Surgical Management Of Impacted Tooth

SUR GI CAL MAN AGE ME NT OF IMPACTED MANDI BULA R II I MOLAR S AND COMP LIC ATI ON S

PRESENTED BY: DR.SATYABRATA PATNAIK 1ST YR P.G

INTRO DU CTION

FACTORS THAT MAKE REMOVAL EASIER CLASS 1

SOFT TISSUE IMPACTION SEPRTATED FROM II MOLAR

POSITION A

ROOT 1/3RD TO 2/3RD

MESIOANGULAR

LESS DENSE BONE

FUSED CONIC ROOTS LARGE FOLLICE

WIDE PERIODONTAL SPACE

FACTORS THAT MAKE REMOVAL DIFFICULT

COMPLETE BONY IMPACTION CONTACT WITH IIMOLAR

CLASS 3 POSITION C

DISTOANGULAR

DENSE INELASTIC BONE

LONG THIN ROOTS

DIVERGENT CURVED ROOTS THIN FOLLICLE

NARROW PERIODONTAL SPACE

ANATOMICAL CONSIDERATIONS  LINGUAL NERVE  INFERIOR ALVEOLAR NERVE  INFERIOR ALVEOLAR VESSELS  RETROMANDIBULAR VESSELS  TEMPORALIS TENDON INSERTION  PTERYGOMANDIBULAR SPACE  FACIAL ARTERY  SUBLINGUAL GROOVE  RETROMOLAR TRIANGLE

LINGUAL NERVE •

LINGUAL NERVE LIES INFERIOR & LINGUAL TO THE CREST OF LINGUAL PLATE OF MANDIBLE WITH A MEAN POSITION OF 2.28MM(±0.9)BELOW THE CREST & 0.58MM(=/-(0.9) MEDIAL TO CREST - KIESSELBACH & CHAMBERLAIN

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15% OF CASES SHOWS IT LIES SUPERIOR TO LINGUAL PLATE CADAVERIC STUDIES SHOWED THAT IT LIES 3.45MM MEDIAL TO ALVEOLAR CREST & 8.32MM BELOW MRI STUDY DEMONSTRATED THAT THE NERVE IS LOCATED AT A

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MEAN DISTANCE OF 2.53MM MEDIAL TO AND 2.75MM BELOW ALVEOLAR CREST

INFERIOR ALVEOLAR NERVE • •

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THE MANDIBULAR NERVE RUNS FROM THE TRIGEMINAL GANGLION THROUGH THE FORAMEN OVALE DOWN TOWARDS THE MANDIBLE THE NERVE ENTERS THE MANDIBLE THROUGH THE MANDIBULAR FORAMEN ON THE MEDIAL SURFACE OF THE ASCENDING MANDIBULAR RAMUS AFTER PASSING THROUGH THE MANDIBULAR FORAMEN, THE NERVE IS CALLED THE INFERIOR ALVEOLAR NERVE WITHIN THE MANDIBULAR CANAL, THE IAN RUNS FORWARDS IN COMPANY WITH THE INFERIOR ALVEOLAR ARTERY AND TOGETHER THEY ARE CALLED THE INFERIOR ALVEOLAR NEUROVASCULAR BUNDLE.

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DIFFERENT VARIATIONS IN THE COURSE OF THE INFERIOR ALVEOLAR NEUROVASCULAR BUNDLE ARE DESCRIBED BY THE CLASSIFICATION BY CARTER AND KEEN (1971) HIGH MANDIBULAR CANALS (WITHIN 2MM OF THE APICES OF THE FIRST AND SECOND MOLARS), 47% INTERMEDIATE MANDIBULAR CANALS 3% LOW MANDIBULAR CANALS 49% OTHER VARIATIONS – THESE INCLUDED DUPLICATION OR DIVISION OF THE CANAL, APPARENT PARTIAL OR COMPLETE ABSENCE OF THE CANAL OR LACK OF SYMMETRY. DUPLICATION OR DIVISION 0,9% BIFURCATION 0.08% NO CASES OF MULTIPLE CANALS IN ORTHOGNATHIC SURGICAL CASES HAVE BEEN REPORTED.

INFERIOR ALVEOLAR VESSELS •

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A BRANCH OF MAXILLARY ARTERY DESCENDING WITH ITS CORRESPONDING VEIN AND NERVE AND FORMING A NEUROVASCULAR BUNDLE SUPPLIES THE TEETH OF THE MANDIBLE,GINGIVAE,AND THE SKIN OVER THE CHIN AND LOWER LIP NEAR ITS ORIGIN THE INFERIOR ALVEOLAR ARTERY GIVES OFF A LINGUAL BRANCH WHICH DESCENDS WITH THE LINGUAL NERVE AND SUPPLIES THE MUCOUS MEMBRANE OF THE MOUTH. OPPOSITE THE FIRST PREMOLAR TOOTH DIVIDES INTO TWO BRANCHES THE INCISIVE AND MENTAL

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VARIATIONS OF THE INFERIOR ALVEOLAR ARTERY ARE QUITE RARE TWO REPORTS OF THE INFERIOR ALVEOLAR ARTERY ARISING FROM THE EXTERNAL CAROTID MANDIBULAR REGION SHOULD BE AWARE OF SUCH A VARIATION IN THE ARTERIAL ARCHITECTURE. IT HAS BEEN REPORTED THAT THE INFERIOR ALVEOLAR ARTERY ORIGINATING FROM EXTERNAL CAROTID ARTERY 3.5CM INFERIOR TO ITS TERMINAL BIFURCATION INTO THE MAXILLARY AND SUPERFICIAL TEMPORAL ARTERIES THIS VESSEL WAS FOUND TO COURSE ANTERIORLY DEEP TO THE RAMUS OF MANDIBLE AND SUPERFICIALLY TO THE LATERAL PTERYGOID MUSCLE THIS VARIATION OF THE INFERIOR ALVEOLAR ARTERY MAY PREDISPOSE A PATIENT TO INCREASED MORBIDITY DURING INFERIOR ALVEOLAR NERVE BLOCK.

RETROMANDIBULAR VESSELS THE RETROMANDIBULAR VEIN IS LOCATED ALONG THE POSTERIOR EDGE OF THE MANDIBLE BLOOD FROM THE PTERYGOID PLEXUS JOINS WITH THE MAXILLARY VEINS JUST DEEP TO THE MANDIBLE. THE SUPERFICIAL TEMPORAL VEIN AND MAXILLARY VEINS COMBINE INTO THE RETROMANDIBULAR VEIN WHICH RUNS POSTERIOR TO THE MANDIBLE. RUNS INFERIORLY AND DRAINS INTO THE INTERNAL AND EXTERNAL JUGULAR VEINS.

TEMPORALIS TENDON INSERTION THE TEMPORALIS MUSCLE IS A BROAD, THICK MUSCLE ORIGINATES FROM THE TEMPORAL FOSSA OF THE SKULL AND THE DEEP SURFACE OF THE TEMPORAL FASCIA. THE FIBERS, DIVIDED INTO ANTERIOR, MIDDLE, AND POSTERIOR DIVISIONS, JOIN TOGETHER AS THEY DESCEND, PASSING DEEP TO THE ZYGOMATIC ARCH, INSERT AS A TENDON INTO THE CORONOID PROCESS OF THE MANDIBLE

PTERYGOMANDIBULAR SPACE  IT IS A TRIANGULAR NARROWING DOWN SPACE WHERE THE MEDIAL PTERYGOID CONVERGE WITH THE MANDIBLE TO WHICH IT IS ATTACHED  THE CONTENT OF THIS SPACE ARE THE LINGUAL NERVE IN FRONT,INFERIORALVEOLAR NERVE BEHIND AND POSTERIOR AND LATERALLY THE INFERIOR ALVEOLAR ARTERY AND VEINS  THE LINGUAL, INFERIOR ALVEOLAR NERVE ENTERS THIS SPACE FROM THE ROOF OF INFRATEMPORAL FOSSA  WHILE INSERTING THE NEEDLE INTO THIS SPACE ONE SHOULD AVOID INJURY TO THE MEDIAL PTERYGOID MUSCLE

 TENDINITIS IS SIMPLY AN INFLAMMATION OF THE INSERTION OF THE TEMPORALIS MUSCLE AT THE CORONOID PROCESS OF THE MANDIBLE.  TEMPORAL TENDINITIS INVOLVES INFLAMMATION OF THE TENDON WITH SUBSEQUENT SYMPTOMS AND REFERRED PAIN.  MAINLY CAUSED DUE TO PROLONGED OPENNING OF MOUTH AND TRAUMA  COMMONLY MANIFESTED BY PAIN AT THE ATTACHMENT OF THE TENDON  NORMALLY RESOLVES IN 5 TO 10 DAYS

FACIAL ARTERY  WHERE THE FACIAL ARTERY CROSSES THE LEVEL OF INFERIOR VESTIBULAR FORNIX IN THE REGION OF 1ST MANDIBULAR MOLAR  THE ARTERY CAN BE SEVERED ACCIDENTALLY DURING SURGICAL PROCEDURE  HENCE DEEP INCISIONS IN 1ST MOLAR AREA PREDISPOSE A RISK OF INJURING FACIAL ARTERY  TO AVOID THE INCISION SHOULD BE MADE DOWNWARD AND INWARD INSTEAD OF STRAIGHT DOWNWARD

SUBLINGUAL GROOVE  IT EXTENDS AS A HORSHOE SHAPED AREA UNDER THE LATERAL EDGES AND BELOW THE TONGUE  EXTENDS INTO THE DEPTH BETWEEN THE MYLOHYOID AND GENIOHYOID MUSCLE  THE GROOVE IS FILLED WITH LOOSE AND FATTY CONNECTIVE TISSUE AND SURROUNDING STRUCTURES CONTAINED IN THE SUBLINGUAL SPACE  STRUCTURES ARE SUBLINGUAL GLAND SUBMANDIBULAR DUCT LINGUAL & HYPOGLOSSAL NERVES SUBLINGUAL ARTERY WITH VEINS SOMETIMES POSTERIOR PART OF SUBMANDIBULAR GLAND

RETROMOLAR TRIANGLE  A TRIANGULAR AREA NEAR THE DISTAL OF THE LAST MOLAR  FORMED BY THE FORK IN THE TEMPORAL CREST LOCATED IN THE INTERNAL FACE OF MANDIBULAR RAMUS AND DISTAL FACE OF THE LAST MOLAR  THIS AREA BONE IS PERFORATED BY NUMEROUS HOLES DESCRIBING THE PASSAGE OF BRANCHES OF BUCCAL ARTERY  HERE THE BUCCAL ARTERY ANASTOMOSE WITH THE INFERIOR ALVEOLAR NEUROVASCULAR BUNDLE  HENCE CREATING A COMMUNICATION BETWEEN THE MANDIBULAR CANAL AND THE RETROMOLAR TRIANGLE

BUCCAL APPROACH VS LINGUAL APPROACH  BUCCAL APPROACH ADVANTAGES MORE TRADITIONAL EASY TO GET THE TOOTH WHEN PATIENT IS CONCIOUS NO DAMAGE TO LINGUAL PERIOSTEUM BOTH CHISEL&BURS CAN BE USED DISADVANTAGES THICK BUCCAL PLATE MORE P.O OEDEMA INCIDENCE OF DRY SOCKET IS HIGHER

LINGUAL APPROACH ADVANTAGES EASIER THAN BUCCAL LESS TIME CONSUMING LESS P.O OEDEMA DRY SOCKET INCIDENCE IS NEGLIGIBLE DISADVANTAGES DIFFICULT TECHNIQUE IN CONSIOUS PATIENT ONLY CHISEL&MALLET TO BE USED CHANCE OF LINGUAL NERVE INJURY SLIIPING OF TOOTH INTO LINGUAL POUCH

SURGICAL PROCEDURE FIVE BASIC STEPS  ADEQUATE EXPOSURE  ACCESS TO THE TOOTH  SECTIONING OF THE TOOTH(OPTIONAL)  ELEVATION FROM THE ALVEOLAR PROCESS  DEBRIDMENT & IRRIGATION

ADEQUATE EXPOSURE  SEVERAL DIFFERENT FLAP TECHNIQUES HAVE BEEN DEVELOPED, AND DISCUSSED TO MINIMIZE POTENTIAL PERIODONTAL COMPLICATIONS TO ADJACENT SECOND MOLAR OR IMPROVE SURGICAL ACCESS.

TYPES OF INCISIONS AND FLAPS L-SHAPED FLAP BAYONET FLAP(WARDS INCISION) THREE CORNERED FLAP(MODIFIED WARDS INCISION) ENVELOPE FLAP COMMA SHAPED INCISION/FLAP VESTIBULAR TONGUE SHAPED FLAP GROOVES AND MOORE FLAPS

L-SHAPED FLAP  THE ANTERIOR LIMB IS THE VESTIBULAR EXTENSION AT THE LEVEL OF 2ND MOLAR  IT CAN BE EXTENDED UPTO 1ST MOLAR  RISK OF DAMAGING FACIAL VESSELS  THE VERTICAL RELIEVING INCISION DIFFERENTIATE IT FROM WARDS INCISION  THIS RELIEVING INCISION IS GIVEN AT 45O ANGLE TO THE LONG AXIS OF THE 2ND MOLAR AND RUNS STRAIGHT ANTERIORLY AND DOWNWARDS  IT TOTALLY COMMITS AN OPERATOR TO A BUCCAL APPROACH

BAYONET FLAP  IT HAS THREE PARTS ANTERIOR INTERMEDIATE OR GINGIVAL DISTAL  ALSO KNOWN AS WARDS INCISION  ANTERIORLY IT EXTENDS AROUND THE GINGIVAL MARGIN OF II MOLAR AND EVEN THE I MOLAR BEFORE TURNING INTO THE SULCUS USUALLY ANGLED FORWARD  OVER EXTENSION OF THE INCISION INTO THE SULCUSMAY CAUSE BRISK OOZING OF BLOOD FROM VENOUS PLEXUS  CAN BE AVOIDED BY MAKING THE ANTERIOR PART MORE OBLIQUE  INTERMEDIATE IS ALONG THE GINGIVA  DISTALLY IT IS PLACED MORE LINGUALLY OVER THE IMPACTED TOOTH BUT LATERALLY TOWARDS THE ASCENDING RAMUS  MORE DIFFICULT THE IMPACTION MORE LINGUALLY PLACED  IT JOINS THE GINGIVAL MARGIN OF THE II MOLAR FROM THE LINGUAL TO THE BUCCAL SIDE

THREE CORNERED FLAP MODIFIED WARDS INCISION LARGER LAYER OF MUCOPERIOSTEAL FLAP USUALLY FOR DEEPLY IMPACTED MOLARS THE ANTERIOR PART SHOULD COMMENCE AT THE DISTOBUCCAL CORNER OF 1ST MOLAR INSTEAD OF 2ND MOLAR  EXTENDS VERTICALLY DOWNWARDS AND THEN CURVED ANTERIORLY  FOLLOWED BY GINGIVAL CREVICULAR INCISION ALONG THE 2ND MOLAR  DISTALLY IT IS SIMILAR TO WARDS INCISION    

ENVELOPE FLAP  EXTENDS FROM MESIAL PAPILLA OF THE 1ST MOLAR AROUND THE NECKS OF THE TEETH TO THE DISTOBUCCAL LINE ANGLE OF THE 2ND MOLAR  THEN EXTENDS POSTERIORLY AND LATERALLY UP TO THE ANTERIOR BORDER OF THE MANDIBLE  IT SHOULD NOT CONTINUE POSTRIORLY IN A STRAIGHT LINE BECAUSE THE MANDIBLE DIVERGE LATERALLY  EASIER TO CLOSE AND BEST HEALING  IN 1971, SZMYD DESCRIBED THIS INCISION

COMMA SHAPED INCISION PROVIDES LAREG ACCESS INDICATED IN CASE DEEP HORIZONTAL IMPACTIONS PERIODONTAL POCKETING DISTAL TO 2ND MOLAR IS LESS

VESTIBULAR TONGUE SHAPED FLAP • • • • • •

BERWICK, IN 1966, DESIGNED A VESTIBULAR TONGUE-SHAPED FLAP EXTENDED ONTO THE BUCCAL SHELF OF THE MANDIBLE INCISION LINE DID NOT LIE OVER THE BONY DEFECT CREATED BY THE REMOVAL OF THE IMPACTED TOOTH ITS BASE AT THE DISTOLINGUAL ASPECT OF THE SECOND MOLAR MAGNUS ET AL WITH THE SAME AIM, DESCRIBED A PARAGINGIVAL FLAP IN WHICH THE ANTERIOR RELEASING INCISION IS LOCATED 0.5 CM APICAL TO THE GINGIVAL MARGIN OF THE SECOND AND FIRST MOLARS

GROVES AND MOORE  IN THE YEAR 1970 THEY DESIGNED THREE FLAPS  RELATED TO INVOLMENT OF THE GINGIVAL MARGIN OF 2ND MOLAR  THE TWO FLAPS THAT DID NOT INVOLVED THE GINGIVAL MARGIN OF THE 2ND MOLAR  PRODUCED AN APPARENT DECREASE IN POCKETING DISTAL TO 2ND MOLAR

ACCESS TO THE IMPACTED TOOTH  IT IS ACHIEVED BY REMOVAL OF OVERLYING BONE  THE BONE ON THE OCCLUSAL,BUCCAL ,DISTAL ASPECT DOWN TO THE CERVICAL LINE OF THE IMPACTED TOOTH SHOULD BE INITIALLY REMOVED  AMOUNT OF REMOVAL DEPANDS ON DEPTH OF THE TOOTH MORPHOLOGY OF ROOT ANGULATION OF TOOTH BONE REMOVAL CAN BE DONE BY CHISELS DRILLS

CHISEL AND MALLET  TRADITIONAL TECHNIQUE,  SUPPORT OF MANDIBLE IS MANDATORY  THE CHISEL IS KEPT PARALLEL TO THE LONG AXIS OF BONE  INDICATIONS YOUNG PATIENTS AN EXTERNAL OBLIQUE RIDGE SLIGHTLY BELOW THE LEVEL OF BONE ENCLOSING THE 3RD MOLAR AN EXTERNAL OBLIQUE RIDGE THAT IS SLIGHTLY BEHIND THE 3RD MOLAR SO THAT THE DISTOLINGUAL CORNER OF THE TOOTH SITS IN A THIN BALCONY OF BONE

 THE CHISEL IS KEPT PARALLEL TO THE LONG AXIS OF BONE  A VERTICAL LIMITING CUT IS MADE AT THE DISTAL ASPECT OF THE 2ND MOLAR WITH CHISEL BEVEL FACING POSTERIORLY  THE LIMITING CUT IS THEN TURNED INTO A VERTICAL GROOVE  THEN THE CHISEL IS PLACED AT 45O ANGLE TO THE LOWER EDGE OF LIMITING CUT IN AN OBLIQUE DIRECTION

 A TRINGULAR PIECE OF BUCCAL PLATE DISTAL TO 2ND MOLAR IS THEN REMOVED  THE DISTAL BONE IS THEN REMOVED IF REQUIRED  THE BONY CUT CAN BE ENLARGED TO UNCOVER THE TOOTH  ELEVATOR IS THEN PLACED AT THE JUCTION OF VERRTICAL LIMITING CUT AND OBLIQUE BONE CUT

LOW SPEED ENGINE DRIVEN DRILLS  INDICATIONS OLD PATIENTS AN EXTERNAL OBLIQUE RIDGE AND INTERNAL OBLIQUE RIDGE OR BOTH ARE FAR FORMED IN RELATIONSHIP TO THE TOOTH HENCE GUTTERING IS NECESSARY TO AVOID EXCESS REMOVAL OF BONE

COMPLICATIONS ACCIDENTAL DENUDEING OF ROOTS OF 2ND MOLAR WHILE GUTTERING THE BONE THE MANDIBULAR CANAL MAY BE OPENED AND DAMAGE TO NERVE MAY OCCUR WHILE CUTTING DISTOLINGUAL SPUR OF BONE HIGH CHANCE OF LINGUAL NERVE DAMAGE HENCE IT SHOULD BE MOVED LINGUAL TO BUCCAL TO PREVENT SUDDEN SLIPPING INTO LINGUAL SIDE

BUCCAL BONE GUTTERING  BEGINS AT THE MESIOBUCCAL LINE ANGLE OF THE 3RD MOLAR  INITIAL BONE CUT IS MADE VERTICALLY DOWN TO EXPOSE THE HEIGHT OF COVEXITY OF THE 3RD MOLAR  THE BUR IS PASSED DISTALLY AT THIS DEPTH TO THE DISTOBUCCAL LINE ANGLE  THEN LINGUALLY AROUND THE DISTAL SURFACE  IF TOOTH CANNOT BE DELIVERED THEN AGAIN BUR IS USED TO INCREASE THE DEPTH OF OSSISECTION TO THE LEVEL OF BIFURCATION

 INITIALLY HOLES ARE DRILLED AT A DISTANCE OF 45MM FROM EACH OTHER AROUND THE BUCCAL ASPECT (FROM THE MESIOBUCCAL LINE ANGLE TO THE DISTOBUCCAL LINE ANGLE OF THE TOOTH)  LARGE ROUND NO-8 BUR IS PREFFERED  THESE HOLES ARE THEN JOINED WITH A FLAT FISSURE BUR NO.701,702 DOWN TO THE CERVICAL MARGIN OF TOOTH  THIS PROVIDES ACCESS FOR ELEVATORS TO GAIN PURCHASE POINT AND A PATHWAY FOR DELIVERY OF TOOTH  THE BONE CUTTING SHOULD BE DONE WITH A CONTINOUS JET OF NORMAL SALINE

SECTIONING OF THE TOOTH  IT ALLOWS PORTIONS OF THE TOOTH TO BE REMOVED SEPERATELY

 DEPANDS PRIMARILY ON ANGULATION OF THE TOOTH UNFAVOURABLE ROOT PATTERN TO PROTECT IMPORTANT STRUCTURES

ADVANTAGES THE INCISION IS LESS EXTENSIVE OPERATION FIELD CAN BE KEPT SMALL LESS POST OPERATIVE SWELLING LESS BONE REMOVAL FORCEFUL ELEVATION OF TOOTH IS NOT NEEDFUL NO DAMAGE TO ADJACENT TOOTH RISK OF FRACTURE IS MINIMISED

DISADVANTAGES TEETH WITH SHALLOW GROOVES DIFFICULT TO SPLIT DIFFICULT TO CONTROL THE LINE OF SPLITING WITH CHISEL SPLITING DAMAGE TO SOFT TISSUE MAY BE CAUSED PATIENT MAY FIND IT INCONVENIENT  IT CAN BE ACHIEVED WITH CHISELS DRILLS

CRITERIA TO DECIDE SECTIONING OF TOOTH THIS CRITERIA DECIDES WHETHER THE TOOTH IS LOCKED OR NOT A LINE IS DRAWN FROM THE MESIOLINGUAL CUSP TILL THE DISTAL ROOT THE DISTANCE IS THEN MEASURED HALF THE DISTANCE IS TAKEN AS THE RADIUS AN ARC IS DRAWN IF THE ARC TOUCHES THE 2ND MOLAR INDICATES LOCKING OF TOOTH SECTIONING IS MANDATORY

ELEVATION FROM THE ALVEOLAR PROCESS  IT CAN BE DONE WITH DENTAL ELEVATORS  IN MANDIBLE THE MOST FREQUENT ELEVATOR USED IS STRAIGHT ELEVATOR,PAIRED CRYER  CAREFUL APPLICATION OF FORCE SHOULD BE DONE IN ORDER TO AVOID FRACTURE OF BUCCAL BONE,ADJECENT TOOTH AND SOMETIME ENTIRE MANDIBLE  THE ELEVATORS SHOULD BE PROPERLY ENGAGED TO THE TOOTH OR TOOTH-ROOT AND FORCE SHOULD BE DELIVERED IN PROPER DIRECTION

DEBRIDMENT AND IRRIGATION AFTER REMOVAL OF TOOTH ALL PARTICULATE BONE CHIPS AND DEBRIS SHOULD BE DEBRIDED THOROUGH IRRIGATION WITH STERILE SALINE INCLUDING UNDER THE REFLECTED SOFT TISSUE FLAP A PERIAPICAL CURETTE CAN BE USED A BONE FILE CAN BE USED TO SMOOTHEN ANY SHARP,ROUGH EDGE OF BONE A HEMOSTAT CAN BE USED TO REMOVE ANY REMNANT OF DENTAL FOLLICLE CLOSURE OF THE FLAP SHOULD BE DONE BY PRIMARY SUTURES

REMOVAL OF MESIOANGULAR IMPACTED III MOLAR TOOTH DIVISION IS NECESSARY IF THE TOOTH IS BISSECTED AT NECK ENAMEL IS VERY THIN LOWER POSITION DISTAL HALF OF THE CROWN IS SECTIONED OFF AT THE BUCCAL GROOVE JUST BELOW THE CERVICAL LINE POSITION OF ELEVATOR UNDER CEMENTO ENAMEL JUNCTION ON MESIAL SURFACE TOOTH IS MOVED UPWARD AND BACKWARD AS FAR AS DISTAL RIM OF BONE WILL ALLOW UPWARD MOVEMENT OF ROOTS

REMOVAL OF DISTOANGULAR IMPACTED III MOLAR  A DISTOANGULAR POSITION BRINGS THE III MOLAR WELL UNDER THE ASCENDING RAMUS  FREQUENTLY DISTALLY CURVED ROOTS ARE ENCOUNTERED  AFTER SUFFICIENT BONE REMOVAL, THE CROWN IS SECTIONED HORIZONTALLY FROM THE ROOTS JUST ABOVE THE CERVICAL LINE  THE ENTIRE CROWN IS FIRST REMOVED  IF ROOTS IF FUSED THEN A ELEVATOR CAN BE STRAIGHT USED TO ELEVATE THE ROOTS INTO THE SPACE PREVIOUSLY OCCUPIED BY THE CROWN  IF ROOTS ARE DIVERGENT SECTIONING OF ROOTS IS NECESSARY AND INDIVIDUAL REMOVAL  EXTRACTION OF THIS TYPE OF IMPACTION IS DIFFICULT,BECAUSE MORE DISTAL BONE HAS TO BE REMOVED AND THE TOOTH TENDS TO BE ELEVATED DISTALLY AND INTO THE RAMUS PORTION OF THE MANDIBLE

REMOVAL OF VERTICALLY IMPACTED III MOLAR  PROCEDURE OF BONE REMOVAL AND TOOTH SECTIONING IS SIMILAR TO MESIOANGULAR IMPACTION  TOOTH SECTIONED VERTICALLY  DISTAL PART REMOVED FIRST,FOLLOWED BY THE MESIAL HALF  IT IS MORE DIFFICULT THAN MESIOANGULAR IMPACTION BECAUSE THE ACCESS AROUND II MOLAR IS LESS AND REQUIRES MORE REMOVAL OF BONE ON THE BUCCAL AND DISTAL SIDES

REMOVAL OF HORIZONTALLY IMPACTED III MOLAR  REQUIRES MAXIMUM BONE REMOVAL  BONE SHOULD BE REMOVED DOWN TO THE CERVICAL LINE TO EXPOSE THE SUPERIOR ASPECT OF THE DISTAL ROOT AND THE MAJORITY OF BUCCAL SURFACE OF CROWN  SUPERIOR(DISTAL) AND INFERIOR(MESIAL) CUSP SECTIONED  SUPERIOR CROWN IS REMOVED FIRST  FOLLOWED BY BULK OF TOOTH AND THEN THE INFERIOR CROWN FRAGMENT  IF SUFFICIENT SPACE IS NOT AVAILABLE THEN A SPLIT IS MADE NEAR THE ANATOMIC NECK OF TOOTH  IF DIVERGENT ROOTS THEN SPITTING OF ROOTS IS NECASSERY  AND THEN EACH ROOT IS DELIVERED INDIVIDUALLY

REMOVAL OF BUCCOANGULAR OR LINGULAR IMPACTED III MOLARS    

NOT SO COMMON TOOTH IS SECTIONED HORIZONTALLY AT THE CERVICAL REGION CROWN IS FIRST DELIVERED FOLLOWING ROOTS IN CASE OF LINGUOANGULAR IMPACTION RETRACTION OF THE LINGUAL MUCOSA IS IMPORTANT

LINGUOANGULAR

BUCCOANGULAR

AMOUNT OF BONE REMOVAL,POINT OF ELEVATION AND OTONTOTOMIES OF IMPACTED 3RD MOLARS

LINGUAL SPLIT-BONE TECHNIQUE  DEVELOPED BY FRY ORIGINALLY DESCRIBED BY WARD IN 1956  USED TO REMOVE IMPACTED 3RD MOLARS IN ALL POSITION PROVIDED THEY ARE NOT BUCCOVERSION  USEFUL IN REMOVING DEEPLY POSITIONED HORIZONTAL AND DISTOANGULAR IMPACTED 3RD MOLARS  IT INVOLVES SPLITTING THE LINGUAL CORTEX AND ELEVATING THE TOOTH IN DISTOLINGUAL DIRECTION  THE INCISION STARTS IN THE BUCCAL SULCUS AT ABOUT THE JUNCTION OF MIDDLE AND POSTERIOR 3RD OF THE 2ND MOLAR AND PASSING UPWARD TO THE GINGIVAL MARGIN AT THE DISTAL ASPECT OF THAT TOOTH  FROM THIS POINT THE INCISION COURSE BEHIND THE 2ND MOLAR TO THE MIDDLE OF ITS POSTERIOR SURFACE AND THEN DISTOBUCCALY UP THE RAMUS TOWARDS THE CHEEK  IF GREATER ACCESS IS NEEDED THE ANTERIOR ND OF THE INCISION CAN BEGIN IMMEDIATELY DISTAL TO THE FIRST MOLAR

 AFTER THE BUCCAL FLAP IS RAISED THE LINGUOOCLUSAL TISSUE IS ELEVATED  A RETRACTOR IS PLACED UNDER THE LINGUAL FLAP TO PROVIDE EXPOSURE OF THE SURGICAL SITE AND TO PROTECT THE LINGUAL NERVE  A VERTICAL STOP OF ABOUT 5MM IN HEIGHT IS MADE WITH A CHISEL IN THE BUCCAL CORTEX IMMEDIATELY DISTAL TO THE 2ND MOLAR  A SECOND VERTICAL STOP IS MADE ABOUT 4MM DISTOBUCCAL TO THE 3RD MOLAR  THE TWO CUTS ARE THEN JOINED AND THE BUCCAL PLATE COVERING THE CROWN IS REMOVED  ANY BONE OVER THE SUPERIOR ASPECT OF CROWN IS REMOVED\  NOW THE CHISEL IS INSERTED ON THE INSIDE OF THE LINGUAL PLATE AT AN ANGLE OF 45 DEGREES TO THE UPPER BORDER WITH ITS CUTTING EDGE PARALLEL TO EXTERNAL OBLIQUE LINE WITH THE BEVEL FACING LINGUALLY  A LIGHT TAP WITH A MALLET SPLITS OFF A PORTION OF THE LINGUAL CORTEX WHICH IS THEN REMOVED  ONCE LINGUAL BONE IS REMOVED,THE TOOTH CAN BE REMOVED BY APPLICATION OF ELEVATOR FROM THE BUCCAL ASPECT

LINGUAL SPLIT BONE TECHNIQUE BY LEWIS  FLAP IS DESIGNED SUCH THAT BONE BODY ATTACHED TO THE FLAP IS PRESERVED  FLAP IS RAISED LINGUAL TO II MOLAR AND NOT THE IIIMOLAR  VERTICAL LINGUAL STEP CUT IS GIVEN JUST DISTAL TO THE II MOLAR  LINGUAL PLATE IS HINGED AS AN OSTEOMUCOPERIOSTEAL FLAP  LESS TISSUE TRAUMA THAN OTHER ACCEPTED TECHNIQUE  ASSISTS IN PRIMARY WOUND CLOSURE,  OBLITERATION OF DEAD SPACE,

LATERAL TREPHINATION TECHNIQUE           

PROPHYLACTIC REMOVAL OF DEVELOPING 3RD MOLAR AGE GROUP 10 TO 16 YRS BEFORE CALCIFIED CUSPS ARE UNITED A MODIFIED S-SHAPED INCISION IS MADE FROM RETROMOLAR FOSSA ACROSS THE EXTERNAL OBLIQUE RIDGE THEN IT CURVES DOWN ALONG THE MUCOUS MEMBRANE ABOVE THE VESTIBULE EXTENDING UPTO 1ST MOLAR LEAVING BEHIND 5MM CUFF OF ATTACHED MUCOSA AT THE DISTOBUCCAL REGION OF 2ND MOLAR THE BUCCAL CORTICAL PLATE IS TREPHINED OVER 3RD MOLAR THEN VERTICAL CUTS ARE MADE ANTERIORLY AND POSTERIORLY THESE CUTS ARE JOINED AND BUCCAL PLATE IS FRACTURED OUT EXPOSING 3RD MOLAR CRYPT COMPLETELY ELEVATOR THEN APPLIED TO DELIVER THE TOOTH

COMPLICATIONS  INTRAOPERATIVE  DURING INCISION FACIAL OR BUCCAL VESSEL MAY BE CUT LINGUAL NERVE INJURY RETROMOLAR VESSELS

 DURING BONE REMOVAL DAMAGE TO SECOND MOLAR AND ROOTS FRACTURE OF MANDIBLE BLEEDING

 DURING ELEVATION CROWN FRACTURE ROOT FRACTURE FRACTURE OF THE JAWS SLIPPING OF TOOTH INTO LINGUAL POUCH DAMAGE TO NERVE ASPIRATION OF THE TOOTH

 DURING DEBRIDEMENT DAMAGE TO INFERIOR ALVEOLAR NERVE

 POSTOPERATIVE            

PAIN SWELLING/EDEMA HEMATOMA BLEEDING TRISMUS INFECTION DRY SOCKET TMJ PAIN PARAESTHESIA SENSITIVITY LOSS OF VITALITY POCKET FORMATION

INCIDENCE OF NERVE INJURY  LINGUAL NERVE-0-23%  INFERIOR ALVEOLAR NERVE-0.4-8.4% CLINICAL MANIFESTATIONS OF NERVE INJURY ANAESTHESIA OR HYPOESTHESIA FOR MORE THAN 3 MONTHS TONGUE , LIP & CHEEK BITING ALTERED MASTICATION & TASTE TRIGGERING,SIGNS(TINGLING,ELECTRIC SENSATION OVER THE INJURED SITE THAT DOES NOT EXTEND DISTALLY) NO OR MINIMAL RESPONSE TO INSTRUMENTATION ABSENCE IN THE DETECTION OF SHARP, DULL, MOVING TACTILE STIMULI & TWO POINT DISCRIMINATION INCREASE IN HOT OR COLD TEMPERATURE THRESHOLD

CAUSES FOR LINGUAL NERVE INJURY • • • •

CLUMSY INSTRUMENTATION POOR FLAP DESIGN FRACTURE OF LINGUAL PLATE RAISING & RETRACTING MUCOPERIOSTEAL FLAP VARIATION IN LINGUAL NERVE POSITION

PREVENTION OF LINGUAL NERVE DAMAGE  USE OF BROAD LINGUAL RETRACTOR  BUCCAL APPROACH WITHOUT A LINGUAL RETRACTOR SHOULD BE THE STANDARD APPROACH  AVOIDING LINGUAL FLAP RETRACTION  USE OF SMALL 10MM MALLEABLE RETRACTOR  SPLITTING WITH BUR RATHER THAN USING LINGUAL SPLIT TECHNIQUE

MANAGEMENT OF LINGUAL NERVE DAMAGE  SURGICAL TREATMENT SHOULD BE UNDERTAKEN AFTER 3MONTHS TO LOCATE & SUTURE THE NERVE  WHILE SUTURING CARE MUST BE TAKEN TO AVOID INTERPOSITION OF NON NERVOUS TISSUE  NONOPERATIVE TREATMENT – CORTICOSTEROID  CHANCES OF NEUROMA.

CAUSES OF INFERIOR ALVEOLAR NERVE INJURY  DEEPLY PLACED IMPACTED MOLAR  MESIOANGULAR & HORIZONTAL IMPACTION  SURGICAL TECHNIQUE USING BUR CONDITIONS FAVOURING NERVE INJURY INTERUPTION OF WHITE LINE OF CANAL DEFLECTION OF ROOT DIVERSION OF CANAL DARK &RIGID APEX OF ROOT NARROWING OF CANAL NARROWING OF ROOT

 MANDIBLE FRACTURE • RARE • DEEPLY IMPACTED THIRD MOLAR IN OLDER INDIVIDUAL WITH DENSE BONE • USE OF EXCESSIVE PRESSURE WITH ELEVATORS • SHOULD PERFORM IMMEDIATE REDUCTION AND FIXATION OF FRACTURE. INJURY TO ADJACENT TEETH •DAMAGE TO FILLINGS AND ADJACENT TEETH, • DAMAGE TO BRIDGEWORK OR TO SURROUNDING BONE CAN OCCUR DURING THE REMOVAL OF IMPACTED WISDOM TEETH.

DISPLACEMENT INTO LINGUAL POUCH  INDEX FINGER IN THE LINGUAL ASPECT  MOBILIZE THE TOOTH TOWARDS SOCKET  CAREFULLY ELEVATE THE TOOTH

 TMJ PAIN • TMJ DYSFUNCTION FOLLOWING THE REMOVAL OF WISDOM TEETH IS UNUSUAL AND USUALLY TEMPORARY. • IF TREATMENT IS REQUIRED, IT IS USUALLY CONSERVATIVE IN NATURE AND INCLUDES ANTIINFLAMMATORY MEDICINES, PHYSICAL THERAPY AND IN SOME CASES SHORT TERM BITE SPLINT THERAPY.

PAIN  USUALLY REACHES MAXIMUM DURING FIRST 12 TO 24 HOURS POSTOPERATIVELY.  NSAIDS BEFORE SURGERY MAY OR MAY NOT BE BENEFICIAL  MOST IMPORTANT DETERMINANT OF AMOUNT OF POST OPERATIVE PAIN IS THE LENGTH OF OPERATION.  THERE IS A STRONG CORRELATION BETWEEN POST OPERATIVE PAIN AND TRISMUS

 EDEMA  USE OF CORTICOSTEROIDS.  ICE – MAY BE COMFORTING BUT HAS LITTLE EFFECT ON SIZE OF SWELLING.  SWELLING REACHES MAXIMUM BY END OF SECOND POST OPERATIVE DAY AND RESOLVED BY 5TH TO 7TH DAY.

 TRISMUS  USE OF CORTICOSTEROIDS.  MINIMAL FLAP REFLECTION  CAREFUL PLACEMENT OF MOUTH PROP  LENGTH OF SURGERY  REACHES MAXIMUM BY SECOND POST OPERATIVE DAY AND RESOLVED BY END OF FIRST WEEK. INFECTION  INCIDENCE BETWEEN 2-3%  50% ARE LOCALIZED SUBPERIOSTEAL ABSCESS WHICH OCCUR 2-4 WEEKS AFTER USUALLY CAUSED BECAUSE DEBRIS UNDER THE FLAP DEBRIDEMENT AND ANTIBIOTICS.

 BLEEDING  USE GOOD SURGICAL TECHNIQUE, MINIMIZE TRAUMA, AVOID TEARS OF FLAPS.  MOST EFFECTIVE MEASURE TO ACHIEVE HEMOSTASIS IS VIA MOIST GAUZE PRESSURE OVER WOUND.  APPLICATION OF TOPICAL THROMBIN ON GELFOAM INTO SOCKET AND OVERSUTURING.  OTHER HEMOSTATICS: OXIDIZED CELLULOSE (OXYCEL OR SURGICEL), MICROFIBRILLAR COLLAGEN (AVITENE).  PATIENTS WITH ACQUIRED OR CONGENITAL COAGULOPATHY MAY NEED BLOOD PRODUCT REPLACEMENT.

 ALVEOLAR OSTEITIS (DRY SOCKET)

• INCIDENCE BETWEEN 3% AND 25%. • INCIDENCE APPEARS HIGHER IN SMOKERS AND FEMALES TAKING ORAL CONTRACEPTIVES. • PATHOGENESIS NOT ABSOLUTELY DEFINED BUT MOST LIKELY RESULT OF LYSIS OF FULLY FORMED BLOOD CLOT BEFORE THE CLOT IS REPLACED WITH GRANULATION TISSUE. • THIS FIBRINOLYSIS OCCURS DURING THE 3RD – 4TH POST OPERATED DAY •GOAL OF TREATMENT IS RELIEF OF PAIN •IRRIGATION OF EXTRACTION SITE •PLACEMENT OF EUGENOL DRESSING •ANALGESICS •PAIN USUALLY RESOLVES WITHIN 3-5 DAYS BUT UP TO 10 TO 14 DAYS

 AIR EMBOLISM/ SUBCUTANEOUS EMPHYSEMA  A GAS RELATED EMBOLUS CAN BE CAUSED BY INADVERTENT INJECTION OF A MIXTURE OF AIR AND WATER UNDER PRESSURE  WHICH THEN PASSES INTO THE MANDIBLE (JAW) TO THE VEINS AND THEN TO THE LARGE VESSELS LEADING TO THE HEART.  LARGE AMOUNTS OF AIR CAN CAUSE SERIOUS PROBLEMS INCLUDING CARDIAC ARREST AND DEATH,  BY TRAVELING TO THE LARGE VEINS LEADING TO THE HEART, AND MECHANICALLY BLOCKING THE FLOW OF BLOOD THROUGH THE HEART.

CORTICOSTERIODS  INHIBITS PROSTAGLADIN SYNTHETASE  HENCE PREVENT THE INFLAMMATORY COMPLICATIONS OF REMOVAL OF 3RD MOLAR  HENCE REDUCES SWELLING AND PAIN  ABSOLUTE CONTRAINDICATED TUBERCULOSIS OCULAR HERPEX SIMPLEX ACUTE PSYCHOSIS  RELATIVE CONTRAINDICATION EARLY PREGNANCY

NSAID  BLOCKS PROSTAGLANDIN SYNTHESIS  LOKKEN IN 1980 INDICATED PARACETOMOL THOUGH NOT A PROSTAGLANDIN SYNTETASE BLOCKER BUT CAN BE EFFECTIVE IN REDUCING PAIN IN FIRST 24 HRS  IT ACTS BY ACCELERATINGTHE CONVERSION OF PROSTAGLANDIN G2  A PRIME FACTOR IN OEDEMA AND PAIN

CONCLUSION  EXTRACTION OF IMPACTED THIRD MOLAR NOT ONLY INCLUDES A PROPER TECHNIQUE WITH MAXIMUM CONSIDERATION FOR COMPLICATIONS  BUT ALSO THE EVALUATION OF THE PSHYCOLOGICAL FACT OF THE PATIENT UNCERTAINITY OF THE PROCEDURE  THE COMBINATION OF BOTH PATIENT PSHYCOLOGY AND SURGEON ABILITY WILL ONLY LEAD TO A SUCCESSFUL TREATMENT

REFERENCES TEXTBOOK OF OMFS BY PETERSON TEXTBOOK OF OMFS BY DANIEL M LASKIN THE IMPACTED LOWER WISDOM TOOTH BY GREGOR HUMAN ANATOMY BY DUTTA A JOURNAL ON NEUROSENSORY DISTURBANCE AFTER BILATERAL SAGITTAL SPLIT OSTEOTOMY BY LEENA YLIKONTIOLA  A RARE VARIATION OF THE INFERIOR ALVEOLAR ARTERY WITH POTENTIAL CLINICAL CONSEQUENCES BYAmir Afshin Khaki 1 ,R.SHANE TUBBS 2 ,MOHAMMADALI MOHAJEL SHOJA 1 ,GHAFFAR SHOKOUHI 1 ,RAMIN MOSTOFIZADEH FARAHANI  SIMPLIFIED SPLIT-BONE TECHNIQUE FOR REMOVAL OF IMPACTED MANDIBULAR THIRD MOLARS IN INTERNATIONAL JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY VOLUME 24, ISSUE 5, OCTOBER 1995,     