Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7

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Removal of impacted mandibular third molars using an inward

fragmentation technique (IFT) e Method and rst results
Wilfried Engelke a, *, Vctor Beltrn b, Mario Cantn b, c, Eun-Jin Choi a, Pablo Navarro d,
Ramn Fuentes b
a
Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. Dr. Henning Schliephake), School of Dentistry, Georg-August-University, School of Dentistry,
Gttingen, Germany
b
Department of Adult Integral Dentistry (Head: Prof. Dr. Ramn Fuentes), Faculty of Dentistry, Universidad de La Frontera, Temuco, Chile
c
Doctoral Program in Morphological Sciences, Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
d
Department of Mathematics and Statistics, Universidad de La Frontera, Temuco, Chile

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: Conventional surgical extraction of impacted mandibular third molars (M3M) requires a lateral
Paper received 5 January 2013 ap reection in conjunction with lateral bone removal for outward mobilization of the tooth. The aim of
Accepted 10 May 2013 this report is to outline a novel inward fragmentation technique (IFT) in conjunction with an occlusal
miniap approach to reduce the amount of bone removal to a minimum.
Keywords: Patients and methods: Seventeen consecutive patients (7 men and 10 women; mean age 24.4 years, range
Mandibular third molars
18e36 years) required the extraction of 21-impacted M3M with a close relationship to the inferior
Endoscopes
alveolar nerve (IAN).
Microsurgical removal
Occlusal approach
Occlusal miniaps were used and only occlusal bone removal was performed to expose the M3M
under endoscopic vision. A central space-making cavity was created followed by inward fragmentation
and mobilization of the crown and subsequent root removal through the space created.
Results: 20 of 21 sites healed uneventfully, one late infection was observed, no permanent neurosensory
lesion occurred. The mean preoperative buccal bone height was 15.5 (11e18) mm and the postoperative
buccal bone height 14.7 (11e17) mm. On the 2nd day, the mean swelling level was 1.38 (0e2) on a 4
point scale, the pain level was 2.30 (0e5) on a 10 cm VAS, mean pain duration was 2.04 days.
Conclusion: An inward fragmentation technique allows preservation of >90% of the buccal bone height
adjacent to mandibular third molars and may reduce postoperative morbidity without raising the risk of
IAN lesions.
2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.

1. Introduction
Third molars are present in 90% of the population, with 33%
having at least one impacted third molar (Scherstn et al., 1989)
thus extraction is a relatively common procedure. Extraction in-
volves the manipulation of both soft and hard tissues, so the patient
usually experiences pain, oedema, and trismus in the immediate
postoperative period. Conventional surgical extraction of impacted
mandibular third molars (M3M) requires lateral bone removal
(Thoma, 1969) to allow an outwardly directed mobilization of the
tooth. In cases of deep impaction this technique may be associated
* Corresponding author. Department of Maxillofacial Surgery, University of Gt-
tingen, Robert-Koch-Str. 40, 37099 Gttingen, Germany.
E-mail address: wengelke@med.uni-goettingen.de (W. Engelke).
with the risk of mandibular angle fracture (Iida et al., 2005). A
mucoperiosteal ap exposing the buccal bone of the M3M and of
the adjacent second molar is most commonly used. Research has
shown that such exposure, even without bone removal or extrac-
tion, leads to bone resorption (Bergstrm and Henrikson, 1974;
Wood et al., 1972; Yaffe et al., 1994, 1997).
Morbidity following third molar surgery is currently being dis-
cussed with the aim of reducing intra- as well as postoperative
complications to a minimum (Praveen et al., 2007). Recently a shift
in paradigms can be observed towards atraumatic techniques in
third molar surgery, such as odontosection (Gen and Vasconcelos,
2008; Arakeri and Arali, 2010; Ngeow, 2009) partial removal of
M3M crowns (Landi et al., 2010) and use of piezoelectric devices
(Rullo et al. 2013). Flapless third molar surgery has been shown in
horizontally dislocated teeth (Kim et al. 2011) which were partially
erupted.

1010-5182/$ e see front matter 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jcms.2013.05.003

Please cite this article in press as: Engelke W, et al., Removal of impacted mandibular third molars using an inward fragmentation technique
(IFT) e Method and rst results, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.05.003
2 W. Engelke et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7

Despite this there is no signicant discussion in the literature on inclusion in the study, in particular with regard to the time needed
how to perform atraumatic procedures in particular for complex for the surgery and the pros and cons of the conventional vs. inward
situations and fully impacted M3M in close relationship with the fragmentation technique.
IAN.
In implant surgery, apless techniques have become increas- 2.1. Surgical procedure
ingly important. There are signicant advantages, which make
apless surgery attractive for both surgeon and patient (Choi and Surgery was performed under local anaesthesia (4% Articaine
Engelke, 2009): Minimal trauma to the soft tissue reduces scar with 1:100,000 epinephrine. The surgeon worked in a 12 oclock
formation, preservation of osseous vascularization via the perios- position observing the site on a video screen via a Storz Hopkins
teum and reduced patient discomfort. As an alternative to punch support endoscope (30
view angle, 2.7 mm or 4 mm diameter, Karl
techniques, occlusal mini-incisions have been used in implant Storz, Tuttlingen, Germany) (Fig. 1). The support endoscope was
surgery (Choi et al., 2010). For exodontic surgery in contrast, placed posterior to the surgical site. Surgery is shown step by step
occlusal miniaps have not been recommended previously due to in Figs. 2e6.
inadequate visualization of the surgical site. A sulcus incision was performed near the mesiobuccal edge of
Endoscopically assisted procedures are currently being intro- the second molar to its distal surface. The incision line continued
duced in maxillofacial traumatology (Mensink et al., 2009) and sagittally towards the mandibular ramus along the extension of the
orthognathic surgery (Gonzles-Garca, 2012; Mommaerts, 2010; M3M. Soft tissue reection was carried out over the crest only to
Rohner et al., 2001). In oral surgery endoscopes have contributed to allow the insertion of the support endoscope at the distal aspect of
reduction of the trauma of augmentation procedures, in particular the site; no reection of the periosteum was performed on the
sinus oor elevation (Engelke and Capobianco, 2005; Schleier et al., lateral and lingual aspects of the M3M region (Fig. 2A).
2008). Iwai et al. (2012) used endoscopes to remove a displaced Crestal exposure of the M3M was performed using a round bur
maxillary third molar via the extraction socket. In a study to with a low speed handpiece and sterile saline irrigation. Exposure
determine the indications, efcacy, and advantages of the support
immersion endoscopic method for extraction socket assessment,
Juodzbalys et al. (2008) stated Support immersion endoscopy can
be used as an adjunct tool in assessing extraction socket
morphology and bone conditions without ap elevation.
Using support immersion endoscopy (Engelke, 2002) it has
become possible to reduce the osseous trauma in implant surgery.
The use of rigid endoscopes has been also reported for visualization
of anatomical structures in the oral cavity in various indications
(Beltrn et al., 2012). The improvement of visualization has created
the basis for a change towards less invasive removal of M3M, which
formerly was impossible to achieve due to limited insight into the
intraalveolar site (Engelke et al., 2011). The aim of the present
report is to present a novel inward fragmentation technique via an Fig. 1. Storz Hopkins support endoscope.
occlusal miniap approach used to reduce the surgical trauma
caused by the conventional bone removal access and outward
mobilization of the impacted M3M in complex anatomical
situations.

2. Materials and methods

21 consecutive mandibular third molars (9 right, 12 left side)

were included in a prospective study on 17 medically healthy pa-
tients (10 women and 7 men) aged 18e36 years (mean age 24.4).
The patients did not have any illness or take any medication that
could inuence the surgical procedure or postoperative wound
healing. Only single side extractions were included. Patients had
been referred to the Department of Maxillofacial Surgery at Uni-
versittsmedizin Gttingen, Germany and to the Centre of Oral
Microsurgery at the Faculty of Dentistry of the Universidad de La
Frontera, Temuco-Chile. This study was approved by the research
ethical committees of Gttingen University and Universidad de La
Frontera. Mandibular third molar removal was prompted by pro-
phylactic and orthodontic considerations. The criteria for inclusion
in the present study were M3M completely or partially impacted
and completely covered by soft tissue with the absence of acute
inammatory symptoms. Only M3M with a close relationship
(apical distance below 1 mm on cone-beam computed tomography
(CBCT) or orthopantomogram (OPG), respectively) to the mandib-
ular canal were included. Thus, all cases belonged to a high-risk
Fig. 2. Schematic diagram of endoscopic odontosection, third molar removal by sup-
group for postoperative neurosensory disturbances. All teeth port endoscopic assistance. Preoperative position of the molar and its close relation
were removed under local anaesthesia. Before the surgical proce- with the inferior alveolar nerve. A, sulcular incision. B, Crestal exposure of the third
dure, all patients accepted and signed the informed consent for molar. SE e Support endoscopy.

Please cite this article in press as: Engelke W, et al., Removal of impacted mandibular third molars using an inward fragmentation technique
(IFT) e Method and rst results, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.05.003
 W. Engelke et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7 3

Fig. 3. A, Trepanation oriented in a transverse direction using a Lindemann straight

bur. SE e Support endoscopy, LB e Lindemann straight bur. B, Internal reduction of the Fig. 5. A, Mobilization of the distal root with a round bur under direct vision.
crown. RB e Round bur. SE e Support endoscopy, SRB e Straight round bur. B. Distal root removed with
elevator. E e Elevator.

Fig. 4. A, Crown reduction under direct vision using large a diamond bur. SE e Support
endoscopy, DRB e Diamond round bur. B, Removal of the mesial part of the crown.
E e Elevator.
Fig. 6. A, Final control of the alveolus under endoscopic vision for root remnants and
determination of the bone level using a periodontal probe. SE e Support endoscopy,
PP e Periodontal probe. B, Closure with 2 interrupted sutures for primary healing.

was restricted to the occlusal aspect only, independently of the

angulation and degree of impaction of the tooth (Fig. 2B).
Trepanation of the M3M was performed using Lindemann
straight burs in order to provide access to the pulp. The trepanation
was oriented in a transverse direction intending to create an in-
ternal space-making cavity, which may vary depending on the in-
dividual situation. The transverse cut was performed in the buccal
and central parts of the crown with the exception of the lingual
aspect (Fig. 3A). Thus, using a round bur with a low speed
handpiece and sterile saline irrigation, the pulp was opened widely
towards the level of the furcation in order to obtain a space for
inward fragmentation of the crown. At the same time an overview
of the internal tooth anatomy and the furcation area was obtained
(Fig. 3B).
Crown removal was performed by inward fragmentation. The
use of large diamond round burs in the furcation area is essential to
ensure complete separation of the roots before inward

Please cite this article in press as: Engelke W, et al., Removal of impacted mandibular third molars using an inward fragmentation technique
(IFT) e Method and rst results, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.05.003
4 W. Engelke et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7
fragmentation while avoiding lingual nerve damage (Fig. 4A).
Following removal of the distal crown by inward fracturing with an
elevator, the mesial part is luxated, also inwardly, (Fig. 4B) and
subsequently removed. In the majority of cases the adjacent root
can be removed together with the mesial crown fragment. The
space created by removal of the crown fragments opens the sight
towards the furcation area and remaining roots.
After removal of the crown, the remaining roots were identied
(Fig. 5). The majority of roots could be removed with elevators. In
case of ankylosis the roots were removed with round burs under
direct vision. In critical zones at the lingual aspect of the mandible
and adjacent to the alveolar nerve, diamond burs mounted on a low
speed handpiece were used.
Final examination of the alveolus was performed under endo-
scopic vision for root remnants and determination of the bone level
using a periodontal probe. Probing was performed along the axis of
the tooth to the buccal side with reference to the most apical
extension of the alveolus (Fig. 6A). Wound closure was performed
depending on the preoperative situation. The socket was rinsed
with physiological saline, and the incision was closed (Fig. 6B) with
2 interrupted sutures (silk 4-0).
All patients received paracetamol 500 mg 4 times daily, addi-
tionally an antibiotic treatment (amoxicillin 750 mg 3 times daily)
was administered for 4 days.
2.2. Evaluation
Primary outcome parameters were: Preoperative bone height
(POBH) and Intraoperative bone height (IOBH) following extraction,
duration of surgery, swelling and pain level at 2 days, pain duration
and postoperative complications. The POBH was assessed from
panoramic images (Fig. 7). A tangent (CT) was drawn along the
occlusal crown surface, and the longitudinal axis (LA) of the M3M
was constructed with reference to the most apical root tip (A). Bone
height (BH) was assessed along the longitudinal axis as the distance
of the apical point (A) to the intersection with the upper alveolar
bone contour (BC).
The IOBH (Fig. 6A) was evaluated following tooth removal with a
periodontal probe placed along the longitudinal axis. The distance
of the apical point (A) to the upper alveolar bone contour (BC) was
measured.
Clinical controls took place at 2 and 7 days after surgery. At 2
days, the pain level was determined on a 10 cm visual analogue
scale (VAS), and the degree of swelling was ranked on a scale from
0 to 3 (0: No swelling; 1: Light swelling (just visible); 2: Moderate
(local) swelling and 3: Severe (extended) swelling. At 7 days after
surgery, the patients were asked how many days their pain had
Fig. 7. Evaluation of the buccal bone height (BH), as distance of the apical point (A) of
the alveolus and the buccal bone contour (BC) along the longitudinal axis (LA) of the
inferior third molar.
Please cite this article in press as: Engelke W, et al., Removal of impacted mandibular third molars using an inward fragmentation technique
(IFT) e Method and rst results, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.05.003
persisted. One year following surgery, the patients les were
revised for postoperative complications. To minimize the risk of
bias a surgeon who had not operated on the patients conducted the
postoperative examinations.
3. Results
During surgery, no intraoperative complications, such as
bleeding, root fragment displacement, visible IAN trauma, lesions
of hard and soft tissues, were observed. All surgical interventions
were performed without the need to raise lateral aps. A maximum
vertical bone loss of 2 mm was observed. The mean duration of
surgery was 27.3 (14e44) min. In Fig. 8, a typical case is shown
which required a CBCT pre- and postoperatively due to a complex
root anatomy. In the preoperative CBCT the root tip is located at the
basal compact bone with close contact to the IAN, the M3M is
mesially angulated, the crown is in alignment with the occlusal
bone level exhibiting a reduced diameter of the lingual wall.
Following removal using IFT, the CBCT taken immediately after
surgery showed the exclusively occlusal approach without reduc-
tion of the lateral or lingual bone walls with maintenance of the
entire alveolar and perialveolar bone architecture. No root or crown
remnants were present; the duration of surgery was 21 min.
In case of direct exposure of the inferior alveolar nerve, the
endoscope served as a tool to document the IAN integrity. In Fig. 9
the exposed IAN is demonstrated via an occlusal endoscopic view
using. The support endoscope was placed at the distal margin of the
site allowing a direct magnied view of the exposed nerve with
intact alveolar walls.
The bone level analysis is presented in Table 1. Comparison of
bone levels before and following removal revealed a signicant
mean bone loss of 0.8 mm (p < 0.01). However 94.8% of the bone
previously adjacent to M3M was preserved using IFT. The post-
operative symptoms pertaining to pain and swelling are light to
moderate as summarized in Table 2.
With respect to the postoperative swelling at day 2 as the main
postoperative symptom, there was a signicant correlation be-
tween the second day pain score, the duration of surgery and the
patients age. No correlation was found concerning bone height and
duration of pain (Table 3).
20 of 21 surgical sites healed uneventfully; one late infection
was seen and 2 temporary incomplete neurosensory distur-
bances, which recovered within 6 and 10 weeks after surgery,
respectively were seen. No permanent neurosensory disturbances
were noted.
4. Discussion
Modern dentistry is based on conservative thinking (Patel et al.,
2010); taking into consideration that the reason for lateral and
distal bone removal for M3M extraction is to allow an outward
directed mobilization, a modern technique should provide a
technical solution which preservation of the mandibular archi-
tecture without the removal of bone necessary for outward
mobilization. As a goal an acceptable amount of bone loss might be
dened as that which does not exceed the area occupied for
normal eruption. This may be achieved relying on the following
principles:
1) Optimized magnied visualization of the surgical site at any
time of the procedure in order to avoid lateral ap elevation
and laterodistal bone removal.
2) Systematic and precise space making procedure in order to
provide stepwise fragmentation and inward mobilization of the
tooth.
 W. Engelke et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7 5

Fig. 8. Cone-beam computed tomographic cross-sectional slice of the third molar area. A, In presurgical slices the close proximity of the roots and the inferior alveolar canal are
clearly visible. B, In postsurgical slices the third molar was completely removed by the endoscopic occlusal approach, resulting in maintenance of the buccal wall.

Table 1
Bone height measurement. T-test evaluation of POBH vs. IOBH revealed signicant
difference (p < 0.01).

n 21 POBH (mm) IOBH (mm)

Mean 15.5 14.7

Min. 11.5 12.0
Max. 18 17.0
Std. dev. 1.47 1.42

Table 2
Postoperative symptoms in 17 patients.

n 21 Swelling level (0e3) Pain level (0e10) Pain duration (days)

Mean 1.38 2.30 2.04

Median 1 2 2
Min. 0 0 0
Max. 2 4 7

It is well known in constructional engineering that a controlled

Fig. 9. Intraoperative nerve exposure: visualization under support endoscopy (Arrow
shows the exposure of inferior alveolar nerve).
demolition of buildings may be achieved by an implosion tech-
nique, thus collateral damage of adjacent buildings in the imme-
diate neighbourhood can be avoided. The implosion technique
makes use of the fact, that the hollow construction of buildings
provides sufcient void space to receive the collapsing structures.

Please cite this article in press as: Engelke W, et al., Removal of impacted mandibular third molars using an inward fragmentation technique
(IFT) e Method and rst results, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.05.003
6 W. Engelke et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7
Table 3
Correlation of postoperative symptoms in 17 patients.
Symptom Associated variable
Swelling level 2nd day Pain level 2nd day
Swelling level 2nd day Bone height postoperative
Swelling level 2nd day Duration of surgery
Swelling level 2nd day Age
Swelling level 2nd day Pain duration
a
ANOVA, level of signicance p < 0.05.
The application of a similar principle for the removal of teeth
therefore requires the formation of an internal cavity before
applying the implosion concept. This cannot be achieved by
odontosection alone. Inward directed mobilization of a M3M only
can be achieved, if the internal space is created sufciently large to
receive the crown fragments as well as the roots following sys-
tematic odontosection under direct observation.
Minimally invasive apless removal of M3M (Kim et al., 2011)
is limited to partially impacted and at least partially erupted cases.
Depending on the angulation, position and anatomical factors of
the M3M, apless removal implies odontosection and extraction
with elevators or forceps without bone removal. Unerupted M3M
with various degrees of complex impaction exhibiting bone levels
above the equator of the crown do not meet the criteria for apless
removal. For these cases in particular, IFT offers a novel approach
to conserve the adjacent bone and soft tissues. If the crown is
impacted below the occlusal bone level, the dimension of the
occlusal bony access cavity lies within the range of the crown
diameter. The advantages for the patients are obvious: Reduction of
the fracture risk, less traumatizing ap design and no detachment
of masticatory muscles. A high fracture risk is given in particular, if a
stable buccal wall during conventional removal is signicantly
reduced down to the basal bone level leaving only a delicate lingual
structure to guarantee mandibular stability (see Fig. 8). As
demonstrated in the case example, the occlusal approach provides
intact bone structures before and following removal to prevent any
risk of intra- or postoperative instability of the mandible.
Support endoscopy (Beltrn et al., 2012) is a key technique to
allow a direct observation of the internal anatomic structures of
alveolus. In this study, we used the technique in a standardized
manner and without additional application of a microscope as in a
previous report (Engelke et al., 2011). This was due to the obser-
vation that those complex cases, such as root fracture, with difcult
access cannot be treated sufciently with microscopes only. Sup-
port endoscopy as a magnifying optical tool provides adequate and
direct insight for this purpose (Beltrn et al., 2011; Cantn et al.,
2012). This is in agreement with various reports on endodontic
surgery (von Arx et al., 2002; Taschieri et al., 2008a). Taschieri et al.
(2008b) stated: The best possible intraoperative visualization is
necessary to maintain a high level of success. The support endo-
scope provides an excellent overview of the internal aspects of the
M3M from a distal perspective (Fuentes et al., 2012). Furthermore it
allows the surgical eld to be viewed at various angles and dis-
tances without losing depth of the eld and focus. Thus, a precise
odontosection and removal of tooth fragments is supported down
to the level of the root tip without the need for lateral access. In
particular the use of endoscopes seems to be very helpful when
removing root fragments attached to the osseous walls of the
mandibular canal. As a means of safety, at the lingual aspect of the
alveolus, as well as apically, in close relationship with the
mandibular canal we recommend the use of diamond round burs or
piezo-surgical instruments.
There is increasing evidence, that the use of endoscopes en-
hances surgical procedures, in particular in orthodontic surgery
(Gonzles-Garca, 2012; Mommaerts, 2010; Rohner et al., 2001). It
Please cite this article in press as: Engelke W, et al., Removal of impacted mandibular third molars using an inward fragmentation technique
(IFT) e Method and rst results, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2013.05.003
may be speculated that the use of support sheathes as, demon-
strated in our report, may also facilitate the observation of details of
p the ramus and the Le Fort 1 osteotomies and simultaneously may
0.013a
serve as a tissue-separating tool. IFT technique furthermore may be
0.14 applied in some other alveolar bone sites (Hrzeler et al., 2010; Al-
0.012a Harbi, 2010), providing a tool for atraumatic extraction in critical
0.04a anterior maxillary sites.
0.668
We observed an increase of postoperative symptoms dependent
on the time of surgery. The mean duration of surgery in our report
may be relatively long compared to previous studies (Renton et al.,
2001; Bello et al., 2011; Chye et al., 1993), but can be explained by
the selection of complex cases. Additional time needed for
sectioning and inward fragmentation instead of outward mobi-
lisation may be taken as a disadvantage for simple access sites, but
plays a minor role in complex and deeply impacted molars.
4.1. Complex cases
As Kim et al. (2011) stated, the degree of surgical difculty in-
creases as the depth of the impacted tooth increases and its section
becomes more difcult. Using magnifying tools, this difculty can
be overcome. 3D e imaging of the case example (Fig. 8) shows
clearly that, independently of the degree of impaction, lateral bone
removal can be avoided. The technique describe here has signi-
cantly facilitated the removal M3M. The removal of the crown from
an occlusal perspective opens the view to the remaining roots and
facilitates the identication as well as the mobilization of root
fragments with a minimum of bone loss. Support endoscopy (SE)
has been proven to be a valuable tool when using microelevators
under monitor control instead of conventional application without
direct vision, in particular when working at close distance to the
mandibular canal. In combination with 3D imaging based on pre-
operative cone beam examination, the depth and location of root
tips can be identied by direct probing under magnication. Ac-
cording to the experience of both centres, the occlusal approach is
of particular value in cases of deeply impacted molars in close
contact with the mandibular canal (see Fig. 8). If required, surgeons
with less experience may extend the bone removal from the
occlusal to the lateral aspect of the mandible in order to get access
for burs mounted in a straight handpiece. Nevertheless the amount
of bone removal always can be kept below a critical size with
respect to fracture risk.
4.2. Incidence of nerve lesions
One of the main complications related to M3M removal is tem-
porary or permanent disturbance of the sensory function of the IAN.
Incidence varies between 1.3% and 5.3% (Renton et al., 2005). There is a
signicant risk if the root tip is projected onto the mandibular canal.
According to Ortiz and San Pedro (2009) the incidence of over-
projection is 55.66% and the adjacent position 25.6%. Gen and
Vasconcellos (2008) reported 23% overprojection and 33% adjacent
position respectively. These gures outline the importance related to
the problem, when minimally invasive surgery is applied. Tolstunov
et al. (2011) described a technique to reduce damage of the IAN in
cases of high-risk patients using pericoronary osteotomy with sec-
ondary removal after spontaneous eruption. Of 14 patients, 3 had a
temporary neurosensory dysfunction. Landi et al. (2010) also reported
a two-stage technique to assist the eruption. Wang et al. (2012)
however suggested an orthodontic approach to reduce the risk of
IAN lesion. It appears obvious, that these approaches only are appli-
cable in cases with favourable anatomical conditions to allow further
eruption of the M3M after primary surgery or during orthodontic
treatment, which in individual cases cannot be predicted. The IFT with
an occlusal miniap as described here does not show an increased risk
 W. Engelke et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7
for nerve damage compared to conventional procedures although it
was applied in cases with high-risk of neurosensory disturbance.
4.3. Postoperative discomfort
Compared to the results of Kim et al. (2011) the pain level of 2.3
vs. 1.7, pain duration 1.95 vs. 1.2 and swelling score 1.38 vs. 0.3 were
higher, but exhibited better values compared with the ap pro-
cedures (pail level 6.2, pain duration 4.2, swelling score 2.0) re-
ported by the authors. This is remarkable insofar as the duration
of surgery was higher (27 vs. 15 min) and the case selection only
included cases of high complexity. The correlation of swelling score
with duration of surgery and age appears independent of the
method applied. Further controlled clinical studies need to be con-
ducted to see if the tendency towards a reduction of postoperative
discomfort using IFT can be conrmed on a larger base of data.
5. Conclusion
The inward fragmentation technique (IFT) with an occlusal
miniap approach allows low traumatic access to M3M, exact
visualization of critical structures and results in vertical buccal
bone loss below 1 mm. Anatomical integrity in highly complex
cases can be maintained with a low complication rate. Special
technical resources and specic training is necessary.
Financial support
No nancial or other study support was received.
Disclosures
Our research, including the Material and methods section of our
manuscript, was approved by our ethical committee in Georg-
August-University and Universidad de La Frontera.
Conict of interest
There is no conict of interest (nancially or personally) for any
of the authors.
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