SURGICAL MANAGEMENT OF IMPACTED

MANDIBULAR III MOLARSAND

COMPLICATIONS

SURGICAL MANAGEMENT OF IMPACTED

MANDIBULAR III MOLARSAND

COMPLICATIONS

PRESENTED BY:

DR.SATYABRATA PATNAIK

1ST YR P.G

INTRODUCTIONINTRODUCTION

FACTORS THAT MAKE REMOVAL EASIERFACTORS THAT MAKE REMOVAL EASIER

SOFTTISSUE

IMPACTION

SEPRTATEDFROM

II MOLAR

LESSDENSE BONE

LARGEFOLLICE

WIDEPERIODONTAL

SPACE

FUSED CONICROOTS

ROOT 1/3RD TO

2/3RD

POSITION A

CLASS 1

MESIOANGULAR

FACTORS THAT MAKE REMOVAL DIFFICULTFACTORS THAT MAKE REMOVAL DIFFICULT

COMPLETEBONY

IMPACTION

CONTACT WITH

IIMOLAR

DENSEINELASTIC

BONE

THINFOLLICLE

NARROWPERIODONTAL

SPACE

DIVERGENTCURVEDROOTS

LONGTHIN

ROOTS

POSITION C

CLASS 3

DISTOANGULAR

ANATOMICAL CONSIDERATIONSANATOMICAL CONSIDERATIONS

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

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

LINGUAL NERVELINGUAL 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

• 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

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

• 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

• 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

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

INFERIOR ALVEOLAR NERVEINFERIOR ALVEOLAR NERVE

• 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.

• 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.

• 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.

• 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 VESSELSINFERIOR ALVEOLAR VESSELS

• 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

• 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

• 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 PREDIS- POSE A PATIENT TO INCREASED MORBIDITY DURING INFERIOR ALVEOLAR NERVE BLOCK.

• 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 PREDIS- POSE A PATIENT TO INCREASED MORBIDITY DURING INFERIOR ALVEOLAR NERVE BLOCK.

RETROMANDIBULAR VESSELSRETROMANDIBULAR VESSELS

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.

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.

THE RETROMANDIBULAR VEIN IS LOCATED ALONG THE POSTERIOR EDGE OF THE MANDIBLE

THE RETROMANDIBULAR VEIN IS LOCATED ALONG THE POSTERIOR EDGE OF THE MANDIBLE

TEMPORALIS TENDON INSERTIONTEMPORALIS TENDON INSERTIONTHE 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

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 SPACEPTERYGOMANDIBULAR 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

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

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 ARTERYFACIAL 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

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 GROOVESUBLINGUAL 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

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 TRIANGLERETROMOLAR 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

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 APPROACHBUCCAL APPROACH VS LINGUAL APPROACH BUCCAL APPROACH BUCCAL APPROACH

ADVANTAGESADVANTAGESMORE TRADITIONAL

EASY TO GET THE TOOTH

WHEN PATIENT IS CONCIOUS

NO DAMAGE TO LINGUAL PERIOSTEUM

BOTH CHISEL&BURS CAN BE USED

MORE TRADITIONAL

EASY TO GET THE TOOTH

WHEN PATIENT IS CONCIOUS

NO DAMAGE TO LINGUAL PERIOSTEUM

BOTH CHISEL&BURS CAN BE USED

DISADVANTAGESDISADVANTAGESTHICK BUCCAL PLATE

MORE P.O OEDEMA

INCIDENCE OF DRY SOCKET IS HIGHER

THICK BUCCAL PLATE

MORE P.O OEDEMA

INCIDENCE OF DRY SOCKET IS HIGHER

LINGUAL APPROACHLINGUAL APPROACH

ADVANTAGESADVANTAGESEASIER THAN BUCCAL

LESS TIME CONSUMING

LESS P.O OEDEMA

DRY SOCKET INCIDENCE IS NEGLIGIBLE

EASIER THAN BUCCAL

LESS TIME CONSUMING

LESS P.O OEDEMA

DRY SOCKET INCIDENCE IS NEGLIGIBLE

DISADVANTAGESDISADVANTAGESDIFFICULT TECHNIQUE IN CONSIOUS PATIENT

ONLY CHISEL&MALLET TO BE USED

CHANCE OF LINGUAL NERVE INJURY

SLIIPING OF TOOTH INTO LINGUAL POUCH

DIFFICULT TECHNIQUE IN CONSIOUS PATIENT

ONLY CHISEL&MALLET TO BE USED

CHANCE OF LINGUAL NERVE INJURY

SLIIPING OF TOOTH INTO LINGUAL POUCH

SURGICAL PROCEDURE SURGICAL PROCEDURE

ADEQUATE EXPOSURE ACCESS TO THE TOOTH SECTIONING OF THE TOOTH(OPTIONAL) ELEVATION FROM THE ALVEOLAR PROCESS DEBRIDMENT & IRRIGATION

ADEQUATE EXPOSURE ACCESS TO THE TOOTH SECTIONING OF THE TOOTH(OPTIONAL) ELEVATION FROM THE ALVEOLAR PROCESS DEBRIDMENT & IRRIGATION

FIVE BASIC STEPS

ADEQUATE EXPOSUREADEQUATE EXPOSURE

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

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

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 FLAPL-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

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 FLAPBAYONET 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

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 FLAPTHREE 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

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 FLAPENVELOPE 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

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 INCISIONCOMMA SHAPED INCISION

PROVIDES LAREG ACCESS

INDICATED IN CASE DEEP HORIZONTAL

IMPACTIONS

PERIODONTAL POCKETING DISTAL TO

2ND MOLAR IS LESS

PROVIDES LAREG ACCESS

INDICATED IN CASE DEEP HORIZONTAL

IMPACTIONS

PERIODONTAL POCKETING DISTAL TO

2ND MOLAR IS LESS

VESTIBULAR TONGUE SHAPED FLAPVESTIBULAR 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

• 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 MOOREGROVES 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

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 TOOTHACCESS 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

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 ONDEPTH OF THE TOOTH

MORPHOLOGY OF ROOT

ANGULATION OF TOOTHBONE REMOVAL CAN

BE DONE BY

CHISELS

DRILLS

CHISEL AND MALLETCHISEL AND MALLET TRADITIONAL TECHNIQUE, SUPPORT OF MANDIBLE IS MANDATORY THE CHISEL IS KEPT PARALLEL TO THE LONG AXIS OF BONE INDICATIONS

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

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

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

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 DRILLSLOW SPEED ENGINE DRIVEN DRILLS

INDICATIONS 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

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

COMPLICATIONSCOMPLICATIONS

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

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 GUTTERINGBUCCAL 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

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 4-5MM 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

INITIALLY HOLES ARE DRILLED AT A DISTANCE OF 4-5MM 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 TOOTHSECTIONING OF THE TOOTH IT ALLOWS PORTIONS OF THE TOOTH TO BE REMOVED

SEPERATELY

DEPANDS PRIMARILY ON

IT ALLOWS PORTIONS OF THE TOOTH TO BE REMOVED SEPERATELY

DEPANDS PRIMARILY ON

ANGULATION OF THE TOOTH

UNFAVOURABLE ROOT PATTERN

TO PROTECT IMPORTANT STRUCTURES

ANGULATION OF THE TOOTH

UNFAVOURABLE ROOT PATTERN

TO PROTECT IMPORTANT STRUCTURES

ADVANTAGESADVANTAGESTHE 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

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

DISADVANTAGESDISADVANTAGES

IT CAN BE ACHIEVED WITH IT CAN BE ACHIEVED WITHCHISELSDRILLS

CHISELSDRILLS

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

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

CRITERIA TO DECIDE SECTIONING OF TOOTHCRITERIA 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

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 PROCESSELEVATION 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

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 IRRIGATIONDEBRIDMENT AND IRRIGATIONAFTER REMOVAL OF TOOTHAFTER 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

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 MOLARREMOVAL OF MESIOANGULAR IMPACTED III MOLARTOOTH DIVISION IS NECESSARY

TOOTH DIVISION IS NECESSARY

IF THE TOOTH IS BISSECTED AT NECK

ENAMEL IS VERY THIN

LOWER POSITION

IF THE TOOTH IS BISSECTED AT NECK

ENAMEL IS VERY THIN

LOWER POSITIONDISTAL 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

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 MOLARREMOVAL 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

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 MOLARREMOVAL 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

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 MOLARREMOVAL 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

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 MOLARSREMOVAL 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

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 LINGUOANGULAR BUCCOANGULAR

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

LINGUAL SPLIT-BONE TECHNIQUELINGUAL 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

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

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 LEWISLINGUAL 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,

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 TECHNIQUELATERAL 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

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

COMPLICATIONSCOMPLICATIONS INTRAOPERATIVE DURING INCISION

FACIAL OR BUCCAL VESSEL MAY BE CUTLINGUAL NERVE INJURY RETROMOLAR VESSELS

DURING BONE REMOVALDAMAGE TO SECOND MOLAR AND ROOTS FRACTURE OF MANDIBLEBLEEDING

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

INTRAOPERATIVE DURING INCISION

FACIAL OR BUCCAL VESSEL MAY BE CUTLINGUAL NERVE INJURY RETROMOLAR VESSELS

DURING BONE REMOVALDAMAGE TO SECOND MOLAR AND ROOTS FRACTURE OF MANDIBLEBLEEDING

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

POSTOPERATIVE

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

INCIDENCE OF NERVE INJURYINCIDENCE OF NERVE INJURY

LINGUAL NERVE-0-23% INFERIOR ALVEOLAR NERVE-0.4-8.4%

LINGUAL NERVE-0-23% INFERIOR ALVEOLAR NERVE-0.4-8.4%

CLINICAL MANIFESTATIONS OF NERVE INJURYCLINICAL MANIFESTATIONS OF NERVE INJURY

ANAESTHESIA OR HYPOESTHESIA FOR MORE THAN 3 MONTHSTONGUE , LIP & CHEEK BITINGALTERED MASTICATION & TASTETRIGGERING,SIGNS(TINGLING,ELECTRIC SENSATION OVER THE INJURED SITE THAT DOES NOT EXTEND DISTALLY)NO OR MINIMAL RESPONSE TO INSTRUMENTATIONABSENCE IN THE DETECTION OF SHARP, DULL, MOVING TACTILE STIMULI & TWO POINT DISCRIMINATIONINCREASE IN HOT OR COLD TEMPERATURE THRESHOLD

ANAESTHESIA OR HYPOESTHESIA FOR MORE THAN 3 MONTHSTONGUE , LIP & CHEEK BITINGALTERED MASTICATION & TASTETRIGGERING,SIGNS(TINGLING,ELECTRIC SENSATION OVER THE INJURED SITE THAT DOES NOT EXTEND DISTALLY)NO OR MINIMAL RESPONSE TO INSTRUMENTATIONABSENCE IN THE DETECTION OF SHARP, DULL, MOVING TACTILE STIMULI & TWO POINT DISCRIMINATIONINCREASE IN HOT OR COLD TEMPERATURE THRESHOLD

CAUSES FOR LINGUAL NERVE INJURYCAUSES FOR LINGUAL NERVE INJURY

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

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

PREVENTION OF LINGUAL NERVE DAMAGEPREVENTION 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

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 DAMAGEMANAGEMENT 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.

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 INJURYCAUSES OF INFERIOR ALVEOLAR NERVE INJURY DEEPLY PLACED IMPACTED MOLAR MESIOANGULAR & HORIZONTAL IMPACTION SURGICAL TECHNIQUE USING BUR

DEEPLY PLACED IMPACTED MOLAR MESIOANGULAR & HORIZONTAL IMPACTION SURGICAL TECHNIQUE USING BUR

CONDITIONS FAVOURING NERVE INJURYCONDITIONS FAVOURING NERVE INJURY

INTERUPTION OF WHITE LINE OF CANALDEFLECTION OF ROOTDIVERSION OF CANALDARK &RIGID APEX OF ROOTNARROWING OF CANALNARROWING OF ROOT

INTERUPTION OF WHITE LINE OF CANALDEFLECTION OF ROOTDIVERSION OF CANALDARK &RIGID APEX OF ROOTNARROWING OF CANALNARROWING 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.

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

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.

•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 POUCHDISPLACEMENT INTO LINGUAL POUCH

INDEX FINGER IN THE LINGUAL ASPECT MOBILIZE THE TOOTH TOWARDS SOCKETCAREFULLY ELEVATE THE TOOTH

INDEX FINGER IN THE LINGUAL ASPECT MOBILIZE THE TOOTH TOWARDS SOCKETCAREFULLY 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 ANTI-INFLAMMATORY MEDICINES, PHYSICAL THERAPY AND IN SOME CASES SHORT TERM BITE SPLINT THERAPY.

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 ANTI-INFLAMMATORY MEDICINES, PHYSICAL THERAPY AND IN SOME CASES SHORT TERM BITE SPLINT THERAPY.

PAINPAIN

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

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.

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.

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 ABSCESSWHICH OCCUR 2-4 WEEKS AFTER USUALLY CAUSED BECAUSE DEBRIS UNDER THE FLAPDEBRIDEMENT AND ANTIBIOTICS.

INFECTION INCIDENCE BETWEEN 2-3% 50% ARE LOCALIZED SUBPERIOSTEAL ABSCESSWHICH OCCUR 2-4 WEEKS AFTER USUALLY CAUSED BECAUSE DEBRIS UNDER THE FLAPDEBRIDEMENT AND ANTIBIOTICS.

BLEEDING USE GOOD SURGICAL TECHNIQUE, MINIMIZETRAUMA, AVOID TEARS OF FLAPS. MOST EFFECTIVE MEASURE TO ACHIEVEHEMOSTASIS IS VIA MOIST GAUZE PRESSURE OVERWOUND. APPLICATION OF TOPICAL THROMBIN ON GELFOAMINTO SOCKET AND OVERSUTURING. OTHER HEMOSTATICS: OXIDIZED CELLULOSE(OXYCEL OR SURGICEL), MICROFIBRILLAR COLLAGEN(AVITENE). PATIENTS WITH ACQUIRED OR CONGENITALCOAGULOPATHY MAY NEED BLOOD PRODUCTREPLACEMENT.

BLEEDING USE GOOD SURGICAL TECHNIQUE, MINIMIZETRAUMA, AVOID TEARS OF FLAPS. MOST EFFECTIVE MEASURE TO ACHIEVEHEMOSTASIS IS VIA MOIST GAUZE PRESSURE OVERWOUND. APPLICATION OF TOPICAL THROMBIN ON GELFOAMINTO SOCKET AND OVERSUTURING. OTHER HEMOSTATICS: OXIDIZED CELLULOSE(OXYCEL OR SURGICEL), MICROFIBRILLAR COLLAGEN(AVITENE). PATIENTS WITH ACQUIRED OR CONGENITALCOAGULOPATHY MAY NEED BLOOD PRODUCTREPLACEMENT.

ALVEOLAR OSTEITIS (DRY SOCKET)

• INCIDENCE BETWEEN 3% AND 25%.

• INCIDENCE APPEARS HIGHER IN SMOKERS ANDFEMALES TAKING ORAL CONTRACEPTIVES.• PATHOGENESIS NOT ABSOLUTELY DEFINED BUT MOSTLIKELY RESULT OF LYSIS OF FULLY FORMED BLOOD CLOTBEFORE THE CLOT IS REPLACED WITH GRANULATIONTISSUE.• THIS FIBRINOLYSIS OCCURS DURING THE 3RD – 4TH POST OPERATED DAY

ALVEOLAR OSTEITIS (DRY SOCKET)

• INCIDENCE BETWEEN 3% AND 25%.

• INCIDENCE APPEARS HIGHER IN SMOKERS ANDFEMALES TAKING ORAL CONTRACEPTIVES.• PATHOGENESIS NOT ABSOLUTELY DEFINED BUT MOSTLIKELY RESULT OF LYSIS OF FULLY FORMED BLOOD CLOTBEFORE THE CLOT IS REPLACED WITH GRANULATIONTISSUE.• 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

•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.

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.

CORTICOSTERIODSCORTICOSTERIODS

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

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

NSAIDNSAID

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

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

CONCLUSIONCONCLUSION

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

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

REFERENCESREFERENCES

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,

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,