Patient Profile
- Chief Complaint: The patient presented with pain in the upper left back tooth region and an ulcer on the adjacent cheek for the past 3–4 days.
- Medical History: No relevant medical history
Clinical Examination
1. Tooth 28 (Upper Left Third Molar)
- Grossly decayed
- Buccally positioned, leading to mucosal irritation
2. Ulcer
- Noted on the adjacent buccal mucosa, likely due to repeated trauma from the malpositioned tooth
3. Radiographic Evaluation
- OPG advised to evaluate root morphology and relation to maxillary sinus
- No evidence of periapical pathology or sinus involvement
Diagnosis
- Decayed and buccally placed tooth 28 causing
- Treatment Plan: Extraction of 28 under local anesthesia
Treatment Procedure: Simple Extraction of Tooth 28
Step-by-Step
1. Preoperative Preparation:
- Informed consent obtained.
- Pre-procedural rinse with 0.12% chlorhexidine.
- Local anesthesia administered using posterior superior alveolar nerve block.
2. Tooth Extraction:
- Atraumatic extraction using elevators and forceps.
- Tooth removed without complications.
- Socket inspected and irrigated with saline to remove debris.
3. Hemostasis:
- Gauze pressure applied to control bleeding.
- Post-extraction instructions provided.
Postoperative Care
1. Analgesics and antibiotics prescribed for pain and infection control.
2.Patient advised to:
- Avoid hot/spicy food to aid ulcer healing
- Use chlorhexidine mouthwash twice daily
- Maintain oral hygiene and avoid rinsing for the first 24 hours
3. Ulcer expected to resolve within a week as the source of trauma is eliminated
Follow-Up
Reviewed after 1 week:
- Ulcer healing well
- No post-operative pain or swelling
- Complete mucosal recovery observed
Outcome
- Successful removal of the symptomatic 28.
- Resolution of mucosal ulcer caused by traumatic occlusion.
- Patient comfortable and pain-free post-treatment.