Principles of Surgical Management of Impacted Third Molar

Part (II)
1.7 Surgical procedure
1.7.1 Patient positioning
Generally, for operative procedures in mandible the occlusal plane of lower teeth should be
parallel to the floor and for the maxillary teeth the occlusal plane of the upper teeth at 45°
angles to the floor. The instruments are arranged in a rational order of their intended use over
the instrument tray of the dental chair or more preferably on a separate instrument trolley.

1.7 ٢‫جإلؾٍجء جُؿٍجق‬

1.7.1 ‫ط‬٣ٍُٔ‫ظغ ج‬ٞٓ ‫ى‬٣‫ضكى‬

‫ًح‬٣َ‫ج‬ٞٓ ‫س‬٤ِ‫ جإلغرحم ُألْ٘حٕ جُٓل‬ٟٞ‫ٕ ٓٓط‬ٌٞ٣ ٕ‫ؿد أ‬٣ ،٢ِ‫ جُلي جُٓل‬٢‫س ك‬٤‫ ذحُ٘ٓرس ُإلؾٍجءجش جُؿٍجق‬،ّ‫ذشٌَ ػح‬
ْ‫ط‬٣ .‫ جألٌض‬٠ِ‫ وٌؾس ػ‬45 ‫س‬٣ٝ‫س ذُج‬٣ِٞ‫ جإلغرحم ُألْ٘حٕ جُؼ‬ٟٞ‫ٕ ٓٓط‬ٌٞ٣ ٕ‫ؿد أ‬٣ ،‫س‬٣ِٞ‫ذحُ٘ٓرس ُألْ٘حٕ جُؼ‬ٝ ،‫س‬٤‫ُألٌظ‬
٠ِ‫ ذشٌَ ٓلعَ ػ‬ٝ‫ جألْ٘حٕ أ‬٢ٌٍْ‫جش جُهحصس ذ‬ٝ‫س جألو‬٤٘٤‫م ص‬ٞ‫و ك‬ٞ‫ح جُٔوص‬ٜٓ‫ الْطهىج‬٢‫د ٓ٘طو‬٤‫جش ذطٍض‬ٝ‫د جألو‬٤‫ضٍض‬
‫جش ٓ٘لصِس‬ٝ‫ػٍذس أو‬.
1.7.2 Incision and Designing the Flap
 As a general rule, the deeper the third molar  more extensive the bone removal
required and the necessity for tooth sectioning.
 The most commonly used flap is the envelope flap, which extends from just posterior
to the position of the impacted tooth anteriorly to the level of the first molar. The
posterior end of the incision is directed buccally along the external oblique ridge.
 If greater access is required, a release incision is given on the anterior aspect of the
incision, creating a triangular flap (started from a point approximately 6 mm down in
the buccal sulcus and then extended obliquely upwards to the gingival margin to a point
at the junction of the posterior and middle thirds of the second molar).
1.7.2 ‫ِس‬٣‫ْ جُٓى‬٤ٔ‫ضص‬ٝ ‫جُشن‬
• ‫ ًِٔح ًحٕ جُعٍِ جُػحُع أػٔن‬،‫ًوحػىز ػحٓس‬ ٕ‫ْ جألْ٘ح‬٤ٓ‫ٌز ضو‬ٍٝ‫ظ‬ٝ ‫ذس‬ِٞ‫أًػٍ جضٓحػح ً ًحٗص ئَجُس جُؼظحّ جُٔط‬.
• ٟٞ‫ ٓٓط‬٠ُ‫ظغ جُٖٓ جُٔ٘طٍٔ ٖٓ جألٓحّ ئ‬ٞٓ ٠ُ‫ ضٔطى ٖٓ جُهِق ٓرحشٍز ئ‬٢‫جُط‬ٝ ،‫س‬٤‫ِس جُٔـِل‬٣‫ جُٓى‬٢ٛ ‫ِس جألًػٍ جْطهىج ًٓح‬٣‫جُٓى‬
‫س‬٤‫ٍ جُكحكس جُٔحتِس جُهحٌؾ‬ٞ‫ غ‬٠ِ‫س ُِشن شىهح ػ‬٤‫س جُهِل‬٣‫ح‬ُٜ٘‫ ج‬ٚ٤‫ؾ‬ٞ‫طْ ض‬٣ .ٍٝ‫جُعٍِ جأل‬.
• ‫ِس‬٣‫ ئٗشحء ْى‬٠ُ‫ ئ‬١‫إو‬٣ ‫ ٓٔح‬،‫ ٖٓ جُشن‬٢ٓ‫ جُؿحٗد جألٓح‬٠ِ‫ٍ ػ‬٣ٍ‫طْ ئؾٍجء شن ضك‬٣ ،ٍ‫ٍ أًر‬ٞ‫ص‬ٝ ٠ُ‫٘حى قحؾس ئ‬ٛ ‫ئيج ًحٗص‬
‫ ٗوطس ػ٘ى ضوحغغ‬٠ُ‫ قحكس جُِػس ئ‬٠‫ قط‬٠ِ‫ٍ ٓرحشٍ ألػ‬٤‫ جُطِْ جُشىم غْ ضٔطى ذشٌَ ؿ‬٢‫ ْٓ ألْلَ ك‬6 ٢ُ‫ج‬ٞ‫ٓػِػس (ضرىأ ٖٓ ٗوطس ق‬

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 ٢ٗ‫ْػ ٖٓ جُعٍِ جُػح‬ٝ‫جأل‬ٝ ٢‫ٖ جُهِل‬٤‫)جُػِػ‬.
 The blunt end of the periosteal elevator is passed beneath the mucoperiosteum to reflect
the soft tissue.
 Reflection of lingual mucoperiosteum is kept to the minimum to avoid injury to lingual
nerve.
• ‫ز‬ٞ‫ ُِٓٔكحم ُطؼٌّ جألٗٓؿس جٍُن‬٢‫س أْلَ جُـشحء جُٔهحغ‬٤‫س جُكحوز ٍُِجكؼس جُٓٔكحه‬٣‫ح‬ُٜ٘‫ٍ ج‬٣ٍٔ‫طْ ض‬٣.
• ٢ٗ‫ ُطؿ٘د ئصحذس جُؼصد جُِٓح‬٠ٗ‫ جُكى جألو‬٠ُ‫ ئ‬٢ٗ‫ جُِٓح‬٢‫طْ جالقطلحظ ذحٗؼٌحِ جُـشحء جُٔهحغ‬٣.

1.7.3 Bone Removal

The amount of bone removal varies with the depth of impaction remove sufficient amount
of bone to free the tooth from obstruction and to provide a point of application for the elevator.
A. A common technique 'lingual split bone technique' introduced by Ward (1956)  a
section of bone lingual to the wisdom tooth is fractured off to facilitate the removal of
the impacted tooth.
B. Buccal approach; should be kept to minimum to avoid weakening of the mandible.
1.7.3 ّ‫ئَجُس جُؼظح‬
ٌ‫س جُؼظحّ جُٔٓطهٍؾس ذحنطالف ػٔن جالٗكشح‬٤ًٔ ‫ضهطِق‬ ‫ٍ ٗوطس‬٤‫ك‬ٞ‫ض‬ٝ ‫ٍ جُٖٓ ٖٓ جالٗٓىجو‬٣ٍ‫س ٖٓ جُؼظحّ ُطك‬٤‫س ًحك‬٤ًٔ ‫ئَجُس‬
‫ن ٍُِجكؼس‬٤‫ضطر‬.
6556( ‫جٌو‬ٝ ‫ح‬ٜٓ‫ هى‬٢‫" جُط‬٢ٗ‫ْ جُؼظْ جُِٓح‬٤ٓ‫س ضو‬٤٘‫ "ضو‬٢ٛ ‫س شحتؼس‬٤٘‫ ضو‬:‫ؼ‬ َ‫ ُعٍِ جُؼو‬٢ٗ‫طْ ًٍٓ ؾُء ٖٓ جُؼظْ جُِٓح‬٣
ٍٔ‫َ ئَجُس جُٖٓ جُٔ٘ط‬٤ٜٓ‫ُط‬.
٢ِ‫ ُطؿ٘د ئظؼحف جُلي جُٓل‬٠ٗ‫ ػ٘ى جُكى جألو‬٠‫ؿد إٔ ضرو‬٣ .‫ؽ جُشىم‬ٜٗ .‫خ‬.
1. The bone on the buccal and the distal aspect of the impacted tooth is removed down
to the level of the cervical line (Further bone removal if required is done in a
manner not detrimental to the strength of mandible)  achieved by drilling a deep
vertical gutter alongside the buccal aspect and if required on the distal aspect of
the tooth.
2. Guttering method will ensure that the height of the buccal plate is maintained
without weakening the mandible and adequate space is created for tooth delivery.
3. As the bur reaches the apex of the tooth, the inferior alveolar canal may be opened
 brisk haemorrhage from inferior alveolar vessels  controlled with pressure
pack or bone wax.

1. ْ‫ (ضط‬٢‫ جُهػ جُؼ٘و‬ٟٞ‫ ٓٓط‬٠ُ‫الً ئ‬ٞ‫ص‬ٝ ٍٔ‫ى ٖٓ جُٖٓ جُٔ٘ط‬٤‫جُؿحٗد جُرؼ‬ٝ ‫ جُشىم‬٠ِ‫و ػ‬ٞ‫ؾ‬ُٞٔ‫ضطْ ئَجُس جُؼظْ ج‬
٢ِ‫ز جُلي جُٓل‬ٞ‫وس ال ضعٍ ذو‬٣ٍ‫ى ٖٓ جُؼظحّ ئيج ُُّ جألٍٓ ذط‬٣ُُٔ‫ئَجُس ج‬ ٍ‫ن قل‬٣ٍ‫ن يُي ػٖ غ‬٤‫طْ ضكو‬٣
ُٖٓ‫ى ٖٓ ج‬٤‫ جُؿحٗد جُرؼ‬٠ِ‫ئيج ُُّ جألٍٓ ػ‬ٝ ‫ ذؿحٗد جُؿحٗد جُشىم‬١‫و‬ٞٔ‫ن ٌُٓجخ ػ‬٤ٔ‫ػ‬.

2. ‫طْ ئٗشحء ٓٓحقس‬٣ٝ ٢ِ‫ٕ ئظؼحف جُلي جُٓل‬ٝ‫س و‬٤‫كس جُشىه‬٤‫ جٌضلحع جُصل‬٠ِ‫ُجخ جُكلحظ ػ‬٤ُٔ‫وس ج‬٣ٍ‫ْطعٖٔ غ‬
ٕ‫الوز جألْ٘ح‬ُٞ ‫س‬٤‫ًحك‬.

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 3. ‫س‬٤ِ‫س جُٓل‬٤‫طْ كطف جُو٘حز جُٓ٘ه‬٣ ‫ هى‬،ُٖٓ‫ هٔس ج‬٠ُ‫صَ جُٖٓ ئ‬٣ ‫ػ٘ىٓح‬

‫س‬٤ِ‫س جُٓل‬٤‫س جُٓ٘ه‬٤‫ػ‬ٝ‫غ ٖٓ جأل‬٣ٍُٓ‫جُُ٘ف ج‬ ٢ٔ‫ جُشٔغ جُؼظ‬ٝ‫ ذحْطهىجّ قُٓس جُعـػ أ‬ٚ٤‫طْ جُطكٌْ ك‬٣
4. Drilling in the region of the mesial surface of impacted tooth should be kept to the
minimum  avoid damage to the distal aspect of second molar.
5. Removing bone on the distolingual aspect  care protect the lingual.
6. Moderate force alone is sufficient to displace the tooth.
7. If the tooth is still resistant  plan for further bone removal or tooth sectioning.
8. At the time of elevating the tooth, the index finger of the operator's left hand should
rest on the occlusal surface of the wisdom tooth to judge its movement and the
other fingers support the mandible.
9. In order to apply the elevator, a point of application (purchase point) is required
either in the bone or a bur cut is made on the tooth  deep enough and placed
in substantial portion of tooth structure  elevation of rather than fracture.
4. ٠ٗ‫ ُألْ٘حٕ جُٔ٘طٍٔز ػ٘ى جُكى جألو‬٢ٓٗ‫ ٓ٘طوس جُٓطف جإل‬٢‫ جُكلٍ ك‬٠‫رو‬٣ ٕ‫ؿد أ‬٣ ‫ضؿ٘د ئضالف جُؿحٗد‬
٢ٗ‫ى ٖٓ جُعٍِ جُػح‬٤‫جُرؼ‬.
5. ٕ‫ىز ػٖ جُِٓح‬٤‫س جُرؼ‬ٜ‫ئَجُس جُؼظحّ ٖٓ جُؿ‬ ٕ‫س جُِٓح‬٣‫س ذكٔح‬٣‫جُؼ٘ح‬.
6. ُٖٓ‫س إلَجقس ج‬٤‫ح ًحك‬ٛ‫قى‬ٝ ‫ز جُٔؼطىُس‬ٞ‫جُو‬.
7. ‫ ًٓح‬ٝ‫ُجٍ ٓوح‬٣ ‫ئيج ًحٕ جُٖٓ ال‬ ٕ‫ْ جألْ٘ح‬٤ٓ‫ ضو‬ٝ‫ى ٖٓ ئَجُس جُؼظحّ أ‬٣ُُٔ ‫نطػ‬.
8. َ‫ ُعٍِ جُؼو‬٢‫ جُٓطف جإلغرحه‬٠ِ‫ ػ‬ٍٟٓ٤ُ‫ى جُٔشـَ ج‬٣ ٖٓ ‫ٓطوٍ ئصرغ جُٓرحذس‬٣ ٕ‫ؿد أ‬٣ ،ُٖٓ‫هص ٌكغ ج‬ٝ ٢‫ك‬
٢ِ‫ جُلي جُٓل‬ٍٟ‫٘ٔح ضىػْ جألصحذغ جألن‬٤‫ ذ‬،ٚ‫ قًٍط‬٠ِ‫ُِكٌْ ػ‬.
9. ‫ن (ٗوطس شٍجء‬٤‫و ٗوطس ضطر‬ٞ‫ؾ‬ٝ ُِّ٣ ‫ن جُٔصؼى‬٤‫)ُططر‬.
ُٖٓ‫ ج‬٠ِ‫طْ ػَٔ هطغ ػ‬٣ ٝ‫ جُؼظْ أ‬٢‫ئٓح ك‬ ٚ‫ظؼ‬ٝ ْ‫ط‬٣ٝ ‫س‬٣‫ جٌُلح‬ٚ٤‫ن ذٔح ك‬٤ٔ‫ػ‬
ٕ‫س جألْ٘ح‬٤٘‫ٍ ٖٓ ذ‬٤‫ ؾُء ًر‬٢‫ك‬ ٌٍُٓ‫جٌضلحع ذىالً ٖٓ ج‬
1.7.4 Sectioning and Tooth Delivery
Tooth sectioning is performed either with a bur or a chisel and it helps to;
 reduce operating time
 Avoid the need to remove additional amount of bone.
A- First section is generally done at the neck of the tooth using bur facilitate the removal
of the crown followed by the roots in one piece.
B- Divergent roots  roots have to be divided and removed separately.
C- The following key points should be observed while performing tooth sectioning:
 If sectioning tooth in a buccal to the lingual direction  only three quarters the
way is cut using bur. The reminder is then split with a straight elevator 
prevents injury to the lingual cortical plates and lingual nerve

1.7.4 ٕ‫ْ جألْ٘ح‬٤ِٓ‫ض‬ٝ ْ٤ٓ‫جُطو‬

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 ‫ يُي؛‬٠ِ‫ٓحػى ػ‬٣ ‫ ٓح‬ٞٛٝ ،َ٤َٓ‫ جإل‬ٝ‫غ جألْ٘حٕ ئٓح ذحْطهىجّ جُٖٓ أ‬٤‫س ضوط‬٤ِٔ‫طْ ئؾٍجء ػ‬٣

• َ٤‫هص جُطشـ‬ٝ َ٤ِ‫ضو‬

• ّ‫س ٖٓ جُؼظح‬٤‫س ئظحك‬٤ًٔ ‫ ئَجُس‬٠ُ‫ضؿ٘د جُكحؾس ئ‬.

ُٖٓ‫ٍ ذشٌَ ػحّ ػ٘ى ػ٘ن جُٖٓ ذحْطهىجّ ج‬ٝ‫طْ جُوْٓ جأل‬٣ -‫أ‬ ‫جقىز‬ٝ ‫ٌ ًوطؼس‬ًٝ‫ جُؿ‬ٚ٤ِ٣ ‫َ ئَجُس جُطحؼ‬٤ٜٓ‫ُط‬.

‫ٌ جُٔطرحػىز‬ًٝ‫ جُؿ‬-‫خ‬ َ‫ح ذشٌَ ٓ٘لص‬ٜ‫ئَجُط‬ٝ ًٌٝ‫ْ جُؿ‬٤ٓ‫ؿد ضو‬٣.

ٕ‫غ جألْ٘ح‬٤‫س ضوط‬٤ِٔ‫س أغ٘حء ئؾٍجء ػ‬٤ُ‫س جُطح‬٤ْ‫ؿد ٍٓجػحز جُ٘وحغ جألْح‬٣ -‫ؼ‬:

• ٢ٗ‫ جُِٓح‬ٙ‫ جالضؿح‬٠ُ‫ئيج ضْ هطغ جُٖٓ ٖٓ جُشىم ئ‬ ْ‫ط‬٣ .‫غ‬ٍٝ‫ن كوػ ذحْطهىجّ جُٔه‬٣ٍ‫طْ هطغ غالغس أٌذحع جُط‬٣
ْ٤‫ٍ ذٔصؼى ٓٓطو‬٤ًً‫ْ جُط‬٤ٓ‫ذؼى يُي ضو‬ ٢ٗ‫جُؼصد جُِٓح‬ٝ ‫س‬٤ٗ‫س جُِٓح‬٣ٍ‫ٔ٘غ ئصحذس جُصلحتف جُوش‬٣
The line of sectioning of crown/tooth should be perpendicular. If NOT 
sectioned segment will be wider at the bottom  elevation will be difficult
 If sectioning in the superior to inferior direction  Entry of bur is limited to
three fourth of the width of the tooth and the rest is separated with elevator 
if NOT  possibility of damaging the contents of the canal

‫ٌٖ ًًُي‬٣ ُْ ‫ ئيج‬.‫ًح‬٣‫و‬ٞٔ‫جُٖٓ ػ‬/‫ْ جُطحؼ‬٤ٓ‫ٕ نػ ضو‬ٌٞ٣ ٕ‫ؿد أ‬٣

َ‫ جألْل‬٢‫ْغ ك‬ٝ‫ٕ جُؿُء جُٔوْٓ أ‬ٌٞ٤ْ ‫ٕ جالٌضلحع صؼرًح‬ٌٞ٤ْ

• ٢ِ‫ جُٓل‬٠ُ‫ ئ‬١ِٞ‫ جُؼ‬ٙ‫ جالضؿح‬٢‫ْ ك‬٤ٓ‫ئيج ًحٕ جُطو‬ َ‫طْ كص‬٣ٝ ُٖٓ‫ غالغس أٌذحع ػٍض ج‬٠ِ‫ٍ جُٖٓ ػ‬ٞ‫وطصٍ ون‬٣
‫ ذٔصؼى‬٢‫جُرحه‬ ٌٖ٣ ُْ ‫ئيج‬ ‫حش جُو٘حز‬٣ٞ‫س ئضالف ٓكط‬٤ٗ‫ئٌٓح‬
1.7.5 Modifications for Removal of Impacted Tooth
 Mesioangular impaction; Buccal gutter is extended mesially to reach the mesial surface
of impacted tooth beneath the cementoenamel junction  tip of the elevator can engage
beneath the cervical cementum on the mesial aspect the tooth turns distally  mesial
angulation of the tooth into a vertical position  deliver the tooth. If removal is difficult
 remove necessary distal bone and/ or sectioning the distal half of the crown to just
below the cervical line.
 Mesioangular tooth is 'locked' beneath the distal convexity of the crown of the second
molar  section impacted tooth’s crown at the cervical region  remove coronal
portion by applying force below its inferior surface The roots are removed by
engaging the bifurcation.
1.7.5 ‫الش إلَجُس جألْ٘حٕ جُٔ٘طٍٔز‬٣‫ضؼى‬
• ‫صِس‬ُٞ‫ ُألْ٘حٕ جُٔ٘طٍٔز ضكص ج‬٢ٓٗ‫ جُٓطف جإل‬٠ُ‫ٍ ئ‬ٞ‫ص‬ُِٞ ٢ٓٗ‫ ذشٌَ ئ‬٢‫ى جٌُُٔجخ جُشىه‬٣‫طْ ضٔى‬٣ .٢‫ْط‬ُٞ‫ ج‬١ٝ‫جٗكشحٌ جُُج‬
‫س‬٤‫س جُٔالغ‬٤‫٘حت‬٤ُٔ‫ج‬ ٢ٓٗ‫ جُؿحٗد جأل‬٠ِ‫ ػ‬٢‫٘هٍغ أْلَ جُٔالغ جُؼ٘و‬٣ ٕ‫ٌٖٔ أ‬٣ ‫غٍف جٍُجكغ‬ ٠‫ أهص‬٠ُ‫ٍ جُٖٓ ئ‬ٞ‫طك‬٣

4
 ١‫و‬ٞٔ‫ظغ ػ‬ٝ ٢‫ ُِٖٓ ك‬٢ٓٗ‫ جإل‬١ُٝ‫جُط‬ ‫ ئيج ًحٗص جإلَجُس صؼرس‬.ْٖ َ٤‫ص‬ٞ‫ض‬
‫ أْلَ نػ ػ٘ن جٍُقْ ٓرحشٍز‬٠ُ‫ى ٖٓ جُطحؼ ئ‬٤‫ هطغ جُ٘صق جُرؼ‬ٝ‫أ‬/ٝ ١ٌٍٝ‫ى جُع‬٤‫هْ ذاَجُس جُؼظْ جُرؼ‬.
• ٢ٗ‫ى ُطحؼ جُعٍِ جُػح‬٤‫ أْلَ جُطكىخ جُرؼ‬٢‫ْط‬ٝ‫ جأل‬١ٝ‫طْ "هلَ" جُٖٓ جُُج‬٣ ‫ ٓ٘طوس ػ٘ن‬٢‫هْٓ ضحؼ جُٖٓ جُٔ٘طٍٔ ك‬
ْ‫جٍُق‬ ٢ِ‫ جُٓل‬ٚ‫ز أْلَ ْطك‬ٞ‫ن جُو‬٤‫ن ضطر‬٣ٍ‫ ػٖ غ‬٢ِ٤ًِ‫ئَجُس جُؿُء جإل‬ ‫ن ئشٍجى جُطشؼد‬٣ٍ‫ٌ ػٖ غ‬ًٝ‫ضطْ ئَجُس جُؿ‬
 The horizontal impaction; Bone is removed superiorly to expose the whole width of the
crown and the upper third of the root  tooth sectioned at the cervical region  crown
is removed  The root is then brought forwards into the space previously occupied by
the crown  removed either in a single piece or after sectioning. If impacted tooth is
not locked beneath the crown of the second molar  turn the tooth into a vertical
position by application of force in the mesial aspect.
 Deep vertical impaction; one of the more difficult ones to remove. Bone is removed
first from the occlusal, buccal, and distal aspect. The distal half of the crown is then
sectioned and removed, and the tooth is elevated by applying a small straight elevator
at the mesial aspect of the cervical line.
 Less deep vertical impactions, mesial application of force with an elevator can dislodge
the tooth
• ًٌ‫ ٖٓ جُؿ‬١ِٞ‫جُػِع جُؼ‬ٝ ‫ ٌُشق جُؼٍض جٌُحَٓ ُِطحؼ‬١ِٞ‫ ضطْ ئَجُس جُؼظْ ذشٌَ ػ‬.٢‫جالٗكشحٌ جألكو‬ ‫ ٓ٘طوس‬٢‫ٓوطغ جُٖٓ ك‬
ْ‫ػ٘ن جٍُق‬ ‫ضطْ ئَجُس جُطحؼ‬ ‫ح جُطحؼ ْحذوًح‬ِٜ‫شـ‬٣ ٕ‫ ًح‬٢‫ جُٔٓحقس جُط‬٠ُ‫طْ ئقعحٌ جُؿًٌ ُألٓحّ ئ‬٣ ْ‫غ‬ ٢‫ ئٓح ك‬ٚ‫ضطْ ئَجُط‬
٢ٗ‫ٌٖ جُٖٓ جُٔ٘طٍٔ ٓـِوًح أْلَ ضحؼ جُعٍِ جُػح‬٣ ُْ ‫ ئيج‬.ْ٤ٓ‫ ذؼى جُطو‬ٝ‫جقىز أ‬ٝ ‫هطؼس‬ ١‫و‬ٞٔ‫ظغ ػ‬ٝ ٠ُ‫َ جُٖٓ ئ‬٣ٞ‫هْ ذطك‬
‫ْػ‬ٝ‫ جُؿحٗد جأل‬٢‫ز ك‬ٞ‫ن جُو‬٤‫ن ضطر‬٣ٍ‫ػٖ غ‬.
• ْ‫ط‬٣ .‫ىز‬٤‫جُرؼ‬ٝ ‫س‬٤‫جُشىه‬ٝ ‫س‬٤‫جٗد جإلغرحه‬ٞ‫الً ٖٓ جُؿ‬ٝ‫ ضطْ ئَجُس جُؼظحّ أ‬.‫ح‬ٜ‫ ئَجُط‬٢‫ذس ك‬ٞ‫جقىز ٖٓ أًػٍ صؼ‬ٝ .‫ن‬٤ٔ‫ ػ‬١‫و‬ٞٔ‫جٗكشحٌ ػ‬
٢ٓٗ‫ جُؿحٗد جإل‬٠ِ‫ْ ػ‬٤‫ٍ ٓٓطو‬٤‫ن جْطهىجّ ٓصؼى صـ‬٣ٍ‫طْ ٌكغ جُٖٓ ػٖ غ‬٣ٝ ،ٚ‫ئَجُط‬ٝ ‫ى ٖٓ جُطحؼ‬٤‫ذؼى يُي هطغ جُ٘صق جُرؼ‬
ْ‫ٖٓ نػ ػ٘ن جٍُق‬.
• ُٖٓ‫ ئَجقس ج‬٠ُ‫ ئ‬١‫إو‬٣ ٕ‫ٌٖٔ أ‬٣ ‫ْطس ذحْطهىجّ جُٔصؼى‬ٞ‫ز جُٔط‬ٞ‫ن جُو‬٤‫ع إٔ ضطر‬٤‫ ق‬،‫ أهَ ػٔوًح‬١‫و‬ٞٔ‫جٗكشحٌ ػ‬
 Vertical impaction with widely divergent roots; crown is divided first followed 
sectioning of the roots and its subsequent removal.
 A deep, vertically impacted third molar below the cervical line of the second molar and
fully covered with bone  tooth should be exposed and a buccal and distal trough
(guttering) created  sectioning of crown in a horizontal fashion  roots can be elevated in
one piece or sectioned and removed (distal preceding that of the mesial).
• ‫طرغ‬٣ ‫ال‬ٝ‫ جُطحؼ ٓوْٓ أ‬.‫جْغ‬ٝ ‫ ٗطحم‬٠ِ‫ٌ ٓطرحػىز ػ‬ًٝ‫ ؾ‬ٝ‫ ي‬١‫و‬ٞٔ‫جٗكشحٌ ػ‬
‫ح القوًح‬ٜ‫ئَجُط‬ٝ ًٌٝ‫ْ جُؿ‬٤ٓ‫ضو‬.
• ْ‫ ذحٌُحَٓ ذحُؼظ‬٠‫ٓـط‬ٝ ‫س‬٤ٗ‫ جُػح‬٠‫ ٍُِق‬٢‫ًح أْلَ جُهػ جُؼ٘و‬٣‫و‬ٞٔ‫ٓ٘طٍٔ ػ‬ٝ ‫ن‬٤ٔ‫ظٍِ غحُع ػ‬ ‫ض‬ٞ‫ق‬ٝ ‫كًح‬ٞ‫ٕ جُٖٓ ٌٓش‬ٌٞ٣ ٕ‫ؿد أ‬٣
‫ى‬٤‫جُرؼ‬ٝ ‫جُشىم‬
(‫ح‬ٛ‫د) ضْ ئٗشحؤ‬٣ٌ‫س جُُٔج‬٤‫وس أكو‬٣ٍ‫ْ جُطحؼ ذط‬٤ٓ‫ضو‬ ‫ ضٓرن جُؿُء‬٢‫س جُط‬٤‫ح (جُوحص‬ٜ‫ئَجُط‬ٝ ‫ح‬ٜٔ٤ٓ‫ ضو‬ٝ‫جقىز أ‬ٝ ‫ هطؼس‬٢‫ٌ ك‬ًٝ‫ٌٖٔ ٌكغ جُؿ‬٣
‫ْػ‬ٝ‫)جأل‬.
 The distoangular impaction; Most difficult tooth to remove  because the pathway of
delivery is into the vertical ramus (more distal bone must be removed)  create an
5
 adequate buccal and distal trough (guttering) around the full crown of the tooth to a
depth below the cervical line  create a point of application of elevator on the buccal
aspect of the tooth  using the buccal cortical plate as the fulcrum  elevate the tooth
out of the socket upwards and distally  some movement  distal portion of the crown
sectioned in a horizontal fashion and removed (section the tooth segments further as
needed rather than to remove more bone)  The roots delivered together or sectioned
and delivered independently with a Cryer's elevator.
• ‫ جإلَجُس‬٢‫ذس ك‬ٞ‫ أًػٍ جألْ٘حٕ صؼ‬.‫س‬٣ٝ‫ى جُُج‬٤‫جالٗكشحٌ جُرؼ‬ ْ‫ؿد ئَجُس جُؼظ‬٣( ١‫و‬ٞٔ‫ جُلٍع جُؼ‬٢‫وغ ك‬٣ ‫الوز‬ُٞ‫ألٕ ٓٓحٌ ج‬
‫ى‬٤‫جُرؼ‬ ْ‫ ػٔن أهَ ٖٓ نػ ػ٘ن جٍُق‬٠ُ‫ٍ جُطحؼ جٌُحَٓ ُِٖٓ ئ‬ٞ‫ى (ٌُٓجخ) ٓ٘حْد ق‬٤‫ذؼ‬ٝ ٢‫ض شىه‬ٞ‫ئٗشحء ق‬ ‫ئٗشحء‬
ُٖٓ‫ جُؿحٗد جُشىم ٖٓ ج‬٠ِ‫ن جُٔصؼى ػ‬٤‫ٗوطس ُططر‬ َ‫س ً٘وطس جٌضٌح‬٤‫س جُشىه‬٣ٍ‫كس جُوش‬٤‫جْطهىجّ جُصل‬ ٖٓ ُٖٓ‫ٌكغ ج‬
٠‫ أهص‬٠ُ‫ئ‬ٝ ٠ِ‫ق ألػ‬٣ٞ‫جُطؿ‬ ‫ذؼط جُكًٍس‬ ‫ْ أؾُجء‬٤ٓ‫ (ضو‬ٚ‫طْ ئَجُط‬٣ٝ ‫س‬٤‫وس أكو‬٣ٍ‫ع ذط‬ٞ‫ى ٖٓ جُطحؼ ٓوط‬٤‫جُؿُء جُرؼ‬
ّ‫ى ٖٓ جُؼظح‬٣ُُٔ‫ قٓد جُكحؾس ذىالً ٖٓ ئَجُس ج‬٢‫جألْ٘حٕ ذشٌَ ئظحك‬ ‫ح‬ٜٔ٤ِٓ‫ض‬ٝ ‫ح‬ٜٔ٤ٓ‫ ضو‬ٝ‫ٌ ٓؼًح أ‬ًٝ‫َ جُؿ‬٤‫ص‬ٞ‫طْ ض‬٣
‫ ذشٌَ ٓٓطوَ ذحْطهىجّ ٓصؼى‬Cryer.

1.7.6 Other Methods for Removal of Impacted Lower Third Molar

 Sagittal split ramus osteotomy: In this technique two cortical cuts are done: horizontal
cut through the medial aspect of the ramus to area posterior and above the lingula, and
a vertical cut through the anterior border of ramus and extends down to the inferior
border of mandible. An osteotome is used to complete the split along the horizontal and
then the vertical cuts. the result is longitudinal split of the mandible in the cut area. The
technique is used in patients with;

 history of recurrent infection with/ or without trismus associated with a deeply

impacted lower right third molar tooth, and/or
 impacted lower third molar intimately involved with the inferior alveolar nerve.
1.7.6 ‫س جُٔ٘طٍٔز‬٤ِ‫ جُػحُػس جُٓل‬٠‫ إلَجُس جٍُق‬ٍٟ‫غٍم أن‬
• ٠ُ‫ْػ ٖٓ جُلٍع ئ‬ٝ‫ ػرٍ جُؿحٗد جأل‬٢‫ هطغ أكو‬:ٖ٤٣ٍ‫ٖ هش‬٤‫طْ ئؾٍجء هطؼ‬٣ ‫س‬٤٘‫ جُطو‬ًٙٛ ٢‫ ك‬:٢ُٜٔٓ‫هطغ ػظْ جُلي ج‬
‫ جُلي‬.‫س ُِلٍع‬٤ِ‫ جُكحكس جُٓل‬٠ُ‫ٔطى ئ‬٣ٝ ‫س ُِلٍع‬٤ٓ‫و جألٓح‬ٝ‫ ػرٍ جُكى‬١‫و‬ٞٔ‫هطغ ػ‬ٝ ،ٕ‫م جُِٓح‬ٞ‫ك‬ٝ ‫س‬٤‫جُٔ٘طوس جُهِل‬
٢ُٞ‫ جٗوٓحّ غ‬٢ٛ ‫ؿس‬٤‫جُ٘ط‬ٝ .٢ْ‫ غْ جٍُأ‬٢‫ٍ جُوطغ جألكو‬ٞ‫ غ‬٠ِ‫طْ جْطهىجّ ٓرعغ جُؼظْ إلًٔحٍ جالٗوٓحّ ػ‬٣ .٢ِ‫جُٓل‬
‫ٕ ٖٓ؛‬ٞٗ‫ؼح‬٣ ٖ٣ًُ‫ ج‬٠‫ جٍُٔظ‬٢‫س ك‬٤٘‫ جُطو‬ًٙٛ ّ‫طْ جْطهىج‬٣ .‫ ٓ٘طوس جُوطغ‬٢‫ ك‬٢ِ‫ُِلي جُٓل‬

ٝ‫أ‬/ٝ ،٠٘ٔ٤ُ‫س ج‬٤ِ‫ جُػحُػس جُٓل‬٠‫ جٍُق‬٢‫ن ك‬٤ٔ‫ٕ ظَُ ٍٓضرػ ذعٍِ ػ‬ٝ‫ ذى‬ٝ‫ أ‬/‫ ٓطٌٌٍز ٓغ‬ٟٝ‫م ػى‬٣ٌ‫ضح‬
٢ِ‫ جُٓل‬٢‫ن ٓغ جُؼصد جُٓ٘ه‬٤‫غ‬ٝ ٌَ‫س ٓ٘طٍٔز ذش‬٤ِ‫ جُػحُػس جُٓل‬٠‫جٍُق‬.
 Buccal corticotomy: For deeply impacted mandibular teeth  a rectangular window is
made over the deeply impacted tooth using a narrow fissure bur mesial and distal
cuts almost reaching the inferior border of the mandible  window removed with
osteotome  impacted molar divided and removed  The bony (window) replaced.
 Lingual Split technique: Involves the use of a chisel and mallet to remove or displace
6
 the lingual plate of bone adjacent to lower third molar. A small amount of buccal bone
is often removed to facilitate exposure of the crown and provide a point of application
for an elevator. Sometimes tooth division is required for its removal (operated under
general anaesthesia, young patients  elastic bone)
• ‫ جُٔ٘طٍٔز ذؼٔن‬٢ِ‫ ذحُ٘ٓرس ألْ٘حٕ جُلي جُٓل‬:‫س‬٤‫هطغ جُوشٍز جُشىه‬ ‫ٌ ذشىز‬ٞٔ‫م جُٖٓ جُٔ٘ط‬ٞ‫ِس ك‬٤‫طْ ػَٔ ٗحكًز ٓٓطط‬٣
‫ن‬٤‫ذحْطهىجّ شن ظ‬ ٢ِ‫ ُِلي جُٓل‬٢ِ‫ جُكى جُٓل‬٠ُ‫رًح ئ‬٣ٍ‫صَ ضو‬٣ ٢‫هحص‬ٝ ٢‫ْط‬ٝ ‫هطغ‬ ‫ضطْ ئَجُس جُ٘حكًز ذحْطهىجّ ٓرعغ‬
ْ‫جُؼظ‬ ٚ‫ئَجُط‬ٝ ٍٔ‫ْ جُعٍِ جُٔ٘ط‬٤ٓ‫ضو‬ ‫س‬٤ٔ‫ضْ جْطرىجٍ (جُ٘حكًز) جُؼظ‬.
• ‫ جُػحُػس‬٠‫ٌ ٍُِق‬ٝ‫س ُِؼظْ جُٔؿح‬٤ٗ‫كس جُِٓح‬٤‫ ئَجقس جُصل‬ٝ‫ٓطٍهس إلَجُس أ‬ٝ َ٤َٓ‫ ضطعٖٔ جْطهىجّ ئ‬:٢ٗ‫س جالٗوٓحّ جُِٓح‬٤٘‫ضو‬
ٕ‫ح‬٤‫ ذؼط جألق‬٢‫ ك‬.‫ن ُِٔصؼى‬٤‫ٍ ٗوطس ضطر‬٤‫ك‬ٞ‫ض‬ٝ ‫َ ًشق جُطحؼ‬٤ٜٓ‫ٍز ٖٓ ػظْ جُشىم ُط‬٤‫س صـ‬٤ًٔ ‫ ؿحُرًح ٓح ضطْ ئَجُس‬.‫س‬٤ِ‫جُٓل‬
ٌ‫ جُصـح‬٠‫ جٍُٔظ‬،ّ‫ٍ جُؼح‬٣‫ح (جُؿٍجقس ضكص جُطهى‬ٜ‫ْ جألْ٘حٕ إلَجُط‬٤ٓ‫ططِد جألٍٓ ضو‬٣ ‫)جُؼظحّ جٍُٔٗس‬
Partial Odontectomy: (coronectomy, deliberate root retention) procedure devised to
protect the IAN. Radiographic features suggesting an intimate relationship:
 Darkening of the root and interruption of the white line of the canal
 Narrowing of the canal
 Deflection of the roots

Adequate amount of root must be removed below the crest of the lingual and buccal
plates of bone  bone forms over the retained roots. Contraindications to Partial
Odontectomy
‫س‬٣‫ ُكٔح‬ٚٔ٤ٔ‫ جالقطلحظ جُٔطؼٔى ذحُؿًٌ) ضْ ضص‬،‫ (جْطثصحٍ جُطحؼ‬:٢‫ جْطثصحٍ جألْ٘حٕ جُؿُت‬IAN. ‫س‬٤‫ٍ جُشؼحػ‬ٛ‫جُٔظح‬
‫ٔس‬٤ٔ‫و ػالهس ق‬ٞ‫ؾ‬ٝ ٠ُ‫ٍ ئ‬٤‫ ضش‬٢‫جُط‬:
• ‫ط ُِو٘حز‬٤‫جٗوطحع جُهػ جألذ‬ٝ ًٌ‫جو جُؿ‬ْٞ
• ‫ن جُو٘حز‬٤٤‫ضع‬
• ًٌٝ‫جٗكٍجف جُؿ‬
ًٌٝ‫م جُؿ‬ٞ‫ ضطشٌَ جُؼظحّ ك‬- ْ‫س ُِؼظ‬٤‫جُشىه‬ٝ ‫س‬٤ٗ‫س ٖٓ جُؿًٌ أْلَ هٔس جُصلحتف جُِٓح‬٤‫س ًحك‬٤ًٔ ‫ؿد ئَجُس‬٣
٢‫جٗغ الْطثصحٍ جألْ٘حٕ جُؿُت‬ٞٓ .‫جُٔكطؿُز‬

 Active infection around the tooth

 Mobile teeth - any retained mobile root  nidus for infection.
 Horizontally impacted tooth along the course of the nerve sectioning the tooth
will damage the IAN.
 Orthodontic extraction: for the safe extraction of impacted third molars with a high risk
of neurological complication due to the close proximity to mandibular canal;
 Phase 0 Assessment of surgical risks
 Phase 1 Creation of orthodontic anchorage: stainless steel lingual arch and
buccal stainless-steel sectional wire tied from second molar to the first bicuspid.
7
  Phase 2 Surgical exposure of the third molar crown
 Phase 3 Orthodontic extrusion (3rd molar); setting 3rd molar apart from IAN
 Phase 4 Clinical and radiographic assessment of the extrusion level
 Phase 5 Third molar extraction if adequate bone separating the root from INA
• ُٖٓ‫ٍ ج‬ٞ‫ ٗشطس ق‬ٟٝ‫ػى‬
• ٚ‫ ؾًٌ ٓطكٍى ٓكطلع ذ‬١‫ أ‬- ‫جألْ٘حٕ جُٔطكًٍس‬ ٟٝ‫ِ ُِؼى‬ٝ‫ى‬٤ٗ.
• ‫ٍ ٓٓحٌ جُؼصد‬ٞ‫ غ‬٠ِ‫ًح ػ‬٤‫جُٖٓ جُٔ٘طٍٔ أكو‬ ‫ ئضالف جُؼصد‬٠ُ‫ هطغ جُٖٓ ئ‬١‫إو‬٤ْ IAN.
• ‫س ذٓرد‬٤‫ظ ٓعحػلحش ػصر‬ٝ‫ الْطهٍجؼ جألظٍجِ جُػحُػس جُٔ٘طٍٔز ذشٌَ آٖٓ ٓغ جٌضلحع نطٍ قى‬:ٕ‫ْ جألْ٘ح‬٣ٞ‫هِغ ضو‬
٢ِ‫ح ٖٓ ه٘حز جُلي جُٓل‬ٜ‫هٍذ‬.
• ‫س‬٤‫ْ جُٔهحغٍ جُؿٍجق‬٤٤‫ ضو‬0 ‫جٍُٔقِس‬
• ‫ّ ُِصىأ‬ٝ‫الي جُٔوح‬ٞ‫ ٖٓ جُل‬٢‫ِْي ٓوطؼ‬ٝ ‫ّ ُِصىأ‬ٝ‫الي جُٔوح‬ٞ‫ ٖٓ جُل‬٢ٗ‫ِ ُٓح‬ٞ‫ ه‬:٢ٔ٣ٞ‫ ئٗشحء جُٔػرص جُطو‬٠ُٝ‫جٍُٔقِس جأل‬
ٍٝ‫ جُعٍِ جأل‬٠ُ‫ ئ‬٢ٗ‫غ ٖٓ جُعٍِ جُػح‬ٞ‫شىم ٍٓذ‬.
• ‫ جُػحُع‬٢ُُٞٔ‫ ُِطحؼ ج‬٢‫ جُطؼٍض جُؿٍجق‬:‫س‬٤ٗ‫جٍُٔقِس جُػح‬
• ٖ‫ىًج ػ‬٤‫ظغ جُعٍِ جُػحُع ذؼ‬ٝ ‫ْ جألْ٘حٕ (جُعٍِ جُػحُع)؛‬٣ٞ‫ ذػن ضو‬:‫ جٍُٔقِس جُػحُػس‬IAN
• ‫ جُرػن‬ٟٞ‫ ُٔٓط‬٢‫جُشؼحػ‬ٝ ١ٍ٣ٍُٓ‫ْ ج‬٤٤‫جٍُٔقِس جٍُجذؼس جُطو‬
• ‫ جُػحُػس‬٠‫جٍُٔقِس جُهحٓٓس جْطهٍجؼ جٍُق‬ ٖ‫لصَ جُؿًٌ ػ‬٣ ‫٘حى ػظْ ٓ٘حْد‬ٛ ٕ‫ ئيج ًح‬INA

2 Upper third molars

2.1 Classification of impacted maxillary third molars:
 State of Eruption; 1. Fully erupted 2. Partially erupted 3. Unerupted
 Angulation of the Tooth; 1. Vertical, 2. Mesioangular, 3. Distoangular, 4. Laterally
displaced with the crown facing the cheek, horizontal, inverted and transverse positions,
5. Aberrant position
 Pell and Gregory Classification;
 Position A; 3rd molar occlusal surface is at the same level of that of 2nd molar.

Position B; 3rd molar occlusal surface is between occlusal plane and cervical line
nd
2 molar.
2 ‫س‬٣ِٞ‫جألظٍجِ جُػحُػس جُؼ‬
2.1 ‫س جُٔ٘طٍٔز‬٤ٌ‫ق جألظٍجِ جُػحُػس جُل‬٤٘‫ضص‬:
• ٍ‫٘لؿ‬٣ ُْ .3 ‫ًح‬٤‫ غحٌ ؾُت‬.2 َٓ‫ جٗىُغ ذحٌُح‬.6 .ٕ‫ٌج‬ٞ‫قحُس جُػ‬
• ‫ذس‬ِٞ‫جُٔو‬ٝ ‫س‬٤‫ظحع جألكو‬ٝ‫جأل‬ٝ ،‫ ُِهى‬ٚ‫جؾ‬ُٞٔ‫ًح ٓغ جُطحؼ ج‬٤‫ ُٓجـ ؾحٗر‬.4 ،١ٝ‫ى جُُج‬٤‫ ذؼ‬.3 ،‫ْػ‬ٞ‫ ٓط‬١ٝ‫ َج‬.2 ،١‫و‬ٞٔ‫ ػ‬.6 .ٕ‫س جألْ٘ح‬٣ٝ‫َج‬
،‫س‬٤‫جُؼٍظ‬ٝ
5. ‫هق جُشحي‬ُٞٔ‫ج‬
• ١ٌٞ‫ؿ‬٣ٍ‫ؾ‬ٝ َ٤‫ق ذ‬٤٘‫ضص‬.
‫س‬٤ٗ‫ جُػح‬٠‫ ْطف جٍُق‬ٟٞ‫ ٗلّ ٓٓط‬٠ِ‫ٕ ػ‬ٌٞ٣ ‫ جُػحُػس‬٠‫هق أ؛ ْطف جإلغرحم ٍُِق‬ُٞٔ‫ج‬.

٢ٗ‫ جُػح‬٢ُُٞٔ‫نػ ػ٘ن جٍُقْ ج‬ٝ ‫ جإلغرحم‬ٟٞ‫ٖ ٓٓط‬٤‫وغ ذ‬٣ ‫ جُػحُع‬٢ُُٞٔ‫هق خ؛ ْطف جإلغرحم ج‬ُٞٔ‫ج‬.
 Position C; 3rd molar occlusal surface is at or above cervical line of 2nd molar

8
  Relationship of Impacted Maxillary Third Molar to the Maxillary Sinus
 Sinus approximation (SA): No bone or a thin partition of bone between third
molar and maxillary sinus.
 No sinus approximation (NSA): 2 mm or more bone between third molar and
maxillary sinus.
 Nature of Roots; 1. Fused (conical) 2. Multiple—Favourable/Unfavourable
ٚ٘ٓ ٠ِ‫ أػ‬ٝ‫س أ‬٤ٗ‫ جُػح‬٠‫ جُػحُػس ػ٘ى نػ ػ٘ن جٍُقْ ٍُِق‬٠‫وغ ْطف جإلغرحم ٍُِق‬٣ ‫ظغ ؼ؛‬ُٞٔ‫ج‬
• ١ِٞ‫ جُؼ‬٢ٌ‫د جُل‬٤‫س جُٔ٘طٍٔز ذحُؿ‬٤ٌ‫ جُػحُػس جُل‬٠‫ػالهس جٍُق‬
‫س‬٤‫خ جألٗل‬ٞ٤‫د جُؿ‬٣ٍ‫( ضو‬SA): ٢ٌ‫د جُل‬٤‫جُؿ‬ٝ ‫ جُػحُػس‬٠‫ٖ جٍُق‬٤‫ن ٖٓ جُؼظْ ذ‬٤‫ هْٓ ٌه‬ٝ‫ؾى ػظْ أ‬ٞ٣ ‫ال‬.
‫س‬٤‫خ جألٗل‬ٞ٤‫د ُِؿ‬٣ٍ‫ؾى ضو‬ٞ٣ ‫( ال‬NSA): 2 ٢ٌ‫د جُل‬٤‫جُؿ‬ٝ ‫ جُػحُػس‬٠‫ٖ جٍُق‬٤‫ أًػٍ ٖٓ جُؼظْ ذ‬ٝ‫ْٓ أ‬.
• ‫ٍ ٓ٘حْد‬٤‫ؿ‬/َ‫ ٓلع‬- ‫ ٓطؼىو‬.2 )٢‫غ‬ٍٝ‫ٍ (ٓه‬ٜ‫ ٓ٘ص‬.6 .ًٌٝ‫ؼس جُؿ‬٤‫غر‬
2.2 Indications for the Removal of Maxillary Third Molar
1. Extensive dental caries which is beyond restoration
2. Recurrent pericoronitis
3. Buccally or distally erupting tooth  cheek biting
4. Tooth involved in pathological process
5. Over erupted and non-functional upper third molar
6. Buccally erupting upper 3rd molar impinging on the coronoid process  pain during
movement.
7. Interference with placement of prosthesis
2.2 ‫س‬٤ٌ‫ جُػحُػس جُل‬٠‫ٓإشٍجش إلَجُس جٍُق‬
1. ٚٔ٤ٍٓ‫ٌٖٔ ض‬٣ ‫ ال‬١ًُ‫ج‬ٝ ‫جْغ جُ٘طحم‬ُٞ‫ِ جألْ٘حٕ ج‬ٞٓ‫ض‬
2. ٌٌٍ‫ػ جُطحؼ جُٔط‬٤‫حخ ٓك‬ٜ‫جُط‬
3. ‫ى‬٤‫ جُطٍف جُرؼ‬ٝ‫ جُشىم أ‬٢‫ٌ جألْ٘حٕ ك‬ٜٞ‫ػط جُهى ظ‬
4. ‫س‬٤‫س جٍُٔظ‬٤ِٔ‫ جُؼ‬٢‫جألْ٘حٕ جُٔشحًٌس ك‬
5. ٚ‫ػىّ ًلحءض‬ٝ ١ِٞ‫َ جُعٍِ جُػحُع جُؼ‬ٍٝ‫ذ‬
6. ٢‫ح ذحُ٘حضة جُطحؾ‬ٜٓ‫جصطىج‬ٝ ‫ جُشىم‬٢‫س ك‬٣ِٞ‫ جُػحُػس جُؼ‬٠‫َ جٍُق‬ٍٝ‫أُْ أغ٘حء جُكًٍس ذ‬.
7. ٢‫ظغ جُطٍف جالصط٘حػ‬ٝ ٢‫جُطىنَ ك‬
2.3 Local Contraindications for Removal
1. Symptom-less upper third molar completely embedded in bone.
2. Third molar high in alveolus  displacing into antrum or infratemporal fossa
3. Deeply impacted tooth removal can damage the adjacent second molar

2.4 Radiographic Examination

1. Periapical X-ray
2. OPG
3. Occlusal X-ray
4. True lateral view
5. PNS (paranasal sinus) view of maxilla  if associated pathology

9
 6. CT scan—especially if associated pathology
2.1 ‫س ُإلَجُس‬٤ِ‫جٗغ ٓك‬ٞٓ
1. ّ‫ جُؼظح‬٢‫ٕ أػٍجض ٓىٓؽ ذحٌُحَٓ ك‬ٝ‫ ذى‬١ِٞ‫جُعٍِ جُػحُع جُؼ‬.
2. ‫ جُٓ٘م‬٢‫ جُػحُػس ك‬٠‫جٌضلحع جٍُق‬ ‫س‬٤‫ جُكلٍز ضكص جُصىؿ‬ٝ‫ جُـحٌ أ‬٠ُ‫ُ٘جـ ئ‬٣
3. ٌٝ‫ جُٔؿح‬٢ٗ‫ ئضالف جُعٍِ جُػح‬٠ُ‫ ئَجُس جألْ٘حٕ جُٔ٘طٍٔز ذؼٔن ئ‬١‫ٌٖٔ إٔ ضإو‬٣
2.2 ٢‫جُلكص جُشؼحػ‬
1. ‫ز‬ًٌُٝ‫ٍ ج‬ٞ‫س ق‬٤٘٤ُٓ‫جألشؼس ج‬
2. ٢‫ ؾ‬٢‫ ذ‬ٝ‫أ‬
3. ‫س ُإلغرحم‬٤٘٤ُٓ‫جألشؼس ج‬
4. ‫س‬٤‫و‬٤‫س قو‬٤‫س ؾحٗر‬٣‫ٌؤ‬
5. ‫ ػٍض‬PNS (١ِٞ‫) ُِلي جُؼ‬٢‫د جألٗل‬٤‫جُؿ‬ ‫ئيج ًحٕ ٍٓضرطًح ذؼِْ جألٍٓجض‬
6. ‫ نحصس ئيج ًحٗص جألٍٓجض ٍٓضرطس‬- ‫س‬٤‫جألشؼس جُٔوطؼ‬

2.5 Determining the Degree of Difficulty of Removal

1. Angulation: same angulations in mandibular third molar cause opposite degree of
difficulty for maxillary third molar extraction.
2. Position in buccoangular direction: directed towards the buccal aspect  easy.
Positioned towards the palatal aspect  difficult to remove.
3. Type of overlying tissues; only soft tissue covering is easier to remove
4. Proximity to maxillary sinus
5. Proximity to maxillary tuberosity; tuberosity can be fractured. Factors contributing to
this hazard are:
 Dense and non-elastic bone as in old age
 Multirooted tooth with large bulbous roots
 Large maxillary sinus (that include roots of third molar)
 Use of excessive force to elevate the tooth
 Mesioangular impactions
6. Other factors influencing the degree of surgical difficulty:
 Tooth with roots which are thin difficulty increased
 Hypercementosis difficulty increased
 Wide periodontal space difficulty decreased.
2.5 ‫ذس جإلَجُس‬ٞ‫ى وٌؾس صؼ‬٣‫ضكى‬
1. ‫ جُػحُػس‬٠‫ جْطهٍجؼ جٍُق‬٢‫ذس ك‬ٞ‫س ضٓرد وٌؾس ٓؼحًٓس ٖٓ جُصؼ‬٤ٌ‫ جُػحُػس جُل‬٠‫ جٍُق‬٢‫حش ك‬٣ُٝ‫ ٗلّ جُط‬:١ُٝ‫جُط‬
‫س‬٣ِٞ‫جُؼ‬.

10
 2. ‫ جُؿحٗد جُشىم‬ٞ‫ ٗك‬ٚ‫ؾ‬ٞٓ :١ٝ‫ جُُج‬٢‫ جُشىه‬ٙ‫ جالضؿح‬٢‫ظغ ك‬ُٞ‫ج‬ ٢ٌ٘‫ جُؿحٗد جُك‬ٞ‫ػس ٗك‬ٞ‫ظ‬ٞٓ .َْٜ ‫صؼد‬٣
‫ح‬ٜ‫ئَجُط‬.
3. ‫ز كوػ‬ٞ‫َ ئَجُس ؿطحء جألٗٓؿس جٍُن‬ْٜ‫ ٖٓ جأل‬.‫ع جألٗٓؿس جُٔـطحز‬ٞٗ
4. ١ِٞ‫ جُؼ‬٢ٌ‫د جُل‬٤‫جُوٍخ ٖٓ جُؿ‬
5. ٢ٛ ٍ‫ًج جُهط‬ٛ ٢‫ْ ك‬ٛ‫ ضٓح‬٢‫جَٓ جُط‬ٞ‫ جُؼ‬.‫ٌٖٔ ًٍٓ جُكىذس‬٣ .‫س‬٤ٌ‫ذس جُل‬ٝ‫جُوٍخ ٖٓ جُكى‬:
• ‫نس‬ٞ‫ه‬٤‫ جُش‬٢‫ جُكحٍ ك‬ٞٛ ‫ٍ ٍٓٗس ًٔح‬٤‫ؿ‬ٝ ‫لس‬٤‫ػظحّ ًػ‬
• ‫ٍز‬٤‫ٌ ٓ٘طلهس ًر‬ًٝ‫ٌ يجش ؾ‬ًٝ‫أْ٘حٕ ٓطؼىوز جُؿ‬
• ‫ جُػحُػس‬٠‫ٌ جٍُق‬ًٝ‫طعٖٔ ؾ‬٣ ١ًُ‫ٍ (ج‬٤‫ جٌُر‬١ِٞ‫ جُؼ‬٢ٌ‫د جُل‬٤‫)جُؿ‬
• ُٖٓ‫ز جُٔلٍغس ٍُكغ ج‬ٞ‫جْطهىجّ جُو‬
• ‫ْطس‬ٞ‫ّس جُٔط‬٣ٝ‫جٗكشحٌ جُُج‬
6. ‫س‬٤‫ذس جُؿٍجق‬ٞ‫ وٌؾس جُصؼ‬٠ِ‫ جُٔإغٍز ػ‬ٍٟ‫جَٓ جألن‬ٞ‫جُؼ‬:
• ‫حوز‬٣ُُ‫صؼرس ج‬ٝ ‫وس‬٤‫ٌ ٌه‬ًٝ‫جألْ٘حٕ يجش ؾ‬
• ‫كٍغ جُط٘ٓؽ‬ ‫ذس‬ٞ‫حوز جُصؼ‬٣َ
• ‫جضٓحع ٓٓحقس جُِػس‬ ‫ذس‬ٞ‫جٗهلحض جُصؼ‬.
 Tooth with a wide follicular space difficulty decreased
 Bone is more elastic as in young patients difficulty decreased
 Close relationship to second molar difficulty increased
 Fusion of third molar with roots of second molardifficulty increased
 Presence of large restoration on second molar difficulty increased
 Difficult access due to small oral aperture or trismusdifficulty increased
• ‫جْؼس‬ُٞ‫س ج‬٤‫ر‬٣ٍ‫جألْ٘حٕ يجش جُٔٓحقس جُؿ‬ ‫ذس‬ٞ‫جٗهلحض جُصؼ‬
• ٌ‫ جُصـح‬٠‫ جٍُٔظ‬٢‫ جُكحٍ ك‬ٞٛ ‫ٗس ًٔح‬ٍٝٓ ٍ‫جُؼظحّ أًػ‬ ‫ذس‬ٞ‫ضوَ جُصؼ‬
• ٢ٗ‫ جُػح‬٠‫وس ذحٍُق‬٤‫غ‬ُٞ‫جُؼالهس ج‬ ‫ذس‬ٞ‫حوز جُصؼ‬٣َ
• ‫س‬٤ٗ‫ جُػح‬٠‫ٌ جٍُق‬ًٝ‫ جُػحُػس ٓغ ؾ‬٠‫جٗىٓحؼ جٍُق‬ ‫ذس‬ٞ‫حوز جُصؼ‬٣َ
• ‫س‬٤ٗ‫ جُػح‬٠‫ جٍُق‬٠ِ‫ٍ ػ‬٤‫ْ ًر‬٤ٍٓ‫و ض‬ٞ‫ؾ‬ٝ ‫ذس‬ٞ‫حوز جُصؼ‬٣َ
• ‫ذس‬ٞ‫حوز جُصؼ‬٣َ - ‫ جُعُى‬ٝ‫ٍز أ‬٤‫ٍ ذٓرد كطكس جُلْ جُصـ‬ٞ‫ص‬ُٞ‫ذس ج‬ٞ‫صؼ‬

2.6 Steps in the operative procedure for removal of unerupted third molar
One of the difficulties that will be encountered during its surgical removal is the limited access
due to the presence of the coronoid process. This can be overcome by opening the mouth only
partially.

1. Incision: It starts from the mesial aspect of first molar and extends posteriorly beyond
the distobuccal aspect of second molar and then continued into the tuberosity. If greater
access is required (deep impaction)  release incision in the mesial aspect of second

11
 molar to raise a triangular flap.
2. Using a Howarth's periosteal elevator, the mucoperiosteum is reflected.
3. Bone removal is restricted to the occlusal and the buccal aspect of the tooth down to the
cervical line (using chisel or bur). Additional bone is removed on the mesial aspect of
the tooth above the height of contour of the crown  for the insertion of an elevator and
to act as a purchase point.

2.6 ٍ‫ٍ جُٔ٘لؿ‬٤‫ إلَجُس جُعٍِ جُػحُع ؿ‬٢‫جش جإلؾٍجء جُؿٍجق‬ٞ‫نط‬

‫ٌٖٔ جُطـِد‬٣ٝ .‫س‬٤ِ٤ًِ‫س جإل‬٤ِٔ‫و جُؼ‬ٞ‫ؾ‬ٝ ‫ح ذٓرد‬ٜ٤ُ‫ٍ ئ‬ٞ‫ص‬ُٞ‫س ج‬٣‫و‬ٝ‫ ٓكى‬٢ٛ ‫ًح‬٤‫ح ؾٍجق‬ٜ‫ح أغ٘حء ئَجُط‬ٜ‫ط‬ٜ‫جؾ‬ٞٓ ْ‫ط‬٤ْ ٢‫ذحش جُط‬ٞ‫ جُصؼ‬ٟ‫ئقى‬
‫ًح كوػ‬٤‫ن كطف جُلْ ؾُت‬٣ٍ‫ يُي ػٖ غ‬٠ِ‫ػ‬.

1. ‫ ئيج‬.‫ذس‬ٝ‫ جُكى‬٠‫ٓطٍٔ قط‬٣ ْ‫س غ‬٤ٗ‫ جُػح‬٠‫ ٍُِق‬٢‫قش‬ُٞ‫ ٓح ذؼى جُؿحٗد ج‬٠ُ‫ٔطى ُِهِق ئ‬٣ٝ ٠ُٝ‫ جأل‬٠‫ ٍُِق‬٢ٓٗ‫رىأ ٖٓ جُؿحٗد جإل‬٣ :‫جُشن‬
‫ن‬٤ٔ‫ٍ أًرٍ (جٗكشحٌ ػ‬ٞ‫ص‬ٝ ٠ُ‫٘حى قحؾس ئ‬ٛ ‫ًحٗص‬ ‫ِس‬٣‫س ٍُكغ جُٓى‬٤ٗ‫ جُػح‬٠‫ ٖٓ جٍُق‬٢ٓٗ‫ جُؿحٗد جإل‬٢‫ٍ شن ك‬٣ٍ‫هْ ذطك‬
‫جُٔػِػس‬.

2. ‫ ُِٓٔكحم‬٢‫٘ؼٌّ جُـشحء جُٔهحغ‬٣ ،٢‫جٌظ جُٓٔكحه‬ٞٛ ‫ذحْطهىجّ ٓصؼى‬.

3. .)‫ جُٔػوحخ‬ٝ‫َ أ‬٤َٓ‫ نػ ػ٘ن جٍُقْ (ذحْطهىجّ جإل‬٠ُ‫الً ئ‬ٞ‫ص‬ٝ ُٖٓ‫جُشىم ٖٓ ج‬ٝ ٢‫ جُؿحٗد جإلغرحه‬٠ِ‫وطصٍ ئَجُس جُؼظحّ ػ‬٣
‫ػ جُطحؼ‬٤‫م جٌضلحع ٓك‬ٞ‫ ُِٖٓ ك‬٢ٓٗ‫ ٖٓ جُؿحٗد جإل‬٢‫ضطْ ئَجُس ػظْ ئظحك‬ ‫ٕ ذٔػحذس ٗوطس شٍجء‬ٌٞ٣ٝ ‫إلونحٍ جُٔصؼى‬
4. Maxillary third molars rarely need sectioning (overlying bone is usually thin and elastic).
If bone is thick, sclerotic and less elasticbone removal rather than tooth sectioning.
5. Delivery of the tooth: using small straight elevators. The following points should be
borne in mind while elevating the tooth
 Due to the proximity of the maxillary sinus and infratemporal fossa  no upward
pressure exerted during bone removal and delivery
 This can be avoided by creating sufficient room between crown and surrounding
bone
 Moderate pressure is exerted downward and outward with the forefinger placed
posterior to maxillary tuberosity to detect tuberosity fracture if it occurs.
 Minnesota retractor or periosteal elevator can be placed distal to impacted
maxillary third molar during final elevation avoid displacement under the flap
and into the infratemporal fossa.
4. ‫ ًٌح‬٤ْٔ ْ‫ ئيج ًحٕ جُؼظ‬.)ً‫ٍٓٗح‬ٝ ً‫وح‬٤‫ٕ ٌه‬ٌٞ٣ ‫ ػحوز ٓح‬٢‫ْ (جُؼظْ جُٔـط‬٤ٓ‫ جُطو‬٠ُ‫س ئ‬٤ٌ‫ٗحوٌجً ٓح ضكطحؼ جألظٍجِ جُػحُػس جُل‬
ٕ‫ ضطْ ئَجُس جُؼظحّ ذىالً ٖٓ ضؿُتس جألْ٘ح‬،‫ٗس‬ٍٝٓ َ‫أه‬ٝ ‫ٓطصِرًح‬ٝ.
5. ُٖٓ‫س أغ٘حء ٌكغ ج‬٤ُ‫ؿد ٍٓجػحز جُ٘وحغ جُطح‬٣ .‫ٔس‬٤‫ٍز ٓٓطو‬٤‫ ذحْطهىجّ ٓصحػى صـ‬:ُٖٓ‫ْ ج‬٤ِٓ‫ض‬
• ‫س‬٤‫جُكلٍز ضكص جُصىؿ‬ٝ ١ِٞ‫ جُؼ‬٢ٌ‫د جُل‬٤‫ذٓرد هٍخ جُؿ‬ ‫الوز‬ُٞ‫ج‬ٝ ّ‫ أغ٘حء ئَجُس جُؼظح‬١‫ؾى ظـػ ضصحػى‬ٞ٣ ‫ال‬

12
 • ٚ‫ػ ذ‬٤‫جُؼظْ جُٔك‬ٝ ‫ٖ جُطحؼ‬٤‫س ذ‬٤‫ن نِن ٓٓحقس ًحك‬٣ٍ‫ٌٖٔ ضؿ٘د يُي ػٖ غ‬٣
• ‫ قحُس‬٢‫س ٌُِشق ػٖ ًٍٓ جُكىذس ك‬٤ٌ‫ذس جُل‬ٝ‫ظغ جُٓرحذس نِق جُكى‬ٝ ‫ جُهحٌؼ ٓغ‬٠ُ‫ئ‬ٝ َ‫ جألْل‬٠ُ‫طْ جُعـػ جُٔؼطىٍ ئ‬٣
‫ح‬ٜ‫غ‬ٝ‫قى‬.
• ٢‫حت‬ُٜ٘‫س جُٔ٘طٍٔز أغ٘حء جالٌضلحع ج‬٣ِٞ‫ جُػحُػس جُؼ‬٠‫ىًج ػٖ جٍُق‬٤‫ ذؼ‬٢‫ جُٔصؼى جُٓٔكحه‬ٝ‫ضح أ‬ٞٓ٤٘٤ٓ ‫ظغ ظحٓس‬ٝ ٌٖٔ٣
‫س‬٤‫ جُكلٍز ضكص جُصىؿ‬٠ُ‫ئ‬ٝ ‫ِس‬٣‫ضؿ٘د جإلَجقس ضكص جُٓى‬.
6. Debridement and Closure: A single suture is all that is needed to secure the wound. The
suture is passed from the palatal side of the interdental papilla between the first and
second molars into the anterior end of the buccal flap.
6. ٖ٤‫ٔس ذ‬٤ِ‫ ُِك‬٢ٌ٘‫ػ ٖٓ جُؿحٗد جُك‬٤‫ٍ جُه‬٣ٍٔ‫طْ ض‬٣ .‫ٖ جُؿٍـ‬٤ٓ‫جقىز ُطأ‬ٝ ‫حغس‬٤‫ ن‬ٞٛ ‫خ‬ِٞ‫ ٓط‬ٞٛ ‫ ًَ ٓح‬:‫جإلؿالم‬ٝ ٍ٤‫جُط٘ع‬
‫س‬٤‫ِس جُشىه‬٣‫ ٖٓ جُٓى‬٢ٓ‫ جُطٍف جألٓح‬٠ُ‫س ئ‬٤ٗ‫جُػح‬ٝ ٠ُٝ‫ٖ جألظٍجِ جأل‬٤‫جألْ٘حٕ ذ‬

2.7 Complications During Surgery of Impacted Maxillary Third Molar

1. Displacement of tooth into maxillary sinus:
 partially erupted and has conical roots
 excessive force is exerted for elevating a buried wisdom tooth
 Retrieval can be accomplished via a Caldwell-Luc approach
2. Dislodgement into soft tissues and into the infratemporal fossa may occur:
 Buccal flap is not adequate
 Decreased visibility during surgical extraction
 Incorrect extraction technique
 Distolingual angulation of tooth
 Third molar crown above the level of the adjacent molar root apices.
2.7 ‫س جُٔ٘طٍٔز‬٤ٌ‫ جُػحُػس جُل‬٠‫جُٔعحػلحش أغ٘حء ؾٍجقس جٍُق‬
1. ١ِٞ‫ جُؼ‬٢ٌ‫د جُل‬٤‫ جُؿ‬٠ُ‫ئَجقس جُٖٓ ئ‬:
• ٌَ‫س جُش‬٤‫غ‬ٍٝ‫ٌ ٓه‬ًٝ‫ ؾ‬ُٚٝ ً‫ح‬٤‫ٓ٘لؿٍ ؾُت‬
• ٕٞ‫ز جُٔلٍغس ٍُكغ ظٍِ جُؼوَ جُٔىك‬ٞ‫طْ جْطهىجّ جُو‬٣
• ‫ى‬ُٞ-َ٣ٝ‫وس ًحُى‬٣ٍ‫طْ جالْطٍؾحع ٖٓ نالٍ غ‬٣ ٕ‫ٌٖٔ أ‬٣
2. ‫س‬٤‫ جُكلٍز ضكص جُصىؿ‬٠ُ‫ئ‬ٝ ‫ز‬ٞ‫ جألٗٓؿس جٍُن‬٠ُ‫ـ ئ‬ُٝٗ ‫كىظ‬٣ ‫هى‬:
• ‫س‬٤‫ٓص ًحك‬٤ُ ‫س‬٤‫ِس جُشىه‬٣‫جُٓى‬
• ٢‫س أغ٘حء جالْطهٍجؼ جُؿٍجق‬٣‫جٗهلحض جٍُؤ‬
• ‫كس‬٤‫ٍ صك‬٤‫س جالْطهٍجؼ ؿ‬٤٘‫ضو‬
• ٕ‫ جُٔطرحػى ُألْ٘ح‬١ُٝ‫جُط‬
• ‫ٌز‬ٝ‫ جُٔؿح‬٠‫ هْٔ ؾًٌ جٍُق‬ٟٞ‫م ٓٓط‬ٞ‫ جُػحُع ك‬٠‫ضحؼ جٍُق‬

13
 Such displaced tooth should be removed as early as possible to avoid development of
infection. Tooth retrieval can be done with haemostat or Allis’ forceps. Surgical access
is gained through an incision along the crest of the alveolus. If the tooth could not be
removed after a single effort  patient informed  antibiotic is administered to prevent
infection tooth removed four to six weeks later by an oral and maxillofacial surgeon.
ٕ‫طْ جْطٍؾحع جألْ٘ح‬٣ ٕ‫ٌٖٔ أ‬٣ .ٟٝ‫ٌ جُؼى‬ٞ‫هص ٌٖٓٔ ُطؿ٘د ضط‬ٝ ‫ أهٍخ‬٢‫ جألْ٘حٕ جُ٘حَقس ك‬ًٙٛ ‫ؿد ئَجُس‬٣
‫صالش‬٣ٞ‫ٍ هٔس جُك‬ٞ‫ غ‬٠ِ‫ ٖٓ نالٍ شن ػ‬٢‫ٍ جُؿٍجق‬ٞ‫ص‬ُٞ‫ ج‬٠ُ‫ٍ ئ‬ٞ‫ص‬ُٞ‫طْ ج‬٣ .ّ٤ُ‫ ِٓوػ أ‬ٝ‫ذحْطهىجّ ٍٓهة جُىّ أ‬
‫جقى‬ٝ ‫ى‬ٜ‫ٌٖ ٖٓ جٌُٖٔٔ ئَجُس جُٖٓ ذؼى ؾ‬٣ ُْ ‫ ئيج‬.‫س‬٤‫جت‬ُٜٞ‫ج‬ ‫ط‬٣ٍُٔ‫ئذالؽ ج‬ ‫ ُٔ٘غ‬١ٞ٤‫طْ ئػطحء ٓعحو ق‬٣
ٟٝ‫جُؼى‬ ٖ٤ٌ‫جُل‬ٝ ٚ‫ؾ‬ُٞ‫ج‬ٝ ْ‫جْطس ؾٍجـ جُل‬ٞ‫غ ذ‬٤‫ ْطس أْحذ‬٠ُ‫ضطْ ئَجُس جُٖٓ ذؼى أٌذؼس ئ‬

3 Summary of Instructions to Patient Following Surgical Removal of

Impacted Tooth
1. Remove the gauze pack after 30 minutes to one hour
2. Apply ice (ice cubes taken in a polythene bag) on the face for the first 24 hours.
3. For the first day take cold liquids or semisolids.
4. Avoid warm saline gargle in the first 24 hours.
5. There may be mild to moderate swelling on the side of the face for three to four days.
6. Mild bleeding/oozing of blood can be there from the surgical site for one to two days. In
the event of excessive bleeding bite on a fresh piece of sterile gauze and inform the
doctor.

3 ‫س ُألْ٘حٕ جُٔ٘طٍٔز‬٤‫ط ذؼى جإلَجُس جُؿٍجق‬٣ٍُِٔ ‫ٔحش‬٤ِ‫ِٓهص جُطؼ‬

1. ‫جقىز‬ٝ ‫ ْحػس‬٠ُ‫وس ئ‬٤‫ وه‬30 ‫هْ ذاَجُس ظٔحوز جُشحٔ ذؼى‬

2. ٠ُٝ‫ ْحػس جأل‬24 ‫ ُٔىز‬ٚ‫ؾ‬ُٞ‫ ج‬٠ِ‫ٖ) ػ‬٤‫ػ‬٤ُٞ‫ّ ٖٓ جُر‬٤ً ٢‫ظغ جُػِؽ (ٌٓؼرحش غِؽ ضإنً ك‬.

3. ‫ جُصِرس‬ٚ‫ شر‬ٝ‫جتَ جُرحٌوز أ‬ُٞٓ‫ٍ ج‬ٝ‫ٍ ض٘ح‬ٝ‫ّ جأل‬ٞ٤ُ‫ ج‬٢‫ك‬.

4. ٠ُٝ‫ ْحػس جأل‬24 ‫ جُىجكة نالٍ جُـ‬٢‫ٍ جُِٔك‬ِٞ‫ضؿ٘د جُـٍؿٍز ذحُٔك‬.

5. ّ‫ح‬٣‫ أٌذؼس أ‬٠ُ‫ ُٔىز غالغس ئ‬ٚ‫ؾ‬ُٞ‫ ؾحٗد ج‬٢‫ْػ ك‬ٞ‫ ٓط‬٠ُ‫ق ئ‬٤‫ٌّ نل‬ٞ‫٘حى ض‬ٛ ٌٕٞ٣ ‫هى‬.

6. ‫ هْ ذوطغ‬،‫ى‬٣‫ق شى‬٣ُٗ ‫ظ‬ٝ‫ قحُس قى‬٢‫ ك‬.ٖ٤ٓٞ٣ ٝ‫ّ أ‬ٞ٣ ‫هغ جُؿٍجقس ُٔىز‬ٞٓ ٖٓ ّ‫ ٗحَ ٖٓ جُى‬ٝ‫ق أ‬٤‫ق نل‬٣ُٗ ‫كىظ‬٣ ٕ‫ٌٖٔ أ‬٣
‫د ذًُي‬٤‫ئذالؽ جُطر‬ٝ ْ‫هطؼس ٖٓ جُشحٔ جُٔؼو‬.
7. In the first few days, difficulty may be experienced in opening the mouth. To avoid this,
from the next day of surgery onwards try to open the mouth forcefully.
8. From the next day onwards after surgery or once the oozing of blood has completely

14
 stopped, warm saline mouth-baths can be used at fourth hourly intervals. Avoid
application of dry heat on the face.
9. Tooth brushing have to be done from the next day on wards.
10. Take the drugs prescribed by the doctor at regular intervals.
11. Avoid alcohol, smoking, physical exercise and long journey for the next few days.
12. Report for review to the doctor as suggested for suture removal.
7. ‫ز‬ٞ‫ٍ كطف جُلْ ذو‬ٝ‫ قح‬،‫ ُِؿٍجقس كصحػىًج‬٢ُ‫ّ جُطح‬ٞ٤ُ‫ ٖٓ ج‬،‫ ُطؿ٘د يُي‬.ْ‫ كطف جُل‬٢‫ذس ك‬ٞ‫ صؼ‬ٚ‫جؾ‬ٞ‫ هى ض‬٠ُٝ‫ِس جأل‬٤ِ‫حّ جُو‬٣‫ جأل‬٢‫ك‬.
8. ٢‫ٍ جُِٔك‬ِٞ‫ٌٖٔ جْطهىجّ قٔحٓحش جُلْ جُىجكثس يجش جُٔك‬٣ ،‫هق ُٗف جُىّ ضٔح ًٓح‬ٞ‫ ذٔؿٍو ض‬ٝ‫ كصحػىًج ذؼى جُؿٍجقس أ‬٢ُ‫ّ جُطح‬ٞ٤ُ‫ٖٓ ج‬
ٚ‫ؾ‬ُٞ‫ ج‬٠ِ‫ن جُكٍجٌز جُؿحكس ػ‬٤‫ ضؿ٘د ضطر‬.‫ًَ أٌذغ ْحػحش‬.
9. ٢ُ‫ّ جُطح‬ٞ٤ُ‫ق جألْ٘حٕ ذحُلٍشحز ٖٓ ج‬٤‫ؿد ض٘ظ‬٣.
10. ‫ كطٍجش ٓ٘طظٔس‬٠ِ‫د ػ‬٤‫كس ٖٓ هرَ جُطر‬ٞ‫ص‬ُٞٔ‫س ج‬٣ٝ‫ٍ جألو‬ٝ‫ض٘ح‬.
11. ‫ِس جُوحوٓس‬٤ِ‫حّ جُو‬٣‫ِس نالٍ جأل‬٣ٞ‫جٍُقِس جُط‬ٝ ‫س‬٤ٗ‫حظس جُرى‬٣ٍُ‫ٓٔحٌْس ج‬ٝ ٖ٤‫جُطىن‬ٝ ٍٞ‫ضؿ٘د جٌُك‬.
12. ٍَ‫ ٓوطٍـ إلَجُس جُـ‬ٞٛ ‫د ًٔح‬٤‫ جُطر‬٠ُ‫ٍ ٍُِٔجؾؼس ئ‬٣ٍ‫ضو‬

4 Drug therapy
4.1 Use of antibiotic
Postoperative oral prophylactic antibiotic treatment after the removal of lower third molars
have not shown to contribute to a better wound healing, less pain, or increased mouth opening
and could not prevent inflammatory problems after surgery. And therefore, is not
recommended for routine use. The following principles should be considered before
prescribing antibiotics

4 ٢‫جت‬ٝ‫جُؼالؼ جُى‬

4.1 ‫س‬٣ٞ٤‫جْطهىجّ جُٔعحوجش جُك‬

ٚٗ‫س أ‬٤ِ‫س ذؼى ئَجُس جألظٍجِ جُػحُػس جُٓل‬٤‫س جُؿٍجق‬٤ِٔ‫ن جُلْ ذؼى جُؼ‬٣ٍ‫س ػٖ غ‬٤‫هحت‬ُٞ‫س ج‬٣ٞ٤‫ٍ جُؼالؼ ذحُٔعحوجش جُك‬ٜ ‫ُظ‬٣ ُْ
.‫س ذؼى جُؿٍجقس‬٤‫حذ‬ٜ‫ظ ٓشحًَ جُط‬ٝ‫ٔ٘غ قى‬٣ ٕ‫ٌٖٔ أ‬٣ ‫ال‬ٝ ْ‫حوز كطف جُل‬٣َ ٝ‫َ جألُْ أ‬٤ِ‫ ضو‬ٝ‫ـ أ‬ٍٝ‫ٖ جُطثحّ جُؿ‬٤ٓ‫ ضك‬٢‫ْ ك‬ٛ‫ٓح‬٣
‫س‬٣ٞ٤‫صق جُٔعحوجش جُك‬ٝ َ‫س هر‬٤ُ‫ ٍٓجػحز جُٔرحوب جُطح‬٢‫٘رـ‬٣ .٢٘٤‫ض‬ٌٝ ٌَ‫ ذش‬ٚٓ‫٘صف ذحْطهىج‬٣ ‫ًُُي ال‬ٝ

1. The surgical procedure should harbour a significant risk for infection, for example:
 Long procedure (> 30 minutes) or difficult surgery involving significant tissue
trauma.
 Where there is existing infection in and around the surgical site.
2. Administration of the antibiotic must be immediately prior to or within 3 hours after the
start of surgery:

15
  The ability of systemic antibiotics to prevent the development of a primary
bacterial lesion is confined to the first 3 hours after inoculation of the wound.
 Commencing prophylactic antibiotic cover the day before surgery only leads to
the development of resistant organisms.
 Continuing antibiotics for days after surgery has not been shown to decrease the
incidence of wound infection.
3. Prophylactic antibiotics should be given at twice the usual dose over the shortest effective
time so as to minimize the potential side-effects of long-term use (e.g. diarrhoea) and to
prevent the growth of resistant strains of bacteria.
4. 1. ٍ‫َ جُٔػح‬٤‫ ْر‬٠ِ‫ ػ‬،ٟٝ‫ٍ ُإلصحذس ذحُؼى‬٤‫ نطٍ ًر‬٠ِ‫س ػ‬٤‫س جُؿٍجق‬٤ِٔ‫ جُؼ‬١ٞ‫ؿد إٔ ض٘ط‬٣:
5. • ‫ جألٗٓؿس‬٢‫ٍز ك‬٤‫ صىٓس ًر‬٠ِ‫ ػ‬١ٞ‫س صؼرس ض٘ط‬٤‫س ؾٍجق‬٤ِٔ‫ ػ‬ٝ‫وس) أ‬٤‫ وه‬30 >( َ٣ٞ‫ئؾٍجء غ‬.
6. • ‫هغ جُؿٍجقس‬ٞٓ ٍٞ‫ق‬ٝ َ‫ وجن‬ٟٝ‫ؾى ػى‬ٞ‫ػٔح ض‬٤‫ق‬.
7. 2. ‫ ْحػحش ذؼى ذىء جُؿٍجقس‬3 ٍ‫ نال‬ٝ‫ ٓرحشٍز هرَ أ‬١ٞ٤‫ؿد ئػطحء جُٔعحو جُك‬٣:
8. • ‫ف جُؿٍـ‬٤‫ ْحػحش ذؼى ضِو‬3 ٍٝ‫ أ‬٠ِ‫س ضوطصٍ ػ‬٤ُٝ‫س جأل‬٣ٍ٤‫كس جُرٌط‬٥‫ٌ ج‬ٞ‫ ٓ٘غ ضط‬٠ِ‫س ػ‬٣َ‫ح‬ٜ‫س جُؿ‬٣ٞ٤‫هىٌز جُٔعحوجش جُك‬.
9. • ‫ٓس‬ٝ‫ٌ ًحت٘حش ٓوح‬ٞ‫ ضط‬٠ُ‫ ئال ئ‬١‫إو‬٣ ‫ّ جُٓحذن ُِؿٍجقس ال‬ٞ٤ُ‫ ج‬٢‫س ك‬٤‫هحت‬ُٞ‫س ج‬٣ٞ٤‫س ذحُٔعحوجش جُك‬٤‫ئٕ جُرىء ذحُطـط‬.
10. • ‫ جُؿٍـ‬ٟٝ‫ظ ػى‬ٝ‫وَِ ٖٓ قى‬٣ ‫حّ ذؼى جُؿٍجقس‬٣‫س ُؼىز أ‬٣ٞ٤‫ٍ جُٔعحوجش جُك‬ٝ‫ ض٘ح‬٢‫ػرص إٔ جالْطٍٔجٌ ك‬٣ ُْ.
11. 3. ‫س‬٤‫غحٌ جُؿحٗر‬٥‫َ ج‬٤ِ‫يُي ُطو‬ٝ ‫س كؼحُس‬٤َ٘ٓ ‫س ذعؼق جُؿٍػس جُٔؼطحوز نالٍ أهصٍ كطٍز‬٤‫هحت‬ُٞ‫س ج‬٣ٞ٤‫ ئػطحء جُٔعحوجش جُك‬٢‫٘رـ‬٣
‫ٓس‬ٝ‫ح جُٔوح‬٣ٍ٤‫ ْالالش جُرٌط‬ٞٔٗ ‫ُٔ٘غ‬ٝ )ٍ‫ح‬ْٜ‫َ جألٓى (ٓػَ جإل‬٣ٞ‫جُٔكطِٔس ُالْطهىجّ غ‬.
12. Examples of antibiotic prophylactic regimens:
 Amoxicillin 3 gm orally, 45 minutes before surgery under local anaesthesia.
 Clindamycin 600 mg orally, 30 minutes before surgery under local anaesthesia
for patients allergic to penicillin.
 Benzyl Penicillin 600 mg IV/IM on induction for procedures under general
anaesthesia.
 Erythromycin lactobionate 500 mg IV on induction for surgery under general
anaesthesia for patients allergic to penicillin.

The above dose may be followed with an additional oral dose 6 hours after the initial
dose
12. ‫س‬٣ٞ٤‫س ذحُٔعحوجش جُك‬٤‫هحت‬ُٞ‫ جألٗظٔس ج‬٠ِ‫أٓػِس ػ‬:
• ٢‫ظؼ‬ُٞٔ‫ٍ ج‬٣‫وس ٖٓ جُؿٍجقس ضكص جُطهى‬٤‫ وه‬45 َ‫ح ً هر‬٣ٞٔ‫ ؾْ ك‬3 ٖ٤ِ٤ٓ٤ًٓٞٓ‫أ‬.
• ٕٞٗ‫ؼح‬٣ ٖ٣ًُ‫ ج‬٠‫ ٍُِٔظ‬٢‫ظؼ‬ُٞٔ‫ٍ ج‬٣‫وس ٖٓ جُؿٍجقس ضكص جُطهى‬٤‫ وه‬30 َ‫ هر‬،ْ‫ن جُل‬٣ٍ‫ ِٓؾ ػٖ غ‬600 ٖ٤ٓ٣‫٘ىجٓح‬٤ًِ
ٖ٤ِٓ٘‫س ُِر‬٤ْ‫ٖٓ قٓح‬.
• ّ‫ٍ جُؼح‬٣‫ جإلؾٍجءجش ضكص جُطهى‬٠ِ‫ط ػ‬٣ٍ‫جُؼعَ ػ٘ى جُطك‬/‫ى‬٣ٌُٞ‫ ج‬٢‫ ِٓؾ ك‬600 ٖ٤ِٓ٘‫َ ذ‬٣ُ٘‫جُر‬.

16
 • ٖ٣ًُ‫ ج‬٠‫ٍ جُؼحّ ٍُِٔظ‬٣‫س ضكص جُطهى‬٤‫س ؾٍجق‬٤ِٔ‫ىجً إلؾٍجء ػ‬٤ٜٔ‫ى ض‬٣ٌُٞ‫ ج‬٢‫ ِٓؾ ك‬500 ‫ٗحش‬ٞ٤‫ذ‬ٞ‫ٖ الًط‬٤ٓ٣‫ٓح‬ٍٝ‫ػ‬٣ٌ‫ئ‬
ٖ٤ِٓ٘‫س ُِر‬٤ْ‫ٕ ٖٓ قٓح‬ٞٗ‫ؼح‬٣.

‫س‬٤ُٝ‫ ْحػحش ٖٓ جُؿٍػس جأل‬6 ‫ن جُلْ ذؼى‬٣ٍ‫س ػٖ غ‬٤‫ ذؿٍػس ئظحك‬ٙ‫ٌز أػال‬ًًُٞٔ‫ٌٖٔ جضرحع جُؿٍػس ج‬٣

4.2 Use of Anti-inflammatory Drugs and Steroids

Perioperative corticosteroids have been used to minimize swelling, trismus and pain in oral and
maxillofacial surgery patients. However, the method of usage is extremely variable. The most
widely used steroids are dexamethasone and methylprednisolone. Common dosages of
dexamethasone are 4 to 12 mg given IV at the time of surgery. Additional oral dosages of 4 to
8 mg. twice a day for the day of surgery and 2 days afterwards leads to the maximum relief of
swelling, trismus and pain. Methylprednisolone is most commonly given IV 125 mg at the time
of surgery followed by significantly lower doses, usually 40 mg 3 or 4 times daily taken orally
for the day of surgery and for 2 days after surgery.
4.2 ‫جُٔ٘شطحش‬ٝ ‫حذحش‬ٜ‫س جُٔعحوز ُالُط‬٣ٝ‫جْطهىجّ جألو‬
‫ٓغ‬ٝ .ٖ٤ٌ‫جُل‬ٝ ٚ‫ؾ‬ُٞ‫ج‬ٝ ْ‫ ؾٍجقس جُل‬٠‫ ٍٓظ‬ٟ‫جألُْ ُى‬ٝ ‫جُعُى‬ٝ ٌّٞ‫َ جُط‬٤ِ‫طس ذحُؿٍجقس ُطو‬٤‫ىجش جُٔك‬٣ٍٝ٤‫ْط‬ٌٞ٤‫ٌض‬ٌُٞ‫ضْ جْطهىجّ ج‬
‫ جُؿٍػحش‬.ُُٕٞٝ٤ٗ‫ى‬٣ٍ‫َ ذ‬٤‫ػ‬٤ٓٝ َٕٝ‫ػح‬٤ٓ‫ٌٓح‬٣‫ و‬٢ٛ ‫ جُٔ٘شطحش جألًػٍ جْطهىج ًٓح‬.‫س‬٣‫ٍز ُِـح‬٤‫وس جالْطهىجّ ٓطـ‬٣ٍ‫ كإ غ‬،‫يُي‬
ْ‫ن جُل‬٣ٍ‫س ػٖ غ‬٤‫ ؾٍػحش ئظحك‬.‫هص جُؿٍجقس‬ٝ ٢‫ى ك‬٣ٌُٞ‫ن ج‬٣ٍ‫ ػٖ غ‬٠‫ ِٓؾ ضؼط‬62 ٠ُ‫ ئ‬4 ٢ٛ َٕٝ‫ػح‬٤ٓ‫ٌٓح‬٣‫جُشحتؼس ٖٓ جُى‬
.ُْ‫جأل‬ٝ َُ‫جُع‬ٝ ٌّٞ‫ق جُط‬٤‫ ٖٓ ضهل‬٠‫ جُكى جألهص‬٠ُ‫ ئ‬١‫إو‬٣ ‫ٖ ذؼى يُي‬٤ٓٞ٣ٝ ‫ّ جُؿٍجقس‬ٞ٣ ٢‫ًح ك‬٤ٓٞ٣ ٖ٤‫ ٍٓض‬.‫ ِٓؾ‬8 ٠ُ‫ ئ‬4 ٖٓ
‫هص‬ُٞ‫ يُي ج‬٢‫ ِٓؾ ك‬625 ‫ى‬٣ٌُٞ‫ن ج‬٣ٍ‫ٕ ذشٌَ شحتغ ػٖ غ‬ُُٞٝ٤ٗ‫ى‬٣ٍ‫َ ذ‬٤‫ػ‬٤ٓ ‫طْ ئػطحء‬٣
‫ٖ ذؼى‬٤ٓٞ٣ ‫ُٔىز‬ٝ ‫ّ جُؿٍجقس‬ٞ٤ُ ْ‫ن جُل‬٣ٍ‫ح ضإنً ػٖ غ‬٤ٓٞ٣ ‫ ٍٓجش‬4 ٝ‫ أ‬3 ‫ ِٓؾ‬40 ‫ ػحوز‬،ٍ٤‫ح ؾٍػحش أهَ ذٌػ‬ٜ٤ِ‫ذؼى جُؿٍجقس ض‬
‫جُؿٍجقس‬

4.3 Use of Non-steroidal Anti-inflammatory Drugs (NSAIDs)

they are frequently used after surgical procedures in order to reduce the soft tissue oedema and
pain by suppressing inflammation

4.4 Use of Analgesics

 It has been reported that soluble aspirin 900 mg provides significant and more rapid
analgesia than paracetamol 1,000 mg in the early postoperative period
 Patients should be encouraged to take analgesics either before the onset or at the time
of onset of pain or discomfort rather than waiting till the pain becomes unbearable.
 Long-acting local anaesthetic solutions may be of value in some situations where
extreme pain is likely to be a feature in the immediate post-operative period.

17
  It has been shown that administering a dose of analgesic preoperatively markedly
reduces postoperative pain.
4.3 ‫س‬٣‫ى‬٣ٍٝ٤‫ٍ جُٓط‬٤‫حخ ؿ‬ٜ‫( جْطهىجّ ٓعحوجش جالُط‬NSAIDs)
‫حخ‬ٜ‫ن هٔغ جالُط‬٣ٍ‫جألُْ ػٖ غ‬ٝ ‫ز‬ٞ‫يٓس جألٗٓؿس جٍُن‬ٝ َ٤ِ‫س ُطو‬٤‫حش جُؿٍجق‬٤ِٔ‫ح ذشٌَ ٓطٌٌٍ ذؼى جُؼ‬ٜٓ‫طْ جْطهىج‬٣
4.4 ‫جْطهىجّ جٌُٔٓ٘حش‬
• ‫ كطٍز‬٢‫ ِٓؾ ك‬6000 ٍٞٓ‫طح‬٤ْ‫ؼًح أًػٍ ٖٓ جُرحٌج‬٣ٍْٝ ‫ظًح‬ٞ‫ً٘ح ِٓك‬٤ٌٓ‫كٍ ض‬ٞ٣ ‫ ِٓؾ‬500 ٕ‫ذح‬ًُِٝ َ‫ٖ جُوحذ‬٣ٍ‫ضْ جإلذالؽ ػٖ إٔ جألْر‬
‫ٓح ذؼى جُؿٍجقس جُٔرٌٍز‬
• ‫صرف‬٣ ٠‫ ػىّ جٍُجقس ذىالً ٖٓ جالٗطظحٌ قط‬ٝ‫ أ‬ٌٜٙٞ‫ ػ٘ى ظ‬ٝ‫ٌ جألُْ أ‬ٜٞ‫ٍ جٌُٔٓ٘حش ئٓح هرَ ظ‬ٝ‫ ض٘ح‬٠ِ‫ ػ‬٠‫غ جٍُٔظ‬٤‫ؿد ضشؿ‬٣
َٔ‫ٍ ٓكط‬٤‫جألُْ ؿ‬.
• ‫ى‬٣‫ح جألُْ جُشى‬ٜ٤‫ٕ ك‬ٌٞ٣ ٕ‫ ٖٓ جُٔكطَٔ أ‬٢‫ ذؼط جُكحالش جُط‬٢‫ٔس ك‬٤‫ٍ يجش ه‬ٞ‫ِس جُٔلؼ‬٣ٞ‫ غ‬٢‫ظؼ‬ُٞٔ‫ٍ ج‬٣‫َ جُطهى‬٤ُ‫ٕ ٓكح‬ٌٞ‫هى ض‬
‫ كطٍز ٓح ذؼى جُؿٍجقس ٓرحشٍز‬٢‫ْٔس ك‬.
• ‫ظ ٖٓ آالّ ٓح ذؼى جُؿٍجقس‬ٞ‫وَِ ذشٌَ ِٓك‬٣ ‫ُوى غرص إٔ ئػطحء ؾٍػس ٖٓ جٌُٔٓ٘حش هرَ جُؿٍجقس‬.

5 Complications of Impaction Surgery

5.1 Complications during the Surgical procedure
1. Complications during incision; Excessive bleeding may occur in the following situations:
a. Pre-existing local inflammation.
b. Bleeding from retromolar vessels
c. Bleeding from facial vessels
d. Damage to lingual nerve
5 ٌ‫ٓعحػلحش ؾٍجقس جالٗكشح‬
5.1 ‫س‬٤‫س جُؿٍجق‬٤ِٔ‫جُٔعحػلحش أغ٘حء جُؼ‬
1. ‫س‬٤ُ‫ جُكحالش جُطح‬٢‫ق جُُجتى ك‬٣ُُ٘‫كىظ ج‬٣ ‫ هى‬.‫جُٔعحػلحش أغ٘حء جُشن‬:
‫و ٓٓروًح‬ٞ‫ؾ‬ٞٓ ٢‫ظؼ‬ٞٓ ‫حخ‬ٜ‫ جُط‬.‫أ‬.
٠‫س نِق جٍُق‬٤‫ػ‬ٝ‫ق ٖٓ جأل‬٣ُٗ .‫خ‬
ٚ‫ؾ‬ُٞ‫س ج‬٤‫ػ‬ٝ‫ق ٖٓ أ‬٣ُٗ .‫ؼ‬
٢ٗ‫ ضِق جُؼصد جُِٓح‬.‫و‬

2. Complications during bone removal bundle

a. Use of bur
 Accidental burns
 Laceration of soft tissues
 Injury to inferior alveolar

18
‫‪Injury to adjacent tooth‬‬
‫‪‬‬ ‫‪Injury to lingual nerve‬‬
‫‪‬‬ ‫‪Necrosis of bone‬‬
‫‪‬‬ ‫‪Emphysema‬‬

‫ٓعحػلحش أغ٘حء ئَجُس جُؼظحّ ‪1.‬‬

‫أ‪ .‬جْطهىجّ ذ‪ٌٞ‬‬
‫جُكٍ‪ٝ‬م جُؼٍظ‪٤‬س •‬
‫ضُٔم جألٗٓؿس جٍُن‪ٞ‬ز •‬
‫ئصحذس جُكُٓس جُٓ٘ه‪٤‬س جُٓلِ‪٤‬س •‬
‫ئصحذس جألْ٘حٕ جُٔؿح‪ٌٝ‬ز •‬
‫ئصحذس جُؼصد جُِٓحٗ‪• ٢‬‬
‫ٗهٍ جُؼظحّ •‬
‫جٗطلحل جٍُتس •‬

‫‪19‬‬
 b. Use of chisel:
 Splintering of bone  Injury to lingual nerve
 Fracture of mandible  Injury to second molar
 Displacement of tooth tooth and soft tissues
into lingual pouch
3. Complications during sectioning of tooth
 Incorrect line of sectioning of crown
 Injury to mandibular canal: During
4. Complications during elevation of tooth
 Fracture of impacted tooth/  Dislodgement of tooth/crown
root into the lingual pouch or
 Breakage of bur lateral pharyngeal space
 Injury to second molar  Injury to mandibular canal
 Fracture of mandible

5.2 Post-Surgical Sequelae and Complications

1. Haemorrhage 11. Pyrexia
2. Oedema 12. Osteomyelitis
3. Trismus 13. Temporomandibular joint (TMJ)
4. Pain complications
5. Infection 14. Fracture of instruments: Especially
6. Alveolar osteitis (Dry socket) that of sharp Ones
7. Nerve Injury 15. Periodontal pocket formation distal
8. Surgical Emphysema to second molar
9. Hematoma 16. Aspiration /Swallowing of tooth
10. Pain during swallowing

20