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I
n Tibetan philosophy, wisdom tooth has special significance, where only the appearances of 3rd
molars are pre ordained relationship of individual teeth to one another completed. In contrast to this
view, wisdom tooth has proved to be a precursor of problems where it leads to serious disturbance in
harmony of mastcatory apparatus, general health and is Often responsible for the host of complications. It
also influences the treatment in all dental specialties and forms a focal point of dental surgery.
DEFINITIONS:
According to WHO-
A). "Impaction is any tooth that is prevented from reaching its normal position in the mouth by tissue or
bone or another tooth,
B). A tooth that is completely or partially unerupted and is positioned against another tooth/bone/soft
tissue, so that its further eruption is unlikely, described according to its anatomical position".
C). A tooth that fails to erupt and will not eventually assume its anatomical arch relationship beyond its
chronological eruption date".
THEORIES OF IMPACTION:
2) PATHOLOGIC THEORY
There is osteosclerosis in the region of 3r molar as a result of early infection to 1st and 2 molars, this is a
small percentage of cases as studies have shown people to have normal and vital 1st and 2nd molars but
have impacted 3rd molars.
3) MENDELIAN THEORY
As an individual gets half of genes from one parent and the other half from the other parent; he may have
small jaws from one parent and large teeth from the other parent. This may result in 3rd molar impaction.
A. Systemic factors
1. PRENATAL: HEREDITY
Shape and size of the jaws resemble of the parents & often-same tooth is impacted as their parents.
2.POSTNATAL:
Condition interfering with normal development of child can cause Impaction along with local predisposing
factors.Eg, Rickets, anaemia, TB, malnutrition, endocrine dysfunction, Congenital syphilis.
3.RARE SKELETAL DEFORMITIES:
Cleidocranial dysostosis. Achondroplasia, cleft lip&palate, Oxycephaly, Progeria (premature aging)
B. Local factors
Irregularity in position especially when it is buried under crown of adjacent tooth
Increased density of overlying surrounding bone.
Increased density of overlying mucosa due to inflammation.
Jaw size discrepancy.
Premature loss/retained deciduous dentition.
Infection in bone due to local/systemic causes
o Necrosis following infection.
o Exaotbematous diseases in children.
C. Other factors
1. Chronology
On the basis of chronological order of teeth a few teeth arc predispose) To impactions.
E.g.: mandibular & maxillary 3 molars, mandibular&maxiUary Canines, mandibular premolars.
2.Lack of space
Impaction is due discrepancy in arch size &tooth dimension. Tooth Erupting late chronologically with
insufficient space will itself present clinically As impacted. Eg-a) Mandibular 3""rnolars are impacted due to
lack of space Between 2ndmolar&anterior border of ramus of the mandible.
Canine root being longest, the crown has to cross a long distance before erupting into the oral cavity.
This is further complicated with lack of space or increased mesio-distal width and progressive
decrease in arch length due to evolution.
3. Obstructions:
During eruptions, obstructions like retained deciduous teeth, thick scar band, odontome, cyst,
odontogenic tumors, then the tooth remains unerupted even beyond its chronological age.
4. Dilacerations:
Trauma to deciduous anterior teeth transmits traumatic forces to underlying tooth bud. This leads
to shift in long axis of crown while root formation proceeds in the predetermined manner leading
to dilacerations & failure.
FREQUENCY
1. Position of the tooth in relation to long axis of 2nd molar,WINTER'S classification. (1926)
1. Vertical,
2. Horizontal,
3. Mesioangular
4. Distoangular
5. Inverted
6. Unusual position
2. Skeletal anatomic space between posterior aspect of 2nd molar & anterior border of ram us
of mandible; PELL & GREGORY (1933)
1. CLASS I There is sufficient amount of space between the ramus of mandible & distal surface of
2nd molar to accommodate mesiodjsial width of crown of 3rd molar.
2. CLASS II Space between distal surface of 2nd & ramus of the mandible is less than mesio
3. distal width crown of 3rd molar.
4. CLASS III 3rd molar is situated within the ramus of mandible.
5. AAOMS Classification
It is based on operation performed to remove an impacted tooth. It is not used due to whether procedure is
either understood\oy exsha do wed to Anatomical variation during surgery.
6. ADA Classification
Based on amount of hard & soft tissues covering coronal surface of impacted tooth.
1. Soft tissue impactions.
2. Partial bony impactions.
3. Complete bony impactions.
4. Complete bony impactions + surgical difficulties
RETROMOLAR TRIANGLE
It is a topographic design for a usually concave space posterior to2nd molar. It is a roughened area distal
to 2nd molar into which 3rd molar would erupt. It is bounded by anterior border of ascending ramus &
LINGUAL NERVE
It may be hidden beneath or in the mucosa, medial to the location of impacted 3rd molar near the crest in
an abnormal superior position. Studies have demonstrated that lingual nerve at times is located slightly
superiorly to the crest of the bony ridge, medial to the 3rd molar, l-2mm towards the midline in the
lingual soft tissues. It is thus vulnerable to tear. Eg- In class I, where sufficient surgical access is possible,
risk of injury to the lingual nerve is minimal, while in class II & III, the distance between 2nd molar to the
ramus of the mandible is less hence, the lingual nerve is more superiorly placed where risk of damage to
lingual nerve is increased. Thus depending on the type of impaction on patients is told before procedures
about post op lingual nerve dysfunction. Care is to be taken not to extend the incision, backwards distal to
2nd molar in the direction of medially inclined plane in the dental arch-Injecting into the lingual nerve
will lead to protracted anesthesia of anterior 2/3rd of the tongue. Ncurotemesis causes permanent
anesthesia of anterior 2/3 of the tongue on the affected side. Surgical exposure often reveals a traumatic
neuroma of the nerve.
SUBMANDIBULAR FOSSA
Cortex of the submandibular fossa is thin, thus vulnerable to acute inflammation & inadvertent
penetration of fragments of teeth into the space.
BLOODVESSELS
Facial artery & anterior facial vein cross inferior border of mandible just anterior to the masseter & are in
close relationship to the 2nd molar. It is possible to cause injury to the vessels if scalpel slips. It is thus
sensible to begin incision at the depth of the sulcus and direct the blade towards the teeth.
MUSCLES
Attachment of temporalis muscle extend from the coronoid process, to the root of ascending ramus,
occasionally they reach (he distal surface of 3rd molar. It always terminates as 2 limiting prongs on
borders of retro molar triangle. Consequence of this is severe post-op pain, if these fibers arc stripped.
LINGUAL POUCH
Presence of 3rd molar predominantly in the lingual region with its root or their apices in close proximity
may even perforate the lingual plate. Any attempt to elevate such roots may cause displacement of
fragments through thin lingual cortical plate, deflecting it posteriorly below myelohyoid muscle & along
the medial surface of mandible into a space called LINGUAL POUCH, after which retrieval of such
fragments is difficult A tooth in lingual version may slip into lingual soft tissue if the force is misdirected.
Sometimes the tooth along with the fractured lingual plate may be driven into the lingual soft tissues.
BONE TRAJECTORIES
It is related to mechanical stress & runs longitudinally. A buccal chisel cut is parallel to the superior of the
mandible in 3rd molar region. Care is to be taken on the account of force delivered; else an extensive
horizontal split in compact bone may result, limiting this is possible with a vertical stop distal to 2nd
molar and at right angle to free edge of the bone. Omission may lead to split in buccal cortical plate all
along till the 1st molar & denude the roots of mandibular 1st & 2nd molars. Careless application of chisel
lingually will result in fracture of lingual plate, sometimes the lingual that is about 25mm distal to 3rd
molar. Accidents have been recorded where coronoid process has been a part of fracture fragment.
Correct removal of lingual plate with chisel, may not necessitate giving a vertical stop/ limit cut distal to
2nd molar on the lingual side. In this vicinity, a thin cortex surrounding the 3 molar Iingually joins thicker
border of mandible & inner plate breaks off at that junction & doesn't extend forwards further.
Chisels may be used in younger patients where a natural line of cleavage along the grain of bone is
present In the mandible it runs vertically in ascending ramus .almost parallel to border) & horizontally in
the body of the (almost parallel to occlusal surface). In the maxilla, there is no true grain but the thin
plates is of bone are easily cut In older patients (>40 yrs) chisels are contraindicated as bone is brittle and
mandible may shatter in unpredictable planes.
RADIOLOGICAL ASESSMENT
1. Angulation & Depth
2. No. & Shape of roots
3. Relation to canal
4. Condition of 2nd molar
5. Density of bone
6. Bone loss around the teeth
7. Existing Pathology
WHARFE'S ASSESSMENT:
It helps beginners to anticipate problems and avoid difficult impactions. In this type of assessment the
total scoring to individual cases re directly related to corresponding difficulties that one is liable to
encounter during removal of an impacted tooth. Scoring details
Horizontal 2
Distoangular 2
WINTER S CLASSITION
Mesioangular 1
Vertical 0
1-30 mm 0
HEIGHT OF MANDIBLE 31-34 mm 1
35-39 mm 2
1-50 0
60-69 1
ANGULATIONS OF 3rd MOLAR
70-79 2
80-89 3
a. BENIGN
b. MALIGNANT
15. Skeletal diseases - Osteogenesis imperfecta, osteopetrosis...
BURS: Medium sized bur either Roschead (Ash 7-16) or fissure (Ash 7-12) are used. Cutting with fine
control can be achieved with high speed & minimal pressure. Use of irrigation with sterile saline prevents
over heating of tissues & clogging of bur. It may be used to grind bone (Roschead) / remove blocks of
bone. A gentle sweeping motion is used along the whole length of area concerned, thereby leaving a
smooth even edge. Blocks of bone are removed using fissure bur (Ash-7) to make cuts through the cortex
into the medulla around an area, which can be prized out.
CHISELS: They may be used to great advantage in young patient (<40yrs), where natural lines of
cleavage along the 'grain' of bone is present. In the mandible these run vertically in the ascending ramus
(almost parallel to posterior border) & horizontally in the body (parallel to the occlusal surface). In the
maxilla there are no grains, but the thin plate of bone makes the work easier to cut. In patient (>40yrs)
chisels are contraindicated as bone is brittle. With sharp chisels and carefully placed stop cuts, the degree
of control exercised is not inferior to that obtained by burs. Chisels may be used by hand / mallet in any
case support should be firm to avoid slipping. Chisel may be used to plane bone/ cut blocks of bone.
Chisel cuts is determined by the angle of beveled surface.
To remove blocks of bone the beveled surface is usually turned towards the bone, which is to the left.
When used to plane the bevel face is placed against the bone and driven along the required depth to shave
off wafers of bone.
Angle of holding chisel determines amount of chamfer, which the surgeon wishes to leave on this bone
edge. Outline of area with shallow cuts made with small chisel (3mm) before using broader chisel (5mm)
prevents splitting of bone along a long distance. Tooth sectioning used beveled chisels. Maximum force at
point of contact is from 5-7 lb depending on spring used. Lightest blow, which will effect reduction, is at
least 15 lbs. Blow delivery should be constant. There should be forward movement of cutting blade not
les than 1mm, which eliminates "follow through "effects.
'Ossisectors/ Hand powered chisels are alternatives to burs / chisels.
BURS: Used with sterile hand piece with coolant usually 0.9% NS
Types Diameters:
2.3mm (round)
1.6-2.6 at widest diameter (tapered)
1.6-2.6 cross cut (fissure burs)
Advantage:
1. Control over hand piece aids in control over removal of bone in that particular area.
2. Slipping is possible if chisel is used.
3. Less traumatic to patient, hence heating of wound is better with better post op complications.
4. Chisels produce efficient bone reduction and tooth sectioning
5. Burs are precise.
Disadvantage:
1. Chisel force cannot be controlled
2. Possibility of cleavage along grain over a long distance
Burs:
1. Emphysema into fascial planes / Submandibular space by forcing gases & liquid
2. Deleterious frictional heat (dull bur) m the bone resulting in undesirable inflammation / bone
necrosis & delayed healing
3. Fracture of the bur tip into the bone
4. Damage to adjacent teeth with bur.
5. Lingual plate perforation wit mandibular 3rd molars.
6. Time consuming.
BUCCAL APPROACH:
More traditional, easier surgical removal on conscious patients. Post op infection likely to be superficial.
Any damage to the lingual perioslium of mandible results in more pain. Buccal cortical plate may be thick
& tedious making removal difficult, more often tooth splits from this side. In some occasions lingual bone
removal especially on distally may be associated with lingual nerve damage & increased paresthesia. It
should be avoided unless necessary.
LINGUAL APPROACH:
With ungual obliquity, the lingual plate is markedly thinner & weaker.
Advantages:
1. Fractures with case provide nerve is protected, thereby preventing major complications.
2. Breaching of buccinator muscle in buccal approach is avoided.
3. When external oblique ridge is damaged, dry socket rate increases.
Disadvantage:
1. Lingual nerve damage
2. Paresthesia in region of myclohyiod nerve supply of lower Jip.
OPERATIVE PROCEDURES
1. Preliminary considerations:
Presence of infection: Treatment of pericoronitis is essential before surgery. If maxillary 3rd molars are
impinging on infected mandibular 3rd molar then removal of maxillary 3rd molar is indicated.
3. DRAPING:
STERILE TOWELS: to provide a sterile field as well as to cover the eyes to decrease psychological
trauma.
TECHNIQUE
The following steps are to be used in all 3rd molar removal
1. Incision & Flap
2. Elevation of Flap
3. Flap retraction
4. Bone Removal, Tooth Division and its removal
5. Wound cleansing
6. Suturing
7. Packing
8. Aftercare
L- shaped: it extends from a posterior limit just lateral to ascending ramus into the sulcus. It may just
avoid the distobuccal periodontium of 204 moiar or just include it, depending on proximity of 3rd molar
to 2nd molar. The incision is curved at the junction of the limbs; it may also be angled where it gives
good apposition while suturing. This incision commits the surgeon for a buccal approach because
removing a lingual flap is difficult.
ENVELOPE FLAP: This is confined to the gingival trough/ sulcus. Deeper the tooth is, more anterior
the incision can be given sometimes as far as premolar. Advantages are it's easy to suture, less post op
pain & less distortion in heating. Entire mucosa periostium are stripped from the bone to a point approx to
apical l/3rd of tooth.
RETRACTION OF FLAP:
The main purpose is to provide access for operation and provide protection to soft tissues. Most gentle
way is to place the periosteal elevator firmly on the bone and res*, the retracted soft tissue on the opp side
of the bone. Care is to be taken that the retractor is not pulled down the surface of bone / soft tissue, else
the flap over the
EOR may be enlarged and may lead to swelling. Types of Retractor: Dyson's malleable copper retractor.
Lingual retractor, Ward's-Kilner retractor, Lack's retractor, Bowdler Henry retractor.
BONE REMOVAL, TOOTH DIVISION & ITS REMOVAL: Both are interdependent and are determined
by
Shape of tooth
Position of tooth
Shape of surrounding bone
Age of patient.
Bone removal to exposure crown will not be required in cases where the tooth is in front of the amber line
& is fully exposed. Either a bur or chisel or combination can be used if required. Bur when used with
hand piece gutter can be made around the tooth neck and a point of elevation for the elevator. The point
of elevation if on the mesial and an elevator is placed, should stand at 45 to the body of mandible
without support Lingual soft tissues should he protected if ungual spur of bone is to be removed. 2 basic
principles in removal of 3rd molars:
WOUND TOILET:
Socket contains blood contaminated by variety of organisms, bone chips, slurry from burs, and lubricants
from hand piece, talcum powder from gloves, granulation tissue and follicular remnants.
Measures taken immediately after removal of 3rd molar is critical for successful healing. Cutting the
bone, which is heated if bur is used, may damage wall of the socket. Outside the socket the tissues have
been damaged and debris collection is seen at the angle of reflection.
Steps to prepare the socket:
Wedge removal: removal of triangular wedge of tissue immediately posterior to 2nd molar to
provide for surgical drainage and repair by secondary intention through production of granulation
base and gingival attachment posterior to 2nd molar. Any excess tissue is excised as a triangular
form thru an elliptical incision. Incision line on the buccal aspect is beveled in lateral direction to
remove bulk of submucosa. Tighe sealing of gingival crest margin against 2nd molar provides
tight edge to edge closure.
Debridement; Initial step is to swoothen osseous surgical margin with bur operating with saline/ bone file.
Using generous lavage of saline and suction apparatus does debridement of alveolar bone. The surgeon to
inspect the alveolus may use suction. Cnrrattage is not recommended if cystic/pathologic conttnts are
absent, as it may damage residual periodontal tissues attached to the alveolar walls. Pathologic tissues
should be removed-withcare to prevent injury to IAN If a cystic lining is to be removed in 3rd molar
region, curettage is done in areas involved only white not involved is not curetted
INTRAORAL DRESSING
Important is preserving coagulum during die critical hours of repair. Gauze folded with smooth surface is
placed over the socket. Popularly used is Whitehead's varnish on gauze.
POSTOPERATIVE COMPLICATIONS.
Alveolar Osteitis (Dry Socket): Lack of blood clot in the extraction socket.
ETIOLOGY:
Trauma to bone Infection
Vasoconstriction due to L.A
PREVENTION:
0.12 percent chlorexidine 10ml preop.rinse
Paint the surgical site with 10% povidone iodine
Irrigation before closure
Tetracycline powder in the socket
TREATMENT:
Lavage the surgical site with warm normal saline. Soak iodoform gauze containing eugenol into the
socket & dressing changed every 3-4 days. Usually granulation tissue covers in a weeek. Patient can at
home irrigate with a plastic needle. . Use of either an obttmdant ( eugenol/ guiacol) or topical
anesthetic(benzocaine) is recommended.
INFECTION:
Infection is possible if no signs of remission, increased in 3-5 days. Etiolcgy:
May be prcop in origin , from preexistin conditions in periapical granuloma/ periodontal tossues, general
oral sepsis.
Failure to use an aseptic technique
Patient unable tot maintain proper oral hygiene post op
TREATMENT:
socket packed with hintera oral medicament
Examine wound carefully for foreign body.
Patient on antibiotics to prevent secondary infection.
TRISMUS:
1. Common causes of pose 3rd molar extraction are
2. Inflammmtion after operative trauma results in muscle spasm-trismus
3. Infection of pterygomandibular / submassctric/prctemporal/infVatemporalspace
4. Improper LA technique-injury to medial pterygoid
5. Injury to TMJ during surgery
TREATMENT:
Intraoral & extra oral heat application to decrease inflammation and spasm (caution as a preop infection
may increase due to flare up.
Administration of analgesics for pain
Antibiotics if infection is present.
OPERATIVE COMPLICATIONS
HAEMORRHAGE:
Intra op haemorrhage during surgical procedure may result from inferior alveolar vessels. Blood loss may
be rapid/continous then patient may reach hypovolemic shock
Preop radiograph-disclose vascular anomalies, proximity to IAC radioiucency produced by AV aaerysms.
In an IAN cut the haemorrhage is prompt while if the vessels are in completely it results in intermittent
copious flow.
Control haemorrhage:
Cleanse alveolus under direct vision possibly
Crush contiguous bone into bleeding site
Severe neurovascular bundle allowing retraction and contraction of arteries
Elecrtocautery
Vascular defect procedure aagressive haemorrhage treated by packed oxidized cellulose /
microfibrilar collagen material.
Arteriovenous aneurysms may occurin any location of the mandible also in the 3rd molar region. It
presents as a radilucent lesion. Management of an aneurysm takes a predence over 3rd molar surgery.
If haemorrhage is seen when removing a root tip then temporarily pack gauze for 5-10 mm & proceed
with surgery. If bleeding recurs then in may necciate to pack the socket and suture. Removal of the root
up may be attempted later.
INJURY TO IAN:
Injudicious instrumentation
Position of the tooth
Any force that will crush bony walls of the mandibular canal will cause decompression of the nerve
leading to anesthesia or paresthesia of that area supplied by it especially in the chin & lower lip. Minor
transient nerve dys function
Post op is usually accepted by educated patient, which may last up to 6 months. If it still persists then
surgical solution may be considered like surgical decompression / neuroma resection/ microsurgical
grafting.
Fracture of the root: Injury may occur if the root tip is close to the mandibular
canal. Small apices 3-5mm in length can be left behind when the tooth is vital. It
is essential to remove all roots if infection is present.
Fracture of the instrument: Search for the fracture instrument. Radiograph may be necessary. Breakage
of LA needle during IAN block is possible hence only 2/3 of the needle is inserted. Grasp with artery
forceps and remove. Fracture of the bur may be due to excessive force during drilling. Fracture of the
suture needle is possible. Metal foreign body detector may be of great assistance.
Displacement of tooth: Fracture of the thin cortex lingually may force the fragment into Submandibular
gland.
Treatment is
Indefinite observation and treatment.
Delay of 3-4 weeks to await stabilizing fibrosis.
Immediate / early removal.
SUBMANDIBULAR REGION: continuous upward external pressure displaces the tooth / fragment and
may aid visualization. Else, lingual gland is reflected till canine region and mylohyoid muscle carefully
dissected after locating the fragment, then removing it carefully.
Dislocation of TMJ: is seen in patients with weak supporting muscles and lax capsule. Prevention is by
application of less force, also use mouth prop/ Willi's mouth gagprevents dislocation. Jaw if dislocated
should be reduced before the patient comes back to consciousness.
ODEMA: raising the lingual flap will lead to odema owing to the thin fascia.
Notes: