Lingual Plate Research Articles

Displacement of lower third molar into floor of mouth: a single institutional experience

The displacement of the tooth/tooth fragment into the floor of mouth sometimes happens during the lower third molar surgery and the patients are usually referred to oral and maxillofacial surgeons. To date, however, there is no consensus how to manage the displaced tooth due to the lack of available data. In this study, we have retrospectively analyzed the management of the displaced lower third molar into the floor of mouth. Our institute experienced seven cases during 2010 to 2020. Incidence rate of the lingual nerve injury caused by displacement of the lower third molar was 1/7. Six patients out of seven underwent surgical removal of the displaced fragment. The direct approach was used when the fragment was palpable superficially and the fragment was horizontally located away from the lingual plate (2 cases), while when the fragment was not palpable, or was palpable and adjacent to the lingual plate, the lingual mucoperiosteal flap was selected (4 cases). We conclude that the palpation and preoperative diagnosis with computed tomographic images are significantly important to decide a better and most effective surgical approach.

Three-dimensional alveolar bone assessment of mandibular molars for immediate implant placement: a virtual implant placement study

BackgroundTo elucidate the anatomical features of the mandibular molar region to allow safe immediate implant placement.MethodsCone-beam computed tomography images of 150 patients (600 teeth) were reviewed retrospectively. The virtual implants were placed in the mandibular first and second molar region. The anatomic structures of the mandible and inter-radicular septum were both categorized into three types. The relationship between implant and inferior alveolar nerve (IAN), and the horizontal distance from the implant surface to the bone wall were analyzed. Variables were compared using a student’s t-test, or Mann–Whitney U test.ResultsType U (39.0%) and type S (56.0%) were the most common in the first molar, while type U (67.7%) and type M (54.7%) had the highest prevalence rate in the second molar. The mean distance from the level where the virtual implant was completely surrounded by bone to IAN was 7.06 mm. The mean horizontal widths from the implant to the mesial and distal socket wall were 1.59 mm and 1.89 mm. The widths of the inter-radicular septum and the distances from implant to the buccal and lingual plate on different sections were significantly associated with tooth position (P < .05).ConclusionsIn the first molar region, the implant is suggested to be placed in the center of the inter-radicular septum, while in the second molar region, the mesial root socket could be considered. Immediate implant placement in the mandibular second molar sockets shows a high risk of IAN injury, lingual perforation, and inadequate primary stability.

Evaluating the presence of IAN injury in patients with juxta-apical radiolucency after third molar surgery: a retrospective cohort study

BackgroundJuxta-apical radiolucency (JAR) has been presented as a radiographic sign, suggestive of the IAN injury through third molar surgery. This study aimed to evaluate the relation of JAR with IAN injury in cone-beam computed tomography (CBCT) images and to determine whether the presence of JAR is related to tooth angulation, proximity to the mandibular canal, position to the IAN, and thinning of the cortical plates.MethodsOf an initial sample of 545 mandibular third molars, a total of 75 JAR+ and 75 JAR− teeth were evaluated by CBCT. We assessed the relationship between the presence of JAR in cone-beam computed tomography (CBCT) images and the presence of IAN injury after mandibular third molar surgeries. Moreover, we investigated whether the presence of IAN injury is related to tooth angulation, proximity to the mandibular canal, position to the IAN, and thinning of the cortical plates. Descriptive statistics, Chi-square test, and Fisher’s exact test were performed for statistical analysis.ResultsA significant relationship was found between JAR and temporary IAN injury (P = 0.036). However, there was no case of permanent IAN injury. IAN injury showed no significant relationship with the tooth angulation, position to IAN and proximity to the mandibular canal, lingual cortical plate thinning, sex, and age.ConclusionsJAR is generally in contact with the mandibular canal, and some degree of cortical thinning can be found in most cases. In this study, JAR was significantly related to temporary IAN injury. JAR may increase the risk of nerve injury during the surgical removal of third molars.

Alveolar bone thickness overlying healthy maxillary and mandibular teeth: A systematic review and meta-analysis

To systematically review and meta-analyse the Alveolar Bone Thickness (ABT) overlying healthy teeth. The secondary objective was to review the association of ABT with gender, age, and smoking. The PubMed, Embase, Scopus, ProQuest, Web of Science, and Cochrane Library databases were searched up to July 2020. English articles (sample size≥10) which had used CT or CBCT to measure the ABT at clearly defined reference points were included. The maximum likelihood approach meta-analysis was used to estimate the means (95% CIs). A total of 68 articles were included. The meta-analysis results were as follows: In the anterior maxilla, the mean labial plate thickness ranged from 0.42-1.75mm, while it was thicker for the posterior teeth (0.78-4.31mm). The palatal plate thickness ranged from 0.97-8.13mm. In the anterior mandible, the thickness of labial and lingual plates ranged from 0.4-3.71mm and 0.38-5.44mm, respectively. The alveolar bone was thicker for the posterior teeth both at the labial (0.66-6.31mm) and lingual (2.31-7.77mm) sides. Meta-regression revealed a significant relationship between gender and ABT at several points. There was a controversy regarding the association of ABT with age. No significant difference was evidenced between smokers and non-smokers. This study presents a clear image of the alveolar bone structure. Since it has pooled ABT values from various populations, outcomes could be acknowledged as global averages. Therefore, it could provide perspective for several dental procedures, including orthodontic treatments and immediate implant placement.

Preservation of Alveolar Ridge using Graft Material after Tooth Extraction: A Clinical Trial.

Background:The alveolar process is a tooth-dependent structure, and hence, removal of teeth results in the alteration of alveolar process. To alter bone remodeling after dental extraction, various techniques have been put forward for ridge preservation.Aim:The aim of this study is to evaluate and compare the changes of hard and soft tissues in postextraction socket after the application of bone graft material.Materials and Methods:Healthy patients of sample size of 40 were selected who underwent the extraction of anterior tooth irrespective of the arch, from premolar of one side to another, with the exception of incisors in mandible. Twenty patients were randomly selected as the control group and other 20 as the experimental group using an allograft bone material, i.e., beta-tricalcium phosphate to fill the socket. Cone-beam computed tomography (CBCT) was done as baseline preoperative and postoperative at 14 weeks after the extraction. CBCTs data help in recording linear and volumetric measurements which was performed by calibrated examiners to record all the measurements. After measurements, digital planning of dental implants was performed.Results:Forty participants were selected, in which 20 patients each were as the experimental and control groups. No significant difference was found at basal line at any of the cases. At follow-up of 14 weeks, statistical significance was seen in buccal and lingual plate height in the experimental group, and no significant difference was seen in the control group.(P = 0.023).Conclusions:This study clearly points out that an alveolar ridge preservation technique provides therapeutic benefit by limiting bone resorption in comparison to extraction alone.

FREQUENCY OF TYPE OF COMMON MAJOR CONNECTOR DESIGN EMPLOYED IN REMOVABLE PARTIAL DENTURES PROVIDED TO PATIENT

Objective:&#x0D; To determine the frequency of the types of common major connector designs in removable partial dentures provided to patients.&#x0D; Materials and Methods:&#x0D; A cross-sectional study was done at Khyber College of Dentistry. Participants fulfilling the inclusion and exclusion criteria were invited to take part in the study. The information was collected using a single interviewer-administered questionnaire. The demographic information of the patient was recorded. Information related to the design of major connector wasrecorded after it was drawn on the cast, before it was sent to the laboratory. Data was analyzed using SPSS version 17.&#x0D; Results:&#x0D; Data from 207 subjects were collected over a period of 24 months. The mean age of subjects was 41.21 ± 9.13 (SD) years. Out of 207 subjects, 41.1% were males and 59.9% were females. Female to male ratio was 1.43:1. Out of total, 49.3% were maxillary and 50.7% were mandibular removable partial dentures.Removable partial dentures constructed from cobalt-chromium accounted for 152 of the observed cases.Of the 152 observed cases of removable partial dentures made of cobalt-chromium, 81 were in the mandibular arch and 71 were maxillary. The remaining 55 were made of acrylic resin, out of which 31 were maxillary and 24 belonged to the mandibular arch.The study concluded that the horse shoe shaped connector is the most common type of connector used in the maxillary removable partial dentures (both cast partial and acrylic RPD’s) and the lingual plate is the most frequent type of connector given in the mandibular removable partial dentures.&#x0D; Conclusion:&#x0D; The studyshowed that common maxillary cobalt-chromium major connectorwas the horseshoe shape, and that of mandibular cobalt-chromium major connector design was the lingual plate. Additionally, common acrylic RPD were horseshoe shape in maxilla and lingual plate in mandible.

Use of a ‘low and short’ medial cut limits sagittal ramus osteotomy interferences

The traditional ‘high and short’ medial cut of the sagittal ramus osteotomy (Hunsuck modification) is a frequent cause of lingual plate interferences in patients undergoing mandibular yaw or cant corrections. We describe how the modified ‘low and short’ medial cut of the sagittal ramus osteotomy reduces lingual plate interferences with improved passive alignment of the osteotomy segments.

Effects of implant buccal distance on peri-implant strain: A Micro-CT based finite element analysis

Bone-implant mechanics is one of the factors that contribute to implant stability and success. In this work, voxel-based finite element models were built based on the micro-CT images of human cadaveric mandible specimens before and after implant placement. The computed results show high strain at the bone-implant contact locations and the buccal and lingual bone plates. The strain concentration in the thinner buccal plates was more substantial than that in the thicker lingual plates. The average values of maximum principal strain in the buccal and lingual ROIs were in good agreement with those measured using mechanical testing coupled with micro-CT and digital volume correlation.The implant position was then virtually changed in the models to be placed lingually or buccally. The computed strain in the buccal bone decreased when the implant was placed away from the buccal plate. The strain in lingual bone also deceased when the implant was moved from the center of the alveolar socket towards the lingual or buccal plate. The results indicate that the distance from implant to the buccal plate can affect the mechanical stimuli in bone, especially in the buccal plate, which may subsequently affect the bone remodeling process and buccal bone resorption.

Reabilitação implantossuportada de molar superior com implante cônico interno de diâmetro extra-largo – relato de caso

Tooth loss can occur due to several factors including dental caries. Immediate replacement of posterior teeth with dental implants facilitates to plan and to obtain consistent results with good prognosis. Factors such as minimally traumatic extraction, primary implant stability, maintenance of proximal bone ridges, buccal and lingual bone plates, in addition to a temporary or customizable component for tissue stabilization are important parameters to make the case predictable. The immediate technique for implants placement in the posterior regions has been described in the literature since the 1990s, presenting a high success rate and predictability of patients rehabilitation with shorter waiting times and maintenance of soft and bone tissue architecture. This study reports a clinical case of extraction of an upper molar tooth (26) with dental caries and placement of an extra-wide diameter implant, followed by filling of the surgical alveolar socket with bioactive calcium phosphate ceramic and placement of a customizable healing abutment. Clinical and radiographic control was performed after 8 months with success, with maintenance of soft tissue and marginal bone.

Can a panoramic radiograph predict the inferior alveolar nerve canal's position, or canal compression, near third molar root apices?

Background: Injury to the inferior alveolar nerve can occur during surgical removal of the mandibular third molars (M3Ms), resulting in numbness of the mandibular teeth, chin, and lower lip. This occurs when the roots of M3M compress the inferior alveolar canal (IAC) against the lingual cortical plate. Cone-beam computed tomography (CBCT) reveals the buccolingual relationship of the IAC and M3M, but the panoramic radiograph (PR) has not been evaluated to determine whether the plane film can reveal this relationship. Aims: The aim of the study is to determine whether PR could predict buccal or lingual IAC position or compression near M3M. Design: This retrospective study evaluated 200 M3M sites in 42 women and 67 men, aged 17–28 years. Ninety-one bilateral measurements were taken; 98 left and 102 right halves were analyzed. Methods: IAC position and degree of compression were interpreted from the CBCT. Utilizing imaging software, 13 different measurements were obtained. Statistical Analyses: Fisher's exact test, t-test, principal component analysis, and multivariate analysis were utilized. Results: Male and female canal positions significantly differed. Canal position was significantly different comparing partially erupted to erupted and fully bony impacted molars. Lingual canal position, versus buccal, was more frequently associated with moderate-to-severe IAC compression. “Anterior-posterior ramus at the occlusal plane” and “anterior ramus to anterior IAC at the occlusal plane” contributed most to the severity of IAC compression. Conclusion: The variables evaluated did not identify a significant relationship. A larger data set is needed to evaluate any role the dimension of the ramus has on IAC compression.

Measurement of Peri-Implant Bone Width with and without Metal Artifact Reduction Algorithm Using Two Cone-Beam Computed Tomography Software Programs

Objective: To assess the effect of metal artifact reduction (MAR) algorithm of two cone-beam computed tomography (CBCT) software programs on the accuracy of peri-implant bone width measurements . Material and Methods: This in vitro study evaluated 35 bovine rib bone blocks measuring 8 x 8 x 11 mm. Titanium implants were inserted in bone blocks and placed in a wax model of mandible. CBCT scans were obtained with ProMax 3D and Cranex 3D CBCT systems with and without the MAR algorithm. The width of buccal and lingual bone plates surrounding the implant was measured on CBCT scans by two observers. The Cronbach’s alpha was calculated to assess inter-observer agreement. The area under the curve (AUC), sensitivity and specificity values were calculated and compared. Results: The two observers had an excellent agreement. The accuracy of Cranex 3D was higher than that of ProMax 3D (p<0.05). Both CBCT systems showed higher accuracy when the MAR algorithm was not used (p<0.05). Both CBCT systems showed higher accuracy for measuring the width of the lingual plate than buccal plate (p<0.05) . Conclusion: The application of MAR algorithm did not notably increase the measurement accuracy in any CBCT system. Cranex 3D showed generally higher measurement accuracy than ProMax 3D.

Latest trends in atraumatic extraction of teeth

Ridge preservation is crucial in any extraction situation, especially if the site is planned for a future dental implant. Atraumatic extraction and socket management will lead to a predictable foundation for future treatment. Traditionally, conventional forceps along with elevators have been used in the extraction process. With forceps, the tooth is usually rotated in a buccal-lingual direction, which may result in weakening or fracturing of the buccal or lingual plate. An elevator is most commonly inserted mesially or distally with a leveraging or wedging force, which also may traumatize the hard and soft tissue. The basic process of atraumatic tooth extraction and preservation of soft and hard tissues begins with four generalized principles that should be applied to all extractions. By following atraumatic extraction technique, the quantity and quality of bone will be preserved, along with the gingival architecture. This will ultimately lead to more predictable implant positioning and placement. By adhering to the basic principles of atraumatic extractions and the use of atraumatic extraction kit rather than the use of periotome is a more predictable healing pattern may be obtained, as the vitality of the periodontal ligament and the surrounding blood supply is maintained.

Assessing the frequency of deep lingual concavities in 826 posterior mandible sockets

PurposeTo evaluate the frequency of deep lingual concavities in the lower jaw, which can cause surgical complications while inserting dental implants. MethodsCross-sections of the mandible alveolar ridge at the edentulous sockets were obtained via cone-beam computed tomography. Measurements were carried out using the freeware ‘IC Measure’ and based on the basic definitions of a previous study. ResultsMost (767/826 = 93%) sockets had concavities of various degrees (30–90°), while 59 (7%) sockets had no concavity. However, the majority of the concavities (71%) were mild, with angles > 60°. The other 220 (26%) sockets had deeper concavities of <60°; among these, 12 (1%) had extremely deep concavities of <40°. ConclusionsOnly a few cases have deep lingual concavities that pose a high risk for lingual plate perforation during dental implantation.

OSTEOSARCOMA OF THE MANDIBLE: A CASE REPORT

Osteosarcoma (OS) is an aggressive malignant neoplasm, frequent in long bones but rare in jaws. A 21-year-old female patient reporting the emergence of a large, painful, and bleeding oral lesion in the area of the right mandible with a 1-month evolution was referred to the dental care center. Incisional biopsy was performed, and histopathologic results showed peripheral ossifying fibroma; she was referred for the exeresis of the lesion. Resurgence of the lesion with rapid progression occurred. It showed up as a tumorous lesion in the area from the teeth 44 to 48, extending to the area of the tongue and to the vestibule of the mouth with an increase in the visible external volume of the mandible area of 4.0 × 2.5 × 3.0 cm. Computed tomography showed bone destruction involving teeth 46, 47, and 48, compromising cortical bone and lingual cortical plate. Anatomopathologic analysis determined diagnosis of OS of the mandible. The patient was referred to the oncology department and died after the diagnostic.

The vulnerability of lingual plate of the mesioangular impacted mandibular third molars: a measurement on CBCT images

AbstractObjectivesThe innate fragility of lingual plate (LP) is assumed to be the main reason leading to injuries of lingual neurovascular bundles and surrounding fascial spaces during mandibular third molar (MTM) surgery. The aim of this study was to assess the LP and lingual cortical plate (LCP) thickness of mesioangular impacted MTM.MethodsA total of 130 cone beam computed topography images were collected and studied. The related landmarks of MTM roots and LP were identified for measurements. At three positions of each root, including middle third, apical third and apex, the integrity of LP together with thickness of LP and LCP were evaluated.ResultsThe results showed that mean values of LP and LCP thickness of the most lingual root at apical third were 0.89 and 0.57 mm respectively. The average values of LP and LCP thickness surrounding mesial root were significantly smaller than those of distal root at all examined positions, except LP thickness at the apex. Moreover, the thickness of LP presumably increased together with the horizontal and vertical impacted levels according to Pell–Gregory classification. The percentage of losing LP integrity was determined as 89.5%, 93.4% and 77.4% at middle third, apical third and apex, respectively.ConclusionIn conclusion, LP surrounding the mesioangular impacted MTM is considerably thin, which can be the reason of lingual neurovascular bundles traumas and fascial spaces damages, especially at the apical third of the mesial root and in class A MTM.

Computed Tomography for the Assessment of the Potential Risk After Implant Placement in Fresh Extraction Sites in the Posterior Mandible

Immediate implant placement (IIP) is considered a reliable procedure, with survival rates of 94.9%-98.4%. Nevertheless, in the posterior mandible, it poses a high risk of damage to anatomic structures. The aim of this study was to determine the risk of anatomic structures injury associated with IIP in the posterior mandible based on apical primary stability, respecting a safe distance from the inferior alveolar nerve and lingual plate, and to evaluate the influence of different factors on those risks. Pre-extraction cone beam computed tomography scans of 100 patients were retrospectively analyzed. Measurements were taken from tooth apices to lingual plate and to mandibular canal. Values of <4 mm of the former and <6 mm of the latter were categorized as considerable risk. Values of <2 mm at both measurements were considered high risk. Two-sided P < .05 was considered statistically significant. Mean root-to-alveolar canal distance was 7.6 ± 2.7 mm in the first molar, 6.5 ± 3mm in the second premolar, and 5.4 ± 3 mm in the second molar (P < .005). The mean distance to the outer lingual cortex was 3.9 ± 2.1 mm in the first molar and 3.2 ± 0.1 mm in the second molar. Thus, second molars were at higher risk of inferior alveolar nerve injury and lingual plate perforation during IIP. Background factors associated with higher IIP risk were female sex and age < 40 years. In the mandible, the anatomic risk posed by IIP is greatest for second molars and lowest for first molars. Several background factors affect the distances between root apices and the mandibular canal.

Prevalence and position of mandibular incisive canal, anterior loop of the mandibular canal and lingual foramen using cone beam computed tomography

Objective: Comprehensive knowledge about the anatomy of the surgical site is an important prerequisite for any surgical procedure. This study aimed to assess the prevalence, position and anatomical characteristics of mandibular incisive canal (MIC), lingual foramen (LF) and anterior loop of the mandibular canal (ALMC) in an Iranian population using cone beam computed tomography (CBCT). Materials and Methods: This study was conducted on 103 patients who underwent CBCT prior to implant placement. The CBCT scans of patients were evaluated by two observers to determine the visibility and length of MIC, LF and ALMC. The buccolingual inclination of MIC at the initiation point of canal and canal path were also studied. Results: The prevalence of MIC, LF and ALMC was 90%, 76% and 84% on CBCT scans, respectively. The mean length of MIC and ALMC was 7.5mm and 1.2mm, respectively and the mean width of LF was 0.9mm. The MIC had a buccal inclination at the initiation point and approximated the lingual plate as extended towards the midline. Analytical statistics including independent samples t-test, paired samples t-test, ANOVA analyses were applied. Conclusion: Considering the high prevalence of MIC, ALMC and LF and wide range of MIC (1.2mm to 20mm) and ALMC (1mm to 9.9mm) length, CBCT is recommended for patients prior to surgical procedures in the anterior mandible to determine the exact location of these anatomical structures.

Prosthetically driven immediate implant placement at lower molar area; an anatomical study.

To examine the effectiveness and safety of immediate implant placement (IIP), we evaluated the risk of lingual plate perforation (LPP) and mandibular canal perforation (MCP) associated with posterior mandible anatomy using cone beam computed tomography (CBCT) images. A morphological study of the molar sockets of 135 patients (age: 18-84 y) was done and its relationship to the mandibular canal was investigated. The risk of LPP and MCP was recorded as yes or no. Mandibular cross-sectional morphology was defined as one of three types (U-P-C) using the criteria of Chan et al. The risk of LPP was significantly higher for second molars (p = 0.0001), and the risk increased with age (p = 0.039). There was a strong relationship between the risk of LPP and cross-section type U (p = 0.0001). The mean root to alveolar canal (RAC) distance (mm) of males was significantly higher than that of females. The mean RAC value was 5.02 mm for males and 3.49 mm for females. There was no statistically significant relationship between the risk of MCP and sex. There was a significant relationship between the risk of MCP and cross-section type U (p = 0.0001). Although the MCP risk was higher in second molars, there was no statistically meaningful relation between MCP and tooth type. The results suggest that IIP in the mandibular molar area carries a high risk of MCP and LPP. Based on the elevated level of risk, a delayed implant protocol should be considered.

Risk factors for lingual plate fracture during mandibular third molar extraction.

The aim of this study was to predict the risk of lingual plate fracture during mandibular third molar (M3) extraction. Cone beam computed tomography (CBCT) data from 264 mandibular M3s (erupted and impacted) from 264 patients (104 males and 160 females; age range, 17-75years) were retrospectively analyzed. Lingual plate thicknesses at the levels of the mid-root and root apex of the M3s were measured and defined as "thicker" (bone thicker than 1mm), "thinner" (bone thinner than 1mm), or "perforated" (bone perforated by the M3 root). These measurements were correlated with potential risk factors for thinner and perforated lingual plates: tooth position of the mandibular M3, morphology of the lingual plate, and patient characteristics (age and sex). The mean thickness of the lingual plate was 1.49 ± 1.38mm at the mid-root of the M3s, and 2.35 ± 2.03mm at the root apex. Multivariate regression analyses revealed that mesioangularly and horizontally impacted M3s were significantly associated with thinner and perforated lingual plates at the mid-root (P < 0.001), whereas the M3s in infra-occlusion positions (in infra-occlusion when compared with the adjacent second molar) had thinner lingual bone at the root apex (P= 0.022 and P= 0.027, depending on the level of impaction). Female patients were less likely to have lingual plate perforation (P = 0.036). Mesioangulation, infra-occlusion, and male sex were risk factors for lingual plate fracture. When the risk of lingual plate fracture is high, a sufficiently large flap, osteotomy, and tooth section by bur or piezosurgery are recommended to create a good operative field and avoid excessive pressure on the lingual plate.

Iatrogenic fracture of lingual plate of bone and Displacement of Mandibular Third Molar into Submandibular Tissue Space. A Case Report.

Abstract: displacement of impacted third molar tooth or fragment during surgical extraction to adjacent tissue spaces such as submandibular or pterygomandibular is not a common complication. Retrieval of displaced tooth or fragment is complicated by difficult visibility, accessibility and instrumentation. Patient and methods: Referred male patient with displaced decapitated lower third molar tooth into submandibular tissue space. The displaced tooth was retrieved intra orally by raising lingual flap, using local anesthesia nerve block. The tooth was removed safely without complications and wound healing was normal. Conclusion: wisdom tooth removal must be done by an expert surgeon with adequate clinical and radiological assessment to avoid inadvertent complications. In case of iatrogenic displacement of the tooth or fragment into tissue space, computed tomography (CT) is a proper tool to estimate its exact location. Introduction: Surgical removal of impacted wisdom teeth is common surgical procedure with minimum complications of about 1% of cases which include bleeding, pain, swelling, infection and nerve parenthesis (lingual, inferior alveolar) either temporary or permanent. 1-4 Displacement of wisdom tooth or fragment into tissue space (submandibular or pterygomandibular) is uncommon complication in practice and in literature.5, 6 Iatrogenic displacement of wisdom occur due to lack of experience, improper preoperative clinical and radiographic estimation, improper treatment plan and uncontrolled application of force specially by elevators.7 This case report showing iatrogenic displacement of decapitated lower left wisdom retrieved surgically by intraoral lingual flap approach under local anesthesia.