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Study of pattern and prevalence of mandibular impacted third molar among

Delhi‑National Capital Region population with newer proposed classification of
mandibular impacted third mo...

Article in National Journal of Maxillofacial Surgery · June 2019

DOI: 10.4103/njms.NJMS_70_17

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Original Article

Study of pattern and prevalence of mandibular impacted

third molar among Delhi‑National Capital Region
population with newer proposed classification of
mandibular impacted third molar: A retrospective study
ABSTRACT
Aim/Objective: The mandibular third molar is the most frequently impacted tooth with incidence varies from 9.5% to 68% in different populations.
Hence, the aim was to study the prevalence and pattern of mandibular impacted third molar among Delhi‑National Capital Region (NCR) population.
Materials and Methods: The study was conducted with data collected from registered hospitals and dental clinics of Delhi NCR region. The study
represents a retrospective analysis of panoramic radiographs and intraoral periapical radiograph of patients at these centers from June 2014 to June 2016.
Results: Out of 960 patients with the third molar investigated, a total of 250 patients having impacted mandibular third molar (152 [60.8%]
males and 98 [39.2%]) females between June 2014 and June 2016 were included in the study. The age ranged from 20 to 55 years, with a mean
age of 27.6 years and the standard deviation was 5.8 years. The prevalence of impacted mandibular third molars for this study was 26.04%.
Conclusion: This study demonstrated that males (60.8%) were more likely to present with impacted mandibular third molars than
females (39.2%). The prevalence of third molar impactions was almost the same on both the left (45.8%) and right (54.2%) sides. This study
also noted that mesioangular impactions (49.2%) were the most common type of impaction. The least common form of impactions was the
transverse types (2%). The prevalence of impacted mandibular third molars for this study was 26.04%.

Keywords: Alveolar osteitis, impaction, nerve injury, pericoronitis, ramus relationship

Deepak Passi, Geeta Singh1, Shubharanjan Dutta2,

INTRODUCTION
Dhirendra Srivastava3, Lokesh Chandra3,
Sonal Mishra3, Anchal Srivastava4, Manish Dubey5
The word impaction is originated from the Latin word “impact” Department of Oral and Maxillofacial Surgery, Inderprastha
means organ or structure, which because of an abnormal Dental College and Hospital, Ghaziabad, 1Department of Oral and
mechanical condition has been prevented from assuming Maxillofacial Surgery, Faculty of Dental Sciences, King George
its normal position. William stated impacted tooth as one Medical University, 5Departmemt of Dentistry, T. S. Misra Medical
which is completely or partially unerupted and is positioned College and Hospital, Lucknow, Uttar Pradesh, 3Department of Oral
against another tooth, bone, or soft tissue so that its further and Maxillofacial Surgery, ESIC Dental College and Hospital, Delhi,

eruption is unlikely.[1] Impacted teeth are those which fail to

4
Department of Oral Pathology, Govt. Dental College and Hospital,
Aurangabad, Maharashtra, India, 2Department of Oral and
erupt or develop into the proper functional location in oral
Maxillofacial Surgery, M. B. Kedia Dental College, Birgunj, Nepal
cavity beyond the time usually expected. Etiology may be
multifactorial usually due to adjacent teeth, dense overlying Address for correspondence: Dr. Manish Dubey,
bone or soft tissue, size of the mandible or maxilla with the Department of Dentistry, T. S. Misra Medical College and Hospital,
Lucknow, Uttar Pradesh, India.
resultant lack of space in the jaw, aberrant path of the eruption, E‑mail: [email protected]
abnormal positioning of tooth bud, differential root growth
Received: 08-11-2017, Revised: 28-12-2017, Accepted: 12-01-2018
between the mesial and distal roots, or pathological lesions.[2]
This is an open access journal, and articles are distributed under the terms of the Creative
Access this article online Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to
Quick Response Code remix, tweak, and build upon the work non-commercially, as long as appropriate credit
Website: is given and the new creations are licensed under the identical terms.

www.njms.in For reprints contact: [email protected]

How to cite this article: Passi D, Singh G, Dutta S, Srivastava D,

Chandra L, Mishra S, et al. Study of pattern and prevalence of mandibular
DOI:
impacted third molar among Delhi-National Capital Region population
10.4103/njms.NJMS_70_17 with newer proposed classification of mandibular impacted third molar: A
retrospective study. Natl J Maxillofac Surg 2019;10:59-67.

© 2019 National Journal of Maxillofacial Surgery | Published by Wolters Kluwer - Medknow 59

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Passi, et al.: Passi D (2018) classification of impacted mandibular third molar

Impacted teeth can lead to impaction of food, pericoronitis, the 250 patients, there were 152 (60.8%) male patients and
caries, pain, and development of pathology. Therefore, 98 (39.2%) female patients [Graph 1]. The male to female ratio
impacted third molar prophylactic removal is becoming a of the study group was 1.5:1 (152:98).
common practice nowadays.
The patients were divided into 5 years of age groups ranging
The current study aims to compare and assess the from 20 to 55 years. The 25–30 years of age group had the
prevalence and pattern of impacted mandibular third highest prevalence of tooth impaction (48.8%), but decreases
molars in Delhi National Capital Region (NCR) region with with increasing age except in the 30–35 years of age group
the proposal of newer classification of impacted mandibular showed an increase in impactions when compared to age
third molars. group of 20–25 years. The patients were divided into seven
groups, ranging from 20 to 55 years, each group spanning
MATERIALS AND METHODS over a 5 years’ period [Table 2].

A retrospective study of patients was carried out from Presentation of angulations in impacted mandibular
January 2014 to January 2016 in the Dental Department of third molars reveals that the mesial angulation is most
Hospitals and Dental Clinics of Delhi‑NCR region. A total prevalent – 49.2% [Figure 1], vertical position – 24% [Figure 2],
of 960 cases of patients aged between 20 and 55 years horizontal position – 20% [Figure 3], and distal
were selected for the study. The clinical and radiographic
records of these patients were evaluated after the consent
of patients. Parameters studied into the study were an
age group, gender, location of the impacted third molar
(left/right), angulation, position, and level of the impacted
tooth.

The exclusion criteria were patients below 20 years of

age, incomplete clinical radiological records, incomplete
root formation of the third molar, severe systemic disease
conditions, craniofacial anomalies or syndromes such
as achondroplasia, progeria, oxycephaly, cleidocranial
dysostosis, and Down’s syndrome, any previous trauma or
pathology.

They were analyzed for the angulation, position, and depth Graph 1: Distribution of impacted teeth in different gender
of impaction. Only teeth which had not attained functional
occlusion were taken as impacted tooth. The angulation was Table 1: Basic data for number of patients and age in years
assessed using Quek’s adaptation of the Winter’s classification, Basic data for age and years Total
which incorporated the use of an orthodontic protractor to Male Female
quantify the angulation to reduce the errors associated with n 152 98 250
the evaluation by visual impression alone. The position and Mean 28.2 26.6 27.6
level of the impacted teeth were assessed using the Pell and SD 6.6 5.4 6.2
SD: Standard deviation
Gregory classification. The analysis of the collected data was
performed using the Pearson’s Chi‑square test with the help of
Table 2: Number of patients at different age groups
Statistical Package for Social Sciences (version 18.0) software
Age groups (years) Patient with impacted teeth Total (%)
IBM , Chicago, Illinois, United States of America (USA).
Male Female
20-25 21 13 34 (13.6)
RESULTS 25-30 73 49 122 (48.8)
30-35 28 20 48 (19.2)
Among 960 patients, a total of 250 patients having third molar 35-40 16 9 25 (10)
impactions in the year 2014–2016 were evaluated. The age 40-45 8 4 12 (4.8)
ranged from 20 to 55 years, with a mean age of 27.6 years 45-50 4 2 6 (2.4)
and the standard deviation was 6.2 years [Table 1]. Among 50-55 2 1 3 (1.2)

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Passi, et al.: Passi D (2018) classification of impacted mandibular third molar

position – 4.8% [Figure 4]. The transverse position was molar (7.2%) [Figure 7]. Associated odontogenic cyst was also
the least prevalent – 2% [Figure 5 and Table 3]. Based on a found [Figure 8 and Table 5].
Chi‑square test, it was found the prevalence of mesioangular
angulation (49.2%) was significantly higher than other Complications during surgical removal include bleeding,
angulations [Graphs 2 and 3]. damage to the second molar, displacement of root into
lingual space, and dentoalveolar fracture. Postoperatively,
Among the three impaction levels, Level B (64.2%) was complications were persistent pain, swelling, bleeding,
significantly more prevalent than Level A and Level ecchymosis, trismus, and dry socket. Few potential
B additionally, the Class II ramus relationship was complications include paresthesia of lower lip and tongue,
significantly more prevalent followed by Class I and Class III,
respectively [Table 4]. The distributions of the angulations Table 3: Types and percentage of impacted teeth in different
of impaction on the right and left sides do not differ gender
significantly (Fisher’s exact test [P = 0.78]). Angulation of impaction Male Female Total (%)
Mesioangular 73 50 123 (49.2)
Vertical 38 22 60 (24.0)
The most common pathologies associated with impacted
Horizontal 30 20 50 (20.0)
third molars were caries of impacted teeth (35.6%) and Distoangular 8 4 12 (4.8)
pericoronitis (30.8%) with or without trismus. Other Transverse 3 2 5 (2)
problems were periodontal pockets between second and Inverted ‑ ‑ ‑
third molar causing food lodgment (14.8%), caries of second Total (%) 152 (60.8) 98 (39.2) 250 (100)
molar (11.2%) [Figure 6], and root resorption of second

Figure 2: Vertically impacted teeth

Figure 1: Mesioangular impacted teeth

Figure 4: Distoangular impacted teeth

Figure 3: Horizontally impacted teeth

Figure 5: Transverse placed impacted teeth Figure 6: Caries of second molars

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Passi, et al.: Passi D (2018) classification of impacted mandibular third molar

Figure 8: Impacted third molar associated with odontogenic cyst

60

Figure 7: Root resorption of second molar 50

Mesioangular
Vertical
60 40
Horizontal
Mesioangular Distoangular
30
50
Vertical Transverse
Horizontal 20
40
Distoangular
10
30 Transverse

0
20 1
Prevalence of impacted teeth in females (%)
10
Graph 3: Prevalence of impacted teeth in females
0
1 impacted due to insufficient space. Third molar teeth
Prevalence of impacted teeth in males (%)
are the last to erupt and have a relatively high chance
Graph 2: Prevalence of impacted teeth in males of becoming impacted. The etiology of third molar
impactions has been reviewed by various authors over the
Table 4: Distributions of the different level and class of years. Lack of space, retardation of facial growth, distal
impacted teeth
direction of eruption, early physical maturity, late third
Level/Class of impaction Total (%)
molar mineralization or lack of sufficient eruption force
Level/depth of impaction (Pell and Gregory) (%)
follicular collision, obstruction by physical/mechanical
Level A 24.8
Level B 64.2
barriers, such as scar tissue, fibromatosis, compact bone,
Level C 11.0 unattached mucosa, odontogenic cyst, and tumors are the
Ramus relationship (Pell and Gregory) (%) common reasons. Higher rates of impaction in the lower
Class I 36 jaw can also be attributed to the imbalance of the bone
Class II 48 deposition‑resorption process at the mandibular ramus,
Class III 15 resulting in either a decrease in the angulation of the
mandible or increase in the angulation of the mandibular
temporomandibular joint pain, and fracture of angle of plane.[4] Pathologies associated with impacted third molar
mandible. are pericoronitis, caries, food lodgment, pocket formation,
periodontal bone loss, root resorption of adjacent teeth,
DISCUSSION and development of cysts and tumors.[5]

A tooth which is unable to erupt physiologically into Third molar impaction is a common pathological deformity of
its functional anatomic position with time is said to be modern civilization. The prevalence of impaction in different
impacted. The normal age of occurrence of third molars populations ranges from 9.5% to 68% according to various
is 18–25 years.[3] More than one‑third of third molars get authors.[6]

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Passi, et al.: Passi D (2018) classification of impacted mandibular third molar

Table 5: Distribution of pathologies with different type of impacted teeth

Pathology Mesioangular Vertical Horizontal Distoangular Total
Pericoronitis 31 28 7 11 77
Caries third molar 52 17 18 2 89
Caries second molar 14 2 12 ‑ 28
Periodontal pocket 16 13 4 4 37
Root resorption of second molar 9 ‑ 9 ‑ 18
Cyst/tumor 1 ‑ ‑ ‑ 1

Because of the increased incidence of unerupted third molars between the occlusal plane and the cervical line of the second
and the association of numerous complications with these molar. Similar results were shown by the studies of Blondeau
retained teeth, assessment of third molars in terms of its and Daniel,[20] Almendros‑Marqués et al.,[21] Quek et al.,[6] and
position, angulation, and level in relation to gender, and arch Hassan[13] that Class B was the most common impaction level.
is a necessary intervention for better patient management and In contrast, Monaco et al.,[22] Obiechina et al.,[23] Hugoson
decision‑making of whether to retain or remove these teeth. and Kugelberg,[15] and Hashemipour et al.[8] reported Class A
as the predominant impaction level. The different findings
In our study, the prevalence of an impacted third molar of different studies can be explained by the difference in
was 26.4%. Other study shows variable finding depending classification methods used for their studies.
on region. Morris and Jerman[7] reported (65.6%) and Quek
et al.[6] reported (68.6%) a higher prevalence of impaction in a Our study showed that Class II ramus relationship was
study population from the USA and Singapore, respectively. the most frequently occurred ramus relationship class
However, a lower prevalence has been reported by in mandibular impacted third molars (48%), followed by
Hashemipour et al. (44.3%) in the Southeast region of Iran.[8] Class I (36%) and Class III (15%). Class II relation means
Other authors reported rate Eliasson et al. 30.3%,[9] Montelius tooth is positioned posteriorly so that approximately one
32%,[10] Hattab et al. 33%,[11] Rajasuo et al. 38%,[12] and Hassan half is covered by the ramus. Similar results were reported
40.8%.[13] by Monaco et al.,[22] Obiechina et al.,[23] Blondeau et al.,[20]
Almendros‑Marqués et al.,[21] and Hashemipour et al.[8]
We found that the incidence of mandibular third molar
impaction was significantly higher in males in comparison Wisdom teeth have long been identified as a source of
to females. This is in contrast with the study of Muhamad problems and continue to be the most commonly impacted
et al.,[14] Hashemipour et al.,[8] Quek et al.,[6] Hugoson and teeth in the human mouth. The classification of impacted
Kugelberg,[15] Ma’aita and Alwrikat,[16] and Kim et al.[17] They teeth should help the clinicians to determine the probabilities
reported a gender predilection for females. However, Brown of impaction, infections, and complications associated with
et al.[18] and Montelius[10] studies no sexual predilection wisdom teeth removal. It should help in the best possible
gender‑wise for incidence of mandibular third molar. path of removal of impacted teeth and amount of difficulty.
There exist number of classification of impacted mandibular
The distribution of angulation of impacted third molars in third molar in medical literature based on spatial relationship
our study showed that mesioangular impaction was the most and angulations, in relation with ramus and second molar,
frequent (49.2%) followed by vertical (24%), horizontal (20%), on the basis of status of eruptions and roots, the amount of
and distoangular (4.8%). Our finding is supported by studies soft tissue or bone (or both) that covers them, etc. Some of
of Kramer and Williams,[19] Quek et al.,[6] Moris and Jerman,[7] the classifications are listed with their merits and demerits.
Hassan,[13] and Hashemipour et al.[8] who reported that
mesioangular impaction was the most prevalent type of Quek et al. proposed a classification system using orthodontic
impaction in the mandibular third molars of African American, protractor. In their study, angulation was determined by the
Singaporean, American, Arabian, and Iranian populations, angle formed between the intersected long axis of second
respectively. and third molars. They classified mandibular third molar
impaction as follows.[6]
Evaluation of the level of impaction showed that 24.8% a. Vertical (0°–10°)
impacted third molars were positioned at Level A, 64.2% were b. Mesioangular (11°–79°)
positioned at Level B, and 11% were positioned at Level C. c. Horizontal (80°–100°)
Hence, the most common type of impaction level was Level d. Distoangular (−11°–−79°)
B which means impacted tooth with an occlusal surface e. Others (−111°–−80°).
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Passi, et al.: Passi D (2018) classification of impacted mandibular third molar

The classification is based on angulation only. It is easy and 4. Distoangular impaction: Only approximately 6%. Most
quick to use but parameters such as depth of impaction, difficult to remove
difficulty level, nerve relation with injury predictability, and 5. Buccoangular
association with pathology is not mentioned. 6. Linguoangular
7. Inverted.
Pell and Gregory classification
Classified impacted mandibular third molars; first, according The classification is based on angulation, prevalence, and
their position according to the distance between the second prediction of difficulty but parameters such as depth of
impaction, nerve injury predictability, and association
molar and the anterior border of the ramus of the mandible.
pathology is not given.[26,27]
Second, according to the depth of impaction and proximity to
the second molar.[24] [Table 6 and Figure 9] This classification
American Dental Association’s‑American Association of
is helpful in predicting surgical difficulty. A composite Oral and Maxillofacial Surgeons classification of impacted
relationship of angulation, ramus relationship, and depth of teeth
impaction can provide a surgical extraction difficulty index, The American Dental Association’s‑American Association of
as described by Pedersen[25] [Table 7]. Oral and Maxillofacial Surgeons classification describes type
of impacted teeth tissue/partial bony/complete bony types,
Archer and Kruger classification surgical steps and was given particular numerical designation
1. Mesio Angular: (Most Common) 43% and least difficult for it. No description of angulation, relevant depth, nerve
to remove relation, and associated pathology was there [Table 8].
2. Horizontal: (Less Common) only 3%. More difficult than
mesioangular Winter’s classification (based on angulations)
3. Vertical impactions: Second greatest frequency, 38%. According to the position of the impacted third molar to the
Considered third in ease of removal long axis of the second molar.[28]

Table 6: Pell and Gregory classification

Based on the amount of tooth covered by the anterior border of the ramus
Class I relationship Class II relationship Class III relationship
If the mesiodistal diameter of the crown is completely If the tooth is positioned posteriorly so that The tooth is located completely within the
anterior to the anterior border of the mandibular ramus approximately one half is covered by the ramus mandibular ramus
If the mesiodistal diameter of the crown is completely If the tooth is positioned posteriorly so that The tooth is located completely within
anterior to the anterior border of the mandibular ramus approximately one half is covered by the ramus the mandibular ramus

Figure 9: Pell and Gregory classification of impacted mandibular third molars

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Passi, et al.: Passi D (2018) classification of impacted mandibular third molar

• Mesioangular – 45% neurosensory deficits of the IAN after mandibular third

• Horizontal – 10% molar extraction[30] [Figure 2]. IAN may be involved after
• Vertical – 40% third molar removal from 0.5% to 5%. Lingual nerve
• Distoangular – 5%. involvement shows incidence of 0.2%–2% of lower third molar
These may occur simultaneously in buccal version, lingual removals[31] [Figure 10].
version, and torsoversion Killy and Kay classification of
mandibular impacted teeth[29] [Table 9]. Thoma, as quoted by Obimakinde, classified the curvature
of the roots of the impacted mandibular molars into three
Classification of the third molar in relation to inferior categories.[32]
alveolar nerve (IAN) superimpositions predicting significantly a. Straight roots (separated or fused)
b. Curved roots in a distal position
Table 7: Difficulty level prediction for impacted mandibular third
c. Roots curved mesially.
molar removal (Pederson Scale‑1998)
Classification Score
The number of roots may be two or multiple. The impacted
Spatial relationship
Mesioangular 1
tooth can also present with fused roots.
Horizontal 2
Vertical 3 The classification of impacted third molar should be systemic
Distoangular 4 and meticulous. It should cover all the parameters related to
Depth impacted teeth, that is, position, depth, relative incidence,
Level A 1 difficulty level, and possible complications. Hence, an attempt
Level B 2
is here y made to propose a new classification system of
Level C 3
mandibular impacted third molar hoping it will benefit for
Ramus relationship
Class I 1
students and researchers to update their knowledge and
Class II 2 understanding.
Class III 3
Difficulty level Deepak Passi (2018) classification of impacted mandibular
Very difficult 7-10 third molar [Table 10].
Moderately difficult 5-7
Minimally difficult 3-4
The newer proposed classification describes almost all the
clinical and radiological parameters such as angulation,
Table 8: ADA‑AAOMS classification of impacted teeth degree and incidence of impacted teeth, relationship with
ADA codes Description anterior border of mandible, relation with alveolar crest and
07220 Soft tissue impaction (requires incision of overlying soft tissue second molar (depth), nerve relation and injury risk with both
and removal of tooth)
07230 Partially bony impaction (incision of overlying soft tissues,
lingual and IAN. It also describes the degree of difficulty of
elevation of flap and either removal of bone and tooth or removal, pathology associated with impacted third molar and
sectioning and removal of the tooth) complications. The main limitation of this classification is
07240 Completely bony impaction (incision of overlying soft tissues,
that it is applies to mandibular third molar only, not maxillary
elevation of flap, removal of bone and sectioning of the tooth)
07241 Completely bony with unusual surgical teeth and bit lengthy to write.
complications (incision of overlying soft tissues, elevation
of flap, removal of bone and sectioning of the tooth and/ CONCLUSION
or presents with unusual difficulties and circumstances)

This was the most recent and perhaps first ever studies to
Table 9: Killy and Kay classification of mandibular impacted
teeth
evaluate the prevalence and pattern of mandibular third
molar impactions in Delhi–NCR region of India. In our study,
Parameter Classification
Based on angulation Mesioangular/horizontal/vertical/distoangular
only 26.04% of the population had impacted mandibular third
and position molar condition which is comparatively less when compared
Based on state of Completely erupted/partially erupted/unerupted to other studies from different countries and regions. From
eruption
our study, it can be concluded that recurrent pericoronitis and
Based on roots Number of roots‑fused roots/two roots/
multiple roots
caries are two most common causes of impacted teeth removal.
Root pattern‑surgically favorable/surgically Mesioangular type of impaction was most common type of
unfavorable impactions. Impacted level B and Class II ramus relationship
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Passi, et al.: Passi D (2018) classification of impacted mandibular third molar

Figure 10: Classification of third molar in relation to inferior alveolar nerve

Table 10: Passi D (2018) classification of impacted mandibular third molar

Mandibular third molar Components
Spatial position (S) Mesioangular (49%) Vertical Horizontal Distoangular
Incidence (%) and (31°-60°) (24%) (20%) (5%) (91°-120°)
Degree (°) (61°-90° (0°-30°) (Transverse- 2%)
Relationship with Class I: Sufficient space Class II: Sufficient space Class III: Tooth is partially Class IV: The tooth is located
anterior border of ramus is present in the dental is not present in the dental impacted in the ramus completely within the
of mandible (R) arch to accommodate arch to accommodate the and more than one half is mandibular ramus
the mesiodistal diameter mesiodistal diameter of covered by the ramus
of the crown and it the crown. About 1/3 of is
completely anterior to covered by ramus
the anterior border of the
mandibular ramus
Relation to the second Position A: Occlusal Position B: Occlusal surface Position C: Occlusal surface Position D: Occlusal surface of
molar and alveolar surface of the impacted of impacted tooth is between of the impacted tooth is the impacted tooth is below
crest (M) tooth is in level with the the occlusal plane and the below the cervical line of the half of the root length.
occlusal plane of the cervical line of the second the second molar. Widest Completely embedded in the
second molar. Tooth is molar. Partially impacted, but part of the crown is below bone
completely erupted widest part of the crown is the bone
above the bone
Degree of difficulty (D) Easy/simple Slightly difficult Moderately difficult Very difficult/complicated.
Extraction requiring Extraction requiring Requiring osteotomy and Extraction (roots section)
forceps/elevators osteotomy coronal section
Bucco‑lingual location of Location B Impacted tooth is closer to buccal wall
third molar (lingual nerve Location B‑L Impacted tooth is in the middle between lingual and buccal walls
injury risk)‑L
Location L Impacted tooth is closer to lingual wall
Relation to the I0 Mandibular canal runs apically/buccally/lingually with respect to the tooth but without touching it. The
mandibular distance IAN/tooth is >3 mm
canal (IAN injury risk)‑I I1 Mandibular canal runs apically/buccally/lingually touching the root
I2 Root of the impacted tooth contacting or penetrating the mandibular canal
I3 Mandibular canal runs between fused roots or roots surrounding the mandibular canal
Associated patholgy (P) Type 1 No associated pathology
Type 2 Associated with pericoronitis, caries, pocket formation, root resorption, crowding of anterior
dentition
Type 3 Associated with inflammatory radiographic changes like periapical granuloma, furcation involvement,
osteomyelitis, space infection
Type 4 Associated with pathology like odontogenic cysts and tumors
Compications (C) 1° Persistent pain, bleeding, swelling, infection, wound dehiscence, periodontal pocket distal to second
molar, trismus
2° Alveolar osteitis (dry socket), damage to adjacent teeth, dentoalveolar fracture, displacement of tooth,
ecchymosis of submandibular and sternum region
3° Peresthesia of lingual and IAN, TM joint injury and dislocation, fracture angle of mandible
TM: Temporomandibular, IAN: Inferior alveolar nerve

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