Classification of Impaction and Methods & Techniques of Third molar/Manidibular impaction removal,Flap designs of impaction removal techniques and more

1. IMPACTION
Dr. BABURAJ.M

2. DEFINITION
Latin - Impactus
An organ or structure which because of an abnormal
mechanical condition has been prevented from assuming its
normal position.
Rounds (1962) The condition in which a tooth is embeded in the alveolus so
that its further eruption is prevented.
Andreasen (1997)
A cessation of the eruption of a tooth caused by a clinically
or radio-graphically detectable physical barrier in the
eruption path or by an ectopic position of the tooth.
Archer (1975)
A tooth which is completely or partially unerupted and is
positioned against another tooth or bone or soft tissue so that
its further eruption is unlikely.
Peterson
A tooth is considered impacted when it has failed to fully
erupt into the oral cavity within in its expected
developmental time period and can no longer reasonably be
expected to do so.

3. TOOTH ERUPTION
Eruption stage Eruption mechanism Structures resisting eruption
Pre-eruptive stage - -
Intra-osseous stage Vascular hydrostatic Pressure
Root formation
Bone formation
Bone
Primary predecessors
Mucosal stage Vascular hydrostatic Pressure
Root formation
Bone formation
Mucosa
Pre-occlusal stage Vascular hydrostatic Pressure
Root formation
Bone formation
Periodontal ligament
Mastication
Occlusal stage Root elongation
Bone formation
Periodontal ligament
Mastication
Occlusion
Maturation Root elongation
Bone formation
Periodontal ligament
Mastication
Occlusion
Movement of a tooth from its
site of development within
the alveolar bone to its
functional position in the oral
cavity

4. TERMINOLOGIES
IMPACTED TOOTH MALPOSED TOOTHUNERUPTED TOOTH
It is the tooth that
has failed to erupt
completely or
partially to its
correct position
in the dental arch
and its eruption
potential has
been lost
It is a tooth that is
in the process of
eruption and is
likely to erupt
based on clinical
and radiographic
findings
A tooth un
erupted or
erupted which is
in an abnormal
position in the
maxilla or in the
mandible

5. COMMONLY IMPACTED TEETH
Impacted teeth seen in the following order of
frequency:
1. Mandibular third molars
2. Maxillary third molars
3. Maxillary canine
4. Mandibular premolar
5. Maxillary premolar
6. Mandibular canine
7. Maxillary central incisors
8. Maxillary lateral incisors

6. THEORIES OF IMPACTION (DURBECK)
Orthodontic theory
Endocrinal theoryPathological theory Mendelian theory
Phylogenic theory
Jaws develop in downward and forward
direction. Growth of the jaw and
movement occurs in forward direction,
so any thing that interfere with such
moment will cause an impaction (small
jaw-decreased space).A dense bone
decreases the movement of the teeth in
forward direction
Nature tries to eliminate the disused organs
[More functional masticatory force,
better the development of the jaw] Due to
changing nutritional habits ,use of large
powerful jaws have been practically
eliminated.Thus,over centuries the mandible
and maxilla decreased in size leaving
insufficient room for third molars
Heredity is most common
cause. The hereditary
transmission of small jaws
and large teeth from parents
to siblings. This may be
important etiological factor
in the occurrence of
impaction
Chronic infections
affecting an individual
may bring the
condensation of osseous
tissue further preventing
the growth and
development of the jaws
Increase or decrease in
growth hormone
secretion may affect the
size of the jaws

7. CAUSES OF IMPACTION - BERGER
LOCAL CAUSES SYSTEMIC CAUSES
1. Obstruction for eruption
2. Lack of space
3. Ankylosis of tooth
4. Non absorbing, over
retained tooth
5. Non absorbing alveolar
bone
6. Ectopic position of tooth
bud
7. Dilaceration of roots
8. Soft tissue or bony
lesions
9. Habits
1. Prenatal causes- Heredity
2. Postnatal-Rickets,
Congenital Syphilis,
Anaemia,Malnutrition
3. Endocrinal disorders
4. Rare Causes-
Cleidocranial
disorder,Osteopetrosis,
Achondroplasia,Cleft lip
and palate

8. PROBLEMS OF RETAINED IMPACTED TOOTH
 Pain
 Difficulty in mastication
 Paraesthesia of lip
 Swelling of retro-molar tissue
 Soreness
 Erythemia of overlaying soft tissue or operculum
 Trismus
 Facial swelling of the affected side
 Space involvement
 Raised temperature
 Regional lymphodenopathy
 Dental Caries
 Risk of Cyst and Tumour development

9. INDICATIONS CONTRA INDICATIONS
 Tooth in line of fracture
 Recurrent pericoronitis
 Deep periodontal
pocket
 Prior to orthodontic
treatment
 Prevention of root
resorption and caries
 Retained Deciduous
teeth
 Management of cysts
and tumors
 Management of
preprosthetic concerns
 Prophylactic removal
 Extremes of age
 Compromised medical
status
 Excessive risk of
damage to adjacent
structure
 When there is question
about the future status
of the second molar
 Uncontrolled active
pericoronal infection
 Socioeconomic status
 Fracture of atrophic
mandible may occur
 Abutment selection

10. Tooth in line of fracture
Orthodontic ProblemsTooth adjacent to CystCaries in adjacent tooth
Retained DeciduousRecurrent Pericoronitis
& Deep Pocket

11. CLASSIFICATION OF IMPACTIONS
WINTERS CLASSIFICATION OF MANDIBULAR THIRD MOLARS - 1929
BASED ON ANGULATION
Mesioangular Distoangular HorizontalVertical
Buccoangular InvertedLinguoangular

12. BASED ON DEPTH
PELLAND GREGORY CLASSIFICATION OF MANDIBULAR THIRD MOLARS - 1933
CLASSIFICATION OF IMPACTIONS
LEVELA LEVEL CLEVEL B
The highest
position of the
tooth is on a
level with or
above the
occlusal line
Highest position
is below the
occlusal
plane, but above
the cervical level
of the second
molar
Highest position
of the tooth is
below the
cervical level of
the second molar

13. CLASSIFICATION OF IMPACTIONS
PELLAND GREGORY CLASSIFICATION OF MANDIBULAR THIRD MOLARS - 1933
CLASS I CLASS IIICLASS II
Sufficient space
available between the
anterior border of the
ascending ramus and the
distal side of the second
molar for the eruption of
the third molar
The space available
between the anterior
border of the ramus and
the distal side of the
second molar is less than
the mesiodistal width of
the crown of the third
molar
The third molar is totally
embedded in the
bone from the ascending
ramus because of
absolute
lack of space
BASED ON SPACE AVAILABLE DISTAL TO SECOND MOLAR

14. CLASSIFICATION OF IMPACTIONS
ARCHERS CLASSIFICATION OF MAXILLARY THIRD MOLARS
BASED ON ANGULATION
Mesioangular HorizontalVerticalDistoangular
Buccoversion InvertedLinguoversion

15. CLASSIFICATION OF IMPACTIONS
PELLAND GREGORY CLASSIFICATION OF MAXILLARY THIRD MOLARS
BASED ON OCCLUSAL PLANE
CLASS A CLASS CCLASS B
The occlusal plane of
the impacted tooth is
apical to the cervical
line of the adjacent
tooth
The occlusal plane of
the impacted tooth is
between the occlusal
plane and the cervical
line of the adjacent
tooth
The occlusal plane of
the impacted tooth is
at the same level as
the adjacent tooth

16. CLASSIFICATION OF IMPACTIONS
CLASSIFICATION OF MAXILLARY THIRD MOLARS
BASED ON RELATION TO MAXILLARY SINUS
NO SINUS APPROXIMATION SINUS APPROXIMATION
2mm or more bone is present
between the sinus floor and the
impacted maxillary third molar
No bone or thin bony partition
present between impacted
maxillary third molar and the floor
of the maxillary sinus

17. CLASSIFICATION OF IMPACTIONS
CLASSIFICATION OF MAXILLARY CANINE
CLASS I CLASS VCLASS IVCLASS IIICLASS II
Impacted
cuspids located
in palate
a) Horizontal
b) Vertical
c) Semi
Vertical
Impacted
cuspids located
in palatine and
maxillary bone
e.g.crown is on
the palate and
root passes
through the root
of the adjacent
teeth and ends
in the labial or
buccal surface
of maxilla
Impacted
cuspids located
in the alveolar
process,usually
vertically
between incisor
and first
bicuspids
Impacted
Cuspid located
in edentulous
maxilla
Impacted
cuspids located
in Labial or
buccal surface
of maxilla
a) Horizontal
b) Vertical
c) Semi
Vertical

18. DIFFICULTY INDICES FOR REMOVAL OF IMPACTED MANDIBULAR THIRD MOLARS
PEDERSON SCALE - 1988
CLASSIFICATION SCORE
SPATIAL
RELATIONSHIP
Mesioangular 1
Horizontal 2
Vertical 3
Distoangular 4
DEPTH
Level A 1
Level B 2
Level C 3
RAMUS
RELATIONSHIP/
SPACE AVAILABLE
Class I 1
Class II 2
Class III 3
DIFFICULTY
LEVEL
Very Difficult 7 - 10
Moderately Difficult 5 – 7
Minimally Difficult 3 - 4

19. DIFFICULTY INDICES FOR REMOVAL OF IMPACTED MANDIBULAR
THIRD MOLARS
PARRANT SCALE
TECHNIQUE USED DIFFICULTY
EXTRACTION REQUIRING FORCEPS ONLY EASY I
EXTRACTION REQUIRING OSTECTOMY EASY II
EXTRACTION REQUIRING OSTEOTOMY AND
CORONAL SECTION
DIFFICULT III
COMPLEX EXTRACTION ( ROOT RESECTION) DIFFICULT IV

20. DIFFICULTY INDICES FOR REMOVAL OF IMPACTED MANDIBULAR THIRD MOLARS
WINTERS LINES / WAR LINES
 Corresponds to occlusal plane of molar teeth.
 Indicates the difference in occlusal level of
second and third molar
 Represents the bone level.
 Denotes the alveolar bone covering the
impacted tooth and the portion of tooth not
covered by the bone
 The red line is an imaginary line drawn perpendicular from the amber line to an
imaginary point of application of an elevator
 Represents depth of the tooth in bone and the difficulty encountered in removing the tooth.
Indicates the amount of bone that has to be removed before elevation
 If the length of red line is more than 5 mm then extraction is difficult.
 For Every additional 1mm difficulty increases three times(3X).
WHITELINEREDLINEAMBERLINE

21. DIFFICULTY INDICES FOR REMOVAL OF IMPACTED MANDIBULAR THIRD MOLARS
WHARFE ASSESSMENT
CRITERIA SCORE
Winters
Classification
Horizontal 2
Distoangular 2
Mesioangular 1
Vertical 0
Height of
Mandible
1 to 30 mm 0
31 to 34 mm 1
35 to 39 mm 2
Angulation of
Third Molar
1 to 59 degrees 0
60 to 69 degrees 1
70 to 79 degrees 2
80 to 89 degrees 3
90 + degrees 4
CRITERIA SCORE
Root Shape Complex 1
Favorable Curvature 2
Unfavorable
Curvature
3
Follicle Size Normal 0
Possibly Enlarged 1
Enlarged 2
Path of Exit Space Available 0
Distal cusp covered 1
Mesial cusp covered 2
Both covered 3

22. RADIODGRAPHS IN IMPACTION MANAGEMENT
OCCLUSAL OPG
RADIOGRAPH
CBCT
LATERAL
CEPHIOPA
PA VIEW

23. USES OF IOPA RADIOGRAPH
Radiological assessment aids in determining
 Classification of impacted tooth
 Orientation & Depth of the tooth (WAR Lines)
 Root Pattern
 Relation to inferior alveolar canal(Howe & Poyton)
 Localization of impacted tooth(Clarks rule/Tube shift)

24. ROOT PATTERN
 Limited development (Rolling Tooth) –Difficult
 2/3rd to complete Development – Easy
 Extremely Curved - Difficult
 Multiple , Fused & Conical – Easy
 Multiple & Separated – Moderately difficult
 Multiple & Diverged – Difficult

25. RELATION TO INFERIOR ALVEOLAR CANAL (HOWE & POYTON – 1960)
DARKENING OF ROOT
DEFLECTION OF ROOT
NARROING OF CANAL
DIVERSION OF CANAL
INTERUPTION OF
WHITE LINE OF CANAL
DARK BIFID APEX
NARROWING OF ROOT
RELATEDTOROOT
RELATEDTOCANAL

26. FACTORS THAT MAKE REMOVAL EASIER
MESIO
ANGULAR
CLASS 1
POSITION A
ROOT 1/3RD
TO
2/3RD
FUSED CONICAL
ROOTS
WIDE
PDL
SPACE
LARGE
FOLLICE
LESS
DENSE
BONE
SEPRTATED
FROM
II MOLAR
SOFT
TISSUE
IMPACTION

27. FACTORS THAT MAKE REMOVAL DIFFICULT
DISTO
ANGULAR
CLASS 3
POSITION C
LONG
THIN
ROOTS
DIVERGENT
CURVED
ROOTS
NARROW
PERIODONTAL
SPACE
THIN
FOLLICLE
DENSE
INELASTIC
BONE
CONTACT
WITH
II MOLAR
COMPLETE
BONY
IMPACTION

28. RISKS OF NONINTERVENTION RISKS OF INTERVENTION
A. Crowding of dentition
B. Resorption of adjacent
tooth and Periodontal
status
C. Development of
Pathological conditions
such as Infection, Cysts,
Tumors
A. Minor transient- Sensory
nerve alteration, Alveolitis,
Trismus and infection.
Haemorrhage,
Dentoalveolar fracture and
Displacement of tooth.
B. Minor permanent-
Periodontal injury, Adjacent
tooth injury, TMJ injury.
C. Major – Altered sensation,
Vital organ infection,
Fracture of mandible,
Maxillary tuberosity

29. SURGICAL TECHNIQUES IN
REMOVAL OF IMPACTED
MANIBULAR THIRD MOLARS

30. SURGICAL PROCEDURES
GENERAL CONSIDERATIONS
ADEQUATE EXPOSURE
ACCESS TO THE TOOTH
SECTIONING OF THE TOOTH(OPTIONAL)
ELEVATION FROM THE ALVEOLAR PROCESS
DEBRIDMENT & IRRIGATION
REPOSITION OF FLAPS AND CLOSURE
POST OPERATIVE FOLLOW UP

31. INCISIONS AND FLAP DESIGNS
PARTS OF INCISION
Limb A Limb CLimb B
It was carried
along the gingival
crevice of the third
molar extending
upto the middle of
exposed distal
surface of the
tooth.
Started from a
point where
intermediate
gingival incision
ended and was
carried laterally
towards the cheek
at mucosal depth.
This arm should be
about 25.4 mm
long
The anterior incision
started from a point
about 6.4 mm down
in the buccal sulcus
approximately at the
junction of posterior
and middle third of
the second molar,
passes upwards
extended upto the
distobuccal angel of
the second molar at
the gingival margin
for a distance of 1-
2cm
Standard Incision line

32.  The base of the flap must be broader than the free margin to
preserve an adequate blood supply.
 Must be of adequate size - sufficient soft tissue reflection -
provide necessary visualization of the area.
 The flap should be a full-thickness mucoperiosteal flap.
 The incisions must be made over intact bone
 Should be designed to avoid injury to local vital structures in the
area of the surgery.
 Incisions should be well away from the lingual aspect of the
mandible to preserve lingual nerve.
 Vertical-releasing incisions should cross the free gingival margin
at the line angle of a tooth and should not be directly on the facial
aspect of the tooth nor directly in the papilla.
PRINCIPLES OF FLAP DESIGN

33. BAYONET FLAPL SHAPED FLAP
Suits only the buccal approach
since it is difficult to raise a
lingual flap from this approach.
The posterior limb of the incision
extends from a point just lateral to
the ascending ramus of the
mandible into the sulcus.It passes
disto-lateral periodontium by
avoiding or including it -
depending upon the proximity of
the third molar with the second
molar.
The junction bw
the limbs may be
Curved & incision
made in one sweep
or it may be
angled
This incision has three parts
a. Distal or Posterior
b. Intermediate or Gingival
c. Anterior part
The posterior part of the incision
goes round the gingival margin
of the second and even the first
molar, before turning into the
sulcus

34. ENVELOPE FLAP TRIANGULAR FLAP
Extends from the mesial papilla of
the mandibular first molar and
passes around the neck of the teeth
to the disto buccal line angle of the
second molar.
Now the incision line extends
posteriorly and laterally upto the
anterior border of the mandible.
Its anterior extension is directly
proportional to the depth at which
the impacted tooth is present
deeper the tooth,
longer the Ant
extension
Advantage
Easier to close
and heal better
This flap is the result of an L-shaped
incision with a horizontal incision
made along the gingival sulcus and a
vertical or oblique incision.
The vertical incision begins
approximately at the vestibular fold
and extends to the interdental papilla
of the gingiva.
The triangular flap is performed
labially or buccally on both jaws and
is indicated in the surgical removal of
root tips, small cysts, and
apicoectomies.
Advantages
Good blood supply,Satisfactory vision,
Good stability&
reapproximation
Disadvantages
Limited access,
Tension builds
when flap held with
retractor, and it causes
a defect in the
attached gingiva

35. COMMA SHAPED INCISION WARDS INCISION
Provides Large area of access
Indicated In case of deep
Horizontal Impactions
Periodontal Pocketing Distal to 2nd
Molar
WARDS MODIFIED WARDS
The anterior line of the incision runs
from the distal aspect of the second
molar curving ,downward and forward
to the level of the apex of the distal
root of the first molar.
This second type of incision is used
when a linguoverted tooth impaction
is present.
The posterior part of the incision is the
same but the anterior part commences
as the junction of the anterior and
middle thirds of the second molar and
runs down to the apex of the distal
root of the first molar

36. REFLECTION OF FLAP
 Reflection of the flap begins at the papilla.
 The end of the Woodson elevator or the no. 9 periosteal elevator
begins a reflection.
 The sharp end is slipped underneath the papilla in the area of the
incision and turned laterally to pry the papilla away from the
underlying bone. This technique is used along the entire extent of
the free gingival incision.
 Once the flap reflection is started, the broad end of the periosteal
elevator is inserted at the middle corner of the flap, and the
dissection is carried out with a pushing stroke, posteriorly and
apically. This facilitates the rapid and atraumatic reflection the
soft tissue flap.

37. BONE REMOVAL
Aim:
1. To expose the crown by
removing the bone
overlying it.
2. To remove the Bone
obstructing the pathway for
removal of the impacted
tooth
Types:
1. By consecutive sweeping
action of bur(in layers).
2. By chisel or osteotomy cut
(in sections).
Amount to be removed:
Bone should be removed till we
reach below the height of
contour, where we can apply the
elevator.
Extensive bone removal can be
minimized by tooth sectioning.
CRITERIA BUR CHISEL&MALLET
TECHNIQUE EASY DIFFICULT
CONTROL OVER
BONE CUTTING
CONTROLLED UNCONTROLLED
PATIENT
ACCEPTANCE
WELL
TOLERATED
UNDER L.A
NOT TOLERATED
UNDER L.A
HEALING OF
BONE
DELAYED GOOD
POST
OPERATIVE
EDEMA
MORE LESS
CHANCES OF
DRY SOCKET
MORE LESS
POST
OPERATIVE
INFECTION
MORE LESS

38. A. Preferred method to use a hand piece with adequate speed and high torque
to remove the overlying bone.
B. Ideal length – 7mm Diameter – 1.5mm.
C. Large rose head bur (size 12) or fissure bur (no.7) used for gross bone
removal.
D. The bur should rotate in correct direction and at maximum speed.
E. Cutting instruments that induce air should not be used.
F. Handpiece should not rest on the tissues of the cheek and lips to avoid
burning.
G. Bone removed:
a. Mesially – to create a point of application
b. Buccaly – cutting a trough or gutter around the tooth to the root furcation
c. Distolingually – lingual plate should not be breached to protect the lingual
nerve
H. Copious amount of normal saline is irrigated to avoid thermal necrosis of
bone.
I. To keep the operator field clean an efficient suction should be used.
J. In the mesial side adequate bone must be removed so that the elevator
stands up an angle of 45° to the mandible without any support.
BUR TECHNIQUE

39. Irrigation Rate
a. 15 mL/min -for intermittent drip
b. 24 mL/min -for continuous flow
A large plastic syringe with a blunt & angled I8-gauge needle is
used
Solutions Used
a. Saline
b. Sterile water
c. Ringer’s lactate.
d. 1% Povidone iodine
Advantages of Irrigation
a. Irrigation cools the bur
b. Prevents bone-damaging heat buildup
c. Increases the efficiency of the bur
IRRIGATION TECHNIQUE

40. A. Mandible should be adequately supported.
B. The mallet is used with a loose, free-swinging wrist motion gives maximum
speed to head of the mallet without introducing the weight of the arm or
body into the blow.
C. To plane bone with a chisel, the bevel have to be turned towards the bone.To
penetrate the bone, turn the bevel away from the bone.
D. To restrict the bony cut to the desired extent a vertical limiting cut is made by
placing a 3 mm or 5 mm chisel vertically at the distal aspect of the II molar
with the bevel facing posteriorly. Its approximate height is 5-6 mm.
E. Then the chisel is placed at an angle of 45° at the lower edge of the limiting
cut in an oblique direction. This will result in the removal of a triangular
piece of buccal plate distal to the II molar.
F. If necessary, bony cut can be enlarged to uncover the impacted tooth to the
desired level.
G. Finally distal bone must be removed so that when the tooth is elevated, there
is no obstruction at the distobuccal aspect.
CHISEL & MALLET TECHNIQUE

41. SECTIONING OF TOOTH
BUR OSTEOTOME
WITH
 Safe and Easy
 Bur Used
Fissured Type
No.8 with larger
cutting surface
 Used with sufficient
amount of Coolant
 Quicker but Hazardous
 Osteotome Used
Width: 6.4 mm(1/4 in)
Length: 17.5cm(7 in)
 When splitting a tooth longitudinally through the
root bifurcation the osteotome blade should be
placed in the buccal anatomical groove between
the mesial and distal coronal cusps at an angle of
450 to the vertical axis of the tooth
A
D
V
A
N
T
A
G
E
S
 Amount of bone to be removed is reduced. The time of operation is
reduced.
 The field of operation is small and therefore damage to adjacent teeth
and bone is reduced.
 Risk of jaw fracture is reduced.
 Risk of damage to the inferior alveolar nerve is reduced

42. 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 MESIOANGULAR IMPACTED III MOLAR

43. REMOVAL OF DISTOANGULAR IMPACTED III MOLAR
 Distoangular position brings the 3rd 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

44. 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 2nd
molar is less and requires
more removal of bone on the
buccal and distal sides

45. REMOVAL OF HORIZONTALLY IMPACTED III MOLAR
 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

46. 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
REMOVAL OF BUCCO/LINGUO ANGULAR IMPACTION
BUCCOANGULAR IMPACTION LINGUOANGULAR IMPACTION

47.  It is described originally by Sir William Kelsey Fry
 Later popularized by T Ward
 Useful in removal of deeply positioned horizontal distoangular impactions
(Rud, 1970).
1. First, a vertical stop cut about 5 mm in height is made with a 3 mm width chisel
in the buccal cortex immediately distal to the second molar. A second vertical
stop cut will be made about 4 mm disto-buccal to the third molar crown.
2. With the chisel bevel downward, a horizontal cut is made backward from the
lower end of the vertical limiting stop cut.
3. The buccal bone plate is removed above the horizontal cut.
4. Thedistolingual bone is then fractured inward by placing the cutting edge of the
chisel along the dotted line A. Bevel side of the chisel is facing upward and
cutting edge is parallel to the external oblique ridge. The chisel is held at 45º to
the bone surface.
5. Finally small wedge of bone, which then remaining distal to the tooth and
between the buccal and lingual cut, is excised and removed.
6. A sharp straight elevator is then applied and minimum force is used to elevate
the tooth. As the tooth moves upward and backward, the lingual plate gets
fractured and facilitates the delivery of the tooth.
7. After the tooth is removed, the lingual plate is grasped with the hemostat and
freed from the soft tissue and removed.
8. Smoothening of the edges is done with bone file. Wound irrigated and sutured.
LINGUAL SPLIT/ KELSEY FRY TECHNIQUE

48. 1 32 4
5 6 7 8
STEPS:
1. Vertical Stop Cut
2. Horizontal Cut
3. Removal of Buccal Plate
4. Fracturing Distolingual Bone
5. Removing Bony wedge
6. Elevation of Tooth
7. Repositioning of flap
8. Suturing
LINGUAL SPLIT/ KELSEY FRY TECHNIQUE
ADVANTAGES
 Faster tooth removal.
 Less risk of inferior alveolar nerve damage.
 Reduces the size of residual blood clot by means of saucerization of the socket
 Decreased risk of damage to the periodontium of the second molar.
 Decreased risk of socket healing problems.
DRAWBACKS
 Risk of damage to the lingual nerve. The incidence of lingual nerve and inferior alveolar
nerve damage has been reported as 1- 6.6% .
 Increased risk of postoperative infection
 Patient discomfort due to the use of a chisel and mallet for lingual bone removal or
fracturing.
 Only suitable for young patients with elastic bone

49. LINGUAL TREPHENATION TECHNIQUE
This procedure was first described by
Bowdler-Henry to remove any partially
formed and unerupted third molar in the
age group of 9-16 years.
Modified S-shaped incision is made from
retromolar fossa across the external oblique
ridge. It then curves down to the I molar
anteriorly in the vestibule.
The mucoperiosteal flap is elevated and
buccal cortical plate is trephined over the
III molar crypt. bur is used to make vertical
cuts anteriorly and posteriorly.

50. LINGUAL TREPHENATION TECHNIQUE
 A chisel or an osteotome is applied in the vertical
direction over the bur holes. Then the buccal plate is
fractured out, exposing the third molar crypt completely.
 Elevator is applied to deliver the tooth out of the crypt.
Any follicular remnant present in the crypt is carefully
scooped out, avoiding injury to the inferior alveolar
(dental) canal at the lower part of the crypt.
 Flap repositioned and Suturing done
Advantages:
a. Partially formed unerupted 3rd molar can be removed.
b. Can be preformed under general or regional anesthesia
with sedation.
c. Post-op pain is minimal.
d. Bone healing is excellent and there is no loss of alveolar
bone around the 2nd molar.
Disadvantages :
a. Virtually every patient has some post operative buccal
swelling for 2-3 days after surgery

51. WOUND CLOSURE
 The most important suture is the one placed immediately behind the second
molar, ensuring there is accurate apposition of wound edges .
 It is also useful to place a suture across the distal incision where the soft tissue
thickness and potential bleeding source is greatest.
 Many clinicians often do not place sutures across the buccal relieving incision,
which permits a dependent area of drainage.
 Watertight closure is unnecessary and may in some cases increase postoperative
pain and swelling.
 Primary closure of the wound should not be attempted unless – atleast 5mm of
a band of buccal attached mucoperiosteum is present.
DRAIN BY TUBE
 When using primary wound closure, a small surgical tube drain or gauze strip
may be inserted in buccal incision before suturing to facilitate drainage.
Small surgical tube inserted with Primary
Closure
WOUND CLOSURE AND MANAGEMENT
 It should be removed after 24-72 hours.
 With this technique, the postoperative
problems are expected to be less severe.

52. COMPLICATIONS
INTRA OPERATIVE POST OPERATIVE
During
incision
1. Injury to Facial Nerve or
Vessels
1. Pain
2. Swelling/edema
3. Hematoma
4. Bleeding
5. Trismus
6. Infection
7. Dry socket
 Incidence between 3% and 25%.
 Higher in smokers and Females
taking oral contraceptives.
 Occurs during the 3rd – 4th post
operated day
 Goal of treatment is relief of
pain
 Irrigation of extraction site &
Placement of eugenol dressing
 Pain usually resolves within 3-5
days but up to 10 to 14 days
8. TMJ Pain
9. Paraesthesia
10. Sensitivity
During bone
removal
1. Damage to second molar
2. Slipping of bur into soft tissue
& causing injury
3. Fracture of the mandible when
using chisel & mallet
During
elevation
1. Luxation of neighbouring
tooth.
2. Soft tissue injury due to
Slipping of elevator.
3. Fracture of mandible.
4. Forcing tooth root into
submandibular space or
inferior alveolar canal.
5. Breakage of instruments.
6. TMJ Dislocation
During
debridement
1. Injury to inferior alveolar
neurovascular bundle.