Peri-operative Management

of Impacted Third Molars

Dr Chamara Atukorala MD
Consultant Oral and Maxillofacial Surgeon

Definition
Prevalence
Indications for Surgical removal, /Guidelines
Investigations and Diagnosis
Classification
Surgical management
Assessment
Planning
Execution
Post op Management
Complications and their Management
Medico-legal Background

Definition
Prevalence
Indications for Surgical removal, /Guidelines
Investigations and Diagnosis
Classification
Surgical management
Assessment
Planning
Execution
Post op Management
Complications and their Management
Medico-legal Background

Impacted tooth is a one that has not erupted to its

functional position in the occlusion and does not
show clinical or radiological features indicating
that it may erupt.

Causes

Angulation
Hard or soft tissue obstruction
Pathological lesions
Lack of space

Definition
Prevalence
Indications for Surgical removal, /Guidelines
Investigations and Diagnosis
Classification
Surgical management
Assessment
Planning
Execution
Post op Management
Complications and their Management
Medico-legal Background

The management of asymptomatic, disease-free ITM

is controversial, the best evidence currently available

neither supports nor refutes extraction .

(Symptomatic ITM?)

Available Guidelines
Local- None
Foreign
NICE
AAOMS

What is a Guideline ?

Guidance

1.1 The practice of prophylactic removal of pathology-free ITM should be

discontinued .
1.2 The standard routine programme of dental need be no different.

1.3 Surgical removal of ITM should be limited to patients with evidence

of pathology. Such pathology includes unrestorable caries, non-treatable
pulpal and/or periapical pathology, cellulitis, abcess and osteomyelitis,
internal/external resorption of the tooth or adjacent teeth, fracture of
tooth, disease of follicle including cyst/tumour, tooth/teeth impeding
surgery or reconstructive jaw surgery, and when a tooth is involved in or
within the field of tumour resection.
1.4 The evidence suggests that a first episode of pericoronitis, unless
particularly severe, should not be considered an indication for surgery.

The Guidelines boil down to waiting for some

pathology to develop, (such as decay in the wisdom tooth or the
adjacent tooth, gum disease around the wisdom tooth,infection around the
tooth crown, cellulitis, abscess and including cyst / tumour,tooth / teeth
impeding surgery or reconstructive jaw surgery )

Why Do British Practice This ?

This is regarded by some as supervised

neglect.

The American Association of Oral & Maxillofacial Surgeons (AAOMS), the

professional organization representing more than 8,500 OMF surgeons in
the USA .
Asymptomatic does not mean Disease Free Pathology is always
present before symptoms appear. Once damage has occurred, it is not
always treatable
25% of wisdom teeth patients who perceive themselves as asymptomatic
actually already have inflammatory periodontal disease. Blakey GH, Marciani
RD, Haug RH, et.al: Periodontal pathology associated with asymptomatic third molars;
Journal of Oral and Maxillofacial Surgery. 2001;60:1227-1233

 The risk of future disease requiring removal of retained wisdom teeth in

asymptomatic patients who retain their wisdom teeth, exceeds 70%
after 18 years of follow-up. Venta I, Ylipaavalniemi P, Turtola L: Clinical outcome of
third molars in adults followed during 18 years. J Oral Maxillofac Surg. 62:182, 2004

20 years after UK adopts the National Institute of Clinical Excellence

(NICE) guidelines, volume of third molar surgeries decrease, with a
corresponding increase in mean age for surgical admissions and an
increase in caries and pericoronitis as etiologic factors. Renton T, AlHaboubi M, Pau A, Shepherd J, Gallagher JE: What has been the United Kingdoms experience
with retention of third molars? J Oral Maxillofac Surg. 70:48-57, 2012, Suppl 1

Retention of third molars is associated with increased risk of second

molar pathology in middle-aged and older adult men. Nunn, ME, et al.

Retained Asymptomatic Third Molars and Risk for Second Molar Pathology. Nunn et al. J DENT
RES published online 16 October 2013.

AAOMS firmly supports the surgical management of erupted and

impacted third molar teeth, even if the teeth are asymptomatic, if there
is presence or reasonable potential that pathology may occur caused by
or related to the third molar teeth. November 10, 2011

Indications for removal of ITM identified in the Parameters

and Pathways published by the AAOMS include
1. Pain , 2. Carious tooth , 3. Pericoronitis
4. Facilitation of the management of progression of periodontal disease
5. Nontreatable pulpal or periapical lesion

6. Acute and/or chronic infection (e.g., cellulitis, abscess)

7. Ectopic position (malposition, supraeruption, traumatic occlusion)
8. Abnormalities of tooth size or shape precluding normal function
9. Facilitation of prosthetic rehabilitation
10. Facilitation of orthodontic tooth movement and promotion of stability of

the dental occlusion

11. Tooth in the line of fracture complicating fracture management
12. Tooth involved in surgical treatment of associated cysts and tumors

13. Tooth interfering with orthognathic /or reconstructive surgery

14. Preventive or prophylactic removal, when indicated, for patients with medical
or surgical conditions or treatments (e.g., organ transplants, alloplastic implants,
bisphosphonate therapy, chemotherapy, radiation therapy)

15. Clinical findings of pulp exposure by dental caries

16. Clinical findings of fractured tooth or teeth Impacted tooth
18. Internal or external resorption of tooth or adjacent teeth
19. Patients informed refusal of nonsurgical treatment options
20. Anatomic position causing potential damage to adjacent teeth
21. Use of the third molar as a donor tooth for tooth transplant
22. Tooth impeding the normal eruption of an adjacent tooth
23. Resorption of an adjacent tooth

24. Pathology associated with the tooth follicle

25. Abnormality of size or shape precluding normal function

When managing a patient with asymptomatic,

disease-free ITM, one must carefully review the
risks and benefits of extraction or retention, and
heavily weight the patients treatment
preference.

strong indication for removal of impacted

third molar should be complemented with
a strong contraindication to its retention
Mercier P., Precious D., Risk and benefits of removal of impacted third
molars, IJOMS 21:17, 1992.

Definition
Prevalence
Indications for Surgical removal, /Guidelines
Investigations and Diagnosis
Classification
Surgical management
Assessment
Planning
Execution
Post op Management
Complications and their Management
Medico-legal Background

Radiological Investigations
Radiographs
Intra Oral
IOPA
Occlusal views
Extra Oral
DPT (OPG)
Lateral Oblique Views

CT
Cone Beam CT
Conventional CT

Radiological Assessment Helps In

Classification of the ITM
Localisation and orientation of the ITM
Assessment of the crown and root morphology of
the ITM
Assessment of the ramal bone cover
Assessment of the second molar tooth and its root
morphology
Relationship of the ID canal to the roots of ITM
Associated pathological lesions with the ITM

Definition
Prevalence
Indications for Surgical removal, /Guidelines
Investigations and Diagnosis
Classification
Surgical management
Assessment
Planning
Execution
Post op Management
Complications and their Management
Medico-legal Background

Systematic classification of the position of

Impacted Third molar ( ITM) teeth helps in
Assessing the best possible path of removal of the
ITM
Managing difficulties encountered during removal

Prediction of operative difficulty before the extraction

of ITM allows a design of treatment that minimises
the risk of complications.

Both radiological and

clinical information must be taken into account.

Classification of Impacted Mandibular 3rd

Molars
1. ADA-AAOMS Classification
2. Nature of the overlying tissues
3. Winters Classification
4. Pell & Gregorys Classification

ADA-AAOMS Classification
Impacted tooth-with overlying soft tissue.
Impacted tooth-Partial bony impaction.
Impacted tooth-complete bony impaction .
Impacted tooth-complete bony impaction with unusual
surgical complications.

Nature of the overlying tissues

Soft Tissue Impaction. is usually the
easiest of type of impacted tooth to remove.
Hard Tissue ('Bony') Impaction.
Partial Bony. The superficial portion of the tooth is
covered only by soft tissue but the height of the
tooth's contour is below the level of the surrounding
alveolar bone.
Complete Bony. The tooth is completely encased in
bone so that when the gingiva is cut and reflected
back, the tooth is not seen. These are often the most
difficult tooth to remove

Winter's Classification

Mesioangular - 45%
Vertical
- 40%
Horizontal - 10%
Distoangular 5%
Inverted
Bucco-version
Linguo-version
Transverse

Pell & Gregory's Classification

Based on the relationship between the ITM to the ramus of the
mandible (lower jaw) and the 2nd molar (based on the space
available distal to the 2nd molar).
Class A. The highest portion of impacted 3rd molar is on a level
with or above the occlusal plane.
Class B. The highest portion of impacted 3rd molar is below the
occlusal plane but above the cervical line of the of 2nd molar.

Class C. The highest portion of impacted 3rd molar is below the

cervical line of the of 2nd molar.

Definition
Prevalence
Indications for Surgical removal, /Guidelines
Investigations and Diagnosis
Classification
Surgical management
Assessment
Planning
Execution
Post op Management
Complications and their Management
Medico-legal Background

Assessment
Case history

General medical status of the patient ( Fitness to undergo ITM

surgery)

Extra oral examination

Mouth opening and TMJ

Facial form, mental nerve functioning

Intra oral

Surgical site
ITM in question

Assessment of the degree of difficulty of the ITM

surgery
Assess the radiological features

Assessment of the degree of difficulty of

the surgery
WAR (Winters) Lines
WHARFEs ASSESSMENT by McGregor (1985)
PEDERSONS DIFFICULTY INDEX

Category
1. Winters
classification

WHARFEs
ASSESSMENT by
McGregor (1985)

Horizontal
Distoangular
Mesioangular
Vertical
2. Height of mandible
1-30mm
31-34mm
35-39mm
rd
3. Angulation of 3
1 - 50
molar
60 - 69
70 -79
80 - 89
90+
4. Root shape
Complex
Favourable curvature
Unfavourable curvature
5. Follicles
Normal
Possibly enlarged
Enlarged
6. Exit (Path of exit) Space available
Distal cusp covered
Mesial cusp covered
Both cusp covered
Total

Score
2
2
1
0
0
1
2
0
1
2
3
41

2
3
0
1
2
0
1
2
3
33

PEDERSONS DIFFICULTY INDEX

Very difficult
:
Moderataly difficult:
Minimally difficult :

7 to 10
5 to 7
3 to 4
Scoring

Mesio angular
Horizontal
Vertical
Distoangular
Level A
Level B
Level C
Class I
Class II
Class III

1
2
3
4
1
2
3
1
2
3

Radiological features indicating a close association

between IAN and ITM

If the ID nerve is closely associated indicating a

high risk of injury ; best is to assess using
advanced imaging methods
Cone Beam CT
Conventional CT

Important Anatomical Structures

Definition
Prevalence
Indications for Surgical removal, /Guidelines
Investigations and Diagnosis
Classification
Surgical management
Assessment
Planning
Execution
Post op Management
Complications and their Management
Medico-legal Background

ITM Management options

*Observation

and periodic review

*Surgery
**Conventional
***Intra Oral
****Buccal Approach
****Lingual Split Technique
****BSSO
***Extra Oral Approach

**Coronectomy

** Staged Removal

Planning

Observation and periodic review

For patients who elect retention, the frequency of follow
ups should be designed to match the symptoms or
disease associated with ITM
( physical and radiographic examination every 12 to 24
months by a health care professional trained to evaluate
third molars.)

Surgery
Set up of care
LA +/- sedation
GA

Definition
Prevalence
Indications for Surgical removal, /Guidelines
Investigations and Diagnosis
Classification
Surgical management
Assessment
Planning
Execution
Post op Management
Complications and their Management
Medico-legal Background

Steps In Surgical Removal

(Buccal Access)

Anesthesia
Incision and mucoperiosteal flap design and flap
reflection
Removal of bone
Sectioning of tooth/roots

Elevation/Extraction
Wound debridement and smoothening of bone
Achieve Haemostasis

Wound closure, Analgesics

Postoperative follow-up

Principles of flap design

Adaquate access
Viability of the flap ( Base> top)
Avoid vital structures
Plan ease of repositioning
Ability to extend if the need arises
Clean incisions

Types of flap designs

Envelope flap
L- shaped incision
Bayonet shaped incision
Triangular shaped incision
Wards incision and Modified Wards incision.
Comma shaped incision.
S -shaped incision
Szmyd and modified Szmyd incision
Berwicks tongue shape flap.

Wards incision

Modified Wards

Incision Not to be extended

too distally Bleeding from buccal vessels &
other arteries

Postoperative trismus temporalis

muscle damage
Herniation of buccal fat pad
Damage to lingual nerve (lingual
extention)

Envelop flap

Triangular shaped Incision

Bone Removal
Bone belongs to the patient
and tooth belongs to the
dentist
Minimize the amount of bone removal as possible
Instead section the tooth and deliver in pieces
Excessive bone removal results in poor healing and
bone defect.
High risk of alveolar osteitis, post op pain and
trismus.

 Once the soft tissue is elevated and retracted, the

surgeon must make a judgment concerning the amount
of bone to be removed.
Bone must be removed in an atraumatic, aseptic, and
nonheat-producing technique, with as little bone
removed and damaged as possible.

The amount of bone that must be removed varies with

the depth of impaction, the morphology of roots, and the
angulation of tooth.

No bone should be removed from lingual aspect so as to

protect the lingual nerve from injury.

Bone removal - Moore & Gillbes Collar

Technique

Tooth Division
Rationale of tooth sectioning is to create
a space into which impacted tooth can be

displaced & thence removed.

Tooth is sectioned in various ways depending on the type &
degree of impaction.
Tooth is sectioned of the way

towards the lingual aspect. A straight elevator is inserted

into the slot made by the bur and rotated to split the tooth

Extra Oral Approach

SSO

Coronectomy

Coronectomy
What is it ?
Indications
Technique
Post op Mx
Follow up

Staged Removal

Debridement of Wound & Closure

Thorough debridement of the socket by Periapical curettage.
Remove the follicle of the ITM.
Smoothening of sharp bony margins by Bone file / burs.
Thorough irrigation of the socket Betadine solution + Saline .
Initial wound closure is achieved by placing 1stsuture just
distal to 2ndmolar, sufficient

proper closure.

number of sutures to get

Definition
Prevalence
Indications for Surgical removal, /Guidelines
Investigations and Diagnosis
Classification
Surgical management
Assessment
Planning
Execution
Post op Management
Complications and their Management
Medico-legal Background

Post Operative Instructions

Pressure pack , Ice application

Soft diet 1st two days

1st dose of analgesic should be taken before the
anesthetic effect of LA wears off.
Avoid strenuous exercises for 1st 24 hrs.
Avoid gargling / spitting / smoking / drinking
with straw.
Warm water saline gargling after 24 hrs + mouth
wash regularly thereafter.
Suture removal on 5th POD.

Antibiotics ?
Steroids?

Definition
Prevalence
Indications for Surgical removal, /Guidelines
Investigations and Diagnosis
Classification
Surgical management
Assessment
Planning
Execution
Post op Management
Complications and their Management
Medico-legal Background

Complications and their Management

Intra Operative

1. During incision
a. Injury to facial artery
b. Injury to lingual nerve
c. Hemorrhage careful history

2. During bone removal

a.
b.
c.
d.
e.

Damage to second molar

Slipping of bur into soft tissue & causing injury
Extra oral/ mucosal burns
Fracture of the mandible when using chisel & mallet
Subcutaneous emphysema

3. During elevation or tooth removal

a. Luxation of neighbouring tooth/

fractured
restoration
b. Soft tissue injury due to slipping of elevator
c. Injury to inferior alveolar neurovascular bundle
d. Fracture of mandible
e. Forcing tooth root into submandibular space or
inferior alveolar nerve canal
f. Breakage of instruments
g. TMJ Dislocation careful history

Post-operative complications
Immediate
- Hemorrhage
- Pain
- Edema
- Drug reaction
Delayed
- Alveolitis

- Infection
- Trismus

From Medico-legal point of view to avoid

getting in to problems.
Make correct decisions
Get patient actively involved in
decision making
INFORMED CONSENT
Proper investigations
Correct treatment.
Manage complications
Communicate with the patient
Be nice to your patient