Chief Complaint:

A patient reported with pain localized to:

  • Upper left back tooth region, and
  • Lower right back tooth region

No relevant medical history was noted

Clinical Examination:

Intraoral Findings:

1. Tooth 28 (Upper Left Third Molar):

  • Grossly decayed
  • Erupted and visible in the oral cavity
  • Tender on percussion 

2. Tooth 18 (Upper Right Third Molar):

  • Buccally positioned
  • Mild soft tissue impingement noted
  • No decay, but prone to trauma from occlusion 

3. Tooth 48 (Lower Right Third Molar):

  • Clinically non-visible
  • Buccal and distal swelling noted
  • Tender on palpation

Radiographic Evaluation:

OPG Findings:

Tooth 28: Cariously involved crown with visible roots; not impinging on the maxillary sinus

Tooth 18: Fully erupted, buccally tilted, without pathology

Tooth 48: Mesioangular impaction, distal caries, close proximity to the inferior alveolar canal, requiring surgical intervention

Diagnosis:

  • Caries with symptomatic pulpitis in 28 and 48
  • Soft tissue irritation from malpositioned 18
  • Mesioangular impaction of 48 with pericoronal inflammation

Treatment Plan:

1. Non-surgical extractions:

  • Tooth 28 (grossly carious but erupted)
  • Tooth 18 (buccally placed, asymptomatic caries-free but causing trauma) 

2. Surgical disimpaction:

  • Tooth 48 (impacted, decayed, symptomatic)

All treatment to be performed under local anesthesia in outpatient setting, with strict asepsis.

Detailed Procedure

Step 1: Non-Surgical Extraction of Tooth 28 (Upper Left Third Molar)

Anesthesia:

  • Posterior superior alveolar (PSA) nerve block administered with 2% lignocaine with 1:80,000 adrenaline

Procedure:

  • Tooth isolated and surrounding soft tissues retracted
  • Luxation done using straight elevator
  • Maxillary molar forceps applied, gentle buccopalatal rocking
  • Tooth delivered intact
  • Socket checked for any root remnants
  • Hemostasis achieved with gauze pressure

NHGBAnesthesia:

PSA and greater palatine nerve block

Procedure:

  1. Buccally placed 18 was accessible for conventional extraction
  2. Minimal luxation due to position
  3. Tooth removed using maxillary molar forceps
  4. Care taken to avoid fracture of the thin buccal plate
  5. Socket irrigated and packed

Step 3: Surgical Disimpaction of Tooth 48 (Lower Right Third Molar)

Anesthesia:

  • Inferior alveolar nerve block
  • Long buccal nerve infiltration
  • Lingual nerve retraction done cautiously

Surgical Protocol:

Flap Design:

  • Modified Ward’s incision given extending from second molar to anterior ramus
  • Full-thickness mucoperiosteal flap raised

Bone Removal:

  • Buccal bone overlying crown removed using #702 surgical bur under copious saline irrigation
  • Bone guttering extended until sufficient crown visibility achieved

Tooth Sectioning:

  • Crown cut horizontally into mesial and distal halves to minimize bone trauma
  • Root separation avoided unless needed

Elevation and Removal:

  • Tooth fragments elevated using Cryer and Warwick James elevators
  • Removed in parts with minimal pressure to avoid root fracture or nerve injury

Debridement & Irrigation:

  • Socket irrigated thoroughly with saline and diluted povidone-iodine
  • Sharp bone spicules removed
  • Bleeding controlled using Gelfoam if necessary

Closure:

  • Flap repositioned and sutured with 3-0 black silk using interrupted sutures
  • Gauze pressure pack placed

Post-Operative Care & Instructions

Medications:

Antibiotics: Amoxicillin 500 mg TID for 5 days / or as per sensitivity

Analgesics: Ibuprofen 400 mg + Paracetamol 325 mg TID

Mouthwash: 0.12% Chlorhexidine gluconate, twice daily from day 2 onwards

Patient Instructions:

First 24 Hours:

  • Bite gently but firmly on the gauze pad for 30–45 minutes
  • No spitting, rinsing, or straw use to avoid dry socket
  • Apply ice pack externally over the surgical site (15 mins on/off cycle)

Days 2–7:

  • Warm saline rinses 4–5 times daily after meals
  • Brush other teeth normally; avoid brushing surgical site
  • Take soft diet: avoid spicy, hot, and hard foods
  • Do not disturb the extraction sites with tongue or fingers

Follow-Up:

  • Suture removal after 7–10 days
  • Evaluate for healing, swelling, infection, or nerve injury
  • Educate patient on signs of complications (e.g. numbness, foul taste, persistent swelling)

Clinical Insight:

This case demonstrates the necessity of tailoring third molar management based on:

  • Position
  • Accessibility
  • Pathology present

Non-surgical extractions prevent prolonged chair time and are appropriate for erupted, accessible molars. Impacted and decayed teeth like 48 must be surgically managed to avoid complications such as pericoronitis, cyst formation, or nerve damage.

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