PKB for PM
A 28-year-old woman underwent extraction of all four third molars at her first visit with a general dentist under local anesthesia. After the local anesthetic wore off, she developed persistent numbness and pain involving the right side of her face.
Her course progressed through follow-up evaluations with another dentist and then oral and maxillofacial surgery, ultimately leading to assessment by an oral surgeon with subspecialty training in facial nerve injuries (documented diagnosis: right inferior alveolar nerve (IAN) injury). Initial management was conservative, including a trial of gabapentin that was discontinued due to sedation and replaced with an alternative medication. Despite medical therapy, she continues to report right-sided facial numbness with “electrical” sensations that worsen with prolonged talking, biting of cheek, and dental issues on the right side. A surgical option was discussed and declined.
The current damages issues for review are the chronicity and severity of her sensory deficits, how these symptoms affect daily function, anticipated long-term trajectory over a normal life expectancy, and future care needs (ongoing medication management, potential pain specialist/neurology involvement, dental/oral follow-up, and reconsideration of surgical options if symptoms evolve).
Files:
Q: How long has it been since surgery? Is there a panoramoic pre-op xray to see relationship of tooth and nerve?
A: Surgery was 6/2024. Preop XR has been posted as photo to case.
Do you believe there might have been medical error?
Paresthesia is only about 2-3% by specialists (oral surgeons). It would be higher for general dentists doing this procedure. What indications were present to even do all 4 wisdom teeth? Tooth #32 where injury occurred should have had a coronectomy if it was indicated at all to be removed. This would have significantly reduced paresthesia risk. Also person was 28 so there has to be a very good indication for surgery (not just because it is impacted).
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The surgery definitely caused the injury. Whether the dentist was qualified enough and need for surgery needs to be determined, The preop xray shows a very close nerve proximity. A CBCT taken preop would possibly show how close the nerve was to the roots and dictate the coronectomy as the standard procedure. Since it is 2 years since injury permanancy is most likely
What makes you a good expert for this case?
40 years of oral surgery experience Reviewed similar cases including one of my own
How often do you encounter cases similar to this one in your practice?
I see about 5 paresthesia cases /year between cases referred to me and my own patients.
Do you believe there might have been medical error?
I would need a pre-operative film but poor technique could lead to the issues the patient is having. Having an operative report to evaluate would also be beneficial.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I would need a pre-operative film but poor technique could lead to the issues the patient is having. Having an operative report to evaluate would also be beneficial. Based on the reviewed films this is a highly challenging case for a general dentist to attempt. It is very likely nerve damage occurred due to inexperience.
What makes you a good expert for this case?
I have reviewed dozens of cases of nerve injury after tooth extraction and implant placement.
How often do you encounter cases similar to this one in your practice?
Dozens of times. I have reviewed many cases of nerve injury after extractions, dental implant placement and trauma.
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