Patient Presentation
A 25-year-old patient reported with a complaint of pain in the lower right back tooth region for several days. The pain was associated with difficulty in chewing and mild swelling of the overlying gum.
The patient had no relevant medical history.
On clinical examination, the mandibular right third molar (48) was partially visible with inflamed gum tissue surrounding it. The tooth was impacted and associated with pericoronitis (infection of the gum flap overlying the tooth).
Considering the symptoms and findings, a surgical extraction of 48 under local anesthesia was planned and performed.
Diagnosis
- Chief Complaint: Pain in lower right back tooth.
- Clinical Findings: Partially erupted and tender 48 with inflamed operculum (pericoronitis).
- Radiographic Findings (OPG): Impacted mandibular right third molar (48).
- Final Diagnosis: Impacted 48 with pericoronitis.
Treatment Performed: Surgical Extraction of 48
Step 1: Preparation & Anesthesia
- The patient was prepared under aseptic conditions.
- Local anesthesia was administered: Inferior alveolar nerve block, lingual nerve block, and long buccal nerve block using 2% lignocaine with 1:80,000 adrenaline.
- Adequate anesthesia was confirmed before starting the procedure.
Step 2: Incision & Flap Reflection
- A Ward’s incision was placed extending along the external oblique ridge with a relieving incision anteriorly.
- A full-thickness mucoperiosteal flap was carefully reflected to expose the surgical site.
Step 3: Bone Removal
- Buccal and distal bone covering the impacted tooth was removed using a straight surgical bur under continuous sterile saline irrigation.
- Bone guttering created sufficient access for tooth removal.
Step 4: Tooth Sectioning & Removal
- As the tooth was partially impacted, sectioning of the crown was carried out for easy removal.
- The tooth was luxated using elevators and delivered in parts.
- The socket was checked for any remaining root fragments and sharp bony edges were smoothened with a bone file.
Step 5: Irrigation & Debridement
- The extraction socket was thoroughly irrigated with sterile saline to remove bone and tooth debris.
- Infected granulation tissue associated with pericoronitis was debrided.
Step 6: Suturing
- The flap was repositioned properly over the socket.
- Primary closure was achieved using 3-0 black silk sutures with simple interrupted technique.
- Hemostasis was confirmed.
Postoperative Instructions
- Apply cold packs intermittently on the surgical area for the first 24 hours to reduce swelling.
- Do not spit, rinse, or drink with a straw for the first 24 hours.
- Maintain a soft diet and chew away from the surgical site.
- Keep the mouth clean; start gentle warm saline rinses from the next day.
- Medications prescribed: Antibiotics, analgesics, and antiseptic mouthwash.
- Avoid smoking or alcohol for at least a week.
- Return after 7 days for suture removal and follow-up check.
Outcome
The patient tolerated the procedure well. Pain and gum swelling subsided significantly post-extraction. Healing was satisfactory on follow-up after one week, and sutures were removed uneventfully.
Discussion
Pericoronitis is a common infection associated with partially erupted impacted third molars, as food and bacteria get trapped beneath the gum flap. This can cause repeated pain, swelling, pus discharge, and even difficulty in opening the mouth if untreated. Surgical extraction is the most effective and permanent treatment option in such cases.