Removal of impacted maxillary third molars is not significantly different from removal of impacted mandibular third molars. The ramus is not considered in the maxilla, but the tuberosity is important. The inferior alveolar and lingual nerves are not involved, but the maxillary sinus is an important anatomical consideration. Unlike mandibular impactions, maxillary third molar impactions that are directed distally are often easier to remove than those that are mesially impacted. This relates to better access.
Removal of a maxillary third molar requires a posterior incision that is placed along the crest of the alveolus. It usually begins just lateral to the tuberosity and then progresses to the crest, facilitating access and ultimately closure. If the tooth is fully impacted, then the incision should reach the second molar mid distally and then be carried buccally, extending into the gingiva of the second molar (envelope flap). Alternatively, a flap with a vertical releasing incision can be used as long as the aforementioned rules are respected. Upon raising the flap, the periosteal elevator may be used to remove some bone that is buccal to the third molar. This buccal plate is typically thin enough to permit such removal. Then, consideration can be given to the use of a drill to section the tooth or to create a purchase point to facilitate removal, although this is generally not needed. A purchase point on the tooth, if indicated, should be placed in a central area so as to not create a fracture line, and should be of sufficient depth to allow engagement with an instrument. A pyramid-tipped instrument/elevator can be adapted to engage the purchase point and provide a rotational force to deliver the tooth.1,3,5
During instrumentation for maxillary surgery, the distal aspect of the third molar should be protected by placing a flat instrument behind the tuberosity.1 This will prevent the tooth from being dislodged into anatomic spaces such as the maxillary sinus, infratemporal fossa, or maxillary buccal soft tissues. This maneuver helps to stabilize the tuberosity and limit distal movement of the tooth, but it also aids removal by creating a wedge effect. Closure of the surgical wound is accomplished after thorough irrigation.
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