Page 37 - MDJ Volume 47 Number 2 ( Jul-Dec 2024)

Mustafa, et al.: Management of the Impacted Tooth with Dilacerated Roots – A Surgical Challenge
tips of the roots were in close proximity to the inferior impacted lower right premolar and lower left permanent
dental canal. canine [Figure 2b].
Informed consent was obtained from the patient, and The management of the case was discussed, and the
the patient warned that the procedure would be more patient was agreeable to the treatment plan. Informed
complicated than usual and will involve a procedure of consent was obtained for the extraction of supernumerary
longer duration than normal. The patient was warned teeth in the lower right quadrant.
of the possibility of neuropraxia of the inferior dental Local anaesthesia was given using 2% mepivacaine and
nerve.
1:100,000 adrenaline. A lingual flap was raised, and under
Under local anaesthesia using 2% mepivacaine with copious irrigation with normal saline, bone was removed
1:100,000 adrenaline, an envelope flap was raised from from the lingual aspect of the lower premolar using a
the buccal of the lower left first molar to the distal of number 3 fissure bur on a straight handpiece. This was
the left third molar. The soft tissue on the lingual aspect carefully elevated using Warwick James elevators and by
was partially raised and an elevator was placed to protect rotating the tooth lingually we succeeded in removing the
the lingual soft tissues, whilst on the buccal aspect, the premolar without causing fracture of the apical portion
soft tissues were retracted with a Bowdler–Henry rake of the root. The two lingually placed supernumerary teeth
retractor. After good exposure on the buccal aspect of were then extracted using forceps [Figure 2,a,c,d]. The
the right mandible, bone on the buccal and distobuccal recovery was uneventful except for pain. He is currently
to the tooth were removed using a round bur on a straight on follow-up and is due for review and orthodontic
handpiece under copious irrigation with normal saline. consultation and treatment later.
The bone distal to the tooth was removed gradually in a
step-by-step manner. Mesial application of a number 1
and number 2 Coupland’s elevator was used to loosen the Case 2
tooth after each round of distal bone removal. After three A 22-year-old Malay male was referred for the removal
attempts at removing the distal bone, the tooth became of an impacted supernumerary tooth in the left palate
loose and was successfully elevated with the dilacerated before orthodontic treatment. Routine screening prior
mesial root intact [Figure 1d]. The impacted lower left orthodontic management for the patient revealed an
wisdom tooth was then delivered using an upper premolar impacted supernumerary tooth with dilacerated roots in
forceps which provided easier access to the tooth. very close proximity to the maxillary sinus lining.

The mesial root was delivered whole, but the apical 1 mm His past medical history was unremarkable except for
of the distal root tip was fractured. We decided to leave the G6PD. On examination extraorally, there were no
the root tip in situ. Irrigation was performed with saline, abnormal findings. Intraorally, all the permanent teeth
and the wound was closed with one 3/0 sling suture and were present. There was crowding of the anterior segment
one interrupted 3/0 black silk suture. Haemostasis was in the maxilla with 12 in an instanding position in relation
achieved. The procedure was completed in less than one to the upper arch.
hour. Post-operative instructions were given, and a review Panoramic radiograph revealed the presence of an
date for removal of sutures was set. Ibuprofen 400 mg unerupted supernumerary tooth palatal to 24 and 25.
twice daily to be taken orally was prescribed for 3-day Cone beam computed tomography (CBCT) showed that
duration for pain control post-op. Aside from some pain, the apical third of the supernumerary tooth was severely
swelling and a slight limitation in mouth opening, no dilacerated and extended into the otherwise normal-
complications were observed postoperatively. The patient looking left maxillary sinus [Figure 3c].
did not experience altered sensation in the left lower lip.
At the patient’s request, surgery was performed on the
same day. Informed consent was obtained, and 3.5-ml
Case 1 mepivacaine 2% with 1:100,000 adrenaline was used
A 24-year-old male presented with pain and extra teeth in as local infiltration buccal and palatal to the arch. A
the right lower jaw. He had no relevant past medical and palatal flap was raised from the upper right central to
dental history. Clinical examination revealed good mouth the upper left first molar to expose the bone overlying
opening and satisfactory oral hygiene. Intraorally, all the the impacted supernumerary tooth. Under irrigation
permanent teeth were present except the wisdom teeth.
with normal saline, a tungsten carbide Meisinger round
On the lower right quadrant, two conical-shaped bur on a straight handpiece was used to trim the bone
supernumerary teeth were present lingual to the lower overlying the impacted supernumerary tooth. The bone
permanent right canine and first premolar. In the lower on the concave aspect and to the anterior of the impacted
left quadrant, a retained primary canine tooth, the 73, tooth was then removed to enable rotation of the tooth in
was noted. Dental panoramic radiograph showed the a palatal direction during elevation. Once this was done,
presence of all four impacted wisdom teeth and an the tooth was elevated by means of Coupland’s elevators

Malaysian Dental Journal ¦ Volume 47 ¦ Issue 2 ¦ July-December 2024 31