All that glitters is not Gold; Likely, All erupted Wisdom teeth may not be simple to Extract.
Dr. Arka Bhattacharya; BDS
Wisdom teeth are the most discussed and widely accused molars of all teeth. Most of the dental patients are accustomed with this phrase and felt the pain once in life. Well, some patients are lucky enough that they have wide arch space to accommodate the 3rd Set of molars.
Wisdom teeth mostly begin to appear during 17-25 years of life. This time frame for eruption of 3rd Molars coined it with the name of "Wisdom Teeth" in the 17th Century. Some of the historical documents state that even Aristotle had written about Wisdom teeth in his book, The History of animals. As these molars begin to erupt much later than other teeth (late teen ages), at an age where people are presumably 'Wiser' than a child, may have prompted the name Wisdom teeth. According to AAOMS, 85% of people need to remove their 3rd molar as it causes lots of trouble and painful events.
I have seen many cases of 3rd molar extraction during my four years of service as a Dentist in Kolkata. Very few of them are memorable according to their level of difficulty and events. Every cases were individually different. One of the case that dragged me to think again and again is this one, am about to describe.
The patient was 49 years old Female, came up with the complaint of Pain and Discomfort in lower left jaw since many years. Due to lack of time and being indifferent to the dental problems she avoided check ups. Intra-orally the 38 tooth appeared as supra-erupted. It's also visible in the OPG X-ray. Opposite arch 27 was retained as a root stump and by physiologic movements 38 tried to cover up the space.
On Radiograph, there is a very mild radiolucency in the mesio cervical region of 38, but during extraction I have felt the struggle with deep root caries. Due to the created triangle between 37-38 there developed a periodontal pocket. Chronic food deposition at there lead to cervical caries and exposed the pulp. The pain from Pulpitis made the patient think again, and come to a dentist.
As protocol, providing the Pre-op antibiotic prophylaxis fixed an appointment date for the Extraction. My treatment plan was staged in a simple approach with the elevators and then pulling it out with the forceps. After administering the Local Anaesthesia, and having the sound block confirmed I engaged my first instrument to the Mesial side of the tooth.
First attempt made me to stop and re-think about the plan. There was a huge decay on the mesial surface that can never help me with the elevators. The dilaceration at the apical 3rd of the roots was also in my mind. Changed my plan and decided to approach with periosteal flap elevation by modified Ward's incision and then guttering through the buccal surface of 38. After elevating the flap, the condition I witnessed, again drove me to change the new plan. The decay was also present subgingivally and there was no hope to use any elevators at that area. Radiographically this was not present.
Shifted to Plan C, which was not yet generated, and started the guttering procedure with Straight TC bur and Saline-Betadine irrigation. Cutting through the external oblique ridge I was trying to luxate the tooth with Straight War-Wick James elevator and coupland No. 1. There was a mild mobility. It was like a silver lining in that cloudy situation. Again did a guttering margin about 2mm and created a purchase point in the Intra-radicular space of 37-38. Tried my elevator. Yes! The tooth has got its mobility. Finally, there is hope. Hope of pulling out the tooth intact. Initiated my approach with Couplands with gradual increase of Size, from 1-2-3. A cracking sound echoed in the mouth and the Crown part of 38 came off loose. The mobility I have seen was from the crown part only.
Need a Plan D now. Standing at 9'O Clock position the visibility of root part was impossible. There was no purchase point created well enough to engage the roots. Buccally it was also difficult to engage as fragments of decayed roots were coming out with every approach. A good visibility was required to pull out the rest. Going through the radiograph again generated Plan D and Plan E. Plan F was kept in reserve in case these two fails.
Before trying anything else, I have changed my side, from 9'O clock position to 2'O Clock. My assistant came to my early position to retract the tongue and do the irrigation, suction. Views changed. Now I have a good view of the root fragments. Postponed the idea of Plan F and started sectioning of the root. Created a good space between the mesial and distal root that my coupland can easily get engaged.
The smile appeared on my face was broader than the smile I gave my parents when they give me something. Though the smile was hidden beneath the mask and I just gave a simple wedging movement with the No3 Coupland to the Distal root. Like a obedient boy it stood up from its firm position and came out without any objection. Next was the Mesial root. It came out with a mild protest against my pull with the coupland. But when it came out along with the edge of the coupland a memory from my school life flashed in front of my eyes. One of our maths teacher was famous for retracting a student from the bench by pulling the ear. The mesial root came out in the same manner.
After irrigating the socket and securing the wound with sutures, gave the Haemostatic pack on the Area. Well during these phases there was an intermission when I pulled out tooth No 27 with the Coupland No 2. Done with the patient I took the fragments from the pot and assembled them to look at the tooth that helped me to create some wise treatment plans. It appeared like,
It was a great experience for me and my team to be in a part of something unusual. The spice from the plans were good for our taste buds than regular extraction cases. Those plans, or approaches are nothing new in the field of dentistry. But going through the pages of Oral surgery with your own modifications and attempts gives an additive flavor to the procedure.
Post-Op complications were Swelling, trismus and tenderness.
Medications prescribed were:
Antibiotic- Cefixime 200mg + Ornidazole 500mg. (Taxim OZ)
Analgesic- Paracetamol 1gm (Pyrigesic 1 Gm)
Anti-inflammatory Medicines- Rutoside, Trypsin, Chymo-trypsin, Diclofenac (Obetra D)
Mouthwash- Chlorhexidine 0.2% (Eludril Perio)
Acknowledgements:
Dr. Ashif Iqbal Khan, Assistant Surgeon. MDS (OS Pgt)
Kaushik Halder, Assistant
(C) Google Images.
(C) Dr. Lloyd Hudson Blogs on Wisdom teeth
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