British Journal of Oral and Maxillofacial Surgery 45 (2007) 8384

Technical note

Buccal corticotomy for removal of deeply impacted mandibular molars

Andrew B.G. Tay
Department of Oral & Maxillofacial Surgery, National Dental Centre, 5 Second Hospital Avenue, Singapore 168938, Singapore Accepted 23 December 2005 Available online 3 February 2006

Keywords: Mandibular buccal corticotomy; Sagittal split ramus osteotomy (SSRO); Deeply impacted molar; Inferior alveolar nerve (IAN)

Sagittal split ramus osteotomy has been used to remove deeply impacted mandibular third molars.13 The main disadvantages of conventional operations for such teeth are the extent of bone removed, limited visibility,1 high risk of injury to the inferior alveolar nerve, and fracture of the mandible.2 In comparison, sagittal split ramus osteotomy gives good access, conserves bone that would otherwise have been removed, and allows the nerve to be seen and avoided.13 However, the osteotomy puts the occlusion at risk (although this is rare) and there is a risk of an unfavourable split in either the proximal or distal segment (2%).4 This is about twice as high if the third molar is impacted.4 The published incidence of disturbance of the inferior alveolar nerve is high: as much as 58% at 6 months, and 35% at 1 year postoperatively. An alternative approach that offers access to deeply impacted mandibular teeth is by buccal corticotomy.5 A trapezoidal mucoperiosteal ap is raised in the mandibular molar region, and a rectangular window is made over the deeply impacted tooth using a narrow ssure bur, with the mesial and distal cuts almost reaching the inferior border of the mandible (Fig. 1). The buccal corticotomy window is removed with an osteotome, and the deeply impacted molar is exposed, divided with a bur, and removed. The alveolar nerve bundle is often in close proximity and may be seen after the tooth has been removed. The bony fragment removed at buccal corticotomy is replaced and secured with wires or plates and screws at the mesial and distal edges, and the wound is sutured. We did this operation under general anaesthesia in two patients: a 17-year-old girl with a deeply impacted left lower

Fig. 1.

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Fig. 2.

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A.B.G. Tay / British Journal of Oral and Maxillofacial Surgery 45 (2007) 8384

second molar (Figs. 2 and 3), and a 12-year-old boy with a deeply impacted left lower rst molar and a complex odontome in place of the left lower second molar. In both cases computed tomograms showed the location of the mandibular canal in relation to the deeply impacted teeth and the buccal cortex. The deeply impacted teeth (and odontome in the second case) were completely removed piecemeal and both patients recovered well and showed evidence of bony healing on radiography 6 months later. The second patient had mild paraesthesia of his left lower lip and chin, which resolved after a month.

References
1. Jones TA, Garg T, Monaghan A. Removal of a deeply impacted mandibular third molar through a sagittal split ramus osteotomy approach. Br J Oral Maxillofac Surg 2004;42:3658. 2. Amin M, Haria S, Bounds G. Surgical access to an impacted lower third molar by sagittal splitting of the mandible: a case report. Dent Update 1995;22:2068. 3. Toffanin A, Zupi A, Cicognini A. Sagittal split osteotomy in removal of impacted third molar. J Oral Maxillofac Surg 2003;61:63840. 4. Mehra P, Castro V, Freitas RZ, Wolford LM. Complications of the mandibular sagittal split ramus osteotomy associated with the presence or absence of third molars. J Oral Maxillofac Surg 2001;59:8548. 5. Miloro M. Surgical access for inferior alveolar nerve repair. J Oral Maxillofac Surg 1995;53:12245.

Fig. 3.