Category Archives: Articles

Surgical Tip of the Week

#18 Seven Steps For Predictable Removal Of Mandibular Third Molar Impactions

Surgical Tip 18

Step 6 – Close. Primary closure of lower third molar surgical sites is controversial. Several studies have found pain and swelling were less severe with secondary closure than with primary closure.

Surgical Tip 18

A single interrupted suture can be placed distal to the second molar. Envelope flaps for maxillary third molars do not require sutures.

Surgical Tip of the Week

#17 Seven Steps For Predictable Removal Of Mandibular Third Molar Impactions

Surgical Tip 17

Step 6 – Debride and irrigate. Surgical sites must be thoroughly cleansed following the removal of third molars. The socket is gently irrigated, suctioned, and inspected with magnification. Debridement includes irrigation of the full thickness flap with a Monoject 412 syringe and sterile saline.

Surgical Tip 17

The passive flap is retracted and saline is injected with pressure between the lateral surface of the mandible and flap. Meticulous debridement of the flap is necessary to avoid subperiosteal infections.

Surgical Tip of the Week

#16 Seven Steps For Predictable Removal Of Mandibular Third Molar Impactions

Surgical Tip 16

Step 5 – Remove. The 301 and 46R elevators are commonly used for delivery. A Hu-Friedy EL3CSM luxating elevator is helpful when used on the straight buccal of vertical and distoangular impactions. The Cogswell B is recommended when purchase points are placed.

Surgical Tip 16

Excessive force can result in root fracture, unnecessary bone loss, or even fracture of the mandible. An adequate trough and section provide an unobstructed pathway for delivery.

Surgical Tip of the Week

#15 Seven Steps For Predictable Removal Of Mandibular Third Molar Impactions

Surgical Tip 15

Step 4 – Split. An ideal section stops short of the lingual plate and inferior alveolar canal. The tooth is then “split” into separate segments. The split is usually accomplished with a straight elevator, such as a 301, 34, or 46R. The tip of the elevator is placed deep into the section and rotated along its long axis. An audible “pop” is heard accompanied by tactile sensation when the tooth is divided into segments.

Surgical Tip 15

Conservative sectioning will result in an unsatisfactory split. Multiple sections many be required for the novice.

Surgical Tip of the Week

#14 Seven Steps For Predictable Removal Of Mandibular Third Molar Impactions

Surgical Tip 14

Step 3 – Section. Sectioning of mandibular third molars, like troughing, creates space and is best accomplished with the 1703L bur. The section should attempt to divide the tooth into mesial and distal halves. Mandibular third molar sections should cut approximately 3/4 through the tooth stopping short of the lingual plate, submandibular fossa, and lingual nerve. The section should be increasingly conservative as it moves in an apical direction. This precaution will minimize injury to the lingual nerve.

Surgical Tip 14

Surgical Tip of the Week

#13 Seven Steps For Predictable Removal Of Mandibular Third Molar Impactions

Surgica Tip 13

Step 2 – Trough. The trough (gutter, moat) allows for the placement of elevators and mobilization of the tooth. The ideal trough follows the course of the IAN; it is deeper on the mesial than on the distal.The trough is completed using a 1703L bur. The working end of the bur is 7.8 mm in length and 2.1 mm in diameter at the tip.

The 7.8 mm working end of the 1703L bur

The depth of the trough can be estimated using the 7.8 mm working end of the 1703L bur. The trough should be as deep as possible without injuring the IAN.

Surgical Tip of the Week

#12 Seven Steps For Predictable Removal Of Mandibular Third Molar Impactions

Surgical Tip 12

Step 1 – Flap. Many flap designs will work. The two most popular flaps for impacted third molars are the triangular and envelope. Western Surgical and Sedation recommends a large envelope flap starting distal to the second premolar (including papilla) and ending 1-1.5 cm distal to the second molar.

  • Large flaps heal as fast as small flaps
  • Work 100% of time regardless of skill level
  • Increased visibility means decreased complications
  • One suture distal of second molar on mandible, no suture maxilla (triangular flaps require two sutures)

Access is very important when removing impacted third molars. Why not try a large envelope flap?

Surgical Tip of the Week

#11 Seven Steps For Predictable Removal Of Mandibular Third Molar Impactions

The next seven STOW posts will cover seven steps for safe and predictable removal of impacted third molars. The seven steps are:

Adherence to these steps will minimize complications and maximize predictability. Stay tuned for Step #1 in next post.

Surgical Tip of the Week

#10 Impacted Third Molar Flap Design

Surgical Tip #10

The modified triangle flap is used when a large flap is needed for deep impactions or poor access. The incision begins on the external oblique ridge 1 – 1.5 cm distal and buccal to the second molar. The releasing incision includes the papilla and should be in a mesial direction resulting in a broad base flap.

It can be used in the maxilla and mandible. This flap usually requires two 4.0 sutures to close the releasing incision and flap (see arrows). The incision distal to the second molar is left open to drain and heals by secondary intention.

Surgical Tip of the Week

#9 Impacted Third Molar Flap Design

Surgical Tip #9

There are many flap designs recommended for the removal of impacted third molars. Western Surgical and Sedation’s STOW will discuss four different flap designs: “S” flap, triangle, modified triangle, and envelope. The most commonly recommended flaps are the envelope and triangle. No flap is perfect for all situations.

The triangle flap is used when a small, conservative flap is needed. For example, a soft tissue impaction. The incision begins on the external oblique ridge 1 – 1.5 cm distal to the second molar. This full thickness flap requires a releasing incision past the mucogingival junction. The incision should be in a mesial apical direction resulting in a broad based flap.

It can be used in the maxilla and mandible. This conservative flap usually requires one 5.0 suture to close the releasing incision.