CASE PRESENTATION
A 27 year old African male presented to the Department of Oral and
Maxillofacial Surgery, University of Nairobi, Kenya, with spontaneous,
severe pain of left mandible for 7 days. Intraoral examination revealed
bilateral Angle’s class 2 molar relationship. The maxillary canines were
missing (disimpactions performed 10 years ago) and carious lesions were
present on 17 and 36 with both teeth being tender to percussion.
A panoramic radiograph revealed radiolucencies with probable pulpal
involvement on the mesial aspect of 17 and 36. The maxillary third
molars were impacted. Mandibular second and third molars (37, 38, 47,
48) were impacted bilaterally with their occlusal surfaces in contact
and roots pointed in opposite directions (Figure 1). In order to
evaluate the nature of the molar impaction, proximity to mandibular
canal and bucco-lingual positioning within the mandible, a Cone-Beam
Computed Tomography (CBCT) scan was performed (Figure 2-7). The
imaging parameters were as follows: CS 8200 3D (12X10), Voltage, 90kV;
exposure time, 10 s; current 5.0 mA; voxel size 150 microns.
A reconstructed panoramic was generated using CS Version 8 software.
Tracking of the mandibular canal was done by applying the color tracer
to the smallest slice thickness of 15 microns to illustrate the entire
path of the canal in one view (Figure 2). Coronal sections confirmed
contact between the mandibular canal and roots of 37 and 47. For
reproducibility of measurements, only reference (main) orthogonal planes
were examined in split views of 5x5, while oblique sections were only
employed for visual illustration. Additionally, the distal roots of the
37 and 47 were 4.6 mm and 3.3 mm respectively from the inferior border
of the mandible. (Figure 3 and 4). Thinning of the lingual cortex
and paucity of cancellous bone lingual to the 37 and 47 was observed.
Cortical perforation was however ruled out. Curved roots of second
mandibular molars were noted which were in contact with the mandibular
canal. (figure 3-6)
Axial sections of the maxilla imaging revealed three-rooted second
maxillary premolars (15 and 25). Both had divergent mesiobuccal,
distobuccal and palatal roots with corresponding root canals.
(Figure 7) The patient was managed conservatively by endodontic
treatment of the carious teeth (17 and 36). Due to the asymptomatic
nature of presentation, he was advised on disimpaction of impacted
maxillary molars while long term follow up was recommended for the KMs.