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Patient of the Week

 Case of the Week:

 How to convert a moderately difficult impacted wisdom tooth extraction into a straightforward extraction!! 

Hi, welcome to this weeks case of the week. If I recommended that one of your lower third molar wisdom teeth be surgically extracted you might not be too happy?
What with the post-operative pain, swelling, stiffness and the possibility of a getting a numb lip and or tongue, I would not be too enthusiastic myself.
Well this 25 year old patient arrived in on Monday for his recall examination appointment. With college and travelling abroad it had been two years since his last visit. Back then he came to see me with a dental infection around his left lower (mandibular) third molar wisdom tooth. This tooth was partially erupted with the back half of the tooth impacted under the gum. This gum tissue was red, swollen, painful and infected!! This gum tissue was being traumatized by the upper (maxillary) third molar wisdom tooth which had overerupted, growing down and preventing the lower wisdon erupting fully. I call this a gum sandwich!!
At this point we take a radiograph called a panoral OPG x-ray.
 This x ray is showed that the lower third molar wisdom tooth was vertically impacted. The soft gum tissue overlying the back of the tooth and the overerupted upper third molar wisdom tooth were both stopping the lower third molar wisdom tooth coming up and erupting into function. Crucially however the root of the lower wisdom tooth was very close to the nerve that supplies sensation to the lip. This nerve is called the inferior alveolar nerve or the inferior dental nerve (ID nerve). If this nerve got damaged during the surgical extraction of this tooth the patient could end up with a numb lip (sometimes permanently)!!!
Can you guess what treatment we would recommend in a case like this?
My recommendation to the patient was to extract the over erupted upper maxiallary third molar wisdom tooth and a course of antibiotics to sort out the pericoronitis infection around the impacted lower third molar wisdom tooth.
The Advantages of this Treatment Recommendation are:
1.            Upper maxillary wisdom teeth extractions in young adults are usually straightforward and can be quickly done under local anesthetic. Post-operatively there is minimal pain and swelling.
2.             Lower mandibular impacted wisdom teeth extraction can be difficult surgical procedures requiring a general anesthetic and hospital admission under an oral and maxillofacial surgeon. Postoperatively one can expect pain, swelling, brusing and a stiff jaw.
3.            If the lower mandibular wisdom tooth is removed while there is still acute pericoronitis infection present there is an increased risk of post operative complications. These include “dry socket”, pain etc.
4.            Removing te upper maxillary wisdom tooth removes the risk of damage to the nreve that supplies sensation to the lip( inferior alveolar nerve) and the nerve that supplies sensation to the tongue (lingual nerve).
So that’s what we did. Local anaesthetic given and with gentle elevation the upper maxillary third molar was easily extracted. A perscription for antibiotics and anti inflamatory pain medicine was given to the patient to be dispensed by his pharmacist.
One week later we saw the patient again for a post operative review appointment. The extraction socket was healing over nicely and the pericoronitis infection had resolved.
Fast forward two years later to this week. The patients lower mandibular third molar wisdom tooth has fully erupted and he has not had any problems since. He makes a special effort to keep it clean brushing it gently twice a day and flossing it regularly also. He remembers his acute pericoronitis infection and he doesn’t want it to return!!!!
I took another panoral opg radiograph to see how it looked now.
The lower wisdom tooth has really erupted maybe even slightly over erupted. We will be keeping a close eye on it at the patients next recall examination appointment to make sure the gum around it continues to be satisfactory and free from any infection. If it ever needs to be extracted it will be a much easier procedure and I would not expect it to require surgical removal.

The HUGE EXTRA BIG BONUS of this treatment is that the root of the mandibular wisdom tooth has grown away from the nerve that supplies sensation to the lip!!!




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