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Oral Surgery · patient case with 5 questions

Third Molar Surgery and Its Complications

demo: 24-year-old female

chief: “The gum over my lower wisdom tooth is swollen and I can barely open.”

history: Smokes 10 cigarettes daily. Takes combined oral contraceptives. Poor oral hygiene.

meds: Combined oral contraceptive pill

findings: Partially erupted #17 with an inflamed, edematous operculum, purulent exudate on pressure, trismus, and tenderness. Extraction is planned. Four days after a previous extraction of #32, she developed severe radiating pain with an empty socket and exposed bone.

Question 1

In pericoronitis around a mandibular third molar, referred pain most commonly follows which nerve?

  1. The lingual nerve
  2. The greater palatine nerve
  3. The inferior alveolar nerve
  4. The buccal nerve
Show answer and explanation

Correct answer: C. The inferior alveolar nerve

  • A. The lingual nerve supplies the lingual soft tissue and anterior tongue; it is at surgical risk but is not the usual pathway for referred pericoronitis pain.
  • B. The greater palatine nerve is maxillary and irrelevant to a mandibular third molar.
  • C. Correct. The inferior alveolar nerve runs immediately adjacent to the third molar region within the mandibular canal, so inflammation there produces the characteristic radiating pain along its distribution to the lower lip and chin.
  • D. The long buccal nerve supplies buccal soft tissue over the molars, a much more limited territory.

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Question 2

Which two nerves are at greatest risk of injury during removal of an impacted mandibular third molar?

  1. Facial and hypoglossal nerves
  2. Inferior alveolar and lingual nerves
  3. Mental and infraorbital nerves
  4. Glossopharyngeal and vagus nerves
Show answer and explanation

Correct answer: B. Inferior alveolar and lingual nerves

  • A. The facial nerve is extraoral and well away from the surgical field; the hypoglossal is deep in the floor of the mouth.
  • B. Correct. The IAN lies apical or in contact with the roots, and the lingual nerve lies immediately deep to the lingual plate at this level — both are the classic surgical hazards.
  • C. The mental nerve is at risk in the premolar region, not at the third molar; the infraorbital nerve is maxillary.
  • D. The glossopharyngeal and vagus nerves are not within the surgical field.

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Question 3

What most likely caused the dry socket that developed after the previous extraction?

  1. Excessive irrigation with sterile saline
  2. Inadequate suturing of the socket
  3. Smoking and estrogen-containing oral contraceptives, both of which promote premature clot breakdown
  4. Early return to a normal diet
Show answer and explanation

Correct answer: C. Smoking and estrogen-containing oral contraceptives, both of which promote premature clot breakdown

  • A. Gentle irrigation with saline is standard and does not cause alveolar osteitis.
  • B. Routine simple extraction sockets do not require suturing, and its absence is not a recognized cause.
  • C. Correct. Smoking causes clot disruption through suction and local vasoconstriction, and estrogen raises fibrinolytic activity. Combined with poor hygiene, these are the strongest recognized risk factors for alveolar osteitis.
  • D. Diet is not a recognized risk factor, though vigorous suction through a straw is.

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Question 4

Plain gut suture placed in the socket will typically resorb over what period?

  1. 10–14 days
  2. 3–5 days
  3. 3–4 weeks
  4. 8–10 weeks
Show answer and explanation

Correct answer: B. 3–5 days

  • A. Chromic gut, treated with chromium salts, extends this to roughly 10–14 days.
  • B. Correct. Plain gut is digested by proteolytic enzymes and loses tensile strength within roughly 3–5 days — the shortest-lived of the resorbable sutures.
  • C. Polyglactin 910 (Vicryl) retains strength for several weeks before hydrolytic breakdown.
  • D. Polydioxanone (PDS) is the long-lasting monofilament resorbable in that range.

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Question 5

A patient with a longstanding TMJ disorder wants to stop smoking. Which cessation aid is least appropriate?

  1. Varenicline
  2. Nicotine transdermal patch
  3. Nicotine gum, because prolonged chewing loads the joint
  4. Bupropion
Show answer and explanation

Correct answer: C. Nicotine gum, because prolonged chewing loads the joint

  • A. Varenicline is an oral tablet with no mechanical demand on the joint.
  • B. The transdermal patch requires no jaw activity and is the preferred nicotine replacement route for this patient.
  • C. Correct. Nicotine gum requires the repetitive chew-and-park technique for extended periods, which loads an already symptomatic joint and can aggravate myofascial pain.
  • D. Bupropion is likewise an oral tablet and places no load on the masticatory system.

Note: External verification against CDC and VA cessation guidance supports nicotine gum as the answer, on the mechanical-loading rationale. Keyed to nicotine gum here.

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