A Novel Orthodontic Extraction

Method for Removal of Impacted

Mandibular Third Molars in Close
Proximity to Inferior Alveolar Nerve
Zhiqiang Wang, MD, PhD,* Zhenxing Liu, MD,y Yanli Shi, MD, PhD,z Dong Fang, MD,x
Shengfeng Li, MD,k and Dongsheng Zhang, MD, DDS, PhD{
Purpose: The present study has proposed a novel orthodontic extraction method with a removable
appliance to avoid inferior alveolar nerve (IAN) injury during impacted mandibular third molar removal.
Patients and Methods: In the present study, 16 patients were enrolled and divided into 2 groups per
patient choice. In the orthodontic extraction group (n = 8), a removable appliance was first applied to
move the root tips away from the IAN, and the tooth was subsequently removed. In the traditional extrac-
tion group (n = 8), each patient had the tooth removed immediately by the same surgeon.
Results: All teeth were extracted successfully. All 8 patients in the orthodontic extraction group had had
their impacted mandibular third molar removed without IAN injury after surgery. In contrast, 4 patients in
the traditional extraction group had experienced transient IAN injury, and the symptoms persisted for 2 to
8 weeks. None of the patients experienced permanent IAN damage.
Conclusions: Orthodontic extraction with a removable appliance to separate the IAN and impacted
mandibular third molar could be a good alternative treatment option to avoid IAN injury in high-risk cases.
Ó 2019 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 77:1575.e1-1575.e6, 2019

The removal of an impacted mandibular third molar is
one of the most common procedures performed by
oral and maxillofacial surgeons.1 This procedure has
been typically accompanied by postoperative compli-
cations, such as pain, swelling, trismus, and nerve
injury. Among these, damage to the inferior alveolar
nerve (IAN) is a severe complication that can cause
temporary or permanent paresthesia and often results
in legal disputes between doctors and patients.2 The
incidence of IAN injury during the removal of an
impacted mandibular third molar has ranged from
0.35% to 8.4%.3-7
A close anatomic relationship between the root tips
of an impacted mandibular third molar and the IAN
canal is the main cause of IAN injury.8 The prediction
of IAN injury mainly relies on radiographic analysis.
Orthopantomography (panoramic radiography) has
become a routine preoperative examination for
impacted mandibular third molars. This examination
will reveal potential risk factors, including darkening

Received from Shandong Provincial Hospital Affiliated to Shandong
University, Jinan, China.
*Associate Professor, Department of Orthodontics.
yResident, Department of Oral and Maxillofacial Surgery.
zAssociate Professor, Department of Orthodontics.
xAssociate Professor, Department of Oral Radiology.
kProfessor, Department of Oral and Maxillofacial Surgery.
{Professor, Department of Oral and Maxillofacial Surgery.
The present study was partially supported by the National Natural
Science Foundation of Shandong Province (grant ZR2013HM055)
and the National Natural Science Foundation of Jinan Municipality
(grant 201121054).
Conflict of Interest Disclosures: None of the authors have any
relevant financial relationship(s) with a commercial interest.
Address correspondence and reprint requests to Dr Zhang:
Department of Oral and Maxillofacial Surgery, Provincial Hospital
Affiliated to Shandong University, 324 Jingwu Road, Jinan 250021,
China; e-mail: liuzhenxing06@126.com
Received October 18 2018
Accepted April 3 2019
Ó 2019 American Association of Oral and Maxillofacial Surgeons
0278-2391/19/30444-6
https://doi.org/10.1016/j.joms.2019.04.013

1575.e1
1575.e2 ORTHODONTIC EXTRACTION METHOD FOR IMPACTED MANDIBULAR THIRD MOLARS

of the root, deflection of the root, narrowing of the

root, dark and bifid root tips, and narrowing of the
IAN canal.3 Moreover, cone beam computed tomogra-
phy (CBCT) is the best method for displaying the rela-
tionship between the impacted teeth and the IAN
canal in 3 dimensions.9 However, surgeon experience,
patient age and gender, the degree of operative tissue
damage, the surgical instruments used, and postopera-
tive edema have been reported to be related to
IAN injury.3
In addition to radiographic analysis, various surgical
techniques have been proposed to reduce the inci-
FIGURE 1. Orthopantomogram of the lower third molar revealing
dence of IAN injury. The ‘‘orthodontic extraction’’ a lower left third molar completely impacted in the mandible and
technique is a combined orthodontic–surgical compressing the inferior alveolar nerve.
approach for the removal of impacted mandibular Wang et al. Orthodontic Extraction Method for Impacted Mandib-
third molars in patients at a high risk of IAN ular Third Molars. J Oral Maxillofac Surg 2019.
injury.2,10-12 With this technique, 2 main methods
can be applied. One involves the use of orthodontic TRADITIONAL EXTRACTION GROUP (CONTROL
brackets and hooks on the maxillary/mandibular GROUP)
molar, and the other involves the placement of bone
In the traditional extraction group, the patients
miniscrews.
received block anesthesia in the IAN, lingual nerve,
In the present study, we have proposed a novel
and buccal nerve with 2% lidocaine hydrochloride.
orthodontic extraction method using a removable
After incision placement and mucoperiosteal flap
appliance as anchorage. The specific aim of the pre-
elevation, ostectomy and crown sectioning were per-
sent study was to evaluate the clinical utility of this
formed using manual pieces when necessary. Next,
method compared with traditional surgical extraction
the impacted mandibular third molar was completely
of impacted mandibular third molars with a high risk
extracted. After extraction, the residual cavity was
of IAN injury.
cleaned with sterile physiologic saline. The wound

Patients and Methods

STUDY DESIGN
The present retrospective study included patients
who had visited the Department of Oral and Maxillofa-
cial Surgery of Shandong Provincial Hospital from
November 2013 to May 2015 for the removal of an
impacted mandibular third molar and had been identi-
fied as high-risk patients regarding their risk of IAN
injury on orthopantomography and CBCT (Figs 1, 2).
The patients had not taken antibiotics or anti-
inflammatory agents for 14 days before they had
undergone treatment.
The patient population included 7 men and 9
women, with a mean age of 22 years (range, 18 to
32 years). Of these 16 patients, 8 had chosen the ortho-
dontic extraction technique (experimental group),
and the remaining 8 had chosen traditional surgical
extraction (traditional extraction or control group).
All the patients had been informed in detail of the
potential complications with the 2 different tech-
niques and had signed informed consent forms. All
treatments were performed in accordance with the FIGURE 2. Cone beam computed tomography scan of the lower
third molar revealing the relationship between the root tips of the
relevant guidelines and regulations. The medical lower left third molar and the inferior alveolar nerve canal in 3 di-
ethics committee of Shandong Provincial Hospital affil- mensions.
iated with Shandong University approved the present Wang et al. Orthodontic Extraction Method for Impacted Mandib-
research. ular Third Molars. J Oral Maxillofac Surg 2019.
WANG ET AL
was closed primarily with a simple interrupted suture.
Finally, antibiotics were prescribed to the patients.
ORTHODONTIC EXTRACTION GROUP
(EXPERIMENTAL GROUP)
Phase 1: Preparation for the Orthodontic Device
A device for the traction and rotation of the
impacted mandibular third molar was generated,
which consisted of 2 components: a removable appli-
ance with 4 clasps and a buccal arch with a hook end
(Figs 3, 4). The 4 paralleled small clasps and the buccal
arch were generated from 0.8-mm stainless steel. The
buccal arch was fixed on the extrusion side of the
removable appliance and used for force loading. The
4 clasps were used to keep the prosthesis securely
fixed in place but still allowed the patient to easily
remove the prosthesis for regular cleaning and proper
brushing of the remaining natural teeth.
Phase 2: Surgical Exposure of the Impacted
Mandibular Third Molar Crown
The patients received local anesthesia using prima-
caine. Surgical exposure of the impacted mandibular
third molar crown was required for application of
the orthodontic bracket. For a vertically or distally in-
clined third molar, we exposed the tooth’s occlusal
surface. For a mesially inclined third molar with an
angle of impaction <45 , the enamel of the distal or
vestibular surface of the clinical crown was made
visible. The size of the exposed range must meet the
requirements of the fixed orthodontic bracket.
Phase 3: Orthodontic Traction
After the soft tissue recovery period (1 week after
surgery), the orthodontic bracket was attached to the
exposed third molar crown. Next, a hook generated
FIGURE 3. Photograph of the orthodontic device. The removable
appliance received primary support from the maxillary dentition
with 4 clasps.
Wang et al. Orthodontic Extraction Method for Impacted Mandib-
ular Third Molars. J Oral Maxillofac Surg 2019.
1575.e3
FIGURE 4. Photograph of the orthodontic device. The buccal arch
with a hook end was fixed on the extrusion side of appliance and
used for force loading.
Wang et al. Orthodontic Extraction Method for Impacted Mandib-
ular Third Molars. J Oral Maxillofac Surg 2019.
from 0.8-mm stainless steel was fixed to the orthodon-
tic bracket (Fig 5). An orthodontist performed this pro-
cedure. The removable appliance was placed on the
maxillary dentition. Next, rubber bands were fixed
between the buccal arch and the hook to force the
root tips away from the IAN; these were changed every
3 days. The appliance could be removed by the patient
or with the help of their families at any time, such as
for eating, smoking, and speaking. Daily cleaning of
the appliance was recommended. The patients were
requested to return for follow-up visits to reshape
the buccal arch every 4 to 6 weeks.
Phase 4: Extraction of the Impacted Mandibular
Third Molar
Orthopantomography or CBCT was used to assess
the status of traction (Figs 6, 7). When the root tips
were located away from the IAN, surgical removal of
the impacted mandibular third molar was scheduled.
FIGURE 5. An orthodontic bracket was attached to the exposed
third molar crown.
Wang et al. Orthodontic Extraction Method for Impacted Mandib-
ular Third Molars. J Oral Maxillofac Surg 2019.
1575.e4 ORTHODONTIC EXTRACTION METHOD FOR IMPACTED MANDIBULAR THIRD MOLARS
FIGURE 6. Cone beam computed tomography scan revealing the
relationship between the distal root tip and the inferior alveolar
nerve canal before treatment.
Wang et al. Orthodontic Extraction Method for Impacted Mandib-
ular Third Molars. J Oral Maxillofac Surg 2019.
This operation should be quicker and more
straightforward compared with that used in the
control group, given its subluxation status and
should carry little risk of complications, especially
paresthesia.
FIGURE 7. Cone beam computed tomography scan revealing the
relationship between the distal root tip and the inferior alveolar
nerve canal at the end of orthodontic traction (4 months).
Wang et al. Orthodontic Extraction Method for Impacted Mandib-
ular Third Molars. J Oral Maxillofac Surg 2019.
Results
The present study enrolled 16 patients, including
7 men and 9 women. Patient age ranged from 18 to
32 years (average, 22 years). All 16 patients completed
the 6-month follow-up period with no withdrawals.
In the orthodontic extraction group, orthopanto-
mography or CBCT revealed that the root tips had
moved 1 to 3 mm away from the IAN after 1 to
6 months (average, 3 months) of traction. Only 1 pa-
tient’s orthodontic bracket had fallen off after
2 months of traction and was reattached to the teeth
after 2 days, with traction resumed. These impacted
teeth were removed quickly and without lower lip
paresthesia or mandibular fractures. Smooth soft tis-
sue healing was noted, with less postoperative facial
swelling or pain and the absence of any signs
of infection.
In both groups, all the teeth were extracted success-
fully, but with a longer operative time required for the
traditional extraction group. Of the 8 patients in the
traditional extraction group, 4 patients developed
transient lower lip paresthesia, including tingling,
prickling, or burning, due to IAN dysfunction. This
symptom persisted for 2 to 8 weeks after postopera-
tive application of steroids and mecobalamin. None
of the patients experienced permanent IAN damage.
Eventful soft tissue healing was noted, with various
degrees of facial swelling or pain.
Discussion
IAN injury, which can result in paresthesia of the
lower lip region and significantly affect patients’
quality of life, is an infrequent, but serious, nerve
complication that can occur after the extraction of
an impacted mandibular third molar.13,14 IAN injury
occurs primarily owing to the proximity of the tooth
root tips to the IAN canal. Aksoy et al15 measured
the distances between the roots of the molar and the
mandibular canal and found that approximately one
third of all third molars were in direct contact with
the IAN. Previous studies have revealed that IAN pares-
thesia is temporary and will be resolved within
6 months.16 Neurosensory disturbances have been
estimated to constitute 96% of injuries in patients
recovering within 4 to 8 weeks after surgery. Also,
the recovery rates were not influenced by gender
and only slightly influenced by age.17,18 In contrast,
the incidence of permanent injury, in which sensory
impairment persists for >6 months, has been <1%.19
To reduce the risk of IAN injury, several strategies
have been used. Knutsson et al20 introduced coronec-
tomy for impacted mandibular third molars, which
involves sectioning portions of the crown, leaving
the roots in the socket and preventing indirect damage
WANG ET AL
to the IAN. However, this procedure results in the risk
of the need for a second procedure to remove the
retained roots and increased postoperative complaints
and infection due to the retained roots.21,22 Wang
et al12 used the orthodontic extraction technique,
and their results showed that that this method is pref-
erable to the surgical method in reducing the risk of
paresthesia. This technique has been reported to be
safe with regard to nerve injury and can also promote
bone apposition and decrease periodontal defects of
the mandibular second molar.2,23,24 To date,
however, the duration of orthodontic extraction
treatment has varied from 3 weeks to 10 months in
different studies.25 Because it is time consuming and
expensive, it might not be tolerable for some patients.
In the present study, we have presented a novel
orthodontic extraction method that uses a removable
appliance for the prevention of IAN injury. Generally,
the biomechanical systems used for orthodontic
extraction in previous studies can be mainly catego-
rized into 2 groups. One involves the use of orthodon-
tic brackets and hooks on the maxillary/mandibular
molar, and the second involves the placement of
bone miniscrews. In our technique, the use of a
removable appliance enables the orthodontist to
achieve maximum anchorage for regional orthodontic
treatment. The buccal arch has a more comfortable
appearance, a better fit with the gingiva, and reduces
the risk of buccal mucosal lesions. Compared with
orthodontic brackets and miniscrews, the buccal
arch has the advantage of more straightforward re-
shaping and provides better control of anchorage dur-
ing traction. Because the device can be removed by
patients or with the help of their families at any
time, the removable appliance appears to address
both of these issues, enabling effective orthodontic
extrusion with maximal patient comfort and maintain-
ing good oral hygiene. This procedure is suitable for
vertically, distally inclined, and mesially inclined
molars with an angle of impaction <45 . For horizon-
tally or mesially inclined teeth with an angle of impac-
tion >45 , orthodontic extrusion with this device can
cause the root tips to move toward the IAN. However,
the results of the present study have clearly revealed
that such a method can more reliably reduce IAN
injury, with an average duration of device use
of 3 months.
In the present study, preoperative radiologic assess-
ment was essential to evaluate the topographic
relationship between the IAN canal and the impacted
mandibular third molar. Orthopantomography has
become a routine preoperative examination for this
assessment. Kim et al26 found that the significant risk
factors for neurosensory deficits of the IAN after
mandibular third molar extraction using orthopanto-
mography included root deflection, narrowing of the
1575.e5
root, diversion of the canal, and narrowing of the
canal. CBCT can provide a precise evaluation of the
relationship in 3 dimensions.9 Tantanapornkul et al27
analyzed a larger sample of 142 teeth using CBCT
and found that the prevalence of nerve damage was
increased in cases in which contact was observed
between the tooth and canal.
In conclusion, to the best of our knowledge, the pre-
sent study is the first to describe the use of a removable
appliance to extrude impacted mandibular third mo-
lars. More clinical trials of this area could simplify
the biomechanics and, thus, shorten the treatment
time. However, this treatment option does has some
drawbacks, including the need for 2-stage surgery,
the relatively longer treatment time, an uncomfortable
removable appliance, and the additional cost. Howev-
er, orthodontic extraction with a removable appliance
to separate the IAN and the impacted mandibular third
molar could be a good alternative treatment option to
avoid IAN injury in high-risk cases.
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