A Case Report on Minor Oral Surgery to Remove Mandibular ...
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International Medical Journal Vol. 26, No. 4, pp. 343 - 344 , August 2019 CASE REPORT A Case Report on Minor Oral Surgery to Remove Mandibular Third Molar Shaifulizan Ab Rahman 1) , Lee Win Nie 1) , Sanjida Haque 2) , Mohammad Khursheed Alam 3) ABSTRACT Background: Third molar surgery is the most common procedure performed worldwide. Case Presentation: This is a case report of a 30 year old male patient with no known medical illness came for minor oral sur- gery to remove tooth 48 under local anesthesia. During the luxation of the root, there is a small portion of root tip was fractured and left behind in the socket. Periapical radiograph was taken and it shows that the root tip is less than the size of 3 mm. The root remnants was left in situ and kept monitoring. Conclusion: In this report, the discussion will focus on root fracture during minor oral surgery to remove mandibular third molar and its management. KEY WORDS minor oral surgery; third molar surgery, mandibular third molar; root fracture Received on April 17, 2018 and accepted on July 1, 2018 1) Oral surgery and Maxillofacial surgery Department, School of Dental Sciences, Universiti Sains Malaysia 16150 Kubang Kerian, Kelantan, Malaysia 2) Orthodontic Unit, School of Dental Sciences, Universiti Sains Malaysia 16150 Kubang Kerian, Kelantan, Malaysia 3) Orthodontic Department, College of Dentistry, Jouf University Sakaka, KSA Correspondence to: Shaifulizan Ab Rahman (e-mail: [email protected]) 343 INTRODUCTION Third molar surgery is the most common minor oral surgery per- formed worldwide. As we know, third molar removal requires accurate planning and surgical skills of oral maxillofacial surgeons. No matter how good the skill of a surgeon is, complications can always arise. In the literature, the frequency of complication after third molar removal is between 2.6% and 30.9% 1) . The factors that might influence the incidence of complications after third molar removal include age, gender, medical history, oral con- traceptives, presence of pericoronitis, poor oral hygiene, smoking, type of impaction, relationship of third molar to the inferior alveolar nerve, surgical time, surgical technique, surgeon experience, use of periopera- tive antibiotics, use of topical antiseptics, use of intra-socket medica- tions, and anesthetic technique. Therefore, it is very imperative where prior to any surgical procedure, the patient must be informed about the possible accidents and/or complications that may occur during the entire treatment, being aware of the fact that any unexpected situation should be dealt with the best possible way. CASE REPORT A 30 year old Malay man with no known medical illness came for minor oral surgery to remove tooth 48 under local anesthesia. He had gum pain 2 months ago for 3 days on the lower right posterior area. It is continuous throbbing pain that radiates to the lower border of mandible with pain score of 4 out of 10 which is aggravated when with eating. No abnormality was detected on the soft tissue upon intra-oral examination. However multiple toothbrush abrasion lesions were noted. Tooth 38 and 48 were partially erupted. Tooth 48 was mesio-angularly impacted, however whole crown was erupted. The operculum was not present and also not inflamed. Orthopantomogram revealed no abnormality except the tooth 48 was mesioangularly impacted with Pell and Gregory Classification of 1A. The mandibular canal was intact with no deflection. The root of tooth 48 was separated from mandibular canal and also diagnosed with recurrent pericoronitis (Figure 1). It was planned for surgical removal of impacted 48 under local anesthesia. The surgical procedures (Figure 2) are given bellow: 1. Benzocaine 2% topical anaesthesia applied on dried mucosa using orange stick. Inferior alveolar nerve, long buccal nerve and lingual nerve on right mandible were blocked using 3 cartridge of 2.2ml mepivacaine with 1:100000 adrenaline. Local anesthe- sia was achieved. 2. Standard disinfection and draping of patient done. 3. 3 corner incision flap was done. 4. Buccal bone guttering done using round surgical bur followed by straight fissure bur. 5. Tooth was sectioned vertically until furcation of root, separated into 2 sections. 6. Coupland elevator was used to elevate the tooth. 7. However, the small root tip of the distal root was left in the bone. Cryers elevator and bone guttering were done to try to remove the root remnants, however, it is all in vain. The final decision was to leave the small root remnants in situ. The patient was informed about this condition (Peripaical radiograph was taken) (Figure 3). 8. Bone file was used to remove sharp edges. 9. Copious irrigation was done using normal saline. 10. Hemostasis achieved C 2019 Japan Health Sciences University & Japan International Cultural Exchange Foundation
Transcript of A Case Report on Minor Oral Surgery to Remove Mandibular ...
International Medical Journal Vol. 26, No. 4, pp. 343 - 344 , August 2019
CASE REPORT
A Case Report on Minor Oral Surgery to Remove Mandibular Third Molar
Shaifulizan Ab Rahman1), Lee Win Nie1), Sanjida Haque2), Mohammad Khursheed Alam3)
ABSTRACTBackground: Third molar surgery is the most common procedure performed worldwide. Case Presentation: This is a case report of a 30 year old male patient with no known medical illness came for minor oral sur-
gery to remove tooth 48 under local anesthesia. During the luxation of the root, there is a small portion of root tip was fractured and left behind in the socket. Periapical radiograph was taken and it shows that the root tip is less than the size of 3 mm. The root remnants was left in situ and kept monitoring.
Conclusion: In this report, the discussion will focus on root fracture during minor oral surgery to remove mandibular third molar and its management.
KEY WORDSminor oral surgery; third molar surgery, mandibular third molar; root fracture
Received on April 17, 2018 and accepted on July 1, 20181) Oral surgery and Maxillofacial surgery Department, School of Dental Sciences, Universiti Sains Malaysia 16150 Kubang Kerian, Kelantan, Malaysia2) Orthodontic Unit, School of Dental Sciences, Universiti Sains Malaysia 16150 Kubang Kerian, Kelantan, Malaysia3) Orthodontic Department, College of Dentistry, Jouf University Sakaka, KSACorrespondence to: Shaifulizan Ab Rahman(e-mail: [email protected])
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INTRODUCTION
Third molar surgery is the most common minor oral surgery per-formed worldwide. As we know, third molar removal requires accurate planning and surgical skills of oral maxillofacial surgeons. No matter how good the skill of a surgeon is, complications can always arise. In the literature, the frequency of complication after third molar removal is between 2.6% and 30.9%1).
The factors that might influence the incidence of complications after third molar removal include age, gender, medical history, oral con-traceptives, presence of pericoronitis, poor oral hygiene, smoking, type of impaction, relationship of third molar to the inferior alveolar nerve, surgical time, surgical technique, surgeon experience, use of periopera-tive antibiotics, use of topical antiseptics, use of intra-socket medica-tions, and anesthetic technique. Therefore, it is very imperative where prior to any surgical procedure, the patient must be informed about the possible accidents and/or complications that may occur during the entire treatment, being aware of the fact that any unexpected situation should be dealt with the best possible way.
CASE REPORT
A 30 year old Malay man with no known medical illness came for minor oral surgery to remove tooth 48 under local anesthesia. He had gum pain 2 months ago for 3 days on the lower right posterior area. It is continuous throbbing pain that radiates to the lower border of mandible with pain score of 4 out of 10 which is aggravated when with eating.
No abnormality was detected on the soft tissue upon intra-oral examination. However multiple toothbrush abrasion lesions were noted.
Tooth 38 and 48 were partially erupted. Tooth 48 was mesio-angularly impacted, however whole crown was erupted. The operculum was not present and also not inflamed.
Orthopantomogram revealed no abnormality except the tooth 48 was mesioangularly impacted with Pell and Gregory Classification of 1A. The mandibular canal was intact with no deflection. The root of tooth 48 was separated from mandibular canal and also diagnosed with recurrent pericoronitis (Figure 1). It was planned for surgical removal of impacted 48 under local anesthesia.
The surgical procedures (Figure 2) are given bellow:
1. Benzocaine 2% topical anaesthesia applied on dried mucosa using orange stick. Inferior alveolar nerve, long buccal nerve and lingual nerve on right mandible were blocked using 3 cartridge of 2.2ml mepivacaine with 1:100000 adrenaline. Local anesthe-sia was achieved.
2. Standard disinfection and draping of patient done. 3. 3 corner incision flap was done. 4. Buccal bone guttering done using round surgical bur followed by
straight fissure bur. 5. Tooth was sectioned vertically until furcation of root, separated
into 2 sections. 6. Coupland elevator was used to elevate the tooth. 7. However, the small root tip of the distal root was left in the bone.
Cryers elevator and bone guttering were done to try to remove the root remnants, however, it is all in vain. The final decision was to leave the small root remnants in situ. The patient was informed about this condition (Peripaical radiograph was taken) (Figure 3).
8. Bone file was used to remove sharp edges. 9. Copious irrigation was done using normal saline. 10. Hemostasis achieved
C 2019 Japan Health Sciences University & Japan International Cultural Exchange Foundation
Rahman S. A. et al.344
11. Suture was done using absorbably suture Vicryl 3-0 (3 sutures). 12. Final irrigation done using normal saline 13. Damp gauzed placed. 14. Plan: ● Post-operation instruction was given. ● Tab Paracetamol 1000 mg PRN x 4 tabs given. ● Tab Metronidazole 400 mg TDS.● Tab Tramadol 50 mg TDS.● Chlorhexidine gluconate mouthwash 0.2% 15 ml TDS. ● TCA for review 1/52 after minor oral surgery. ● Medical certificate given for 3 days
DISCUSSION
An impacted tooth is defined as the one that fails to erupt into prop-er functional position in the dental arch within the expected time. The wisdom tooth, also known as the mandibular third molar is the most commonly impacted tooth, followed by maxillary third molar, maxillary canine and mandibular canine respectively2).
The surgical removal of third molar elicits a debate worldwide because of the varying degree of difficulty of the operation and researchers have related operative difficulty of impacted third molar to attendant inflammatory complications of the procedure and the resulting morbidity3). Most third molar surgeries are performed without complica-tions, but still serious complications might have chances to occur, such as hemorrhage, persistent pain and swelling, infection, dry socket (alve-olar osteitis), dentoalveolar fracture, paresthesia of the inferior alveolar nerve and of the lingual nerve, temporomandibular joint injury and even mandibular fracture4-8).
In this case report, the intra-operative complication occurs where the distal root tips remained in the bone while the other part was suc-cessfully removed from socket. This may be due to the dilacerated distal root. The dilaceration may occur anywhere along the length of the crown or root. However, studies show that the dilacerations occurs most
frequently in the apical third of the roots. The extraction of the affected teeth may be difficult and result in root fracture on removal9).
According to Knutsson et al., the broken fragments of vital teeth generally heal without complication, if a root is broken during extraction of a regular uninfected tooth, it can be safely be left in situ. But, this is not applicable to all third molar teeth. The teeth with acute infection and mobile teeth should be excluded, because the root rem-nants of those teeth may act like foreign bodies. In this case, the tooth 48 did not have any acute infection and the tooth was not mobile, thus the root remnants still could be left in situ with periodical monitoring for healing process10).
If we decide to leave the root remnant in situ, the patient should be informed of the condition. Radiograph should be taken and the circum-stances should be documented in patient's record. The patient should be put into follow up periodically to ensure uneventful healing. Thus in this case, the condition was explained to the patient and the proper docu-mentation was done. This is very important to avoid any medico-legal issues and avoid any misdiagnosis by other physician.
REFERENCES
1) Bui CH, Seldin EB, Dodson TB. Types, frequencies, and risk factors for complications after third molar extraction. J Oral Maxillofac Surg 2003; 61: 1379-1389.
2) Quek SL, Tay CK, Tay KH, Toh SL, Lim KC. Pattern of third molarimpaction in a Singapore Chinese population: a retrospective radiographic survey. Int J Oral Maxillofac Surg 2003; 32: 548-552
3) Gbotolorun OM, Arotiba GT, Ladeinde AL. Assessment of factors associated with sur-gical difficulty in impacted mandibular third molar extraction. J Oral Maxillofac Surg 2007; 65: 1977- 1983.
4) Azenha MR, Kato RB, Bueno RBL, Neto PJO, Ribeiro MC. Accidents and complica-tions associated to third molar surgeries performed by dentistry students. Oral Maxillofac Surg 2014; 18: 459-464.
5) Rahman SA, Alam MK, Abdullah NH, Shaari R. Prevalence of Infected Socket after Surgical Removal of Mandibular Wisdom Tooth. Int Med J 2014; 21: 117-119.
6) Rahman SA, Alam MK, Yaacob M, Shaari R. Radiological assessment of surgery diffi-culty of impacted mandibular third molar. Int Med J 2014; 21: 110-112.
7) Rahman SA, Alam MK, Woei KC, Shaari R. Pattern of angulations of mandibular third molar impaction in a Malaysian population: a retrospective radiographic investigation. Int Med J 2014; 21: 120-122.
8) Rahman SA, Khoon LC, Shaari R, Alam MK. Novel Concept of Replacing Antibiotic in Surgical Removal of Impacted Mandibular Third Molar. Int Med J 2013; 20: 470-472.
9) Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and maxillofacial pathology. Missouri: Saunders 2009.
10) Knutsson K, Lysell L, Rohlin M. Postoperative status after partial removal of the man-dibular third molar. Swed Dent J 1989; 13: 15-22.
Figure 1. Orthopantomogram (OPG) of the patient.
Figure 2. The sequence of intraoperative photographs through-out the minor oral surgery.
Figure 3. Periapical radiograph showing the root remnant of the tooth 48. The size of the root remnants is less than 3 mm in size. There is no sign of periradicular radiolu-cency or widening of PDL noted.
