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Rguhs Oral Surgery

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oral surgery



1. Discuss classification of impacted mandibular molars. Describe your method of removal of an impacted mandibular 3

molar in horizontal position

Classification- George Winter’s Classification
Gregery Winter’s Classification
Peterson’s Winter’ s Classification
Method – Indications for removal
Pre-operative assessment- History
Clinical Exam
Radiographic Exam
Assessment of difficulty of removal procedure

 Tooth that has failed to erupt completely or partially to its correct position in the dental arch and its eruption
potential has been lost.
 A completely/partially unerupted tooth positioned against a physical such as another tooth, bone/soft tissue, so that
its further eruption is unlikely even beyond its normal chronological age of eruption.
 Peterson: A tooth is considered to be impacted when it has failed to fully erupt in the oral cavity within its expected
developmental time period and can no longer do so.

Aim: Describe general position of impacted tooth estimation of difficulty in removal.

1. Winter’ Classification – 1926
Angulation- Mesioangular

Modified Winter’s Classification
Vertical impaction- +/- 10◦
Mesio+ distoangular- +/- 11-70◦
Horizontal >+/- 70-100◦
Other types- Buccolingual
Mesio inverted
Disto inverted- can be included. This for PG Level

2. Peterson
 Soft tissue impaction
 Partial bony impaction
 Bony impaction

3. Pell + Georgy’s classification (A33)
 Based on the space available distal to 3

Class I Class II Class III
Space between ramus & distal side
of 2
molar is more than
mesiodistal diameter of crown of
impacted 3
Space is less than mesiodistal
diameter of crown of impacted 3

All or most of the 3
molar is in
Position A Position B Position C
Highest portion of impacted tooth is
an level with or above occlusal
plane of 2
Below occlusal plane above cervical
line of 2
Below cervical line of 2

Position of tooth in relation to long axis of second molar
1. Mesioangular
2. Horizontal
3. Vertical
4. Distoangular
5. Lingual defective
6. Buccal
7. Inverted
8. Transverse

4. Kay’s Classification
1. Based on angulation and position
- Mesioangular
- Distoangular
- Vertical
- Horizontal
2. Based on state of eruption
- Fully erupted
- Partially erupted
- Embedded
3. Based on number of roots
- Fused roots
- 2 roots
- Multiple roots
4. Based on root pattern
Unfavourable- curved at different angles

a. According to Peterson
- Prevention of periodontal diseases
- Prevention of dental caries
- Prevention of treating pericohonitis
- Prevention of Root resorption
- Prevention of odontogenic cysts of tumors
- Impacted teeth under a dental prosthesis

Pain in retromolar region of MPDS
TMJ disorders should be ruled out
- Facilitation of orthodontic treatment
- Prevention of fracture of jaw

5. Mandibular angle fractures is more frequent in patients with impacted lower third molar + fracture of condyle is
higher in patients without it
- Crown on 2
- Orthognathic surgery

Contraindications- local- if there is adequate space
if 3
molar is used as abutment
if deeply placed
Tooth in tumour
Asymptomatic tooth
Acute infections
Recently irradiated jaw

Uncontrolled diabetes
Uncontrolled hypetension
Cardiac diseases
Liver diseases
Steroid therapy
Blood dyocrasias
Anticoagulant therapy
Toxic goiter
Fever of unexplained origin
Pregnancy – 1
and 3
Recent M I

Preoperative Assesment-
History-Medical+ Dental history must be recorded
Clinical exam-Facial form-Tapered-access better
Compact-access origin

Presence of swelling
- Small mouth or mandibular retrusion-makes tough removal
- If external oblique ridge is posterior to tooth, access is good, if ridge is odogentic the tooth or anterior to it
access is
If external oblique ridge is lower and posterior to tooth- buccal bone will be relatively
- Soft tissue over wisdom tooth
Check for Fibrosis
Indentation by upper buccal tooth
Active inflammation
- Position of upper 3
molar on periocoronal flap of lower 3
- Larger tongue size- more difficult removal
Radiographic Assessment
- For orthodontic treatment
- Rule out pathologic changes
- Eruption prediction
- For treatment plan in surgical
- Proximity of vital structures
Intraoral Radiographic- IOPA
Bite Sing
Occlusal view
Indication- Tooth in alveolus
Adequate mouth opening
Tube shift
Relationship with inferior alveolar canal
Extraoral – OPG
Lat. Oblique view of mandible
Indication- Trismus
Tooth in abevant position
Associated pathology
Relationship with inferior alveolar canal
Assessment- Angulation, Depth, Space available anatomical relation
Crown size + shape
Roots, configuration length development, curvature, size and root position of adjacent tooth
Bone texture + density- Depth of impacted tooth
Nature of covering tissue
Follicular size
WHARFE’S Assessment
Winter’s classification Height of mandible
Horizontal-2 1-30→0
Mesioangular-1 31-34→1
Vertical-0 35-39→2
A.Angle of 2
molar (degrees)
R-Root shape and development
A. Less than 1/3
B. 1/3-2/3 complete-1
C. More than 2/3
Unfavourable Curve-2
Favourable curve-1
Possible enlarged- (-1)
Impaction relieved-(-3)
Exit path
Distal cusp covered-1
Mesial cusp covered-2
All covered-3
War lines
- White line
- Red line-if>5mm- extraction difficult every additional mm makes removal 3 times more difficult
If > 5mm-better removal under general anaesthesia.
Bone deficiency index
Buccal relationship
Mesioangular 1
Horizontal /Transverse 2
Vertical 3
Distangular 4
Level A-1
Level B-2
Level C-3
Ramus relationship
Class I- 1
Class II-2
Class III-3
Difficulty index
Very difficult- 1-10
Moderatly difficult- 5-7
Minimally difficult- 3-4
Surgical Removal
a. Isolation of surgical site- Scrubbing on skin
Citrinide+povidone+iodine or
Citrinide+absolute alcohol
Citrinide+absolute alcohol+chlorhexidine

- Cleaning solution- Normal saline alcohol
- Painting solution-
a. Povidine-Iodine 5%-skin
1% oral mucosa
b. Chlorhexidine gluconate- 1.5% for skin
0.2% for rinsing oral cavity
Drape the patient
- Local anesthesia- IANB, lingual nerve block + long buccaline block
- Flap design+ Reflection-Ideal requirements for a flap for 3 molar removal

1. Flap must be a full thickness mucoperiosteal flap
2. Provide visibility access
3. Brad base for adequate blood supply
4. After bone + tooth removal, margins of flap are repositioned, they should rest on sound bone.

1. Short envelope flap- shallow or superficial impactions
Distal- incision
2. Long envelope flap- deeper impactions – extend up to mesiobuccal line angle of 1
premolar- but this flap gives inadequate accessibility.
a. Triangular flap- distal part
crevicular part
vertical part
Envelope flap with anterior vertical relieving incision is 3 cornered flap
A. Ward’s incision –distal incision is similar to envelop flow
ii. Anterior relieving incision is started at disto buccal line angle or point on gingiva corresponding to distobuccal cusp tip
of 2
molar taken downwards and anterior till it coincides with buccal groove of the tooth.
iii. Crevicular incision connects both the above

B. Modified Ward’s incision of deeply impacted anterior incision- started from distobuccal corner of crown of lower
molar (instead of 2
C. L-shaped vertical relieving incision is given 45 angle to the long axis 2
molar and runs straight anteriorly and
downwards without having smooth curvature as in ward’s incision.
Raise a mucoperiosteal flap with a periosteal elevator in contact with bone on buccal side, place the periosteal
elevator on lingual side of tooth after reflecting on that side to avoid damage to lingual nerve- 5mm of bone distal to
third molar should be visible
D. Bone removal
i. To expose maximum height of contour of crown that lies on buccal side at junction of cervical of
middle 3
of crown
ii. To facilitate path of removal
iii. To create a fulcrum for elevator

For use of bur For use of mallet
Old patient brittle sclerotic bone Growing elastic bone
External or internal oblique ridges
or both are far forward relation to
External oblique ridge in slightly
below the level of bone internal
oblique ridge is slightly behind
Where sectioning of the tooth Under GA
If surgery is under LA If tooth sectioning not required

Chisel technique through buccal approach
Vertical extent of anterior cut-7mm , so 5mm chisel taken
Chisel is rotated 90 corner of blade is engaged in lower end of anterior cut of horizontal cut joining the vertical
Bone removal using a burr
Remove bone on occlusal surface
Round burr used to create gutter on buccal and distal aspect. Distolingual spur of bone is removed on mesial
aspect. Point to engage elevator is made. Cortical buccal bone is removed and its called ditching.
Removal of tooth- by an elevator
Sectioning- by osteoteme or straight fissure burr or both
Indications-If crown of impacted tooth is obstructed by 2
- Unfavourable root pattern
- To protect anatomic structures nerve, vessels, adjacent tooth from injury
Advantages- Operating field minimized
Reduced bone removal –edema reduced
Reduced weakening of jaw
Reduced damage to important anatrimical re structures
The burr should section ¾ m of the occlusal surface of the tooth from buccal side, to avoid injury to lingual
Horizontal impaction-after sufficient bone is removed down to cervical line to explore superior aspect of distal
root and buccal surface of down. Crown is sectioned from roots of tooth delivered.
Roots are delievered together or independently by elevator with rotational , purchase point made to engage the
elevator, mesial root of tooth is then removed
Debridement of wound closure
Irrigate with saline and inspect, Mosquito haemostat used to remove remnants of dental follule. control bleeding
and sutures are placed -3.0 silk or vicryl can be used.
Post operative care
- Ice pack extra orally
- Instructions same as for non surgical extraction
- Instructions regarding mouth opening good oral hygene trisumus and swelling

Complications (can be included if need be)
Due to LA haematona infection nerve damage
Due to incision- bleeding due to damage of facial artery, retromolar vessels
Damage to lingual nerve
Damage to soft tissue
Complications during bone cutting abrasions (burn)
- injury to adjacent tooth
- Damage to mandibular canal
- injury to lingual nerve
- necrosis of bone
- injection
Complications due to elevation of tooth
- Adjacent tooth injury
- Adjacent tooth luxation
16. Fracture of jaw
Injury to inferior dental canal
Displacement of tooth into lingual pauch
Immediate post operative
Prolonged anaesthesia
Delayed- Trismus
Delayed Healing
Dry socket

1. Inferior Alveolar Nerve Block (IANB)
Other name: Mandibular block

Nerves anaesthetized
 Inferior alveolar
 Incisive
 Mental
 Lingual (commonly)

Areas anaesthetized
 Mandibular teeth to midline
 Body of mandible, inferior portion of ramus
 Buccal mucoperiosteum, nucous membrane anterior to mandibular 1
molar (mental nerve)
 Anterior 2/3
of tongue and floor of oral cavity (lingual nerve)
 Lingual soft tissues and periosteum (lingual nerve)


 Infection or acute inflammation
 Patients who might bit lip or tongue
 Very young child
 Mentally or physically challenged patient

 Wide area of anaesthetized for quadrant dentistry

 Wide area of anaesthetized not needed for localized procedures
 15-20% rate of inadequate anaesthesia
 Intraoral landmarks not consistent
 10-15%- positive aspirations
 Lingual and lower lip anaesthesia –dangerous for patients in whom its contraindicated
 Possible anaesthesia possible where bifid inferior alveolar nerve and bifid mandibular canals.

1. 25 gauge long needle – inserted in mucous membrane on medial side of rames at intersection of 2 lines
 1 horizontal – height of injection
 1 vertical – representing anteroposterior plane of injection

2. Landmarks
i. Mucobuccal fold
ii. Anterior border of mandible
iii. Coronoid notch
iv. Internal and external oblique ridge
v. Retromolar triangle
vi. Buccal sucking pod
vii. Pterygomandibular raphe, ligament and space occlusal plane of mandibular posterior teeth

3. Orientation of needle bevel – at roughly 90◦ to the nerve through mucosa, a thin plate of buccinator muscle, loose
connective tissue and buccal pad of fat.

 Position of operator – for right handed operator Right I ANB – 8 O clock position facing patients
Left I ANB - 10 O clock positions facing patients
 Patient supine or semisupine, mouth opened wide body of mandible is parallel to floor
 Approximating structures when needle is in position
 Superior to: Inferior alveolar nerve + blood vessels
 Insertion of internal pterygoid nerve
 Mylohyoid vessels + nerve
 Anterior to deep part of parotid gland
 Medial to inner ramus
 Lateral to: Lingual nerve, Internal pterygoid, Sphenomandibular ligament

 Left thumb palpates mucobuccal fold is moved posteriorly till contact is made with external oblique ridge in the
greatest depth of ramus i.e coronoid notch in line with mandibular sulcus.
 Palpating finger moved lingually across retromolar triangle and into internal oblique ridge and buccal sucking pad.
 Holding ramus between thumb and index finger, Needle is inserted from opposite side of mouth parallel to occlusal
plane of mandibular teeth.
 At a level bisecting the finger penetrating tissues of pterygoid temporal depression entering pterygoid mandibular
space. Needle must be inverted half the width of ramus that’s hold between index finger and thumb and then
withdrawn about 5mm -1-1.8 ml of LA injected over 1 1/2 -2 min after aspiration.
 Needle is withdrawn and when half of its inserted depth is withdrawn remainder of LA is deposited to anasthetized
lingual nerve (0.1 ml) withdraw syringe slowly and make needle safe wait for 3-5 min before starting therapy.

Symptoms of Anesthesia
 Subjective – Jingling and membranes of areas supplied by inferior alveolar nerve
 Objective – Instrumentation does not elicit pain

 Depositing too inferiorly or anteriorly –follow protocol
 If bidifid inferior alveolar nerve- incomplete anesthesia so, deposit la lower to normal landmark as a 2
foramen is generally present there if central or lateral incisors are supplied by mylohyoid nerve, they don’t get
anaesthetized so infiltrate supraperiostatly or give PDL injection

 Haematoma; trismus, transient facial paralysis

 Bupivacaine HCl
 Amide: Metabolised in liver by conjugation with glucoranic acid, end products
 Potency: 4 times, that of Lidocaine, Mepivacaine, Prilocaine
 Toxicity- less than 4 times that of lidocaine + mepivacaine
 Onset of action: 6-10 min
 Effective dental concentration: 0.5%
 Anaesthetic half life: 2.7 hours
 Maximum recommended dose: 2 mg/kg (upto 825 mg with epinephrine 1: 2,00,000 + 175 mg without vasoconstrictor)
Total doses repeated upto once every 3 hrs not to exceed 400 mg in 24 hrs
 Uses: For postoperative pain: in lengthy dental procedures
 Contraindications: not in children or physically + mentally challenged patients due to risk of self mutilation

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