Extraction Tips for an Impacted Lower Molar

Pre-op Assessment

• Classify the impaction using Winter's classification (mesioangular, horizontal, vertical, distoangular). Mesioangular is the most common and generally easier; horizontal is the most difficult.
• Assess root morphology — fused/conical roots are easier; divergent or hooked roots increase difficulty.
• Note proximity to the inferior alveolar nerve (IAN) — if the roots appear to overlap the mandibular canal on 2D X-ray, consider a CBCT before proceeding.
• Pell & Gregory classification assesses depth and ramus relationship — deeper Class C and ramus-adjacent Class III cases are more surgically demanding.

Surgical Technique

1. Incision & Flap Design
   • Envelope flap: sulcular incision along the second molar extending distally with a releasing incision anteriorly.
   • Adequate mucoperiosteal reflection is critical — don't cut corners here.
2. Bone Removal
   • Use a surgical handpiece with copious saline irrigation.
   • Remove bone on the buccal and distal aspects to expose the CEJ and give instrument purchase.
   • Avoid excessive lingual bone removal (lingual nerve risk).
3. Tooth Sectioning (often necessary for impacted teeth)
   • Section the crown from the root(s) for mesioangular/horizontal impactions — removes the "block" against the second molar.
   • For multi-rooted teeth with divergent roots, section roots individually.
4. Delivery
   • Use luxators first (fine, sharp blade) to sever the PDL before elevators.
   • Apply elevator (Warwick James, Cryer) with controlled force using bone as fulcrum — never the adjacent tooth.
   • Wheel and axle motion rather than levering.
5. Socket Management
   • Debride the follicle, irrigate with saline.
   • Smooth sharp bony edges with a bone file or bur.
   • Primary closure vs. secondary healing — both acceptable, but primary closure reduces dry socket risk.

Key Pearls

Post-op Instructions for Patient

• Bite on gauze for 30–45 min; replace if soaking.
• Soft diet, no smoking, no straws for 72 hours minimum.
• NSAIDs (ibuprofen) ± paracetamol; prescribe antibiotics only if infection present pre-op or immunocompromised patient.
• Return if pain worsens after day 3 (classic dry socket presentation).