Mandibular 3

molar impactions

rd

Mohammad akheel
Omfs pg

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)

Theories of impaction
By Durbeck
1)
Orthodontic theory : Jaws develop in
downward and forward direction. 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 jawdecreased space).
A dense bone decreases the movement of the
teeth in forward direction.

Theories of impaction

2) Phylogenic theory: Nature tries to eliminate the disused

organs i.e., use makes the organ develop better, disuse
causes slow regression of organ.
[More-functional masticatory force better the development of
the jaw]
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.

Theories of impaction
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

What will happen if impact teeth are

retained?
Complications
Infections:
Pericoronal infection
Acute
/
chronic
alveolar abscesses
Chronic
suppurative
osteitis
Necrosis
Osteomyelitis

Complications
Pain:
Slight and restricted
Severe or excruciating
Intermittent, constant or

periodic
Referred to ear, the post

auricular area, any part

of the area supplied by
the trigeminal nerve.
(Eg. Temporal pain)

Fractures:
Impacted tooth proves that weakening of the mandible occurs

due to displacement of bone.

Other complications:
Ringing, singing or buzzing sound in the ear (Tinnitus aurium)
Otitis
Affections of the eye such as
Dimness of the vision
Blindness
Iritis
Pain simulating that of glaucoma

Indications and contraindications for

removal of impacted tooth
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.

Indications:
Pericoronitis 27% to 34% (Swed Den J1987)
Caries 3% to 15% (IJOMS 1988)
Root resorption 5% (Swed Den J 1987)
Formation of follicular cyst 1 to 5%(J Oral Pathol
1998)
Tumors arising in the follicular (Dentigerous cysts) 0.1
to 0.2% (JOMS 1991)

Contraindications:
Acute infection with pericoronitis
Medically compromised state uncontrolled

diabetes
Extremes of age Old age

Historical background on the criteria

for removal of third molar
Historical background
In

1979,

conference

consensus
practicing

development
dentists

and

scientists, on third molar removal was

sponsored

by

National

Institute

Health, USA *.
* -J Oral SurgeryVol38,March 1980

of

Classification
According to Long axis of the impacted tooth in relation to the
long axis of the 2nd molar

Winters classification (1926)

Mesioangular

Vertical

Distoangular

Pell & Gregory's classification (1933)

Position A

Position B
Position C

Based on Relationship of the Tooth to

the Anterior Border of the Ramus of
the Mandible
Class I

Class II

Class III

According to Supero-Inferior Position

of 3rd Molar
Crown to crown
Crown to cervix
Crown to root

Killey & Kays Classification

a) Based on angulation and position:
(Same as Winters 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

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.

Combined ADA and AAOMS

Classification
soft tissue impaction (incision of overlying soft tissue &

removal of tooth)
partial bony impaction (incision of overlying soft tissue,

elevation of flap, either removal of bone & tooth or sectioning

& removal of tooth)
complete bony impaction (incision of overlying soft tissue,

elevation of flap, removal of bone & sectioning of tooth for

removal)
complete bony impaction with unusual surgical complication

(incision of overlying soft tissue, elevation of flap, removal of

bone, sectioning of tooth for removal &/or presents unusual
difficulties & circumstances)

Pre-Operative Assessment
HISTORY

Patients might be asymptomatic

when symptomatic- pain, swelling of the face, trismus
Symptoms of acute pulpitis or abscess
In denture wearers if denture no longer fits & at the same time

show the symptoms of pericoronitis.

General medical history & assessment of physical condition

EXAMINATION

Clinical

Extra oral
Intra oral

Radiographs
DECISION

Diagnosis
Treatment planning type of anesthesia
- surgical procedure

Local Examination
EXTRA ORAL:

Signs of swelling & redness of the cheek

LNs - enlargment & tenderness,

TMJ

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
Periapical film
OPG
Occlusal film

Interpretation
1. Access
2. Position & depth (WAR lines)
3. Shape of the crown
4. Texture of investing bone
5. Position & root pattern of 2nd Molar & impacted tooth
6. Inferior alveolar canal
7. External oblique ridge --vertical & ant. to third molar poor access
-- oblique & post. good access

Relationship of Root to Canal

Related but not involving the canal

Separated
Adjacent
Superimposed
Related to changes in the roots

Darkening of root
Dark and bifid root
Narrowing of root
Deflected root

Related with changes in the canal

Interruption of lines
Converging canal
Diverted canal

Relationship of Inferior Alveolar Nerve

to
the Radiographic
Roots of Third
Molar
Roods
Criteria

of root

Deflection of root

Narrowing of canal

Dark & Bifid a

WAR (Winters) Lines

White line
red line

amber line

Red line <5mm: extraction - easy, there after every 1mm

increase in depth increases the difficulty three folds & if it is

>9mm then plan the surgery under GA.

DIFFICULTY INDEX :

Category
Spatial relationship

Depth

Ramus relationship

Values

Mesioangular

Horizontal

Vertical

Distoangular

Level A

Level B

Level C

Class I

Class II

Class III

WHARFEs ASSESSMENT by McGregor

(1985)
Category
1. Winters
classification

Horizontal
Distoangular
Mesioangular
Vertical
2. Height of mandible
1-30mm
31-34mm
35-39mm
rd
3. Angulation of 3
1 - 50
molar
60 - 69
70 -79
80 - 89
90+
4. Root shape
Complex
Favourable curvature
Unfavourable curvature
5. Follicles
Normal
Possibly enlarged
Enlarged
6. Path of exit
Space available
Distal cusp covered
Mesial cusp covered
Both cusp covered
Total

Score
2
2
1
0
0
1
2
0
1
2
3
4
1
2
3
0
1
2
0
1
2
3
33

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

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 alv

bone

buttressed

by

external

oblique ridge & the narrow inner

cortical plate.
Ramus offset by 20
Retro Molar triangle- depressed

roughned area post. to 3rd molar

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 perforation of roots along the lingual cortical plate.
- may cause # of lingual cortical plate
-displacement of fractured root fragments below the
mylohyoid

Arteries
Facial artery & facial vein run in close approximation with lower 2nd
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.

Inferior Alveolar Nerve

Lies just below the roots of mandibular
molars but slightly buccally placed in
inferior dental canal.
In case of deep seated impaction special care should be taken to
protect this neurovascular bundle during bone drilling & tooth
sectioning.
Calcification of inferior alveolar canal is completed before the roots of
3rd molar are formed. Thus growing roots may impinge upon the canal
or get deflected. So blind elevation is not advisable.

MUCOPERIOSTEAL FLAP
Incision 3 parts: Anterior, posterior & intermediate limb

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)

Factors Governing Planning of Incision

Surgical access
Healing of sutured wound dry socket
Periodontal health of II molar distal pocket
Suture line must rest on normal bone
Partly visible crown: de-epitheliazation

Types of Flaps
L shaped flap
(2nd molar para
marginal Flap with
vestibular extension)

Envelope flap
(2nd molar
sulcus incision)

Bayonet shaped flap

(2nd molar sulcus incision
With vestibular extension)

Buccal extension flap

Wards incision

Triangular flap

Modified Wards incision

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.
2.

By consecutive sweeping action of bur (in layers).

By chisel or osteotomy cut (in sections).

How much bone has to be removed?

1.
2.

Bone should be removed till we reach below the height of

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

Chisel v/s Bur

Sl.N
o

Criteria.

Chisel&Mallet

Bur

1.

Technique

Difficult

Easy.

2.

Control 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.

Bone Removal Techniques

Moore & Gillbes Collar 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.

Split Bone / Lingual Split Technique

Sir William Kelsey
Fry(1933)
- Quick & clean tech
- Reduces the size of blood clot by means of saucerization
of socket.
- Decreased risk of damage to the periodontium of the second
molar.
- Less risk of inferior alveolar nerve damage.
- Decreased risk of socket healing problems
- Can use regional anaesthesia but endotracheal anaesthesia is
preferred one.
- Only suitable for young adults whose bone is elastic
- Inconvenience to patients due to chisel useage.

Incision

Horizontal cut

Removal of distal
& buccal bone

Removal of disto
lingual bone

Vertical stop cut

Split of Disto
lingual bone

Elevation

Closure

Tooth Division
Rationale of tooth sectioning is to create a space into which
impacted tooth can be displaced & thence removed.
Tooth is sectioned in various ways depending on the type & degree
of impaction.

Mesioangular Impaction

Horizontal Impaction

Disto Angular Impaction

Vertical Impaction

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

proper closure.

number of sutures to get

Post Operative Instructions

Pressure pack 1hr
Ice application
Soft diet 1st two days
1st dose of analgesic should be taken before the anesthetic

effect of LA wears off.

Avoid strenuous exercises for 1st 24 hrs.
Avoid gargling / spitting / smoking / drinking with straw.
Warm water saline gargling after 24 hrs + mouth wash

regularly thereafter.
Suture removal on 5th POD.

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.
b.
c.
d.
e.

Damage to second molar

Slipping of bur into soft tissue & causing injury
Extra oral/ mucosal burns
Fracture of the mandible when using chisel & mallet
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

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

Post-operative
Complications
Immediate

- Hemorrhage
- Pain
- Edema
- Drug reaction
Delayed

- Alveolitis
- Infection
- Trismus

Dry Socket
20% of extraction of mandibular 3 rd molar
2% of routine extraction
Moderate-severe pain develops generally on 3 rd/4th day.(with no

signs of infection)
Dull aching pain usually radiates to ear
Empty socket
Bad odour & taste
Etiology - unknown

Possibly excessive fibrinolytic activity

Subclinical infection

Management
Gentle irrigation with warm saline followed by superficial

suctioning.
Pack iodoform gauze socked with medications change every

day for 3-6 days.

Intra-alveolar medicaments(controversial)

-with eugenol
-topical LA
-antifibrinolytic agents.
Analgesics.

Thank you