International Medical Journal Vol. 26, No. 3, pp. 250 - 251 , June 2019

CASE REPORT

Surgical Removal of Impacted Third Molar Presented With Facial Cellulitis

Shaifulizan Ab Rahman1), Manjitra Sukumaram1), Sanjida Haque2), Mohammad Khursheed Alam3)

ABSTRACTBackground: Third molar surgery is one of the most common procedures performed in oral and maxillofacial surgery offic-

es. Nevertheless, this procedure requires accurate planning and surgical skills. With surgical procedures in general, complica-tions can always arise.

Case Presentation: A case of surgical removal of impacted third molar in a 28-year-old Malay male is discussed. Initial clini-cal and radiographic examination revealed that the tooth 48 was mesioangularly impacted with visible crown. The patient then underwent minor oral surgery with the help of local anesthesia whereby raising of a flap was needed. The tooth had to be removed urgently as it was already causing pain and facial cellulitis.

Conclusion: A successful holistic approach to managing the patient is the most vital aspect in treating the patient besides relieving the pain

KEY WORDSminor oral surgery, facial cellulitis, impacted third molar

Received on April 17, 2018 and accepted on July 18, 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: shaifulrahman@lycos.com)

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INTRODUCTION

The impaction of third molars is a very well-known phenomenon. To classify the level and depth of impaction of the third molars, a few classifications have been described such as the Pell and Gregory, Winter's classification (1926) and Killey and Kay's. However, the Pell and Gregory Classification has become the most used classification among others. In fact there are a few theories like Orthodontic theory, Phylogenic theory, and Mendelian theory that discuss on how the impaction happens. In the oral cavity, the third molar is often regarded as the extra tooth and the eruption of the third molar may lead to distur-bances to the general oral health of the patient. Besides that, the report-ed reasons for third molar removal include the risk of impaction associ-ated with caries, pericoronitis, and periodontal defects in the distal sur-face of second molars, odontogenic cysts, facial cellulitis and dental crowding. A prospective study showed that general dentists recommend extraction of third molars in 59% of patients, mainly to prevent future problems or because a third molar had an unfavorable orientation or was unlikely to erupt1).

CASE HISTORY

The patient was 28 year old Malay male came to Klinik Pergigian Padang (KPP), School of Dental Sciences, Universiti Sains Malaysia for the minor oral surgery for the removal of tooth 48 and as well as 38.

Patient had facial swelling and cellulitis for about 9 days prior to com-ing to the dental clinic. Patient also had facial swelling at the lower region on right side of his face and experiences pain upon mouth open-ing. Upon clinical examination, tooth 48 was visible at the occlusal plane level but mesioangulated. It had caries on the occlusal surface. The tooth was non-tender to percussion but was tender on palpation. Upon inspection, no sinus tract or pus discharge noted at the gingival mucosa surrounding the tooth and as well as adjacent to it, but the buc-cal mucosa was swollen. Further investigation was done and an orthop-antomogram radiograph was taken to assess the impaction level of both mandibular third molars. Radiographically, the tooth 48 is mesioangu-lated and based on Pell's And Gregory classification, it can be classified into Class I, Level A. The distal and mesial roots of the tooth are both curved which may complicate the extraction process later on. Besides that, periapical radiolucency can also be noted at that tooth. As for tooth 38, it has a large radiolucency at the occlusal surface reaching close to the pulp of the tooth (figure 1). After discussion, it was decided to remove the impacted 48 surgically under local anesthesia instead of tooth 38 as it is symptomatic and presented with facial cellulitis.

DISCUSSION

The most common angulation of impaction in the mandible was in vertical position (41.4%) followed by mesioangular impaction (33.3%) and the most common angulation of impaction in the maxilla was the vertical (67.4%) which was followed by 15.2% in distoangular impac-tion2). Development of mandibular third molars starts in the ramus of the

C 2019 Japan Health Sciences University & Japan International Cultural Exchange Foundation

Rahman S. A. et al. 251

mandible at about the age of seven years3). The third molars are the last teeth to erupt in all races despite racial variations in the eruption sequence. Racial variation in facial growth, jaw and teeth size, nature of diet, extent of generalized tooth attrition, degree of use of masticatory apparatus and genetic inheritance are the crucial factors which deter-mines the eruption pattern, impaction status and the incidence of agene-sis of third molars4). In our case the patient is presented with facial cellu-litis that is caused by the carious impacted 48, which is classified as of odontogenic origin. Facial cellulitis and deep infections of neck are dan-gerous because of their normal tendency to cause edema, distortion and obstruction of airway5). In the early stages of disease, patient may be managed with observation and antibiotics which the approach used by our dental team. As for advanced infection it would requires the surgical drainage and proper antibiotic therapy6-10). Infections in the mandible may perforate the outer cortical plate below the buccinators attachment and cause swelling of lower half of face11). It is important to recognize cellulitis in the earlier stages of disease, when it is easier to manage. In managing cellulitis it is important to locate and treat source of infection. In our case, the source of infection was the carious tooth 48. Thus, if was removed surgically so as to allow the facial cellulitis to resolve

without any further worsening.

CONCLUSION

From the case it can be concluded that facial cellulitis due to odon-togenic origin can be resolved by removing the source of infection. Besides that, as the third molar was impacted, a wholesome knowledge of both the disease and proper management of impacted third molars are needed to avoid any life threatening complications. A successful holistic approach to managing the patient is the most vital aspect in treating the patient besides relieving the pain.

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Figure 1. The orthopantomogram (OPG) view of the patient reveals that he has impacted 38 and 48. Radiolucency can be noted at the occlusal surface of 38 extending into D2 level. Radiolucency can be noted at the periapi-cal region of tooth 48 as well.