<p> RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA BANGALORE</p><p>ANNEXURE II</p><p>PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION 8. List Of References 1. Gary F. Bouloux, Martin B. Steed, Vincent J. Perciaccante, Complications of Third Molar </p><p>Surgery, Oral Maxillofacial Surg Clin N Am 19 (2007); 117–128 2. Abel Garcia Garcia, Francisco Gude Sampedro, Jose Gandara Rey, Mercedes Gallas </p><p>Torreira: Trismus and pain after removal of impacted lower third molars, J Oral Maxillofac </p><p>Surg 55:1223-1226, 1997 3. Sam E. Farish, Gary F. Bouloux, General Technique of Third Molar Removal , J Oral </p><p>Maxillofacial Surg Clin N Am 19 (2007) 23–43 4. Ngeow WC; Tooth section technique for wisdom teeth, Int J Oral Maxillofac Surg 38:908, </p><p>2009 5. Landi L,Manicone PF,Piccinelli S,Raja A,Raja R:A novel surgical approach to impacted </p><p> mandibular third molars to reduce the risk of paresthesia;a case series, J Oral Maxillofac </p><p>Surg 68(5):969-974, 2010 6. Praveen G,Rajesh P,Neelakandan RS,Nandagopal CM: Comparison of morbidity following </p><p> the removal of mandibular third molar by lingual split,surgical bur and simplified split bone </p><p> technique. Indian J Dent Res 2007;18:15-8. 7. Engelke W,et al.,Removal of impacted mandibular third molars using an inward </p><p> fragmentation technique(IFT)-Method and first results,journal of cranio-maxillo-facial </p><p> surgery(2013) 1-7.</p><p>INFORMED CONSENT</p><p>TITLE: “EFFICACY OF INWARD FRAGMENTATION TECHNIQUE VERSUS CONVENTIONAL TECHNIQUE IN THE SURGICAL REMOVAL OF IMPACTED MANDIBULAR THIRD MOLAR”</p><p>UNDERTAKING BY THE INVESTIGATOR:</p><p>Your consent to participate in the above study is sought. You have the right to refuse consent or withdraw the same during any part of the study without giving any reason. We undertake to maintain complete confidentiality regarding the identity of the subjects and the information obtained from the subject/patient during the course of the study. We assure that all the standard infection control precautions will be strictly adhered to throughout the study. If you have any doubts regarding the study, please feel free to clarify the same. Even during the study, you are free to contact any of the investigators for clarification if you desire. The list of investigators and their contact numbers are below:</p><p>Dr. Chandrashekar raju Dr. K .Ranganath 9448668386 9844181097</p><p>CONSENT</p><p>I ______the undersigned hereby authorize Dr.______at M. S. Ramaiah Dental College and Hospital to perform upon me the following procedure(s) for research purpose:</p><p>1. Surgical removal of impacted mandibular third molar by Conventional Technique on one side and Inward Fragmentation Technique on the opposite side. All the patients undergoing surgical procedure will be advised a 5 day course of oral antibiotic and analgesic. Patients will be advised to take soft diet for 3 days and rinse oral cavity using chlorhexidine mouth wash for 7 days postoperatively.</p><p>The above procedure along with the purpose of the study has been explained to me in detail in intelligible terms. I have received appropriate response to all my doubts and clarifications. I understand that I will be exposed to radiation dose twice or more during the course of the study. I also understand that photographs will be taken in the course of the study and that the results generated from this study can be published in scientific literature, for which I do not have any objections. I have understood that I have the right to refuse my consent or withdraw it at any time during the study. I understand that signing this consent form indicates that I voluntarily agree to participate in this study. </p><p>I confirm that I understand the information presented in this consent form.</p><p>Signature of Participant Date: Place: Signature of Witness</p><p>Date: Place:</p><p>Signature of the investigator 1 (Dr. Chandrashekar Raju) Date: Place:</p><p>Signature of the investigator 2 (Dr. K. Ranganath)</p><p>Date: Place: M. S. RAMAIAH DENTAL COLLEGE AND HOSPITAL</p><p>IMPACTED TOOTH REMOVAL PROFORMA</p><p>Name: O.P.No.: Date: </p><p>Age: Sex: Occupation:</p><p>Address:</p><p>CHIEF COMPLAINT:</p><p>HISTORY OF PRESENT ILLNESS:</p><p>H/O PERICORONITIS/ABSCESS:</p><p>ANY TREATMENT RECEIVED: Y/N</p><p>IF YES, PLEASE SPECIFY:</p><p>DENTAL HISTORY:</p><p>MEDICAL HISTORY:</p><p>DRUG ALLERGY: CLINICAL EXAMINATION:</p><p>EXTRAORAL: </p><p> Facial symmetry:</p><p> Mouth opening(using scale and divider):</p><p> Micrognathia:</p><p> Macrognathia:</p><p> Normal:</p><p>INTRAORAL:</p><p>Impacted tooth: Surrounding soft tissue: </p><p> Inflammed/Normal</p><p> Ulcer: Present/Absent</p><p> Fibrosed: Y/N</p><p> Completely covered by soft tissue or partially exposed:</p><p>Pericoronitis:</p><p> Acute infection if any:  Swelling:</p><p> Discharge:</p><p> Pain/ Difficulty in chewing:</p><p> No. of episodes:</p><p>Condition of adjacent mandibular second molar:</p><p> Any caries:</p><p> Periodontal involvement:</p><p> RCT: Y/N</p><p>Upper tooth:</p><p> Present/Absent</p><p> Impinging on soft tissue: Y/N </p><p> Position: Normal/Buccal/Supra erupted</p><p>Tongue: Macro/Micro/Normal INVESTIGATIONS:</p><p> IOPAR:</p><p> OPG:</p><p>Radiographic and Clinical co-relation:</p><p>Tooth impaction: Y/N</p><p>DIAGNOSIS:</p><p>CLASSIFICATION:</p><p>WAR LINES: WHARF ASSESSMENT:</p><p>TREATMENT PLAN:</p><p>TREATMENT DONE:</p><p>Surgical method:</p><p>Block given:</p><p>Incision:</p><p>Procedure: Duration:</p><p>Medication:</p><p>Follow up and complications:</p><p>TABLE 1: Preoperative parameters</p><p>Type of impaction Interincisal distance Baseline measurement Radiographic assessment of bone height</p><p>TABLE 2: Intraoperative parameters</p><p>Duration of Surgery TABLE 3: Post operative parameters</p><p>Parameters Day 1 Day 3 Day 7 1 Month Pain Swelling Inter-incisal distance Infection Radiographic assessment of bone height Additional findings</p>