MOS

OS
Pre-op assessment
 OPG
• Verify patient’s name and date
• Update OPG if >1 year ago
• Angulation of 3rd molar impaction
• Winter’s classification
• Distoangular / vertical / horizontal /
mesioangular impaction
• Even if just a little bit distally tilted 
still classified as distoangular
OPG – intrinsic obstacles
Crown Root
• Mesio-distal angulation • Multi-rooted
• Bucco-lingual tilting • Conical roots?
• Bulbosity • Curvature
• Caries • Divergence
• Existing restoration • Length
• Root canal treatment • Bulbosity
• Hypercementosis
OPG – intrinsic obstacles
Remarks
• If lower 3rd molar is buccally tilted  tilt patient’s head to
contralateral side to compensate for the tilting
• More difficult to take out the tooth if roots are more divergent
• Upper 1st molar has longer and more divergent roots than 2nd molar
OPG – extrinsic obstacles
• Bone
• Depth of impaction according to
Winter’s line
• Differentiate external vs internal
oblique ridge on OPG  use
internal oblique ridge as reference
• Pell & Gregory
• Class I, II, III: relationship with
ramus
• Class A, B, C: occlusal level
compared with 1st & 2nd molars
OPG – extrinsic obstacles
• 2nd molar
• Crown: existing restoration, caries, root canal treatment
• Root: multi-rooted, length, divergence, conical roots?
• Bone: distal bone loss  warn patient of possible sensitivity after 3rd molar
removal
• If 3rd molar is deeply engaged in the undercut of 2nd molar distal caries
 warn patient that pain may keep going on even after 3rd molar
removal  not post-op pain
OPG – extrinsic obstacles
• Vital structures
• ID nerve – signs of close proximity
• Darkening of root
• Abrupt narrowing of root
• Interruption and loss of white line
representing IDC
• Displacement of IDC by 3rd molar root
• Abrupt narrowing of 1 or both of
white lines
OPG – extrinsic obstacles
• Cannot say ID nerve is not close
• OPG is 2D image, cannot judge actual relationship
• Only for the operator’s reference during surgery
• Should still tell patient it is close and give warnings
OPG – extrinsic obstacles
• Other vital structures
• Lingual nerve
• Mental nerve
• Buccal branches of facial artery
• Maxillary sinus
• Any pneumatization?
• Maxillary tuberosity
• Other findings
• Radiolucency along distal surfaces of 3rd molar crown  follicle?
Possible warnings to patient
• ID nerve & lingual nerve injury
• ID nerve: 0.35%
• Lingual nerve: 0.69%
• Around 1/3 of cases permanent damage
• Consequences: transient/permanent numbness, tingling or funny sensation or loss of sensation
of ipsilateral lower chin, lips, tongue; also altered taste or loss of taste of ipsilateral tongue
• Lower 3rd molar
• Root tip fracture  may choose to leave in situ?
• 2nd molar
• Risk of subluxation
• Distal caries / distal bone loss  sensitivity after 3rd molar removal
• General complications: pain, swelling, bleeding
Treatment planning
• Flap design
• 3-sided full mucoperiosteal flap
• Standard buccal flap  include distal papilla of 2nd molar
• Modified buccal flap  extend the flap to include distal papilla of 1st molar
• For deep impaction
• Rationale: the flap should rest on sound bone
• Bone guttering
• To remove extrinsic obstacles
• To create application point for elevator
Treatment planning
• Tooth sectioning
• Vertical / distoangular impaction
• First attempt removal in one piece without sectioning
• If can’t, switch to transverse sectioning
• Longitudinal sectioning is not recommended as the tooth is not facing you and it would
be hard to do
• Horizontal / mesioangular impaction
• Can do transverse sectioning (decrown) first
• Remember don’t create undercut
• T-sectioning if needed
Treatment planning
• Suture
• Papilla x1  do first to put the flap back in a correct position
• Distal relieving incision x1 or x2
• Mesial relieving incision: usually not required as the flap should fit well after
the above sutures
Post-op instructions
• Don’t brush or rinse or spit forcefully
• Resume normal brushing and rinsing next day
• Can use warm salt water to help clean the wound
• Don’t do vigorous exercise, take more rest
• Don’t smoke or drink alcohol
• Pain, swelling, bleeding is normal within the first week, should get better and
better
• Pain: will prescribe analgesics, take only when have pain
• Bleeding: oozing is normal, put towel on pillow when sleeping, if excessive bleeding try
to use gauze  if fail call emergency
• Swelling: give face mask
Procedures
Flap incision
• Make a full cut down to periosteum  smooth cut  don’t do up &
down
• Distal incision: starting from distobuccal corner of 3rd molar and
extend buccally  don’t extend lingually!
• Mesial incision: after crossing mucogingival junction, do not cut down
 extend the cut anteriorly instead to avoid cutting buccal branches
of facial artery
Raising the flap
• First use the sharp end of dial to raise the flap at the base first
• Convex surface facing the flap; concave surface facing bone
• Should observe white colour bone
• Use a Bowlder Henry to retract the flap (must rest on sound bone)
Bone guttering
• If cortical bone is reached  bleeding from bone
• If cutting the tooth  there will be no bleeding
• Use fissure bur to create narrow groove  application point for
elevator
Tooth sectioning
• Pilot hole(s) with round burs
• Straight fissure burs  cut until feel a drop of bur  pulp has been
reached
• The hand piece should be activated before entering the tooth and
before pulling out from the tooth  otherwise the bur may fracture
easily
• Hand piece: in and out motion
• Tell patient he/she may hear a crack sound as we are trying to split
the tooth
• Insert elevator and rotate to crack the tooth
Delivery, debridement, suture
• Delivery
• Wound debridement
• Use tissue forceps to pick up the flap and irrigate underneath
• DSA: should suction in and out
• Suture
• Surgeon knot (double overhand, single overhand)
• Pull left hand, don’t move right hand with needle holder
• Length of suture: around corner of mouth
• Learn how to collect the suture
Removal of upper 3rd molar
• Concave surface should wrap around the tooth
• Push as palatally and apically as possible
• Path of withdrawal: buccally, distally, occlusally
Prescription
Analgesics
• Paracetamol
• 500mg qid, max dose 4g/day
• Hepatotoxicity, C/I liver failure
• Panadeine 508mg qid (8mg codeine)
• NSAIDs
• GI disturbance  + antacids / H2 blockers / PPI
• E.g. Famotidine 20mg bd (H2 blockers)
• Nephrotoxicity
• Ibuprofen: 200-400mg tid
• Mefenamic acid (Ponstan): 250/500mg tid
• Diclofenac sodium (Diclofen, Voltaren): 25/50mg bid/tid or slow release tab 100mg daily
• Arcoxia: 90mg daily; less GI disturbance but increased risk of stroke & MI
Antibiotics
• Metronidazole (nitroimidazoles): 200/400mg tid
• Amoxicillin (penicillin): 250/500mg tid
• Augmentin (penicillin): 375mg tid (125mg clavulanic acid + 250mg
amoxicillin)
• Cephalosporin: cross-sensitivity to penicillin (6%)
• Clindamycin (lincosamide): 300mg q6h; 1st choice for penicillin
sensitivity
• Erythromycin (macrolides): 250mg q6h
Antibiotic prophylaxis
• Amoxicillin 2g
• Clindamycin 600mg
• 30-60 min pre-op
• Single dose