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Surgical Removal of an Impacted Lower Wisdom Tooth (#38), Retained Roots (#37), and Upper Wisdom Tooth Extraction (#28)

Surgical Procedure

Chief Complaint

Patient presented with pain in the lower left wisdom tooth region.

Clinical Findings

  • Tooth #38

    • Impacted lower wisdom tooth.

    • Extensive occlusal caries with pulpal involvement.

    • Very tender to percussion and palpation.

    • Normal mobility and periodontal probing depths.

    • Negative bite test.

  • Tooth #37

    • Grossly carious retained roots.

    • Very tender to percussion and palpation.

    • Normal mobility and periodontal probing depths.

  • Tooth #28

    • Non-functional upper wisdom tooth causing trauma to the lower ridge.

  • Pre-operative CBCT reviewed with mapping of the Inferior Dental Nerve (IDN).

Treatment Plan

  • Surgical removal of impacted tooth #38.

  • Surgical removal of retained roots of tooth #37.

  • Extraction of non-functional tooth #28.

  • Pre- and post-operative CBCT imaging.

  • Standard post-operative review and care instructions.

Pre-operative Assessment

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

The patient was informed of:

  • The planned surgical procedures.

  • Risk of temporary or permanent altered sensation (paraesthesia) affecting the lower lip and tongue.

  • Risk of oro-antral communication (OAC) or oro-antral fistula (OAF) associated with the upper wisdom tooth extraction.

  • Expected healing process and possible complications.

The patient also demonstrated significant dental anxiety and was counselled regarding the challenges this could present during surgery.

The patient understood the treatment plan and provided informed consent.

Anesthesia

  • Left Inferior Dental Nerve Block (IDN)

  • Lingual Nerve Block (LN)

  • Long Buccal Nerve Block (LBN)

  • Local infiltration for tooth #28

Surgical Procedure

The patient was cleaned and draped under sterile protocol.

Tooth #38

  • Buccal incision made and full-thickness flap elevated.

  • Bone guttering performed.

  • Tooth sectioned.

  • Impacted wisdom tooth removed in three sections.

Tooth #37

  • Retained roots surgically removed in two sections.

During the procedure, treatment was technically challenging because the patient had severe dental anxiety and made sudden involuntary movements whenever force was applied. This significantly increased the difficulty of administering local anaesthesia, tooth sectioning, elevation, and controlled extraction. Despite these challenges, the procedures were completed safely.

  • Extraction sockets thoroughly curetted and irrigated with sterile saline.

  • Three interrupted sutures placed to achieve primary closure.

  • Haemostasis confirmed.

Tooth #28

  • Tooth extracted under local anaesthesia.

  • Socket irrigated with sterile saline.

  • Haemostasis achieved.

A post-operative CBCT confirmed:

  • Complete removal of all teeth and retained roots.

  • No retained tooth fragments.

  • Inferior Dental Nerve remained intact.

  • Maxillary sinus remained uninvolved.

Post-operative Assessment

  • Surgical sites achieved satisfactory haemostasis.

  • Complete removal confirmed radiographically.

  • Inferior Dental Nerve and maxillary sinus remained intact.

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

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