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Surgical Removal of Complex Mesioangular Impacted #38 in Close Proximity to Inferior Alveolar Nerve

Surgical Procedure

Chief Complaint

Pain and swelling associated with lower left wisdom tooth (#38).
Patient requested removal of the affected tooth.

Clinical Findings

Clinical and radiographic assessment revealed:

  • Mesioangular impaction of #38

  • Four-rooted morphology

  • Dense surrounding mandibular bone

  • Inferior alveolar nerve (IDN) passing between the roots of #38

  • Localized pain and swelling in the lower left posterior region

Pre-operative CBCT taken for surgical planning and nerve relationship assessment.

Treatment Plan

  • Surgical removal of impacted #38 under local anesthesia

  • Extraction of #28 planned at a later stage

Risks explained, including possible paresthesia involving the lower lip and tongue due to proximity of the inferior alveolar nerve.
Patient and parents understood and agreed to proceed with removal of #38 first.
Informed consent obtained prior to surgery.

Pre-operative Assessment

CBCT evaluation confirmed:

  • Complex root morphology (four-rooted configuration)

  • Dense surrounding cortical bone

  • Inferiority alveolar nerve positioned between roots of #38

Surgical removal planned with nerve-preservation strategy.

Anesthesia

Inferior Dental Nerve block
Lingual nerve block
Long buccal nerve block

Adequate anesthesia achieved prior to procedure.

Surgical Procedure

Procedure performed as follows:

  • Patient prepared and draped under sterile conditions

  • Incision made

  • Buccal flap elevated

  • Bone guttering performed to expose impacted tooth

  • Tooth sectioned carefully due to complex root anatomy

  • #38 removed in four segments

  • Curettage performed

  • Surgical site irrigated with saline

  • Primary closure achieved with sutures

  • Hemostasis confirmed

Post-operative CBCT taken.

No retained tooth fragments detected.
Inferior alveolar nerve not involved intraoperatively.

Post-operative Assessment

Surgical removal completed successfully.
No nerve involvement detected.
No residual fragments present radiographically.
Patient reassured and post-operative instructions provided.

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