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Report of a Case
An 18-year-old healthy female patient had a consultation
with another surgeon for removal of pathologically impacted third molars, and surgical removal of the teeth was
recommended (Fig 1). The complete bony impactions were
approached in typical fashion using a small incision along
the lateral aspect of the alveolar crest in the area of the
impacted tooth. A subperiosteal dissection was appropriately completed, but during elevation the right maxillary
third molar was displaced beneath the flap. An immediate
exploration was performed to locate the tooth but was
subsequently terminated without success. Postoperatively,
the patient displayed diplopia on upward gaze, warranting
evaluation by an ophthalmologist. Visual acuity and all other
aspects of her examination were normal with the notable
exception of diplopia on extreme upward gaze. A CT scan
was obtained to localize the now foreign-body, and the
patient was referred to the senior author for treatment (Fig
2). A minor orbital disruption was noted on the scan, with
disruption of the tissues surrounding the inferior rectus.
Received from the Department of Oral and Maxillofacial Surgery,
University of Pittsburgh School of Dental Medicine, Pittsburgh, PA.
*Pediatric Oral and Maxillofacial/Craniofacial Fellow.
Associate Professor and Program Director, Chief, Craniofacial
and Cleft Surgery.
Address correspondence and reprint requests to Dr Costello:
Department of Oral and Maxillofacial Surgery, 3471 Fifth Avenue,
Suite 1112, Pittsburgh, PA 15213; e-mail: bjc1@pitt.edu
2010 American Association of Oral and Maxillofacial Surgeons
0278-2391/10/6802-0040$36.00/0
doi:10.1016/j.joms.2009.06.032
Discussion
Complications from third molar removal are, thankfully, rare. The most common complications occur
with regular frequency. These include infection (0.8%
to 4.2%),7-13 alveolar osteitis (0.3% to 26%),7-15 inferior alveolar nerve injury (0.4% to 8.4%),8,18,19 lingual
nerve injury (0% to 23%,10,18,20 with approximately
0.5% being permanent21-23), and clinically significant
hemorrhage (0.1% to 0.7%).7,10,24 Rare complications
of third molar removal include mandible fracture
(0.0033% to 0.0049%),16,17 osteomyelitis, and displacement of teeth during removal, for which the incidences
are unknown. It is likely that displacement of teeth
during removal of third molars is under-reported, as
most surgeons retrieve their own displacements without reporting the complications.
The typical management of displaced third molar
teeth involves an initial, conservative attempt to remove the tooth from the area in which it is believed
to be displaced. If initial retrieval fails then the region
is irrigated and closed, and the patient is placed on
antibiotics. Imaging is obtained to localize the tooth
481
FIGURE 1. Panoramic tomogram of the patient with pathologically impacted teeth before displacement.
Campbell and Costello. Retrieval of Displaced Third Molar. J Oral Maxillofac Surg 2010.
Iatrogenically, displaced teeth are traditionally approached after careful planning using detailed imaging in multiple planes followed by the use of extended
intraoral incisions. Difficulties may be encountered when
teeth are displaced into areas where the tooth can continue to migrate; this is particularly the case with
underdeveloped teeth without roots. Difficult-to-access areas include the buccal fat pad, infratemporal
fossa, sinus cavity, floor of mouth, masticator space,
or other areas of loose fascial planes. A waiting period
of at least several weeks allows fibrous encapsulation
FIGURE 3. Stryker LED mask positioned on patient to allow registration and active navigation.
482
FIGURE 4. Multiplanar views of the displaced third molar using the suction probe to identify the precise location of the displaced tooth in
real time. Probe positioned at inferioranterior aspect of displaced third molar.
Campbell and Costello. Retrieval of Displaced Third Molar. J Oral Maxillofac Surg 2010.
simple intraoral incision involves a coronal or hemicoronal approach, dissection of the temporalis muscle off the lateral skull, and entrance into the infratemporal fossa.29 Although this is a viable approach, it
is aggressive in comparison with the incisions and
recovery expected after routine third molar tooth
removal. This technique works very well and provides maximal surgical exposure; however, the aggressive nature of the procedure has a number of
possible complications associated with it, including
trismus, a residual coronal scar with hair loss, facial
nerve palsy, temporalis wasting, temporal hollowing,
and significant blood loss. These factors limit this
approach to teeth that cannot be accessed in any
other manner. In rare instances a brow incision may
be used to work in concert with an intraoral incision
to manipulate the foreign body from 2 locations in a
minimally invasive fashion. Although this procedure
was not necessary in the current case, it could be
performed with a higher degree of accuracy with
active navigation if necessary.
Image-guided navigation applications for surgery
were first developed for use in neurosurgery.30-33 Navigation techniques with image guidance for craniomaxillo-facial procedures have been popularized by
a number of individuals.30-32,34-37 As the technology
FIGURE 5. Removal of the third molar took just minutes using this
technique.
Campbell and Costello. Retrieval of Displaced Third Molar. J Oral
Maxillofac Surg 2010.
483
displays the 3-dimensional relationship of the probe
to the patients anatomy. Accuracy with the probes is
typically better than within 1 mm.30
This technology has become useful as the convergence of a variety of technologies including highly
accurate imaging, user-friendly software applications
for navigation, and systems to correlate these data in
real time with a high degree of precision. Improvements in navigation technology and availability have
led to a drastic increase in its application over the last
decade. Image-guided navigation in the craniomaxillofacial region has been used in oncologic biopsies
and resections,32,35 craniofacial reconstruction,36,39
facial trauma,40 dental implantology,37 arthroscopy of
the temporo-manibular joint,37,41,42 facial osteotomies,37 and removal of foreign bodies.30,31,34
Limitations when using image-guided navigation exist and are important to consider. Intraoperative activity is based on the preoperatively acquired image
data. Changes occurring at the surgical site during
manipulation are not represented on images viewed
by the surgeon.31,32 Performing surgical procedures
in highly mobile tissues, such as the tongue, may be
unreliable and limited.31 When retrieving foreign bodies any further iatrogenic displacement will make the
preoperative images less useful.
Registration accuracy is crucial for the accuracy of
navigation.43,44 The accuracy obtained depends on
the tracking system used; on the design, number and
arrangement of fidicial markers; and on the image
data. In reality, marker position on the patient always
differs slightly from positions displayed on the image,
but this difference is routinely reduced to less than 1
mm.30,31 A disadvantage to optical navigation systems
relates to the line of sight. A camera senses the LED
markers on the patient for registration; to track instruments relative to the patient the camera must continue to have the markers in view. The surgeon must
position both himself or herself and the patient appropriately at all times to avoid obstruction of the line
of sight. This is not difficult for most procedures but
must be considered during set-up of the equipment.
Many image registration systems require that markers be placed on the patient before image acquisition
or that images be acquired in a specific protocol that
is not routine during initial diagnostic radiography. To
determine the need for image guided navigation the
patient will have already received diagnostic imaging.
The patient would then need additional imaging for
appropriate registration. There is additional cost and
radiation exposure when CT scanning is used.30
Removal of foreign bodies using navigation has
been discussed in previous publications.30,31,34 However, this specific indication has not been well reported, and it is important for dentoalveolar surgeons
to be aware of the capabilities of current systems.
484
This technique allowed exceptionally quick removal
of the foreign body with precise localization. This
permitted us to avoid exploratory blunt dissection in
the infratemporal fossa and to limit postoperative
pain, swelling, and potential scarring for our patient.
This minimally invasive approach resulted in a decreased likelihood of complications, as well as in
improved recovery and a better experience for the
patient and family when compared with more aggressive techniques previously described. The use
of navigation provided a safe and precise approach
to the region without the need for extensive exploration while avoiding significant vasculature and
other structures of concern to remove the displaced
tooth. Given the disruption of the orbit and inferior
rectus from the previous procedure, we considered
this very important.
Iatrogenic displacement of a third molar during
routine surgical extraction occurs rarely and is likely
under reported. It can occur even to the most experienced of surgeons. Using navigation allowed us to
remove a displaced wisdom tooth in a minimally invasive fashion in minutes. This technique allows exceptionally accurate localization and removal of displaced teeth, which provides a much better solution
than the more aggressive approaches described in the
literature. It also affords a margin of safety with dissection in this region that has heretofore not been
possible with traditional techniques. In cases in
which surgical manipulation may affect the globe,
vasculature, or various nerves in the region, the accuracy of navigation provides a predictable road map for
successful removal of significantly displaced third molars.
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