• Hydrocortisone injection: Mixed with 2% lignocaine for joint inflammation
• GA contraindications: Hemoglobinopathies, severe hematologic disorders
• Non – depolarizing relaxants: Reversed by neostigmine + atropine
• Succinylcholine: Depolarizing muscle relaxant
• Inferior turbinectomy: Done when maxilla is >6 mm superiorly positioned

Classification and Management of Impacted Third Molars

Impacted third molars, commonly known as wisdom teeth, can present in various orientations and depths, influencing the difficulty of their extraction. Understanding the types of impactions and their classifications is crucial for planning surgical intervention.

Types of Impaction

1. Mesioangular Impaction:

   • Description: The tooth is tilted toward the second molar in a mesial direction.
   • Prevalence: Comprises approximately 43% of all impacted teeth.
   • Difficulty: Generally acknowledged as the least difficult type of impaction to remove.

2. Vertical Impaction:

   • Description: The tooth is positioned vertically, with the crown facing upward.
   • Prevalence: Accounts for about 38% of impacted teeth.
   • Difficulty: Moderate difficulty in removal.

3. Distoangular Impaction:

   • Description: The tooth is tilted away from the second molar in a distal direction.
   • Prevalence: Comprises approximately 6% of impacted teeth.
   • Difficulty: Considered the most difficult type of impaction to remove due to the withdrawal pathway running into the mandibular ramus.

4. Horizontal Impaction:

   • Description: The tooth is positioned horizontally, with the crown facing the buccal or lingual side.
   • Prevalence: Accounts for about 3% of impacted teeth.
   • Difficulty: More difficult than mesioangular but less difficult than distoangular.

Decreasing Level of Difficulty for Types of Impaction

• Order of Difficulty:
  • Distoangular > Horizontal > Vertical > Mesioangular

Pell and Gregory Classification

The Pell and Gregory classification system categorizes impacted teeth based on their relationship to the mandibular ramus and the occlusal plane. This classification helps assess the difficulty of extraction.

Classification Based on Coverage by the Mandibular Ramus

1. Class 1:

   • Description: Mesiodistal diameter of the crown is completely anterior to the anterior border of the mandibular ramus.
   • Difficulty: Easiest to remove.

2. Class 2:

   • Description: Approximately one-half of the tooth is covered by the ramus.
   • Difficulty: Moderate difficulty.

3. Class 3:

   • Description: The tooth is completely within the mandibular ramus.
   • Difficulty: Most difficult to remove.

Decreasing Level of Difficulty for Ramus Coverage

• Order of Difficulty:
  • Class 3 > Class 2 > Class 1

Pell and Gregory Classification Based on Relationship to Occlusal Plane

This classification assesses the depth of the impacted tooth relative to the occlusal plane of the second molar.

1. Class A:

   • Description: The occlusal surface of the impacted tooth is level or nearly level with the occlusal plane of the second molar.
   • Difficulty: Easiest to remove.

2. Class B:

   • Description: The occlusal surface lies between the occlusal plane and the cervical line of the second molar.
   • Difficulty: Moderate difficulty.

3. Class C:

   • Description: The occlusal surface is below the cervical line of the second molars.
   • Difficulty: Most difficult to remove.

Decreasing Level of Difficulty for Occlusal Plane Relationship

• Order of Difficulty:
  • Class C > Class B > Class A

Summary of Extraction Difficulty

• Most Difficult Impaction:
  • Distoangular impaction with Class 3 ramus coverage and Class C depth.
• Easiest Impaction:
  • Mesioangular impaction with Class 1 ramus coverage and Class A dep

• Gow – Gates landmarks:
  • Corner of mouth
  • Disto – palatal cusp of maxillary 2nd molar
  • Neck of condyle
  • Extraoral: Lower border of tragus
• Laryngeal mask airway (LMA): Supraglottic device
• Tracheostomy incision: 4–5 cm below cricoid cartilage
• Common tracheostomy complications:
  • Peri – op: Anterior jugular vein injury
  • Late: Innominate artery fistula

Osseointegration Testing

Torque Testing (Primary Assessment)

• Force required: 10 – 20 N/cm without unscrewing
• Lateral force test: 5 lb should show no movement
• Failed implant indicators:
  • Horizontal mobility >1mm
  • Movement with <500gm force

Clinical Signs of Successful Integration

• Percussion test (no mobility)
• Immobility when placing fixture mount
• Immobility with impression coping placement

Implant Failure

• Most useful radiographic sign: Loss of crestal bone
• Imaging compatibility: MRI and CT scans NOT contraindicated with pure titanium implants
• CT advantage: Can subtract titanium from images, eliminating scatter

Endotracheal Route (L.E.A.N.)

Mnemonic for drugs that can be administered via endotracheal tube:

L - Lidocaine

• Dose: 1-1.5 mg/kg
• Indication: Ventricular arrhythmias, laryngospasm
• Mechanism: Sodium channel blockade
• Dilution: 5-10ml normal saline

E - Epinephrine

• Dose: 0.01-0.1 mg/kg (0.1-1 ml/kg of 1:10,000)
• Indication: Cardiac arrest, severe anaphylaxis
• Mechanism: α and β adrenergic stimulation
• Dilution: 5-10ml normal saline

A - Atropine

• Dose: 0.02-0.04 mg/kg (minimum 0.1mg)
• Indication: Bradycardia, organophosphate poisoning
• Mechanism: Muscarinic receptor antagonism
• Dilution: 5-10ml normal saline

N - Narcan (Naloxone)

• Dose: 0.01-0.1 mg/kg
• Indication: Opioid overdose reversal
• Mechanism: Opioid receptor antagonism
• Dilution: 5-10ml normal saline

Administration Technique

• Volume: Dilute in 5-10ml normal saline
• Method: Inject via suction catheter or directly into tube
• Follow-up: Bag ventilation to distribute drug
• Absorption: Lower bioavailability than IV route
• Monitoring: May need higher doses or repeat administration

Alternative Routes

• Intravenous: Preferred when available
• Intraosseous: Good alternative to IV
• Intramuscular: Limited utility in emergencies
• Sublingual: Some medications (nitroglycerin)

Microsurgical Repair Principles

• Timing: Primary repair (immediate) vs secondary repair (delayed)
• Tension-free approximation: Essential for successful repair
• Precise fascicular alignment: Critical for functional recovery
• Microsurgical technique: 8-0 to 10-0 non-absorbable sutures

Epineural Suturing

• Indication: Pure sensory nerves (like inferior alveolar nerve)
• Technique: Sutures placed through epineurium only
• Advantages:
  • Simpler technique
  • Less surgical trauma
  • Shorter operative time
  • Adequate for sensory function
• Suture material: 8-0 or 9-0 nylon or polypropylene
• Number of sutures: 2-4 sutures typically sufficient

Perineural/Group Fascicular Suturing

• Indication: Mixed motor/sensory nerves
• Technique: Individual fascicles or fascicular groups sutured separately
• Advantages:
  • More precise fascicular alignment
  • Better functional outcomes for motor nerves
  • Reduced cross-innervation
• Disadvantages:
  • More complex technique
  • Longer operative time
  • Greater surgical trauma
• Requirements: High magnification, specialized training

Fascicular Suturing

• Indication: Large mixed nerves with identifiable fascicles
• Technique: Individual fascicle-to-fascicle repair
• Use: Primarily for major peripheral nerves outside oral cavity