Aetiology of impaction

Berger lists the following local and systemic causes of impaction.

Local causes
• Irregularity in the position and pressure of the adjacent tooth.
• Density of the overlying or surrounding bone.
• Localised chronic inflammation with resultant increase in density of
the overlying mucous membrane.
• Lack of space due to underdeveloped jaws. Arch length and tooth size
discrepancy.
• Obstructions: It can be a soft or hard tissue obstruction caused by
retained deciduous teeth, thick fibrous alveolar mucosa or chronically
inflamed mucosa, dense bone with inflammatory changes due to
odontome, cyst or odontogenic tumour that prevents eruption at the
chronological age.
• Dilaceration: Abnormal path of eruption of the tooth due to traumatic
forces during the eruption period.
• Over retained deciduous teeth.
• Ectopic position of tooth bud.
Systemic causes
General causes
A. Prenatal causes: Heredity
B. Postnatal causes: All those conditions that may interfere with the
development of the child, such as:
1. Rickets
2. Anaemia
3. Congenital syphilis
4. Tuberculosis
5. Endocrine dysfunctions
6. Malnutrition
C. Rare conditions:
1. Cleidocranial dysostosis
2. Oxycephaly
3. Progeria
4. Osteopetrosis
5. Cleft palate
Pericoronitis
Pericoronitis refers to inflammation of soft tissues around and covering the
partially or completely erupted third molar.
Causes
• Bacterial growth beneath the soft tissue flap covering the partially or
completely erupted third molar.
• Trauma caused to the soft tissue flap overlying the mandibular third
molar by the cusps of the opposing maxillary third molar. This is
mainly due to supraerupted maxillary third molars opposing an
unerupted or partially erupted mandibular third molar. This
inflammation along with the bacterial invasion causes pericoronitis.
Symptoms
• The overlying soft tissues show the four cardinal signs of inflammation
namely pain, redness, swelling and warmth.
• Trismus is seen due to involvement of the temporalis, medial
pterygoid, pterygomandibular raphe, which is contained in the soft
tissues overlying the partially or completely erupted third molar.
• Chills, fever, malaise and halitosis are present.
• Regional lymph nodes may be enlarged, tender and indurated.
Treatment
When the condition is due to supraeruption of the maxillary third molar, it
should be extracted. The patient should be explained significance of the
removal of the maxillary third molar. Due to the over-eruption, normal
contact
between the maxillary second and third molar is lost which facilitates food
impaction, bacterial growth and loss of interseptal bone and subsequent
loss of
the second and third molar. Hence, the removal should be considered.
The pericoronitis can be treated in the following manner:
• Conservative method
• Surgical removal of the overlying flap
• Surgical removal of the tooth
Conservative method
Irrigation with warm saline should be done beneath the flap. A 10cc
syringe
with a 20 gauge needle which can be bent slightly to gain a better access
can be
used.
Alternatively, 1cc iodine solution can also be used to irrigate beneath the
flap. The usually used irrigating solution consists of:
• Phenol 5%, 6cc
• Tincture of aconite, 12cc
• Tincture of iodine, 18cc
• Glycerine, 24cc
Patient should be instructed to irrigate the area every hour and appropriate
antibiotics should be prescribed. Irrigation is carried out until the acute
symptoms subside and after this the tooth is extracted. If the tooth can
erupt in
a normal position and help in the functioning, the overlying flap should be
removed.
Surgical removal of the overlying flap
Operculectomy
Operculum is the dense fibrous flap which covers about 50% of the
occlusal
surface of a completely or partially erupted mandibular third molar. The
removal of this flap is known as operculectomy. It is not easy to remove
this
flap as the tissues are freely movable and slides away beneath the usual
scalpel or scissors.
This flap can be best removed with the help of electrosurgical scalpel or
radiosurgical loop.
Electrosurgical scalpel
The advantages of using electrosurgical scalpel are:
• There is no necessity to apply pressure to cut the tissues as with a
usual scalpel and, the tissues can be cut accurately as there is no lateral
or sliding movement of the flap.
• Due to coagulation of the small capillaries, bleeding in the site is
reduced and visibility is increased.
Radiosurgical loop
However, the most efficient method for removing this dense fibrous
mucoperiosteal tissue is to use a radiosurgical loop. The radiosurgical loop
is
placed beneath the flap as far posteriorly as possible. Now the current is
applied and the loop moved superiorly resulting in the cutting of the bulk
of
the tissue. Once the flap is removed, the tissue distal to the tooth is excised
to
remove the distal crypt. This helps in the proper eruption of the tooth if it
is
properly positioned.
Indications for removal
• Infections: Removal of any symptomatic impacted tooth should be
considered with food impaction causing halitosis, especially where
there have been one or more episodes of infection such as pericoronitis
(75%–80% of patients with impacted third molar develop
pericoronitis), cellulitis, abscess formation; or untreatable
pulpal/periapical pathology (Fig. 18.6A–C).
• Unrestorable caries: Removal should be considered when there is
caries in the impacted tooth or when there is caries in the adjacent
second molar tooth which cannot be satisfactorily treated without
removal of the third molar (Fig. 18.7).
• Periodontal diseases: When there is periodontal disease between the
third and second molar, early removal of the impacted third molar will
result in repair of the injured periodontium and is therefore beneficial.
Untreated impacted teeth are particularly prone to cause bone loss
distal to the adjacent teeth due to pressure effect.
• Dentigerous cyst formation: Other related pathologies which expand
the bone and results in pathological fracture (Fig. 18.8).
• External resorption of the second molar: Caused by the pressure of the
third molar on 2nd molar (Fig. 18.9).
• Buccoverted impacted molars: May cause cheek bite, frictional
keratosis or traumatic fibroma mandating extraction (Fig. 18.10).
• Third molar removal may occasionally be indicated for orthodontic
reasons.
• Removal of the third molar may be indicated prior to orthognathic
surgery, e.g. when a sagittal split osteotomy is planned, removal of the
third molar diminishes the risk of surgical complications with regard
to that of osteotomy.
• Prophylactic removal in presence of specific medical and surgical
conditions.
• Fracture of the mandible in the third molar region or when a tooth is
involved in tumour resection.
• Atypical pain from an unerupted third molar is the most unusual
situation and it is essential to avoid any confusion with
temporomandibular joint (TMJ) or muscle dysfunction before
considering removal.
• Impacted teeth in edentulous ridge that causes ulcerations in the
mucosa under a denture.
• Third molar removal may be considered for autogenous
transplantation to a first molar socket.
Contraindications for removal
• Impacted teeth which are likely to erupt successfully and have a
functional role in the dentition should not be removed.
• Partially impacted teeth which can be used as an abutment in the
construction of fixed partial denture.
• Medical history contraindicates surgical procedure.
• Deeply impacted third molars in patients with no history of any bony
pathology to avoid damage to the vital structures.
• Third molars should not be removed in patients where the risk of
surgical complications is judged to be unacceptably high or where
fracture of an atrophic mandible may occur.
Classification
Systematic and meticulous classification of the position of the impacted
teeth
helps in assessing the best possible path of removal of the impacted teeth
and
also in determining the amount of difficulty which would be encountered
during removal.
i. Based on the nature of the overlying tissue
ii. Winter’s classification
iii. Pell and Gregory’s classification
I. Based on the nature of the overlying tissue
Based on the nature of overlying tissue, impacted mandibular third molar
can
be classified into:
i. Soft tissue impaction
ii. Hard tissue impaction
Soft tissue impaction
The presence of dense fibrous tissues overlying the teeth sometimes
prevents
its normal eruption. This is frequently seen in cases of permanent central
incisors, in which early loss of primary teeth with subsequent masticatory
trauma to the ridge results in fibrosis.
Hard tissue impaction
When the teeth fail to erupt due to obstruction caused by the overlying
bone, it
is known as hard tissue impaction. Here the impacted tooth is completely
encased in bone so that, when the soft tissue flap is reflected, the tooth is
not visible. Extensive amount of bone must be removed and the tooth may
require sectioning before removal (odontectomy).
II. Winter’s classification
It is based on the inclination of the impacted third molar tooth to the long
axis of the second molar.
Mesioangular: Long axis of 3rd molar bisects the long axis 2nd molar at
or above occlusal plane (Fig. 18.11).
Distoangular: Long axis of 3rd molar away from long axis of 2nd molar
(Fig. 18.12) at the level of occlusal plane (Fig. 18.13).
Horizontal: Long axis of 3rd molar bisect long axis of 2nd molar at right
angle (Fig. 18.14).
Vertical: The long axis of the impacted tooth runs parallel to the long axis
ofthe second molar (Fig. 18.15). Buccal or lingual: In combination to the
abovedescribed impaction, the tooth can also be buccally or lingually
impacted (Figs.18.16–18.18).
Transverse: Tooth completely impacted in the buccolingual direction.
This is the most commonly used classification since it classifies the teeth
according to inclination and each inclination has some definite path of
withdrawal of the teeth. The classification also assesses the difficulty of
removal to some measure. For example, mesioangular impactions are very
easy to remove and distoangular impactions are the most difficult ones to
remove.
III. Pell and Gregory’s classification
(A). Based on their relationship with the anterior border of the
mandible
Class I: The anteroposterior diameter of the tooth is equal to the space
between the anterior border of ramus of the mandible and distal surface of
the second molar tooth (Fig. 18.18).
Class II: A small amount of bone covers the distal surface of the tooth and
the space is inadequate for eruption of the tooth, i.e. mesiodistal diameter
of the tooth is greater than the space available (Fig. 18.19).
Class III: Tooth is located completely within the ramus of the mandible–
least accessible (Fig. 18.20).
(B). Based upon the amount of bone covering the impacted tooth
and relation to occlusal plane
Position A: Occlusal plane of the impacted tooth is nearly in the same
level as the occlusal level of the adjacent second molar tooth (Fig. 18.21).
Position B: Occlusal plane of the impacted tooth is in the midway between
the cervical line and the occlusal plane of the adjacent second molar tooth
(Fig. 18.22).
Position C: Occlusal plane of the impacted tooth below the level of
cervical line of the second molar tooth (Fig. 18.23). This can be applied
for the maxillary teeth also.
(C). Based on long axis of the impacted tooth
It is similar to the one as proposed in the Winter’s classification (described
Fig. 18.13).
Clinical evaluation
Initial assessment should include a full medical and dental history,
extraoral and intraoral clinical examination. Positive findings from this
examination should determine whether removal is indicated and should
include radiological assessment.
General examination
The general examination should be done in a similar manner as for any
other surgical procedure. The presence of any systemic disorders or
diseases should be detected and precautions should be taken accordingly
before surgery.
Patients should also be assessed for undergoing certain therapies like
irradiation therapy and organ transplantation.
• Age and general fitness are important. Increasing age adds to the
difficulty of the removal.
• The presence of facial swellings and enlarged, tender lymph nodes
indicates presence of active infection and treatment should be deferred
till it is treated.
Local examination
• The eruption status of the impacted tooth: The amount of visibility of
the third molar crown is assessed. Completely or partially visible teeth
are less difficult to extract than completely impacted teeth.
• Occlusal relationship: The occlusal relationship of the maxillary third
molars to the mandibular third molars should be assessed.
• The presence of local infection like pericoronitis: The inflammation of
the soft tissues covering the crown of the erupting tooth, increases
vascularity making the procedure difficult.
• Periodontal status: The presence of pocket around the impacted third
molar or the second molar tooth should be assessed.
• Caries in or resorption of, the third molar and the adjacent tooth: Due
to lack of space, there may be food impaction in the area distal or
mesial to the impacted tooth leading to dental caries. This factor
may/may not facilitate extraction.
• Resorption of the second molars: Due to lack of space the impacted
third molar might impinge on the second molar root resulting in
resorption. Following removal of the impacted third molar, the second
molar should be assessed for endodontic or periodontic intervention
depending upon the degree of resorption and pulpal involvement.
• External oblique ridge: The external oblique ridge buccal to the third
molar is palpated to identify its position. If it is low vertical and
posterior to the tooth, it indicates the presence of thin bone buccal to
third molar. If it is high and forward it indicates a thick cortex of ridge
is present buccal to third molar which makes extraction difficult.
• Internal oblique ridge: The internal oblique ridge lingual to the third
molar is palpated to identify its position. If it is posterior to third
molar it indicates thin bone lingually. If it is anteriorly placed the
lingual cortex in relation to the third molar is anticipated to be
nonyielding.
• Upper third molar: Position of upper third molar and its relation to
lower third molar is checked. The indentations of the upper third
molar on the mandibular pericoronal flap indicate extraction of upper
third molar also.
• Soft tissue assessment: Thickness of the buccal soft tissue indicates the
retractability of the cheek. Difficulty in retraction is encountered in
well built patients and also in submucous fibrosis.
• Regional lymph nodes: Swelling and tenderness of the regional lymph
nodes may be indicative of infection of the third molar.
• Temporomandibular joint function: Preoperative assessment of the
TMJ function is done to:
1. Amount of mouth opening: To gauge the degree of
difficulty in surgery
2. Preexisting TMJ pathology: To avoid prolonged mouth
opening and excessive forces on the joint thereby
preventing worsening of the condition.
Factors complicating the removal of mandibular third molar
• Preexisting joint problem: Preexisting joint problem creates a risk of
dislocation or derangement during procedure. Restriction in joint
motion causes reduced mouth opening and difficulty in surgical
procedure.
• Position of the impacted third molar: Deeper the impacted tooth is
buried inside the hard tissues, the more difficult it is to remove it.
• Thickness of the oblique ridge: The presence of a thick oblique ridge
poses difficulty in buccal traction of the impacted tooth during
removal.
• Surrounding bone: Dense surrounding bony socket resists the easy
removal of the tooth. In young age, the bone is expandable and as age
advances, the bone becomes sclerosed and brittle.
Radiological assessment
The purpose of a careful radiological evaluation is to complement the
clinical
examination by providing additional information about the third molar, the
related teeth and anatomical features and the surrounding bone. This is
necessary in order to make a sound decision about the proposed surgical
procedure, the most appropriate location for this to take place and to
highlight
aspects of management which may require specific mention to the patient.
Types of radiographs used
• Intraoral periapical (IOPA) radiograph
• Bitewing radiograph
• Occlusal radiograph
• Lateral oblique radiograph
• Orthopantomograph (OPG)
• CBCT (in indicated cases)
Intraoral periapical radiograph (Fig. 18.24)
An IOPA radiograph is the simple and most suitable radiograph for the
assessment of the lower molar. An ideal IOPA radiograph should show
whole of II and III molar, bone surrounding III molar and inferior dental
canal.
The film should be placed such that
• Mesial edge should lie no further forward than mesial surface of 1st
molar for vertical, mesioangular, distoangular impactions.
• Central ray should pass parallel to occlusal surface of 2nd molar and
pass through the distal cusps of 2nd molar at right angle’s to the film.
If the central ray is correctly angled
• Lingual and buccal cusps of 2nd molar are superimposed on one
another in the same vertical and horizontal plane, giving rise to
enamel cap appearance.
• Contact point between 1st and 2nd molar should be clearly defined as
a check on the free state of contact point between 2nd and 3rd molar.
Disadvantages
• Gagging of the patient
• Deflection of the film by the soft tissues lying in the floor of the mouth
• The deeply impacted tooth may not be visible in the radiograph
• It cannot completely reveal the buccal-lingual version of the impacted
tooth
• Two-dimensional image of three-dimensional structure.
Frank’s technique of localising mandibular canal
Frank suggested that a modification of the ‘tube-shift’ method can be used
to
determine whether the mandibular canal is medial to, lateral to or below an
impacted mandibular third molar. This technique was first described by
Richards. The principle involved is the same as that of the ‘Clark shift’ to
localise a maxillary impacted cuspid.
• By placing two films in identical positions in the mouth, when taking a
lower impacted third molar radiograph and changing the position of
the X-ray tube, we can determine whether the canal lies lingually or
buccally to the impaction; or in the same plane as the tooth.
• An IOPA radiograph of the third molar is taken by conventional
method with the X-rays directed perpendicular to the tooth with no
vertical or horizontal angulations.
• A second IOPA radiograph is taken by directing the X-rays 25degree
below the plane of occlusion. This will make a distant object move
downward in relation to an object in the foreground; if mandibular
canal lies lingual to impaction, it will move downward in relation to
the roots of the third molar.
• If the canal on the buccal side of roots will appear to move upward on
the roots.
• If the canal remains in the same position, it is directly below the roots or
passes between the roots or is in a groove in the root substance
apically, lingually or buccally.
• The ‘Rule of SLOB’ (same side lingual and opposite side buccal) is
applicable here as it is to ‘tube-shift’ technique.
Bitewing radiograph
• In Class I–II impacted mandibular 3rd molars the actual relationship of
the 2nd and 3rd molars is made by correctly angled bitewing film.
• Central ray is directed through the crown of the 2nd molar at right
angle to the film with 0 degree vertical angulations.
Occlusal radiograph
Occlusal radiograph for mandibular 3rd molar assessment is done by
placing the film over the occlusal surface of lower molar and positioned
till the distal edge of the film is in contact with the anterior border of
ramus. It helps in viewing the buccal or lingual version of the impacted
tooth.
• Should be taken for all difficult teeth and particularly when tooth is
completely unerupted.
• Provides an alternative view to the periapical film of the roots of
horizontal teeth especially in the presence of third root.
• Essential for buccolingually placed teeth to identify the position of
crown and shape of the roots.
• Shows the thickness of lingual alveolar plate, in buccally placed molar.
Lateral oblique view
Is useful in assessing:
• Deeply buried teeth
• Grossly misplaced teeth
• Impacted teeth involved in secondary pathology
Disadvantages
• Distance between film and tooth is greater thereby leading to reduced
definition.
• Angulation of central ray is such that the relationship between 2nd and
3rd molars is not accurately shown.
• Because of inevitable distortion, it is of limited value in the diagnosis.
Orthopantomogram
Indications
a. In patient with exaggerated gag reflex where IOPA radiograph may not
be possible.
b. Tooth cannot be projected onto the IOPA film because of its position.
c. There is pathologic lesion larger than that of the film such as cysts,
tumours and fracture.
d. The third molar is in close relationship to lower border of mandible.
Advantages
• Viewing both the upper and lower jaw in one radiograph (Fig. 18.25).
• Detailed description of the anatomy of the hard tissues surrounding
the impacted tooth.
• Position of the too thin relation to the canal.
• Details of the bone surrounding the tooth.
CBCT
Cone beam CT (Fig. 18.26) is indicated in:
• Completely impacted teeth in abnormal position.
• Relationship of the impacted tooth to the canal is questionable using
other radiographs.
• Ectopic presentations.
• Multiple impacted teeth.
• Associated with pathologies like dentigerous cyst, odontoma, etc.
Interpretation of the radiograph
Assessment of access
Easy access to the impacted teeth is determined by the inclination of the
radiopaque line caused by the external oblique ridge (Fig. 18.27).
• When the radiopaque line is more horizontal, access is easy, when it is
more vertical, access is poor.
• If the radiopaque line is situated behind the impacted tooth, the access
is good, if it is situated in front of the tooth, the access is poor.
FIGURE 18.27 (A) External oblique ridge evident as radiopaque
line crossing 3rd molar horizontally down indicating excellent
access. (B) External oblique ridge evident as radiopaque line
crossing 3rd molar vertically down indicating poor access.
Assessment of position and depth
• The orientation of the impacted mandibular third molars may be
mesioangular, distoangular, vertical or horizontal.
• When a vertical impaction is present the anteroposterior width of the
interdental septum between the second and third molars is similar to
that of the septum between the first and second molars. Whereas,
when distoangular impaction is present the interdental septum
between the second and third molars is narrower than between the
first and second molars.
• They may be present at varied depth inside the mandibular jaw bone.
Ectopic positions (in the coronoid or condylar process), though rare,
do exist.
WAR lines
Position and depth of the impacted mandibular third molar can be
determined by means of George Winter’s WAR lines. George Winter
described three imaginary lines drawn on the standard radiograph with
different colours such as white, amber and red.
White line
White line is drawn along the occlusal surfaces of the erupted mandibular
molars and extended over the third molar region posteriorly. The axial
inclination of the impacted tooth can be seen apparently (Fig. 18.28).
• The occlusal surface of the vertically impacted third molar is parallel to
the white line.
• The occlusal surface of the third molar with distoangular impaction
meets the white line in front of the third molar.
• The occlusal surface of the third molar with mesioangular impaction
meets the white line behind the third molar.
• The occlusal surface of horizontally impacted third molar meets the
white line in a perpendicular direction.
• Indicates
▪ The depth of the tooth within the mandible.
▪ Relationship of occlusal surface of impacted tooth with the
erupted molars.
Amber line
Amber line is drawn from the surface of the bone on the distal aspect of
the third molar to the crest of the interdental septum between the first and
second mandibular molars. This line represents the margin of the alveolar
bone covering the third molar (Fig. 18.29).
Red line
Red line is an imaginary line drawn perpendicular from the amber line to
an imaginary point of application of the elevator. Usually this point is the
CEJ on the mesial surface of the impacted tooth (exception is the
distoangular impaction where the point of application of the elevator is on
the CEJ on the distal aspect). The length of the red line indicates depth of
the impacted tooth (Table 18.1). With each increase in length of the red
line by 1 mm, the impacted tooth becomes three times more difficult to
remove (Fig. 18.30).

Surgical removal of impacted third molar

Procedure for surgical removal of the tooth (Fig. 18.45) varies depending
upon
the following factors:
• The type and degree of impaction (local or general anaesthesia).
• Amount of soft tissue exposure to aid removal of bone (type of flap).
• Amount and technique of bone removal (chisel or bur).
• Odentectomy—need to divide the tooth prior to delivery.
Anaesthesia
Mostly the procedure is performed under local anaesthesia which is
obtained
by nerve block of the inferior alveolar nerve, lingual nerve and long buccal
nerve.
General anaesthesia is indicated when the impacted tooth is situated deep
in
the jaw bone (when the red line is more than 5 mm) and when more than
two
impacted molars have to be removed at a time.
Inicision
Most commonly used are:
• Wards
• Modified Wards (for horizontal lower 3rd molar impaction)
Mucoperiosteal flap
Ideal requirements of the flap
• It should provide adequate exposure of the operative site.
• The base of the flap should be wide so that the soft tissues get adequate
blood supply after wound closure.
• To avoid soft tissue trauma during surgical procedures, the flap should
expose the entire site of operation.
• The flap should not be extended too far distobuccally in which case it
might injure the buccal vessels, cause postoperative trismus (due to
the trauma to the temporalis muscle) or herniation of the buccal pad of
fat into the operating field.
• The incision should be designed so that the flap can be primarily
closed over solid bone.
• The incision should not damage any of the vital anatomic structures
(Fig. 18.45).
• The following are the different types of the incisions employed
(Fig. 18.46):
▪ Envelope flap
▪ L-shaped flap
▪ Bayonet flap
▪ Triangular flap

Envelope flap
The flap extends from the mesial papilla of the mandibular first molar and
passes around the neck of the teeth to the distobuccal line angle of the
second
molar.
Now the incision line extends posteriorly and laterally up to the anterior
border of the mandible. Care should be taken not to damage the lingual
nerve.
The advantage of this flap is that the wound heals quickly.
L-shaped flap
This 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 distolateral to 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 the incision made in one sweep or it
may be angled.
Triangular flap
Triangular flap is indicated in cases where the impacted tooth is deeply
embedded in the bone and requires extensive bone removal. The flap
design is discussed in detail in the Chapter 19 on Endodontic Surgery.
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. It
joins the gingival margin of the second molar anywhere from the lingual to
the
buccal side.
The intermediate part of the incision can be carried forward to a variable
extent. It extends entirely around the buccal margin of the second molar to
end
in the papilla in between the first and second molars. The anterior part of
the
incision is angled from the gingiva margin in a forward and downward
direction towards the sulcus. The disadvantage of this flap is that the
overextension of the incision into the sulcus may cause brisk oozing of
blood
from the venous plexus. It can be avoided by making the anterior part of
the
incision more oblique in direction.
Elevation of the flap
To allow an adequate exposure of the bone and the tooth a full thickness
mucoperiosteal flap should be elevated. Periosteal elevator can be used to
elevate this flap. After the elevation of the buccal flap, the lingual soft
tissue
must be reflected. This is accomplished by means of a periosteal elevator
which is inserted under the periosteum and passed in a distolingual
direction
to reach the lingual border of the mandible. Now the flap is elevated very
carefully, avoiding any damage to the lingual and mylohyoid nerve.
Once the flap has been raised adequately appropriate retractors (Bowdler-
Henry, Austin, etc.) are used to retract the flap.
Bone removal
The amber line determines the amount of bone covering the impacted
tooth
which has to be removed for applying the elevator to remove the tooth.
The
red line determines the depth of the ‘point of application’ of the elevator.
When the entire crown lies above and in front of the amber line, there is no
necessity to remove the bone. In other cases, bone can be removed with
the
help of chisel or burs.
Removal of bone with bur
Moore–Gillbe collar technique
The bur is used to create a gutter around the neck of the impacted tooth.
On
the buccal and the distal aspect, the bone must be removed to expose the
entire
crown till the CEJ. When the bone is removed around the distolingual
region,
care must be taken by the operator to avoid any damage to the lingual flap
and lingual nerve. When point of application of the elevator is on the
mesial side,
adequate bone must be removed so that the elevator stands up at an angle
of 45 degree to the mandible without any support. The area should be
irrigated constantly with saline during the drilling procedure to avoid bone
necrosis.
The tooth should not be removed unless enough space exists where the
tooth can be displaced. When the tooth has been removed using
appropriate elevator, sharp bony edges should be removed and
smoothened.
Removal of bone with chisel
Buccal bone may also be carved away by chiselling. When using chisel for
removing the bone in the mandibular third molar region, the mandible
should be adequately supported.
The straight elevator should be applied on the mesial CEJ of the impacted
tooth and sufficient force should be applied so that the tooth rotates in an
arc
whose midpoint is located at the apex of the distal root and is delivered out
of
the socket. In some situations sectioning of the tooth in multiple segments
should be considered before removal, due to the difficulty which is
predicted
to be encountered in the path of removal of the tooth. The direction of the
tooth sectioning primarily depends upon the angulation of the impacted
tooth.
Care must be taken not to injure the lingual nerve while sectioning the
tooth.

Advantages of odontectomy
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.
Disadvantages of odontectomy
• In elderly patients, splitting of the tooth is difficult due to the sclerosis
of the tooth structure.
• Sometimes due to the presence of shallow grooves on the tooth
structure, splitting is difficult.
• Vertically impacted tooth with bulbous crown and prominent cusps
are usually impacted below the distal convexity of the second molars.
Vertical splitting of the third molar is indicated here which permits the
removal of the distal root and portion of the crown attached to it. Then
the mesial root and crown attached to it can be rotated along an arc,
the centre of which lies in the tip of the mesial root to be delivered out.
• In case of mesioangular impaction with bulbous crown, mesial portion
of the crown which is impacted beneath distal convexity of the second
molar can be split at the cementoenamel margin by means of bur or
osteotome. The crown can now be moved distally into the space
created earlier and removed. The roots are then elevated into the space
occupied by the crown and removed.
• If the roots are unfavourably curved, the roots can also be divided at
the bifurcation and then removed separately.
Debridement of wound and wound closure
The wound should be debrided to eliminate particulate bone chips and
debris
which might have accumulated during the surgery. Periapical curette can
be
used to debride the socket mechanically. The sharp margins of the bone
should be smoothened using a bone file. Following this, careful irrigation
with
sterile saline should be carried out thoroughly under the reflected tissue
flaps.
The wound should now be closed with sutures. The initial suture is placed
on the distal aspect of the second molar. Additional sutures are placed in
the
anterior and posterior limbs of the incision. Sometimes the wound may be
left
to heal by granulation tissue formation wherein no sutures are placed, but
it is
packed with gauze soaked with Whitehead’s varnish.
Other techniques in third molar removal
Lateral trephination 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. The
advantage of this technique is that the bone healing is excellent without
any
loss of alveolar bone around the second molar.
Technique
• Local anaesthesia is preferred over general anaesthesia unless the
procedure has to be performed bilaterally.
• Once the anaesthesia is secured, the external oblique ridge is palpated
and an S-shaped incision is made.
• The incision line starts from the retromolar fossa and extends across
the external oblique ridge curving down along the reflection of the
mucous membrane above the vestibule and ends anterior to the first
permanent molar.
• A full thickness mucoperiosteal flap is elevated and retracted using a
Bowdler-Henry retractor.
• Using a round bur, the buccal cortical plate over the third molar crypt
is trephined till it covers the entire anteroposterior length of the crypt.
Following this, a vertical cut is made on the external plate at its
anterior margin.
• At the posterior end of the crypt, a second cut is made through the
outer plate at an angle of 45 degree from the trephine holes.
• Now the buccal plate is fractured to expose the third molar crypt using
a chisel vertically over the trephine holes. The fractured buccal plate
can be removed using a curved haemostat.
• Using an elevator, the impacted tooth is delivered out of the crypt.
• Care should be taken not to leave any follicular remnants and also not
to injure inferior alveolar canal while debriding the follicular sac.
• The bony margins are smoothened, the wound irrigated and closed.
Lingual split technique (Kelsey Fry technique)
This method was introduced by Sir William Kelsey Fry. It takes advantage
of
the thinness of the lingual cortical plate, avoids and preserves plate and
hence
preserves the buccal plate and external oblique ridge.
Procedure
• The incision is made on the 3rd molar region exposing the tooth
surrounding bone. A mucoperiosteal flap is elevated on the buccal side
to expose the bone enclosing the impacted tooth. A vertical stop cut is
made in the anterior end of the impacted tooth using a chisel.
• The chisel is placed horizontally with the bevel facing downwards just
below the vertical stop cut and a horizontal cut is made extending
backwards.
• A point of application for an elevator is made with a chisel by excising
the triangular piece of bone bounded anteriorly by the lower end of
the stop cut and above by the anterior end of the horizontal cut.
• The distolingual bone is now fractured inward by using chisel. The
chisel is held at an angle of 45 degree 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 that separates the lingual
plate from the alveolar bone and hinges it inward on the soft tissue
attached to it. At this point 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.
• The ‘peninsula’ of bone which then remains distal to the tooth and
between the buccal and lingual cuts is excised.
• A sharp, pointed, fine-bladed straight elevator is then applied to the
mesial surface of the tooth and minimum of force is used 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.
After the tooth has been removed from its socket, the lingual plate is
grasped in fine haemostats and the soft tissues are freed from it by
blunt dissection.
• The fractured lingual plate is then lifted from the wound, thus
completing the saucerisation of the bony cavity.
• The bone edges are smoothened with bone files; the wound is irrigated
with saline and closed with sutures.
Advantages
• It is a quick technique
• Helps in removal of lingually impacted third molar without much of
buccal bone removal
• This technique helps in reduction of the size of the residual blood clot
by means of saucerisation of the socket.
It is mostly indicated in children in whom the bone is very elastic. General
anaesthesia is preferred.
Complications (Fig. 18.49)
• Swelling
• Trismus
• Bleeding
• Neurologic
▪ Lingual nerve damage—paraesthesia of tongue
▪ Inferior alveolar nerve damage—paraesthesia lower lip
• Fractured lingual plate
• Loss of tooth into submandibular and sublingual space
• Mandibular fracture
• Second molar
▪ Hypersensitivity
▪ Distal periodontal pocket
▪ Gingival recession