A 27-year-old patient reported with severe pain in the lower right back tooth region, radiating to the ear and head on the same side for the last 3–4 days. The pain persisted despite taking over-the-counter painkillers.
On clinical examination, food lodgment and tenderness were noted in relation to the lower right third molar (tooth 48). Based on the findings, an Orthopantomogram (OPG) was advised, which revealed a mesioangular impaction of 48.
Given the diagnosis and the patient’s symptoms, a surgical extraction of tooth 48 under local anesthesia was planned and carried out.
Diagnosis
Chief Complaint: Pain in lower right back tooth radiating to ear and head, unrelieved with analgesics.
Clinical Findings: Food lodgment, tenderness, and impacted mandibular third molar.
Radiographic Findings: Mesioangular impacted 48 on OPG.
Final Diagnosis: Symptomatic mesioangular impacted mandibular right third molar (48).
Surgical Procedure
Step 1: Preparation & Anesthesia
- Patient was prepared for minor oral surgical procedure under aseptic precautions.
- Local anesthesia (Inferior Alveolar Nerve Block, Lingual Nerve Block, and Long Buccal Nerve Block) was administered using 2% Lignocaine with 1:80,000 adrenaline.
- Adequate anesthesia was confirmed before proceeding.
Step 2: Incision & Flap Design
- A Ward’s incision was made a crestal incision along the external oblique ridge extending posteriorly with a relieving incision anterolaterally.
- A mucoperiosteal flap was carefully reflected buccally using a periosteal elevator to expose the underlying bone.
Step 3: Bone Guttering
- Buccal and distal bone overlying the impacted tooth was removed using a straight surgical bur under constant sterile saline irrigation.
- Bone guttering created sufficient space to access the crown of the tooth.
Step 4: Tooth Sectioning
- Since the tooth was mesioangularly impacted, sectioning was required.
- The crown was sectioned into two parts
Step 5: Tooth Removal
- Tooth fragments were luxated with elevators and delivered in parts to minimize trauma.
- Sharp bony edges were smoothened using a bone file.
Step 6: Irrigation & Closure
- The socket was thoroughly irrigated with sterile saline to remove bone debris.
- Hemostasis was achieved.
- The mucoperiosteal flap was repositioned and sutured with 3-0 black silk sutures.
Postoperative Instructions
- Cold fomentation for the first 24 hours.
- Avoid spitting, rinsing, or using a straw for 24 hours.
- Soft diet and adequate hydration.
- Medications prescribed: Antibiotics, analgesics, and antiseptic mouth rinse as per protocol.
- Follow-up after 7 days for suture removal.
Outcome
The patient tolerated the procedure well. Pain subsided significantly postoperatively, and healing was uneventful on follow-up.
Discussion
Mesioangular impaction of mandibular third molars is one of the most common types of impaction, often leading to food lodgment, pericoronitis, and radiating pain. Surgical extraction remains the definitive treatment. Proper flap design, adequate bone removal, and careful tooth sectioning are key to minimizing complications and ensuring smooth healing.
Key Takeaway for Patients
If you have persistent pain in your wisdom tooth area, especially if it radiates to the ear or head, don’t ignore it. Impacted wisdom teeth often require surgical removal to prevent repeated infection and damage to adjacent teeth. Early diagnosis and treatment ensure faster recovery and fewer complications.