Case Report Upfront

UPFRONT

CASE REPORT

Osteomyelitis or osteitis? Oral surgery lef wisdom tooth was removed and the patient made a satisfactory recovery with no Sir, a 17-year-old male presented to our oral Migrating third molar complications. Te patient and his general and maxillofacial surgery ofce with swelling Sir, the debate over the NICE guidelines dental practitioner were advised regarding and soreness in the lower lef mandible and deliberations on management of the importance of clinical and radiological following removal of four third molars two unerupted asymptomatic wisdom teeth is monitoring of the lower right wisdom tooth on months prior. Initial postoperative course set to continue.1 We would like to present a regular basis. was uneventful, however in the days prior an unusual case of bilateral pathological Pathological migration is an abnormal to presentation, he reported increased migration of wisdom teeth which remained change in the position of a tooth within the discomfort in the 37 area. unnoticed till an acute presentation and dental arch. Tere are many aetiological factors Initial clinical assessment made by eventually required complex surgery. associated with this phenomenon, but the providers was a subperiosteal infection at A 55-year-old gentleman presented to exact cause is ofen difcult to diagnose.2 We the site with possible osteomyelitis. Prior A&E with a large lef submandibular and cannot assertively predict what the future holds to presentation, the patient started a course sub masseteric space abscess, secondary to for asymptomatic, disease-free teeth. We now of clindamycin and would be re-evaluated an unerupted lower lef wisdom tooth and a see patients returning later in life, with more afer fnishing his antibiotic regimen radiographically illustrated radiolucent tract. medical comorbidities for third molar surgery for CT scans and surgical planning for He had previously asymptomatic bilaterally with more advanced wisdom tooth pathology.3 possible debridement. impacted lower wisdom teeth, radiographic Perhaps it is time to alert the readership to At presentation for his one-week follow evidence showed that the lower wisdom insidious pathology in unerupted wisdom teeth up appointment, a CT scan of the afected teeth had migrated (Fig. 1). He underwent in a patient population in their third, fourth area displayed observable buccal bone loss emergency surgery with extraoral incision and ffh decades. Moreover, the message to with bony sequestra (Fig. 1). Debridement and drainage of the abscess under general the GDP should be that symptom free does not under general anaesthesia was discussed anaesthetic for the acute presentation. equal disease free. A comprehensive assessment due to elevated risk for pathologic Further imaging (CTv scan) was carried out of wisdom teeth should include adequate and mandibular fracture. An antibiotic to plan for the elective surgical removal of appropriate radiographs at regular intervals. regimen of clindamycin and metronidazole the deeply impacted 38. C. Aristotelous, M. Ryatt, A. Majumdar, Luton, UK remained in efect in the period before  Te patient was advised to have the procedure. lower wisdom teeth electively removed References but declined removal of the lower right 1. Renton T. National Institute for Health and Care Excellence Guidance Executive: Review of TA1; Guidance on the wisdom tooth. We discussed the options extraction of wisdom teeth. Faculty of Dental Surgery of an intraoral approach +/- sagittal split response. 2014. Available at: https://www.rcseng.ac.uk/-/ osteotomy to gain access to the tooth or an media/fles/rcs/fds/media-gov/nice-review-of-guidance-on- wisdom-teeth-extraction-fds-response-with-appendices. extraoral approach utilising the pre-existing pdf (accessed February 2020). scar. Clinically, there was no evidence of 2. Francis P O, Fowler E B, Willard C C. Migrating third molar: a report of a case. Mil Med 2003; 168: 802–806. a communication intraorally from the 3. Petrosyan V, Ameerally P. Changes in demographics of unerupted lower third molar (no sinus patients undergoing third molar surgery in a hospital setting between 1994 and 2012 and the infuence of the national tract on probing). Te extra-oral approach institute for health and care excellence guidelines. J Oral was preferred due to the pre-existing scar Maxillofac Surg 2014; 72: 254-258. and improved direct access. Te lower https://doi.org/10.1038/s41415-020-1323-2 Fig. 1 A CT scan of the affected area displayed observable buccal bone loss with bony sequestra

Fig. 2 Post-operative CT scans displayed Fig. 1 OPT showing evidence of bilateral pathological migration of lower wisdom teeth complete bone flling without defect