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Lower 3rd molar impaction,its assessment and the buccal approach vz the lingual split technique of its extraction

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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..

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Lower 3rd molar impaction,its assessment and the buccal approach vz the lingual split technique of its extraction

  1. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 18. Investigation n assessmentInvestigation n assessment radiographicradiographic IOPA X-RAY OCCLUSAL VIEW TUBE - SHIFT TECHNIQUE OPG Lateral Oblique View occlusal view OPG occlusal
  19. 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. 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. 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. 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. 23. TWO TECHNIQUES ARE PRACTISEDTWO TECHNIQUES ARE PRACTISED BUCCAL TECHNIQUEBUCCAL TECHNIQUE LINGUAL SPLIT TECHNIQUELINGUAL SPLIT TECHNIQUE
  24. 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. 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. 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. 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. 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. 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. 30. Removal of follicular remnants prevent cysts or tumours follicle peri-apical currette or hemostat is used
  31. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

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