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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 5  |  Issue : 1  |  Page : 19-22

Iatrogenic displacement of impacted mandibular third molar into the submandibular space complicated by submasseteric abscess


1 Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
2 Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, College of Medicine, University of Lagos, Idi-Araba, Lagos; Department of Oral and Maxillofacial Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
3 Department of Oral and Maxillofacial Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria

Date of Web Publication8-Dec-2016

Correspondence Address:
Dr. Olutayo James
Department of Oral and Maxillofacial Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1597-1112.192845

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  Abstract 

The accidental tooth displacement into adjacent anatomical spaces is rare but potentially serious complication of impacted third molar extraction. A few cases of accidental displacement of third molars into anatomical spaces, such as the infratemporal fossa, the pterygomandibular space, the maxillary sinus, or the lateral pharyngeal space, during surgical interventions have been reported. In this paper, a case of a mandibular third molar accidentally displaced into the submandibular space in a 24-year-old male patient is presented. Delayed presentation resulted in infection and trismus which were controlled by antibiotic therapy and the displaced tooth recovered under general anesthesia.

Keywords: Displacement, impacted third molar, infection, submandibular space


How to cite this article:
Adeyemi MO, James O, Lawal AO, Fadeyibi SO. Iatrogenic displacement of impacted mandibular third molar into the submandibular space complicated by submasseteric abscess. Afr J Trauma 2016;5:19-22

How to cite this URL:
Adeyemi MO, James O, Lawal AO, Fadeyibi SO. Iatrogenic displacement of impacted mandibular third molar into the submandibular space complicated by submasseteric abscess. Afr J Trauma [serial online] 2016 [cited 2019 Mar 20];5:19-22. Available from: http://www.afrjtrauma.com/text.asp?2016/5/1/19/192845


  Introduction Top


The surgical removal of impacted third molar is a common procedure performed by dentists as well as oral and maxillofacial surgeons worldwide. Several perioperative complications which are more common in the mandible than in the maxilla have been reported to be associated with this procedure.[1] More commonly reported complications include bleeding, dry socket, nerve injury, delayed healing, periodontal pocketing, and infection.[1]

The inadvertent displacement of a third molar or its root fragments into adjacent anatomical spaces during surgical intervention is a well-recognized complication, but the occurrence is rare. A few cases of accidental dislodgement into the sublingual, submandibular, pterygomandibular, and lateral pharyngeal spaces have been reported.[2],[3] Predisposing factors for this complication include a distolingual positioning of the tooth, fenestration of the lingual cortical plate with root exposure, poor clinical and/or radiological assessment, improper surgical planning, application of uncontrolled or excessive force, and excessive manipulation.[3],[4]

Due to the low incidence of this complication, there is understandably a paucity of reports in literature. Here, we present a case of accidental displacement of a lower third molar into the submandibular space; late presentation also results in submasseteric abscess.


  Case Report Top


A 24-year-old male presented to the exodontia clinic of the Oral and Maxillofacial Surgery Department, Lagos University Teaching Hospital, with 1-month history of the right mandibular swelling, pain, and extreme limitation in mouth opening. The symptom developed a month after he underwent surgical extraction of a painful lower right third molar by a dentist in a private clinic. He claimed that he neither saw the extracted tooth nor was informed about any problem relating to the extracted tooth. Clinical examination revealed an extraoral firm and tender swelling of the right masseteric region [Figure 1], limited mouth opening with a maximal interincisal opening of 11 mm. The socket of the extracted tooth appeared to have healed satisfactorily. Both intraoral and extraoral examinations did not reveal any palpable mass within the soft tissues. An orthopantomograph was taken which showed a healing extraction socket of the right mandibular third molar with radiopaque particles distal to the neck of the second molar and an adjacent inverted tooth in relation to the lower border of the mandible having the crown projecting below it [Figure 2]. An assessment of the relative opacities of the tooth and bone revealed the tooth to be lingually placed. A diagnosis of displacement of the right mandibular wisdom tooth into the right submandibular space with residual crown fragments in the healing socket and submasseteric abscess was made.
Figure 1: Clinical photograph shows swelling over the right masseteric region

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Figure 2: Panoramic radiograph shows the displaced tooth in the submandibular space, 2 months after the initial attempted surgical operation

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The patient was scheduled for removal of the displaced tooth, the residual crown fragments, and drainage of the submasseteric abscess under general anesthesia. He was placed on oral amoxicillin-clavulanate 625 mg 12 hourly and metronidazole 400 mg 8 hourly to control the infection. He was admitted 5 days later and the procedure was carried out under general anesthesia. The healing socket was opened up and the residual crown fragments were removed. The displaced tooth was approached through a submandibular incision [Figure 3] and successfully retrieved [Figure 4] while the abscess was drained through the most fluctuant part. The wound was copiously irrigated with 0.9% saline solution, a drain was placed, and the incision was closed primarily.
Figure 3: Intraoperative picture shows the retrieval of the displaced lower third molar from the lingual side of the mandible

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Figure 4: Displaced tooth retrieved after surgery

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The patient had an unremarkable postoperative course. He was discharged on the third postoperative day and followed up at the outpatient clinic. On the 7th postoperative day, the healing appeared to be satisfactory and the sutures were removed. At the 30th day postoperative visit, the infection had resolved and mouth opening had significantly improved.


  Discussion Top


The first report of a displaced third molar tooth or root fragment into submandibular space appeared in literature in 1958.[4] Since then, few ten sparse reports have surfaced in literature underlining the rarity of this complication of tooth extraction. This inadvertent displacement of impacted tooth into several facial tissue spaces has been reported previously including the submandibular, sublingual, maxillary sinus, and pterygomandibular and lateral pharyngeal spaces, with the maxillary sinus and submandibular spaces being the most commonly involved.[4],[5],[6],[7],[8],[9],[10]

Several risk factors for this complication have been identified and they can be grouped into patient and operator factors.[1],[2] Patient factors include patient age, tooth position, the presence of a lingual plate fracture, and reduced thickness of the lingual plate. Excessive or uncontrolled force, lack of operator expertise, and poor clinical and radiological assessment have all been identified as operator factors that predispose to displacement.[1],[2],[5] Although it was difficult to identify the specific etiology in the present case as the patient presented 2 months after the extraction was done, we speculate that excessive and uncontrolled force was applied to the tooth toward thin lingual bony cortex with elevator during extraction. This may have pushed the tooth through the lingual bony cortex into the submandibular space. Besides, efforts made to retrieve the tooth after its initial dislodgement and possibly blind probing are other probable reasons for deeper displacement to the space. The dentists possibly lack the expertise and experience for the attempted extraction. Wrong surgical techniques are closely related to the transoperative displacement of third molars,[8] potentially justifying the accident reported in our study. The same was observed by Silveira et al.[2] and Olusanya et al.,[6] in which general practitioners performed unsuccessful extractions of impacted third molar, highlighting the need of further training for general dental practitioners who wish to perform third molar extractions. Silveira et al.[2] have earlier suggested that third molar extractions should be preferentially performed by maxillofacial surgeons, who are highly familiarized with the surgical morphology of the head and neck.

Clinical presentation varies depending on its size (whole tooth or root fragment), location, and whether or not there is an associated infection. Most reported cases in literature presented immediately after the accident;[2],[3],[4],[5],[10] the present case presented about 2 months after the accident probably because of transient relief from postoperative antibiotics and analgesics prescribed after the attempted extraction. Some patients are symptom-free whereas others experience pain, swelling, and trismus in the immediate postoperative period and these symptoms tend to occur with a delay in removal.[2] In the present case, the patient presented with persistent pain and submasseteric space infection. The possible explanation for this is that the submasseteric abscess developed from a posteriorly spreading infection from the residual crown tissue in the healing socket. Submasseteric space infection has been reported to be more likely with a distoangular impaction, especially when part of the pericoronal space is situated distal to the origin of the buccinators muscle.[7]

The timing of the retrieval attempt has been the subject of some debates. Most authors favor an early intervention as soon as possible;[3],[6] some, however, has argued that a delay may favor fibrosis and "stabilization" of the fragment.[5] In the present case, delayed removal must have predisposed the patient to submasseteric and would probably have led to greater morbidity if it had not been given prompt attention. A case of an abscess involving the right pterygomandibular and submasseteric spaces extending to the infratemporal fossa and eventually leading to subdural abscess was reported by Ramchandani et al.[7]

Proper localization of the tooth and tooth fragment is imperative to determine the approach for recovery. While manual palpation can be done and is useful, computed tomography scanning has been found to be the most appropriate.[2] If computed tomography scanning is however not available, a panoramic or occlusal radiographs can be used.[2],[3] In the present case, no palpable mass was found on manual palpation; a panoramic radiograph taken was able to give enough radiological information for the surgical retrieval of the displaced tooth.

Both intraoral and extraoral approaches have been described for the retrieval of displaced teeth or teeth fragments.[2],[4],[9] The intraoral approach under local anesthesia is the simplest and less invasive technique for removal. This approach is adjudged to be more esthetic and avoids complications related to the use general anesthesia, which is relatively costly and may involve hospital admission.[2],[4] However, this approach may not provide adequate visibility and access, especially with deep displacement. The extraoral approach provides better access and is particularly useful for teeth in deep spaces and migrated fragments.[8],[9] In the present case, an extraoral approach under general anesthesia was employed considering the depth of displacement, attendant trismus, and the pointed buccal swelling. Tumuluri and Punnia-Moorthy[8] have earlier suggested that an extraoral approach may provide better access if the displacement is deeper into the substance of the medial pterygoid muscle or inferiorly into the submandibular space. A combination of intraoral and extraoral approaches may be needed to retrieve tooth and root fragments in certain situations.[9]

A myriad of complications has been reported following the retrieval of tooth and tooth fragments including paresthesia and hemorrhage due to proximity to nerves and vessels.[8] In the present case, an optimal postoperative recovery was observed and the patient was free from all symptoms, a month after the retrieval.


  Conclusion Top


The accidental displacement of an impacted lower third molar into fascial spaces is rare, but need to be diagnosed and managed early to reduce morbidity. Dental practitioners should be aware of these attendant risks and take all necessary precautions. If the tooth is inadvertently displaced into the adjacent anatomical spaces during the extraction, the patient should be duly informed. An experienced surgeon should be promptly consulted to prevent further complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bouloux GF, Steed MB, Perciaccante VJ. Complications of third molar surgery. Oral Maxillofac Surg Clin North Am 2007;19:117-28, vii.  Back to cited text no. 1
    
2.
Silveira RJ, Garcia RR, Botelho TL, Franco A, Silva RF. Accidental displacement of third molar into the sublingual space: A case report. J Oral Maxillofac Res 2014;5:e5.  Back to cited text no. 2
    
3.
Chang WC, Chang TH, Chiu KC, Wu CT, Chen YW. Accidental iatrogenic displacement of the mandibular third molar into the lateral pharyngeal space - A case report. Taiwan J Oral Maxillofac Surg 2014;25:119-26.  Back to cited text no. 3
    
4.
Jolly SS, Rattan V, Rai SK. Intraoral management of displaced root into submandibular space under local anaesthesia - A case report and review of literature. Saudi Dent J 2014;26:181-4.  Back to cited text no. 4
    
5.
Esen E, Aydogan LB, Akçali MC. Accidental displacement of an impacted mandibular third molar into the lateral pharyngeal space. J Oral Maxillofac Surg 2000;58:96-7.  Back to cited text no. 5
    
6.
Olusanya AA, Akadiri OA, Akinmoladun VI. Accidental displacement of mandibular third molar into soft tissue: A case report. Afr J Med Med Sci 2008;37:77-80.  Back to cited text no. 6
    
7.
Ramchandani PL, Sabesan T, Peters WJ. Subdural empyema and herpes zoster syndrome (Hunt syndrome) complicating removal of third molars. Br J Oral Maxillofac Surg 2004;42:55-7.  Back to cited text no. 7
    
8.
Tumuluri V, Punnia-Moorthy A. Displacement of a mandibular third molar root fragment into the pterygomandibular space. Aust Dent J 2002;47:68-71.  Back to cited text no. 8
    
9.
Yeh CJ. A simple retrieval technique for accidentally displaced mandibular third molars. J Oral Maxillofac Surg 2002;60:836-7.  Back to cited text no. 9
    
10.
Huang IY, Wu CW, Worthington P. The displaced lower third molar: A literature review and suggestions for management. J Oral Maxillofac Surg 2007;65:1186-90.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


This article has been cited by
1 Persistent lingual paresthesia caused by a displaced tooth fragment: a case report and literature review
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Journal of the Korean Association of Oral and Maxillofacial Surgeons. 2017; 43(Suppl 1): S9
[Pubmed] | [DOI]



 

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