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Modified distolingual splitting technique for removal of impacted mandibular third molars: Technique
Modified distolingual splitting technique for removal of impacted mandibular third molars: Technique W. Howard Davis, D.D.S.,* David A. Hochwald, D.D.S.,** Ronald M. Kaminishi, D.D.S.,*** Bell’ower, Calij
and
This first of two articles describes a modified distolingual splitting technique for removal of impactions of various classes. The second article evaluates the efficacy of the technique by reporting and comparing the incidence of postoperative sequelae with earlier research findings. In this technique, the lingual sofl tissue is not separated from the bone. In addition, the fragmented lingual bone attached to the periosteum is not removed. The procedure is best performed with the patient under sedation or general anesthesia.
T
he lingual splitting technique is one of the commonly used methods for removal of impacted mandibular third molars, and it is employed in many parts of the world. The procedure, as originally described by Fry,’ elevates the soft tissue from the lingual aspect of the mandible in the third molar region and removes the lingual plate of bone in this area. Occasionally, excessive bleeding is encountered incident to elevation of the tenacious soft tissue. In approximately 1960, to obviate the bleeding problem, one of us (W.H.D.) modified the procedure by not elevating lingual soft tissue or separating the lingual bone attached to the periosteum. This was accompanied by some modifications of the osteotomy, that is, fragmentation of the bone rather than one-piece separation of bone. TECHNIQUE
We should preface our discussion of the procedure by mentioning that any procedure in which an *Clinical Professor, University of Southern California; Associate Professor, Loma Linda University; Consultant, United States Naval Hospital and Veterans Administration Hospital, Long Beach, Calif. **Clinical Instructor, University of California, Irvine, and University of Southern California. ***Assistant Clinical Professor, University of Southern California; Assistant Professor, Loma Linda University; Consultant, Veterans Administration Hospital, Long Beach and Loma Linda, Calif. 2
Fig. 1. The sagittal arm of the soft-tissue incision is made as usual over the external oblique area of the ramus of the mandible. A 1 cm. vertical incision is made, leaving a cuff of attached tissue just distal to the second molar. The mucoperiosteal flap is reflected buccally.
osteotome is used is probably best performed with the patient under marked sedation or general anesthesia. In addition, since it is imperative that the osteotomes remain sharp throughout the procedure, it is not uncommon to use two or more osteotomes per impaction, because they may become dull when they strike the tooth. With the technique, care should be taken not to rest the shaft of the osteotome on the maxillary teeth or lips, as it may chip the incisors. Also, the osteotome should not be wedged between tooth and bone where a fracture of the mandible might result. The technique for soft-tissue elevation on the buccal area is not critical. The elevation herein described minimizes the release of the periosteum
Volume 56
Modified techniquefor removal of impactedlower third molars 3
Number1
2. Vertical osteotomy at the distal aspect of the second molar to expose the most anterior portion of the crown of the third molar.
Fig.
Fig. 5. The osteotome is again placed in the horizontal portion of the osteotomy to continue the cut distally. This is done in stepwise fashion.
3. A horizontal cut is made, proceeding distally from the bottom of the vertical osteotomy, following the height of contour of the crown, and curling over the superior surface of the crown and somewhat posterior to the cementoenamel junction. Fig.
6. The bone should be sectioned in increments from the superior surface downward to allow the operator to sense the instant the osteotome penetrates the lingual surface of the bone. The osteotome should cut in a vertical plane just distal to the apex of the root of the impacted tooth.
Fig.
as usual, and the mucoperiosteal
Fig. 4. Sectioned bone that is not attached to the periosteum is removed.
from the mandible. This probably diminishes the occurrence of secondary infection in the second molar area. In addition, when possible, a cuff of, attached gingiva is left intact on the distal aspect of the second molar. This was inspired by the work of Lewis,* who called attention to the desirability of preserving the attached gingiva. An approximately 1 cm. vertical incision is made just distal to the second molar (Fig, 1). The sagittal arm is made
flap is reflected
buccally. The principle involved in release of the bone is to fragment the bone, leaving it attached to the periosteum. Only those portions of bone that are not attached to the periosteum are removed. The path of the osteotome is guided primarily by the orientation of its bevel. Osteotomies for various classes of impaction will be described. Horizontal
impaction
To expose the anterior portion of the impaction, a vertical osteotomy is performed
at the distal aspect
of the second molar to expose the most anterior portion of the crown of the third molar (Fig. 2).
4 Davis,Hochwald,andKaminishi
Fig. 7. The osteotome is replaced horizontally almost an osteotome width above the previous cut and again driven distally until it just penetrates through lingual bone, releasing an additional fragment.
8. Osteotomies are continued in this pattern until it can be observed that the entire surface of the root is exposed along with a small amount of the lateral surface sufficient to allow a purchase point with an elevator on the buccal surface of the root.
Fig.
Fig.
9. The osteotome is then placed at an oblique angle
between the tooth and the lingual bone to release any lingual bone that has not yet split spontaneously and to ensure that the lingual bone over the entire lingual portion of the tooth is released.
Oral Surg. July, 1983
10. A straight elevator placed parallel to the root on its buccal surface will usually release the tooth. An interseptal elevator can also be used instead, care being taken not to apply excessiveforce.
Fig.
A horizontal cut is made, proceeding distally from the bottom of the vertical osteotomy, following the height of contour of the crown, and curling over the superior surface of the crown and somewhat posterior to the cementoenamel junction (Fig. 3). The bone that is not attached to the periosteum is removed (Fig. 4). The osteotome is again placed in the horizontal portion of the osteotomy and the cut proceeds distally (Fig. 5). The bone should be sectioned in increments from the superior surface downward (Fig. 6). This will allow the operator to sense the instant the osteotome penetrates the lingual surface of the bone so that the lingual soft tissue and nerve are not significantly traumatized. If the bone were not sectioned in increments from the surface downward and the osteotome were buried completely within the bone, the bone might not fragment. Consequently, the tactile sense of when the edge of the osteotome passes through the lingual plate of the bone would be lost and the lingual nerve might be significantly damaged. In addition, the osteotome should exit in a vertical plane just distal to the apex of the root of the impacted tooth. The posterosuperior fragment of bone just released remains attached to the periosteum. The osteotome is replaced horizontally almost an osteotome width below the previous cut and is again driven distally until it just penetrates through the lingual bone, releasing an additional fragment of bone (Fig. 7). Osteotomies are continued in this pattern until it can be observed that the entire superior surface of the root is exposed along with a small amount of the lateral surface (Fig. 8). The amount of bone removed on the lateral surface of the root should be sufficient to allow a purchase point with an elevator on the buccal surface of the root. The osteotome is then placed at an oblique angle between the tooth and the lingual bone to release any lingual bone that has not as yet split spontaneously
Volume 56 Number I
Modified techniquefor removalof impactedlower third molars 5
Fig. 12. The plane of cut of the osteotome on the lingual surface is again coincident with the root apex. Because of the position of the tooth, this is not as far posterior as with a horizontal impaction,
Fig. 13. Since the path of delivery of the mesioangular impaction is almost completely superior distally, adequate bone must be released posterior to the tooth to allow easy elevation. The bone on the distobuccal region of the tooth is particularly critical. It is not necessaryto release all the bone lingual to the impaction. 11. The amount of bone removed on the anterior, inferior, and buccal portions of the osteotomy is more generous in the case of a mesioangular impaction to provide a purchase point on the mesial aspect of the crown as opposed to the buccal surface of the root in a horizontal impaction. Fig.
(Fig. 9). The lingual bone is released over the entire lingual portion of the tooth. A straight elevator placed on the buccal surface of the root and almost parallel to it will usually release the tooth (Fig. 10). Often the apex of the root will be elevated first, with the tooth rotating on the crown. An interseptal elevator can also be used instead of a straight elevator; it is placed on the slightly exposed buccal surface of the root. However, because of the mechanical advantage of an interseptal elevator, care should be taken not to apply excessive force. If the tooth does not move easily, additional bone should be released until the tooth does move easily, or the crown may be separated from the root by a rotary bur.
Occasionally, the tooth will be displaced lingually rather than superiorly as it is elevated. To prevent the tooth from being lost in the lingual soft tissue, the operator should stop using the straight or interseptal elevator and instead use an angled curette to guide the tooth in the correct delivery path. Mesioangular
impaction
The pattern of the osteotomies performed for the mesioangular impaction is similar to that for the horizontal impaction, with, certain variations. A greater amount of bone is removed on the anterior, inferior, and buccal portions of the osteotomy to provide a point for the elevator on the mesial aspect of the crown (rather than a purchase area on the root, as would be the case for the horizontal impaction)
(Fig. 11).
The plane of exit of the osteotome on the lingual surface is again coincident with the root apex. However, in the case of a mesioangular impaction, this plane is not as far posterior as for a horizontal impaction (Fig. 12). In addition, because the mesioangular impaction
old Surg. July, 1983
6 Davis, Hochwald, and Kaminishi
Fig. 14. Initially, enough bone is removed anteriorly and inferiorly, as in the mesioangular impaction, to allow a purchase point for the elevator on the mesial aspect of the crown of the distoangular impaction.
will be delivered almost completely superodistally rather than superolingually, sufficient bone must be released posterior to the tooth to allow easy elevation (Fig. 13). This is particularly critical on the distobuccal region of the tooth, where the bone is usually quite dense and may unobtrusively impinge on the path of delivery. Because the path of delivery is distal and superior rather than lingual, it is not necessary to release all the bone lingual to the impaction. Distoanguiar
impaction
The same procedure is followed initially as for the mesioangular impaction, that is, removal of enough bone anteriorly and inferiorly to allow a purchase point for the elevator on the mesial aspect of the crown (Fig. 14). As the osteotomy proceeds posteriorly on the lateral side of the impaction, enough bone should be removed to allow access for the osteotome to engage the bone posterior to the impaction (Fig. 15). The release of sufficient bone posterior to the impaction is critical. As illustrated in Fig. 16, bone should be released in increments to a level at least below the cementoenamel junction. This can often be done by directing the osteotome inferiorly, lingually, and posteriorly from the buccal side.
Fig. 15. As the osteotomy is continued posteriorly, enough bone should be removed to allow access for the osteotome to engage bone posterior to the impaction where release of sufficient bone is critical.
Occasionally, access is insufficient and a curved osteotome is required to release the bone posterior to the impaction, as illustrated in Fig. 17. The straight or curved osteotome can be used to release some bone lingual to the impaction (Fig. 18). After sufficient bone has been released, the elevator is placed on the mesial surface of the crown and gently rotated. If the tooth does not move easily, the elevator can be placed on the buccal surface in a horizontal plane and again gently rotated to displace the tooth slightly toward the lingual side. Occasionally, these two placements of the elevator are repeated a time or two to release the tooth. However, one should not hesitate to release more bone posteriorly and lingually if the tooth is not delivered easily. Incompletely
formed third molars
The tooth that has only the crown formed is removed by the same technique as the distoangular impaction. Experience has demonstrated that this
Modified techniquefor removalof impactedlowerthird molars 7
Volume 56 Number 1
Fig. 17. When access is insufficient posteriorly and lingually, a curved osteotome is required to release the bone posterior to the impaction.
Fig. 18. The straight or curved osteotome can be used to release bone lingual to the impaction that has not yet split spontaneously, facilitating the ease with which the tooth can be elevated. Fig. 18. Bone posterior to the impaction should be released in increments to a level at least below the cementoenamel junction. This can be done by directing the osteotome inferiorly, lingually, and posteriorly from the buccal side.
technique allows removal of this type of impaction
rather easily. Unusual buccal placement
of teeth
When the buccal plate overlying
the impacted
tooth is very thin, a different technique to preserve
the lingual plate should be considered. A procedure using a rotating bur is probably appropriate. Fractured
roots
Fracturing
of roots is uncommon because of the
generous release of bone impinging
on the roots.
When a root does fracture, a little more buccal bone may be removed to allow good access and visibility.
If, during removal, a root tip is displaced through very thin or nonexistent lingual bone into the softtissue space, it usually can be visualized and removed through the space provided by the lingual bone or by the release of additional lingual bone. POSTREMOVAL CONSIDERATIONS
After the tooth and follicular sac are removed, any easily accessible piece of bone that is not attached to the periosteum is removed. However, it is not necessary to explore the depth of the osteotomy areas vigorously, as small loose pieces of buried bone are well tolerated. The lingual surface of bone is palpated, and if the bone is protruding, finger pressure will usually ‘mold it to provide a smooth surface. Occasionally, the bone will require manipulation or contouring from within the socket. The soft-tissue incision usually
is not sutured
closed. However, closure of the incision is dependent upon the operator’s preference.
a Davis, Hochwald,and Kaminishi REVIEW
OF IMPORTANT
POINTS
1. The periosteum is not separated from the bone on the lingual area or from the bone over the root. 2. The bone is released in segments to allow tactile control of the osteotome to prevent penetration of the osteotome into soft tissue. 3. More than one osteotome per impaction is usually used to ensure a sharp cutting edge. 4. Wedging the osteotome between tooth and bone should be avoided if this might fracture the mandible. We would like to thank Richard
Berger, D.D.S., Chris-
topher Davis, D.D.S., M.D., James Martinoff, Ph.D., and Laddavan Laohaviranit, Ph.D., for their valuable contribu-
Oral Surg. July, 1983 tions to this study. We wish particularly to thank Randy Landis, D.D.S., for his patience and expertise in providing the artwork for this article. REFERENCES
I. Fry, W. I(.: Cited by Ward, T. G.: The Split Bone Technique for Removal of Lower Third Molars, Br. Dent. .I. 101: 291-304,
1956.
2. Lewis, J. E. S.: Modified Lingual Split Technique for Extraction of Impacted Mandibular Third Molars, J. Oral Surg. 38: 578-583, Reprint
1980.
requests
to:
Dr. W. Howard Davis 14343 Bellflower Blvd. Bellflower, Calif. 90706
and
This first of two articles describes a modified distolingual splitting technique for removal of impactions of various classes. The second article evaluates the efficacy of the technique by reporting and comparing the incidence of postoperative sequelae with earlier research findings. In this technique, the lingual sofl tissue is not separated from the bone. In addition, the fragmented lingual bone attached to the periosteum is not removed. The procedure is best performed with the patient under sedation or general anesthesia.
T
he lingual splitting technique is one of the commonly used methods for removal of impacted mandibular third molars, and it is employed in many parts of the world. The procedure, as originally described by Fry,’ elevates the soft tissue from the lingual aspect of the mandible in the third molar region and removes the lingual plate of bone in this area. Occasionally, excessive bleeding is encountered incident to elevation of the tenacious soft tissue. In approximately 1960, to obviate the bleeding problem, one of us (W.H.D.) modified the procedure by not elevating lingual soft tissue or separating the lingual bone attached to the periosteum. This was accompanied by some modifications of the osteotomy, that is, fragmentation of the bone rather than one-piece separation of bone. TECHNIQUE
We should preface our discussion of the procedure by mentioning that any procedure in which an *Clinical Professor, University of Southern California; Associate Professor, Loma Linda University; Consultant, United States Naval Hospital and Veterans Administration Hospital, Long Beach, Calif. **Clinical Instructor, University of California, Irvine, and University of Southern California. ***Assistant Clinical Professor, University of Southern California; Assistant Professor, Loma Linda University; Consultant, Veterans Administration Hospital, Long Beach and Loma Linda, Calif. 2
Fig. 1. The sagittal arm of the soft-tissue incision is made as usual over the external oblique area of the ramus of the mandible. A 1 cm. vertical incision is made, leaving a cuff of attached tissue just distal to the second molar. The mucoperiosteal flap is reflected buccally.
osteotome is used is probably best performed with the patient under marked sedation or general anesthesia. In addition, since it is imperative that the osteotomes remain sharp throughout the procedure, it is not uncommon to use two or more osteotomes per impaction, because they may become dull when they strike the tooth. With the technique, care should be taken not to rest the shaft of the osteotome on the maxillary teeth or lips, as it may chip the incisors. Also, the osteotome should not be wedged between tooth and bone where a fracture of the mandible might result. The technique for soft-tissue elevation on the buccal area is not critical. The elevation herein described minimizes the release of the periosteum
Volume 56
Modified techniquefor removal of impactedlower third molars 3
Number1
2. Vertical osteotomy at the distal aspect of the second molar to expose the most anterior portion of the crown of the third molar.
Fig.
Fig. 5. The osteotome is again placed in the horizontal portion of the osteotomy to continue the cut distally. This is done in stepwise fashion.
3. A horizontal cut is made, proceeding distally from the bottom of the vertical osteotomy, following the height of contour of the crown, and curling over the superior surface of the crown and somewhat posterior to the cementoenamel junction. Fig.
6. The bone should be sectioned in increments from the superior surface downward to allow the operator to sense the instant the osteotome penetrates the lingual surface of the bone. The osteotome should cut in a vertical plane just distal to the apex of the root of the impacted tooth.
Fig.
as usual, and the mucoperiosteal
Fig. 4. Sectioned bone that is not attached to the periosteum is removed.
from the mandible. This probably diminishes the occurrence of secondary infection in the second molar area. In addition, when possible, a cuff of, attached gingiva is left intact on the distal aspect of the second molar. This was inspired by the work of Lewis,* who called attention to the desirability of preserving the attached gingiva. An approximately 1 cm. vertical incision is made just distal to the second molar (Fig, 1). The sagittal arm is made
flap is reflected
buccally. The principle involved in release of the bone is to fragment the bone, leaving it attached to the periosteum. Only those portions of bone that are not attached to the periosteum are removed. The path of the osteotome is guided primarily by the orientation of its bevel. Osteotomies for various classes of impaction will be described. Horizontal
impaction
To expose the anterior portion of the impaction, a vertical osteotomy is performed
at the distal aspect
of the second molar to expose the most anterior portion of the crown of the third molar (Fig. 2).
4 Davis,Hochwald,andKaminishi
Fig. 7. The osteotome is replaced horizontally almost an osteotome width above the previous cut and again driven distally until it just penetrates through lingual bone, releasing an additional fragment.
8. Osteotomies are continued in this pattern until it can be observed that the entire surface of the root is exposed along with a small amount of the lateral surface sufficient to allow a purchase point with an elevator on the buccal surface of the root.
Fig.
Fig.
9. The osteotome is then placed at an oblique angle
between the tooth and the lingual bone to release any lingual bone that has not yet split spontaneously and to ensure that the lingual bone over the entire lingual portion of the tooth is released.
Oral Surg. July, 1983
10. A straight elevator placed parallel to the root on its buccal surface will usually release the tooth. An interseptal elevator can also be used instead, care being taken not to apply excessiveforce.
Fig.
A horizontal cut is made, proceeding distally from the bottom of the vertical osteotomy, following the height of contour of the crown, and curling over the superior surface of the crown and somewhat posterior to the cementoenamel junction (Fig. 3). The bone that is not attached to the periosteum is removed (Fig. 4). The osteotome is again placed in the horizontal portion of the osteotomy and the cut proceeds distally (Fig. 5). The bone should be sectioned in increments from the superior surface downward (Fig. 6). This will allow the operator to sense the instant the osteotome penetrates the lingual surface of the bone so that the lingual soft tissue and nerve are not significantly traumatized. If the bone were not sectioned in increments from the surface downward and the osteotome were buried completely within the bone, the bone might not fragment. Consequently, the tactile sense of when the edge of the osteotome passes through the lingual plate of the bone would be lost and the lingual nerve might be significantly damaged. In addition, the osteotome should exit in a vertical plane just distal to the apex of the root of the impacted tooth. The posterosuperior fragment of bone just released remains attached to the periosteum. The osteotome is replaced horizontally almost an osteotome width below the previous cut and is again driven distally until it just penetrates through the lingual bone, releasing an additional fragment of bone (Fig. 7). Osteotomies are continued in this pattern until it can be observed that the entire superior surface of the root is exposed along with a small amount of the lateral surface (Fig. 8). The amount of bone removed on the lateral surface of the root should be sufficient to allow a purchase point with an elevator on the buccal surface of the root. The osteotome is then placed at an oblique angle between the tooth and the lingual bone to release any lingual bone that has not as yet split spontaneously
Volume 56 Number I
Modified techniquefor removalof impactedlower third molars 5
Fig. 12. The plane of cut of the osteotome on the lingual surface is again coincident with the root apex. Because of the position of the tooth, this is not as far posterior as with a horizontal impaction,
Fig. 13. Since the path of delivery of the mesioangular impaction is almost completely superior distally, adequate bone must be released posterior to the tooth to allow easy elevation. The bone on the distobuccal region of the tooth is particularly critical. It is not necessaryto release all the bone lingual to the impaction. 11. The amount of bone removed on the anterior, inferior, and buccal portions of the osteotomy is more generous in the case of a mesioangular impaction to provide a purchase point on the mesial aspect of the crown as opposed to the buccal surface of the root in a horizontal impaction. Fig.
(Fig. 9). The lingual bone is released over the entire lingual portion of the tooth. A straight elevator placed on the buccal surface of the root and almost parallel to it will usually release the tooth (Fig. 10). Often the apex of the root will be elevated first, with the tooth rotating on the crown. An interseptal elevator can also be used instead of a straight elevator; it is placed on the slightly exposed buccal surface of the root. However, because of the mechanical advantage of an interseptal elevator, care should be taken not to apply excessive force. If the tooth does not move easily, additional bone should be released until the tooth does move easily, or the crown may be separated from the root by a rotary bur.
Occasionally, the tooth will be displaced lingually rather than superiorly as it is elevated. To prevent the tooth from being lost in the lingual soft tissue, the operator should stop using the straight or interseptal elevator and instead use an angled curette to guide the tooth in the correct delivery path. Mesioangular
impaction
The pattern of the osteotomies performed for the mesioangular impaction is similar to that for the horizontal impaction, with, certain variations. A greater amount of bone is removed on the anterior, inferior, and buccal portions of the osteotomy to provide a point for the elevator on the mesial aspect of the crown (rather than a purchase area on the root, as would be the case for the horizontal impaction)
(Fig. 11).
The plane of exit of the osteotome on the lingual surface is again coincident with the root apex. However, in the case of a mesioangular impaction, this plane is not as far posterior as for a horizontal impaction (Fig. 12). In addition, because the mesioangular impaction
old Surg. July, 1983
6 Davis, Hochwald, and Kaminishi
Fig. 14. Initially, enough bone is removed anteriorly and inferiorly, as in the mesioangular impaction, to allow a purchase point for the elevator on the mesial aspect of the crown of the distoangular impaction.
will be delivered almost completely superodistally rather than superolingually, sufficient bone must be released posterior to the tooth to allow easy elevation (Fig. 13). This is particularly critical on the distobuccal region of the tooth, where the bone is usually quite dense and may unobtrusively impinge on the path of delivery. Because the path of delivery is distal and superior rather than lingual, it is not necessary to release all the bone lingual to the impaction. Distoanguiar
impaction
The same procedure is followed initially as for the mesioangular impaction, that is, removal of enough bone anteriorly and inferiorly to allow a purchase point for the elevator on the mesial aspect of the crown (Fig. 14). As the osteotomy proceeds posteriorly on the lateral side of the impaction, enough bone should be removed to allow access for the osteotome to engage the bone posterior to the impaction (Fig. 15). The release of sufficient bone posterior to the impaction is critical. As illustrated in Fig. 16, bone should be released in increments to a level at least below the cementoenamel junction. This can often be done by directing the osteotome inferiorly, lingually, and posteriorly from the buccal side.
Fig. 15. As the osteotomy is continued posteriorly, enough bone should be removed to allow access for the osteotome to engage bone posterior to the impaction where release of sufficient bone is critical.
Occasionally, access is insufficient and a curved osteotome is required to release the bone posterior to the impaction, as illustrated in Fig. 17. The straight or curved osteotome can be used to release some bone lingual to the impaction (Fig. 18). After sufficient bone has been released, the elevator is placed on the mesial surface of the crown and gently rotated. If the tooth does not move easily, the elevator can be placed on the buccal surface in a horizontal plane and again gently rotated to displace the tooth slightly toward the lingual side. Occasionally, these two placements of the elevator are repeated a time or two to release the tooth. However, one should not hesitate to release more bone posteriorly and lingually if the tooth is not delivered easily. Incompletely
formed third molars
The tooth that has only the crown formed is removed by the same technique as the distoangular impaction. Experience has demonstrated that this
Modified techniquefor removalof impactedlowerthird molars 7
Volume 56 Number 1
Fig. 17. When access is insufficient posteriorly and lingually, a curved osteotome is required to release the bone posterior to the impaction.
Fig. 18. The straight or curved osteotome can be used to release bone lingual to the impaction that has not yet split spontaneously, facilitating the ease with which the tooth can be elevated. Fig. 18. Bone posterior to the impaction should be released in increments to a level at least below the cementoenamel junction. This can be done by directing the osteotome inferiorly, lingually, and posteriorly from the buccal side.
technique allows removal of this type of impaction
rather easily. Unusual buccal placement
of teeth
When the buccal plate overlying
the impacted
tooth is very thin, a different technique to preserve
the lingual plate should be considered. A procedure using a rotating bur is probably appropriate. Fractured
roots
Fracturing
of roots is uncommon because of the
generous release of bone impinging
on the roots.
When a root does fracture, a little more buccal bone may be removed to allow good access and visibility.
If, during removal, a root tip is displaced through very thin or nonexistent lingual bone into the softtissue space, it usually can be visualized and removed through the space provided by the lingual bone or by the release of additional lingual bone. POSTREMOVAL CONSIDERATIONS
After the tooth and follicular sac are removed, any easily accessible piece of bone that is not attached to the periosteum is removed. However, it is not necessary to explore the depth of the osteotomy areas vigorously, as small loose pieces of buried bone are well tolerated. The lingual surface of bone is palpated, and if the bone is protruding, finger pressure will usually ‘mold it to provide a smooth surface. Occasionally, the bone will require manipulation or contouring from within the socket. The soft-tissue incision usually
is not sutured
closed. However, closure of the incision is dependent upon the operator’s preference.
a Davis, Hochwald,and Kaminishi REVIEW
OF IMPORTANT
POINTS
1. The periosteum is not separated from the bone on the lingual area or from the bone over the root. 2. The bone is released in segments to allow tactile control of the osteotome to prevent penetration of the osteotome into soft tissue. 3. More than one osteotome per impaction is usually used to ensure a sharp cutting edge. 4. Wedging the osteotome between tooth and bone should be avoided if this might fracture the mandible. We would like to thank Richard
Berger, D.D.S., Chris-
topher Davis, D.D.S., M.D., James Martinoff, Ph.D., and Laddavan Laohaviranit, Ph.D., for their valuable contribu-
Oral Surg. July, 1983 tions to this study. We wish particularly to thank Randy Landis, D.D.S., for his patience and expertise in providing the artwork for this article. REFERENCES
I. Fry, W. I(.: Cited by Ward, T. G.: The Split Bone Technique for Removal of Lower Third Molars, Br. Dent. .I. 101: 291-304,
1956.
2. Lewis, J. E. S.: Modified Lingual Split Technique for Extraction of Impacted Mandibular Third Molars, J. Oral Surg. 38: 578-583, Reprint
1980.
requests
to:
Dr. W. Howard Davis 14343 Bellflower Blvd. Bellflower, Calif. 90706