The clinical and radiological assessment of lower 3rd molar impaction,as well as the comparison between the buccal approach and the lingual split technique of trans-alveolar extraction of impacted lower 3rd molar is illustrated..

1. IMPACTED LOWER IIIrd MOLARIMPACTED LOWER IIIrd MOLAR
decision making, treatment planning anddecision making, treatment planning and
TTHEHE LLINGUALINGUAL SSPLITPLIT TTECHNIQUEECHNIQUE
Dr. Waikhom Robindro Singh
Assoc. ProfessorAssoc. Professor
DENTAL COLLEGE, RIMSDENTAL COLLEGE, RIMS

2. Impacted toothImpacted tooth
Causes of IIIrd molar impactionCauses of IIIrd molar impaction
i.i. failure of rotation of the tooth bud from horizontal tofailure of rotation of the tooth bud from horizontal to
vertical during developmentvertical during development
ii. lack of space in the alveolar process anterior to theii. lack of space in the alveolar process anterior to the
anterior border of the ramus 3anterior border of the ramus 3rdrd
molars mostmolars most
commonly to be impacted coz they are the last to eruptcommonly to be impacted coz they are the last to erupt
Failure to erupt to its correctFailure to erupt to its correct
position in the dental arch withinposition in the dental arch within
the specified time owing to somethe specified time owing to some
barrier in the pathway of eruptionbarrier in the pathway of eruption
or due to some genetic reasonor due to some genetic reason
Those that fail to erupt without
any obvious reason are typed as
embedded tooth by some authors

3. Periodontal pocket
Pericoronitis
Caries
Root resorption
Denture irritation
Cyst and tumours
Unexplained pain
Jaw fracture
Orthodontic consideration
Inferior Alveolar Canal
the amount of bone on
the distal aspect of 2nd
molar
bone loss
What is the problem? Why remove it?What is the problem? Why remove it?

4. Periodontal pocket
Pericoronitis
Caries
Root resorption
Denture irritation
Cyst and tumours
Unexplained pain
Jaw fracture
Orthodontic consideration
Inferior Alveolar Canal
What is the problem? Why remove it?
d/t entrapment of food, trauma
from opposing tooth and
infection in the operculum.
operculum
operculitis

5. Periodontal pocket
Pericoronitis
Caries
Root resorption
Denture irritation
Cyst and tumours
Unexplained pain
Jaw fracture
Orthodontic consideration
Inferior Alveolar Canal
What is the problem? Why remove it?
Food entrapement and
inaccessibility to toothbrush
on the distal aspect of 2nd
molar

6. Periodontal pocket
Pericoronitis
Caries
Root resorption
Denture irritation
Cyst and tumours
Unexplained pain
Jaw fracture
Orthodontic consideration
Inferior Alveolar Canal
What is the problem? Why remove it?

7. Periodontal pocket
Pericoronitis
Caries
Root resorption
Denture irritation
Cyst and tumours
Unexplained pain
Jaw fracture
Orthodontic consideration
Inferior Alveolar Canal
What is the problem? Why remove it?
Impacted tooth beneath an
edentulous area gradually becomes
superficial d/t resorption of the
overlying bone irritate the soft
tissue beneath the denture

8. Periodontal pocket
Pericoronitis
Caries
Root resorption
Denture irritation
Cyst and tumours
Unexplained pain
Jaw fracture
Orthodontic consideration
Inferior Alveolar Canal
What is the problem? Why remove it?
Follicular sac cystic degeneration
The epithelium contained within the
dental follicle leads to Odontogenic T.

9. Periodontal pocket
Pericoronitis
Caries
Root resorption
Denture irritation
Cyst and tumours
Unexplained pain
Jaw fracture
Orthodontic consideration
Inferior Alveolar Canal
What is the problem? Why remove it?
Pain in the retromolar
region without any
apparent cause

10. Periodontal pocket
Pericoronitis
Caries
Root resorption
Denture irritation
Cyst and tumours
Unexplained pain
Jaw fracture
Orthodontic consideration
Inferior Alveolar Canal
What is the problem? Why remove it?
Impacted tooth occupies space
weak point in the
mandible

11. Periodontal pocket
Pericoronitis
Caries
Root resorption
Denture irritation
Cyst and tumours
Unexplained pain
Jaw fracture
Orthodontic consideration
Inferior Alveolar Canal
What is the problem? Why remove it?
Prevent distal retraction of the 1st
and 2nd
molar during ortho
treatment.
Mesially inclined impacted molar
mesial force recurrence of
crowding after ortho tt.

12. Periodontal pocket
Pericoronitis
Caries
Root resorption
Denture irritation
Cyst and tumours
Unexplained pain
Jaw fracture
Orthodontic consideration
Inferior Alveolar Canal
What is the problem? Why remove it?
Proximity to the nerve leading
to symptoms

13. But why bother If surgical morbidity
outweigh the benefits?
Aged
Medically compromised
Proximity to vital structure
probability of a lately discovered
impacted tooth causing periodontal
complications, caries, cyst n tumour is
low
Highly calcified and less flexible bone
Increased surgical morbidity

14. But why bother If surgical morbidity
outweigh the benefits?
Aged
Medically compromised
Proximity to vital structure
any medical condition which
carries increased surgical risk

15. But why bother If surgical morbidityBut why bother If surgical morbidity
outweigh the benefits?outweigh the benefits?
Aged
Medically compromised
Proximity to vital structure
Too close to the Inferior Alveolar nerve

16. When to remove? … late teens ideallyWhen to remove? … late teens ideally
more than 1/3 bt less than 2/3
less than 1/3
When one-third to two-third of theWhen one-third to two-third of the
normal length of root is formednormal length of root is formed
Healthy period so less postoperativeHealthy period so less postoperative
morbiditymorbidity
LLess chance of periodontal pocket d/t moreess chance of periodontal pocket d/t more
complete regeneration of bone andcomplete regeneration of bone and
reattachment of gingiva to adjacent toothreattachment of gingiva to adjacent tooth
Easier removal d/t flexible bone and widerEasier removal d/t flexible bone and wider
periodontal ligament space in this ageperiodontal ligament space in this age
groupgroup
Y in late teens?Y in late teens?

17. more than 20yrs
mesial tilt
positioned at the cervical level of 2nd molar
covered with bone
inadequate space
LATE ERUPTION LIKELY
less than20 yrs
vertical
positioned above the cervical level of the 2nd
molar
sufficient space
covered with soft tissue/ thin layer of bone
Is it a case of impactionIs it a case of impaction
or will it erupt late ??or will it erupt late ??
LIKELY IMPACTION

18. Investigation n assessmentInvestigation n assessment
radiographicradiographic
IOPA X-RAY
OCCLUSAL VIEW
TUBE - SHIFT TECHNIQUE
OPG
Lateral Oblique View
occlusal view
OPG
occlusal

19. DIFFICULTY ASSESSMENT
for a systematic approach and for a proper surgical technique
3 classification systems are correlated
to determine the accessibility(ease of
exposing tooth, pathway of delivery,
purchase point) of the impacted
tooth and hence calculate
the difficulty score
Winters classificationWinters classification
based on angulation of the
impacted tooth
MESIOANGULAR
HORIZONTAL
VERTICAL
DISTOANGULAR
1.1.

20. DIFFICULTY ASSESSMENTDIFFICULTY ASSESSMENT
for a systematic approach and for a proper surgical technique
Pell & Gregory’s Class I, II & IIIPell & Gregory’s Class I, II & III
based on available space
between the ant. border of
ramus and distal side of
2nd
molar
Pell & Gregory’s Type A, B & CPell & Gregory’s Type A, B & C
based on the depth of the
impacted molar with respect
to the occlusal surface of the
2nd
molar
2.2.
3.3.

21. calculatingcalculating the difficulty score:the difficulty score: impacted tooth isimpacted tooth is
given a difficulty index valuegiven a difficulty index value
Winter’sWinter’s
Mesioangular - 1
Horizontal - 2
Vertical - 3
Distoangular - 4
Pell & Gregory’s Class I, II & IIIPell & Gregory’s Class I, II & III
Class I - 1
Class II - 2
Class III - 3
Pell & Gregory’s A, B & CPell & Gregory’s A, B & C
Level A - 1
Level B - 2
Level C - 3
Very difficult - 8 to 10Very difficult - 8 to 10
Moderately difficult - 5 to 7Moderately difficult - 5 to 7
Minimally difficult - 3 to 4Minimally difficult - 3 to 4
For eg. total difficulty score
of an impacted molar with
vertical angulation, at level
B & under Class I category
will be :
63+2+1 =

22. OTHER FACTORS for difficulty assessmentOTHER FACTORS for difficulty assessment
Contact with 2Contact with 2ndnd
molarmolar
Periodontal ligament spacePeriodontal ligament space
Size of follicular sacSize of follicular sac
Density of boneDensity of bone
Root morphologyRoot morphology
Relation with inf. Alveolar n.Relation with inf. Alveolar n.

23. TWO TECHNIQUES ARE PRACTISEDTWO TECHNIQUES ARE PRACTISED
BUCCAL TECHNIQUEBUCCAL TECHNIQUE
LINGUAL SPLIT TECHNIQUELINGUAL SPLIT TECHNIQUE

24. Flap design – similar for both the buccal and
the lingual split technique
1.Triangular flap (L-shaped)
Incision starts from the anterior
border of ramus the external
oblique ridge distal aspect of IInd
molar
Vertical release from the ant. end of
horizontal incision obliquely
downwards and forward the
vestibular sulcus
incision
bone
horizontal
vertical
BUCCAL TECHNIQUE
‘Depends upon the depth of the impacted
tooth’

25. 2.Variation of the triangular
flap (bayonet)
- Origin of incision same as triangular
flap but continues as sulcular incision along
the cervical line of 2nd
molar upto the 1st
molar
- vertical incision begin at distal
aspect of 1st
molar
- for wider exposure in deep impaction
bone
horizontal
vertical

26. 3. Envelope flap3. Envelope flap
- begins at the ant. border of ramus distalbegins at the ant. border of ramus distal
aspect of 2aspect of 2ndnd
molar, continue as sulcular incisionmolar, continue as sulcular incision
along the cervical lines of last two teeth andalong the cervical lines of last two teeth and
ending at the mesialending at the mesial
aspect of 1aspect of 1stst
molarmolar
-- no vertical release incisionno vertical release incision
- superficial impaction- superficial impaction
bone
incision
no vertical incision

27. Removal of bone
expose the crownexpose the crown
create pathway for removal.create pathway for removal.
- bone is removed from the buccal
n distal aspect
- never lingually
High speed-high torque burHigh speed-high torque bur : no. 7/8
round bur or straight fissure bur ; time
consuming, bone necrosis, no need to
support the mandible, may contaminate
the room
Chisel - malletChisel - mallet : 3-5mm diam. chisel,
less time consuming, no bone necrosis,
need to support the mandible for TMJ
protection, inadvertent # of bone if undue
force, clean technique
B
O
N
E
F
R
O
M
B
U
C
C
O
D
I
S
T
A
L
buccal bone
distal bone
distal bone

28. horizontal mesioangular distoangular
Tooth SectioningTooth Sectioning:: provides less bone removal small dead space; bur orprovides less bone removal small dead space; bur or
chisel; only 1/2 the diam. sectioned n then fractured by elevatorchisel; only 1/2 the diam. sectioned n then fractured by elevator
TOOTH SECTIONING USUALLYTOOTH SECTIONING USUALLY
REQUIREDREQUIRED

29. Elevation of the tooth
Elevators
Winter Cryer’s elevator wedging action
buccal elevation
Coupland St. elevator mesially at the
base of the crown
between the tooth
and alveolar bone
luxation by
distal rotation
elevating the
tooth in a
superior and
distal direction
cryer elevation
coupland luxation
coupland elevation

30. Removal of follicular remnants
prevent cysts or tumours
follicle
peri-apical currette or
hemostat is used

31. After debridement , smoothening of bone margins and irrigation
with normal saline,
3 to 4 simple interrupted sutures given
3-0 black silk; reverse cutting needle used
Start at the distal aspect of 2nd
molar to
provide watertight seal n prevent pocket
1st
suture
SUTURESUTURE

32. TTHEHE LLINGUALINGUAL SSPLITPLIT TTECHNIQUEECHNIQUE
Meant for removal of the impacted lower 3rd
molar.
most types but is usually suitable for lingually placed impaction;
not in bucco-version
1st
introduced by Sir William Kelsey FrySir William Kelsey Fry popularised by
Terence WardTerence Ward Prof. R . PradhanProf. R . Pradhan is a major exponent of this
technique in India.
Purely a chisel - mallet technique
less surgical timeless surgical time PT. COMFORT
LESS OEDEMA
To remove the portion of the lingual plate covering the impacted molar
lingual pathway push the tooth lingually in toto
Tooth sectioning not required
The thin lingual cortical bone is chiseled in a piece instead of multiple
chipping of the thick buccal plate
Rationale no. IRationale no. I

33. Rational no. IIRational no. II
Removal of lingual plate no socket
close adaptation of vascular lingual flap
NO DEAD SPACE
PROPER HEALING
[NO DRY SOCKET]
no socket

34. Muco-periosteal flap similar to buccal
technique
1.Triangular (L-shaped)
2.Modified triangular (Bayonet)
3.Envelope flap
The techniqueThe technique
Fully covered toothFully covered tooth
Triangular incisionTriangular incision
Exposure of boneExposure of bone
Bone ExposureBone Exposure

35. 1.1. Mandible support forMandible support for
TMJ protectionTMJ protection
2. Vertical stop cut (5 to 6 mm ht.) placed2. Vertical stop cut (5 to 6 mm ht.) placed
distal to the 2distal to the 2ndnd
molar - bevel of themolar - bevel of the
chisel (3-5mm) facing posteriorly.chisel (3-5mm) facing posteriorly.
3. Oblique horizontal cut made backward3. Oblique horizontal cut made backward
from the lower end of the vertical limitingfrom the lower end of the vertical limiting
cut – post. limit of the cut being distalcut – post. limit of the cut being distal
aspect of the impacted crownaspect of the impacted crown
4. Buccal bone plate removed above the4. Buccal bone plate removed above the
horizontal cut to expose the crownhorizontal cut to expose the crown
5. Purchase point prepared by removing a5. Purchase point prepared by removing a
gular piece of bonegular piece of bone
Bone RemovalBone Removal :: to expose the crown and to removeto expose the crown and to remove
the obstruction to pathway for removalthe obstruction to pathway for removal
vertical stop cut
horizontal cut
Mandible support

36. The splitThe split
6. Fracture of the distolingual bone -
thethe
lingual splitlingual split
Split lingual plate removed after detaching
the periosteal attachment to expose the
lingual aspect of the tooth
CHISEL POSITIONCHISEL POSITION
Chisel placed at middle of the distal aspect of
2nd molar crown.
Bevel of the chisel is upward.
Cutting edge of chisel parallel to the external
oblique ridge;
Axis of the chisel at 45o
the bone
surface.
Angulation of chisel depends upon the depth
of the tooth; more depth require more
angulation towards the vertical.
Chisel position4 ling. splitChisel position4 ling. split

37. Tooth Elevation:Tooth Elevation:
The Coupland st. elevator is usedThe Coupland st. elevator is used
Elevator placed between the mesial aspectElevator placed between the mesial aspect
of the impacted tooth and the alveolar boneof the impacted tooth and the alveolar bone
and rotated distally for luxationand rotated distally for luxation
The tooth is pushed upward, backwards andThe tooth is pushed upward, backwards and
more lingually with minimum force.more lingually with minimum force.
Tooth easily displaced lingually asTooth easily displaced lingually as
lingual plate is removedlingual plate is removed
DISTALLYDISTALLY
LINGUALLYLINGUALLY
SUPERIORLYSUPERIORLY

38. curette
stitchstitch
1. Socket eliminated
2. Peri-apical currete for debridement
3. Normal saline irrigation for lavage n
decontamination
4. Bone margins rounded
5. Suturing by 3-0 black silk. Vertical incision
may be left unsutured for drainage
Post removalPost removal
No socketNo socket
curretecurrete
irrigationirrigation

39. ComplicationsComplications
PainPain
SwellingSwelling - moderate swelling is part of normal response
TrismusTrismus - inflammatory inv. of m. of mastication ; multiple
injections in Med. Ptygoid. M. ; damage to
temporalis attachment.
Dry socketDry socket - moderate to intense pain without swelling; pain
increasing on 3rd
or 4th
day
ParesthesiaParesthesia - in lower lip due to injury of the inf. alv n. ; in lingual split
technique numbess of tongue d/t lingual n injury is a
significant risk
Jaw fractureJaw fracture - undue force of mallet
Bone necrosisBone necrosis - bur technique
Loss of vitality of adjacent toothLoss of vitality of adjacent tooth - injudicious bone cutting n use of
elevator
TMJ afflictionTMJ affliction - internal derangement meniscus athralgia n clicking

40. Lingual split Buccal technique
No dry socket Dry socket
time consuming - thick buccal
bone n tooth sectioning
Less time consuming
no tooth sectioning
Lingual nerve
No bone necrosis
Less swelling
More pain d/t damage to
lingual periosteum
Clean technique; no bur
Need
practice
Bone necrosis
Chances nil
Bur may spray blood n bony particles
More swelling
Less pain
Easier

41. Bone belongs to the patient and tooth belongs to the surgeonBone belongs to the patient and tooth belongs to the surgeon
CONCLUSIONCONCLUSION
Prefer the technique most comfortable to youPrefer the technique most comfortable to you
Proper assessment of the case for tissueProper assessment of the case for tissue
preservation and rapid removal of thepreservation and rapid removal of the
tooth is empiricaltooth is empirical
Lingual split technique requires expertiseLingual split technique requires expertise
but is an important addition to ourbut is an important addition to our
armamentariumarmamentarium