3rd molar impaction

Name
Age
Sex
Occupation
Social status
Address
Chief complaint
History of present illness:
Apparently well-------days back when the pain started in---------region
Nature of pain
Severity: Dull/ sharp
Site: Retromolar region/ 3rd molar
Origin & mode of onset: Long continuous & intermittent
Progression:
Duration:
Movements of pain: Radiation/ Referred/Migration
Time of occurrence:
Periodicity:
Precipitating or relieving factors:
Associated symptom:
Reported first to-----------
Medications taken in past-------- (details)
Any relief:
Dental history
a) Brushing habits
b) Aids used
c) Regular checkup
Personal history
a) Smoking
b) Deleterious oral habits
c) Diet
d) Alcohol
e) Marital status
f) Menstrual history
Family history
a) Systemic manifestation
b) Members

Physical examination
 a) Built:
b) Nourishment:
c) Gait:
d) Posture:
e) Mental state:
f) Attitude:
g) Skin eruptions (Macules, Papules, Vesicles, Pustules,):
h) Sign/symptom of systemic illness:
i) Weight:
j) Vitals (TPR&BP):
Local examination of Lymph nodes
a) Location
b) size
c) Tender/ Non tender
d) Soft/ /hard/rubbery/shotty
e) Matted/not
f) Mobile/fixed
g) Fixity to underlying structures
General examination by physician;
Maxillofacial examination & palpation:
a) Upper 1/3rd
b) Middle 1/3rd
c) Lower 1/3rd
d) Mouth opening
e) Mandibular movements
f) Motor deficit
g) TMJ
h) Sensory deficit if any
i) Eye
j) Ear
k) Nose
l) Oral aperture
Intraoral examination (Inspection & Palpation):
1. Number of teeth:
2. Occlusion:
3. Carious:
4. Periodontal involvement:
5. Restored:
6. Prosthesis:
7. Tongue : Size & movements
8. Buccal mucosa : Cheek bite & thickness
9. Vestibular depth & lingual sulcus depth:
10. Salivation status or hydration:
11. Status of 7
a) Cusp visible
b) Angulation:
c) Carious or periodontal involvement:
d) Occlusal level in respect to 6, 8 & occlusal plane
12. Status of Impacted 8
a) Cusp visible
b) Angulation
c) Carious or periodontal involvement
d) Level of occlusion
e) Bucco-lingually
f) Mesiodistally
g) Pericoronal flap : blanched/ erythematous or inflamed
h) TFO from upper 8
13. Status of upper 8
a) Cusp visible
b) Angulation
c) Carious or periodontal involvement
d) Level of occlusion
e) Bucco-lingually
f) Mesiodistally
14. Intraoral palpation
a) Tender on percussion : teeth / retromolar region
b) Bleeding on probing
c) Locking under 7 or not
d) Space b/w ramus & 8
e) External oblique ridge
Clinical impression:
Investigations:
1. Routine hemogram
2. Urine RE
3. CT,BT
4. Radiographs:
a) IOPA
b) OPG
c) Lateral oblique

Evaluation of IOPA
 1. Teeth visible:
2. Status of 6/7
a) Mesial relation
b) Lateral relation
c) Furcation
d) Pulp chamber
e) Caries
f) Interdental bone
g) Number, form & length of roots
h) Trabecular pattern
i) Level of occlusion
j) Angulation
3. Status of 8
a) Mesial relation
b) Lateral relation
c) Follicular space
d) Furcation
e) Pulp chamber anatomy
f) Number, form & length of roots
g) Caries
h) Trabecular pattern
i) Level of occlusion
j) Space between ramus & 8
k) Angulation

JP Rood & AA Shehab 1990 Relation to canal:

Changes in relation to root
1. Darkening
2. Dark & bifid
3. Narrowing
4. Deflected
Changes in relation to canal
1. Interruption
2. Narrowing
3. Diverted

Arc of rotation:
Classification:

Winters classification:
WAR line, Length of Red line > 5mm, every 1mm is 3 times more difficult
Pell & Gregory classification (1942)
Position:
Class:
Pederson 1988, KR Koerner 1994 difficulty index:
C Alling & Guy A Catone 1993 (07220, 07230, 07240, 07241)

Treatment plan: Transalveolar extraction

Ward’s or extended Ward’s incision
Raising Mucoperiosteal flap
Moore & Gilbe collar technique for removal of bone by doing distal & buccal
guttering
Removal of distolingual spur
Odontectomy if required