Odontologia

Oral Maxillofacial Surg Clin N Am 19 (2007) 23–43

General Technique of Third Molar Removal
Sam E. Farish, DMDa,b,*,
Gary F. Bouloux, MD, BDS, MDSc, FRACDS, FRACDS(OMS)b
a
Division of Oral and Maxillofacial Surgery, Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA
Division of Oral and Maxillofacial Surgery, Emory University School of Medicine, 1365B Clifton Road NE,
Suite 2300-B,Atlanta, GA 30322, USA

b

The most commonly performed surgical procedure in most oral and maxillofacial surgery
practices is the removal of impacted third molars.
Extensive training, skill, and experience allow this
procedure to be performed in an atraumatic
fashion with local anesthesia, sedation, or general
anesthesia. The decision to remove symptomatic
third molars is not usuallydifficult, but the
decision to remove asymptomatic third molars is
sometimes less clear and requires clinical experience. A wide body of literature (discussed elsewhere in this issue) attempts to establish clinical
practice guidelines for dealing with impacted teeth
[1]. Data are beginning to accumulate from third
molar studies, which hopefully will provide surgeons and their patients withevidence-based
guidelines regarding elective third molar surgery
[2–6]. The association of periodontal pathology
and occlusal caries with asymptomatic third molars has been studied previously. Twenty-five percent of patients with asymptomatic third molars
were found to have increased periodontal probing
depths and attachment loss, increased periodontal
pathogen colonization, and increased levels ofinflammatory mediators [7–9]. Shugars and colleagues [10] examined a group of patients with
at least one fully erupted third molar and found
that 28% had caries in at least one third molar
tooth. It is currently recommended that the indications for elective therapeutic third molar removal be based on good clinical science.
Accordingly, patients and the community at large
should be adequatelyinformed [11].

* Corresponding author.
E-mail address: sefaris@emory.edu (S.E. Farish).

Once the decision is made to remove impacted
third molars, a classification system based on
clinical and radiographic findings becomes a tool
for predicting the difficulty of removal. Accessibility significantly influences the degree of difficulty of removal of a third molar. The ease with
which the tooth can beremoved is also influenced
by the degree of surgical exposure, the ability to
create a pathway for tooth delivery, and the
ability to gain purchase (natural or surgically
prepared) on the tooth. A classification system is
a useful tool to categorize the degree of impaction
and plan a surgical approach that facilitates
removal and minimizes morbidity.
Classification systems of impacted teethMost classifications of third molar impactions
are based on the analysis of periapicaldor more
commonly, panoramicdradiographs. The initial
determination that should be made is the angulation of the third molar to the long axis of the
second molar. The mesioangular impaction, which
accounts for approximately 43% of all mandibular
impacted third molars, is one in which the third
molar ismesially tilted toward the second molar
[12]. Such impactions are generally considered the
least difficult to remove (Fig. 1A).
An exaggerated mesial inclination results in
a horizontal impaction (Fig. 1B), which is considered more difficult to remove than a mesioangular
impaction and accounts for approximately 3% of
all mandibular impactions [12]. The vertical impaction, in which the long axis ofthe impacted
tooth runs parallel to the long axis of the second
molar, is seen in approximately 38% of all mandibular impactions (Fig. 1C) [12]. It is considered

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FARISH & BOULOUX

Fig. 1. Angulation classification system for impacted...