Course Karma

A palatally impacted upper third molar completely changes your flap design.

A routine buccal flap with a vertical release can leave you fighting poor visibility and difficult access from the beginning.

In these cases, a palatal approach gives broader reflection and significantly better exposure around the impaction.

But as you extend posteriorly, anatomy becomes critical.

The greater palatine artery and nerve can quickly turn this into difficult bleeding if violated, which is why the approach should stay conservative at first: Start small. Elevate gradually. Work from known to unknown.

Want to be mentored on third molar extraction cases?
Our 10-week Third Molar Mentorship Program starts next Saturday.

Apply what you learn in clinic with mentorship and accountability from two oral & maxillofacial surgeons. A program that pays for itself.

Starts Satarday!

Link in bio.

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We’re going LIVE today with our Third Molar Masterclass. Comment “Class” and I’ll DM you a link to register.

When you approach a third molar, flap design is one of the earliest decisions you make, and it often determines how controlled and straightforward the surgery will feel.

For maxillary thirds 👉 I will do a buccal sulcular incision distal to the mesial papilla of the second molar and carry it over the crest of the impacted tooth with a distal/buccal release up the tuberosity.

For mandibular molars 👉 I will also do a papilla sparing sulcular incision around the second molar with a very slight crestal extension distally with a a distobuccal release.

⚠️ Keep the extension buccal, to avoid injury to Lingual nerve and possible tongue paresthesia.

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Comment “GUIDE” and I’ll DM you NUMB: A Guide to Local Anesthesia!

Whether it’s a resto, endo, crown or anything in between, the guide covers:
👉 Maxillary LA techniques
👉 Mandibular LA
👉 Tips when it doesn’t go NUMB
👉 Supplemental anesthesia
👉 Simplified LA max dose chart

LA can make or break any case. Failed numbness is also one of the most common reasons patients get referred out. So here’s our exact routine for third molar exos:

Upper third molars: PSA block + palatal infiltration Fair warning: palatal hurts. The mucoperiosteum is tightly bound to the hard palate and does not enjoy being separated from it. For sedation cases Dr. Ben Johnson skips the palatal.

Lower third molars: IANB + long buccal nerve block IANB: syringe angled above the contralateral premolars, bone contact and LA deposited into the pterygomandibular space. Long buccal goes in distal and buccal to the most distal molar.

LA of choice: Marcaine + Lidocaine for most cases. Using Exparel? Marcaine only. Exparel is liposomal bupivacaine, slow-release, long postop analgesia from a single infiltration. Highly recommend.

Learn about these techniques and more in NUMB: A Guide to Local Anesthesia.

Comment “GUIDE” and I’ll slide it into your DM’s 😉

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