Patient Profile:
- Age: 27 years
- Gender: Male
- Chief Complaint: Severe pain in the lower right back tooth region for the past 7 days, radiating to the ear and right side of the head.
Clinical Presentation:
The patient reported continuous, throbbing pain that worsened while chewing and at night. He also experienced:
- Pain radiating to the ear and temple region
- Difficulty opening the mouth (reduced mouth opening/trismus)
- Difficulty chewing on the right side
Clinical Examination:
- Tooth 48 (lower right third molar) was found to be partially visible and impacted.
- Surrounding soft tissues were inflamed.
- The tooth was severely tender on percussion (TOP positive).
- Signs of pericoronal infection were evident.
Radiographic Investigation:
An Orthopantomogram (OPG) was advised to determine:
- The exact position and angulation of the impacted 48
- Its proximity to the inferior alveolar nerve
OPG Findings:
- 48 was mesioangularly impacted, partially erupted, and pressing against the distal root of 47.
- Close approximation to the inferior alveolar nerve canal.
Diagnosis:
- Impacted 48 with pericoronitis
- Trismus and referred pain to the ear and head due to pressure and infection
Treatment Plan:
A surgical extraction of 48 under local anaesthesia was planned and explained to the patient.
Surgical Procedure:
Step 1: Local Anaesthesia
- Inferior alveolar nerve block given using 2% lignocaine with adrenaline
- Buccal and lingual infiltration for enhanced anaesthesia
Step 2: Flap Reflection
- A Ward’s incision was made along the external oblique ridge and extended distally.
- A full-thickness mucoperiosteal flap was elevated to expose the underlying bone.
Step 3: Bone Removal
- The buccal bone was guttered using a surgical bur under copious saline irrigation to expose the crown.
Step 4: Tooth Sectioning
- Due to the angulation and root morphology, the tooth was sectioned into crown and root parts.
- Each section was carefully elevated and removed without exerting pressure on the nerve area.
Step 5: Socket Management and Closure
- The socket was thoroughly irrigated with saline, debrided, and checked for any root remnants.
- The surgical site was sutured with 3-0 silk sutures.
Postoperative Care:
- Prescribed antibiotics and anti-inflammatory analgesics
- Advised cold fomentation for the first 24 hours and warm saline rinses after 48 hours
- Instructions for soft diet, no spitting or straw use, and maintaining oral hygiene
Follow-Up:
The patient returned after 7 days for suture removal with marked relief from pain and improved mouth opening.
Healing was uneventful, and the radiating symptoms had completely resolved.
Conclusion:
Impacted third molars can often cause radiating pain, infection, and limited mouth opening. Early evaluation and timely surgical intervention help prevent complications like abscesses, cysts, or nerve damage. This case highlights the importance of accurate diagnosis through imaging and skilled surgical care.