003: Removing Impacted Upper Third Molars

In Episode 3, Dr. Kirk answers a question he recently received from a dental colleague regarding removing impacted upper third molars. He provides a step-by-step walkthrough of his technique for these challenging extractions.

Case Background

Russell describes the specific scenario:

• The upper third molars #1 and #16 are mesially angulated with the occlusal surface touching the distal of the adjacent second molars.
• The roots are positioned just below the maxillary sinus floor.
• The teeth are fully covered by bone on the buccal aspect.

Russell notes this case presents multiple risks - root proximity to the sinus, plus potential damage to the second molars given the tight contact. He details his systematic approach to safely removing these teeth.

Soft Tissue Flap Design

After anesthetizing the patient, Russell creates an envelope flap:

• Crestal  incision from the tuberosity around the neck of #2 and releasing the interdental papilla between the first and second molar.
• Reflect a full-thickness flap with a periosteal elevator (#9 molt).

With the flap reflected, the bone fully obscures visualization of the impacted third molars. Russell must remove the overlying bone to access the teeth.

Removing Buccal Bone

To remove the buccal bone and create a window to the teeth, Russell has two options:

1. Hall handpiece with a large round bur
2. Hand instrumentation

In many cases, the bone is thin enough that hand instruments suffice without a handpiece. Russell's preferred instrument is the Potts elevator. The curved beak and hook allow precise bone removal in the tight space.

If the Potts won't fit between the teeth, a curved Cryer elevator can also remove bone with its sharp point and thin profile.

Once Russell creates a window through the bone, he can visualize and remove soft tissue follicles to fully expose the third molar crown.

Tooth Removal

With the third molar visible, Russell takes great care in selecting his elevator for extraction to avoid complications:

• He avoids straight elevators like a #301, as this risks excessive apical force toward the sinus.
• Instead, he uses the Potts or Cryer to gently tease the tooth out to the buccal. This delivers the tooth away from the sinus and second molar.
• Finding the space between molars is ideal to get purchase on the third molar only. But the tight proximity can risk damaging the second molar during delivery if not cautious.

Russell reiterates that recognizing when to pick up a handpiece is critical. He does not hesitate to use it when hand instrumentation alone won't provide efficient access and delivery.

In summary, Russell safely removes mesially angled upper third molars by:

1. Conservative buccal window using hand instruments.
2. Meticulous elevator selection to deliver the tooth buccally away from vital structures.
3. Judicious handpiece use when warranted for access and delivery.

This systematic approach helps avoid potential complications like sinus involvement or adjacent tooth damage when extracting challenging upper thirds.

Conclusion

Russell welcomes any questions, suggestions, or alternate techniques listeners have for accessing and removing difficult upper third molars like this case. Email him at [email protected] to continue the conversation and exchange ideas. He reviews emails within 48 hours.

Russell thanks listeners for joining him on another episode. He hopes these tutorials provide helpful tips for tackling complex surgery in your practice. Russell looks forward to delivering further insights and discussions on future episodes.