve and
inferior alveolar nerve damage has been reported as 1- 6.6% .
Increased risk of postoperative infection
Patient discomfort due to the use of a chisel and mallet for lingual bone
removal or fracturing.
Only suitable for young patients with elastic bone

99.  DRAWBACKS OF THIS TECHNIQUE ARE:
Risk of damage to the lingual nerve.
Increased risk of postoperative infection and greater danger of
spread.
Patient discomfort due to the use of a chisel and mallet for lingual
bone removal or fracturing.
Only suitable for young patients with elastic bone in which grain is prominent

100. Modified distolingual bone
splitting technique
 Davis's technique mentions not to separate the mucoperiosteum
from lingual area of bone. The bone was released in segments to
allow tactile control of osteotome to prevent penetration of the
osteotome into soft tissue.
 Lewis technique: Lewis (1980) modified the lingual split-bone
technique by minimizing periosteal reflection and buccal bone
removal and by preserving the fractured lingual plate. He claims that
these modifications reduce the possibility of lingual nerve damage,
minimize periodontal pocket formation, and improve the chances for
primary wound healings.

101. Lateral trephenation technique
 This procedure was first described
by Bowdler-Henry to remove any
partially formed and unerupted third
molar in the age group of 9-16
years.
 Modified S-shaped incision is made
from retromolar fossa across the
external oblique ridge. It then curves
down to the I molar anteriorly in the
vestibule.
 The mucoperiosteal flap is elevated
and buccal cortical plate is trephined
over the III molar crypt. bur is used
to make vertical cuts anteriorly and
posteriorly.

102.  A chisel or an osteotome is
applied in the vertical direction
over the bur holes. Then the
buccal plate is fractured out,
exposing the third molar crypt
completely.
 Elevator is applied to deliver the
tooth out of the crypt. Any
follicular remnant present in the
crypt is carefully scooped out,
avoiding injury to the inferior
alveolar (dental) canal at the
lower part of the crypt.

103.  Advantages:
 Partially formed unerupted 3rd molar can be removed.
 Can be preformed under general or regional anesthesia with
sedation.
 Post-op pain is minimal.
 Bone healing is excellent and there is no loss of alveolar
bone around the 2nd molar.
 Disadvantages :
 Virtually every patient has some post operative buccal swelling
for 2-3 days after surgery

104. Wound toilet
 It is important to irrigate the surgical site,
with particular attention paid to the space
directly underneath the buccal flap where
loose debris may accumulate and cause
a buccal space infection.
 Adequate haemostasis is also important
prior to wound closure to minimize the
risk of persistent postoperative oozing
and haematoma formation.
Closure
 The most important suture is the one
placed immediately behind the second
molar, ensuring there is accurate
apposition of wound edges .
 It is also useful to place a suture across
the distal incision where the soft tissue
thickness and potential bleeding source
is greatest.
 Many clinicians often do not place
sutures across the buccal relieving
incision, which permits a dependent area
of drainage.

105.  Watertight closure is unnecessary and
may in some cases increase
postoperative pain and swelling.
 Primary closure of the wound should not
be attempted unless – atleast 5mm of a
band of buccal attached
mucoperiosteum is present.
 Tube drain
 when using primary wound
closure, a small surgical tube
drain or gauze strip may be
inserted in buccal incision
before suturing to facilitate
drainage. It should be
removed after 24-72 hours.
With this technique, the
postoperative problems of the
Patient are expected to be
less severe.

106. SURGICAL CLOSURE
1) Wedge removal
2) Debridement
3) Intra-alveolar
dressings
4)Closure of soft
tissue flap
5) Intraoral
dressings

107. SURGICAL SIDE-EFFECTS AND
COMPLICATIONS
Intra operative complications:
1. During incision
a.Injury to facial artery.
b.Injury to lingual nerve.
2. During bone removal
a. Damage to second molar.
b. Slipping of bur into soft tissue & causing
injury.
c. Fracture of the mandible when using chisel &
mallet.

108. 3.DURING ELEVATION OR TOOTH REMOVAL
a. Luxation of neighbouring tooth.
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 canal.
f. Breakage of instruments.
g. TMJ Dislocation.

109. POST OPERATIVE
COMPLICATIONS:
a. Dry socket.
Incidence-3%(Heasman,1987)
Predisposing factors-smoking,pre-existing
infection,birth control
medication,extensive bone removal.

110. b. Pain.
c. Trismus.
d. Infection
e. Swelling.

111. f. Paresthesia of Lingual or Inferior
alveolar nerve.
-Over 96% of pts with IAN injury & 87%
of those with lingual n. injuries recover
spontaneously (Alling)
-Spontaneous recovery-
9months(Mozsary,1987)

112. REFERENCES
 Impacted teeth – Charles C. Alling
 Textbook of oral and maxillofacial surgery, vol.
2, Laskin.
 Oral and maxillofacial surgery-Archer
 The impacted wisdom tooth – Killey & Kay
 Textbook of oral & maxillofacial surgery – SM
 Atlas Oral Maxillofacial Surg Clin N Am 20 (2012)
197–223