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Surgical Removal of a High-Risk Vertically Impacted Lower Wisdom Tooth (#38) in Close Proximity to the Inferior Dental Nerve

Surgical Procedure

Chief Complaint

Patient presented with severe pain associated with the lower left wisdom tooth (#38).

Clinical Findings

  • Tooth #38:

    • Vertically impacted and partially erupted.

    • Tender to palpation.

    • Normal mobility.

  • Pre-operative CBCT demonstrated:

    • Three-rooted wisdom tooth.

    • Apical one-third of the roots curved distally by approximately 90 degrees.

    • Inferior Dental Nerve (IDN) closely associated with and entrapped by the root complex.

  • The case was assessed as having a high risk of Inferior Dental Nerve injury during surgery.

Treatment Plan

  • CBCT-guided surgical removal of impacted tooth #38 under local anaesthesia.

  • Careful surgical technique to minimise risk to the Inferior Dental Nerve.

  • Post-operative CBCT to confirm complete tooth removal and assess the surgical outcome.

Pre-operative Assessment

Pre-operative CBCT was reviewed to evaluate the complex root anatomy and relationship between the tooth and the Inferior Dental Nerve.

The patient was informed of:

  • The surgical procedure.

  • The significantly increased risk of temporary or permanent paraesthesia affecting the lower lip and chin due to the close relationship between the roots and the Inferior Dental Nerve.

  • General surgical risks, expected healing, and possible complications.

The patient understood the increased risks and provided informed consent before treatment.

Anesthesia

  • Left Inferior Dental Nerve Block (IDN)

  • Lingual Nerve Block (LN)

  • Long Buccal Nerve Block (LBN)

Surgical Procedure

The patient was cleaned and draped under sterile protocol.

  • Buccal incision made and full-thickness flap elevated.

  • Bone guttering performed to expose the impacted tooth.

  • Tooth sectioned to facilitate controlled removal.

  • Impacted tooth removed in three sections.

  • Extraction socket thoroughly curetted and irrigated with sterile saline.

  • Four interrupted sutures placed to achieve primary closure.

  • Haemostasis confirmed.

A post-operative CBCT confirmed:

  • Complete removal of the impacted tooth.

  • No retained tooth fragments.

  • Close relationship between the surgical site and the Inferior Dental Nerve remained evident.

Post-operative Assessment

  • Surgical site achieved satisfactory haemostasis.

  • Complete tooth removal confirmed radiographically.

  • Due to the intimate relationship between the roots and the Inferior Dental Nerve, post-operative paraesthesia involving the lower lip and chin remained a recognised possibility and appropriate follow-up was planned.

  • Patient was reassured and provided with post-operative care instructions.

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