Dispositivo de seguridad para controlar mejor el tercer molar impactado durante exodoncia:
Una nueva técnica

F. Hernández Altemir, S. Hernández Montero, M. Moros Peña, E. Hernández Montero

Recibido: 20-07-2004

Aceptado: 06-10-2004

1 Jefe del Departamento de Cirugía Oral y Maxilofacial
2 Cirujano oral y maxilofacial
3 Pediatra
4 Otorrinolaringólogo
Departamento de Cirugía Oral y Maxilofacial
Hospital Universitario "Miguel de Servet", Zaragoza, España

Correspondencia:
Francisco Hernández Altemir
Calle Fray Luis Amigó nº8, 0-B.
50006 Zaragoza, España
Email: drhernandezaltemir@yahoo.es

Introduction

Third molars tend to erupt relatively late and slowly, and disturbances associated with their eruption and position, for example pericoronitis and impaction, often arise in the second and third decades of life. These disturbances and their prevention are the major reasons for early removal of third molars. Accidental displacement of impacted third molars, either a root fragment, the crown or the entire tooth, is a complication that occasionally occurs during exodontia. When the molar moves to the maxillary sinus the problem is not as serious as when it gets into the pterygomandibular or infratemporal spaces. Surgeons, of course, are very much aware of this eventuality, which can cause tension and some stress during the luxation and extraction, and even more so when the surgeon is an amateur and is being helped by an experienced specialist, who probably suffers even more in his role as teacher. The surgical procedure for the retrieval of such a displaced tooth may be complex due to poor visibility and limited space. Recently a 43-year-old woman was referred urgently to our Service after a failed attempt at exodontia of an impacted left upper third molar. Radiographic examination (Fig. 1) and TAC (Fig. 2) showed that the molar was displaced into the pterygomandibular space.

The patient was anaesthetised and surgical procedure was initiated. To extract the molar we reached the space using and extending the incisions of the first exodontic attempt. We detached a vestibulotuberosital flap that allowed us to locate and remove the tooth with no complications (Fig. 3).

However, serious disadvantages have been reported in the location of accidentally displaced third molars to this region. We describe an easy technique for a better control of non-erupted mandibular third molars during exodontia.

Material and method

We use an anchoring device we ourselves have developed which is in some ways similar to existing devices which may also prove useful. However, given that in our procedure, the anchoring of the device with its security thread is carried out in the vestibular and/or occlusal face of the impacted molar when it has been surgically exposed, we have had to make both instrumental modifications on the anchorage itself and on the dental installation elements, that because of the nature of the molar; enamel and dentin, and its position, requires a more specialized instrument.

Our instrument consists of the anchoring devices normally used to fix tendons and muscles etc. on small joints but in this case it is fixed into the relevant tooth by drilling an orifice of exactly the right calibre and depth to fit the anchoring device (Fig. 4).

Once the vestibular/occlusal faces of the molar to be extracted have been sufficiently exposed, a drill is used to make a cavity at the most appropriate level, depending on the position of the non erupted third molar, a cavity (Fig. 4A) that will act as a shroud enabling us to install our anchorage accurately (Fig. 4B). The anchorage supports a surgical thread which acts as a guide and/or a traction system (Fig. 4C) to locate and/or extract the luxated molar more easily towards the sinus or the subtemporal fossa. Thus the recovery of the molar is undoubtedly made simpler.

Discussion and conclusions

Providing maximum safety and guarantee of success to the patient in any surgical procedure is, of course, an obligation. If, at the same time the surgeon benefits with a reduction in stress during this operation, which is, repeated thousands of times every day around the world, then the use of this device is more than justified. Moreover, the displacement of non erupted molars is repeatedly referred to in the literature, and surgical procedures for their retrieval may be very complex, especially if the molar gets into the pterygomandibular space or the infratemporal fossa when the complexity of the surgery required is often underestimated by the patient and not infrequently by specialists and Health Managers too.

Since we began to use this procedure, stress levels during surgery have been reduced. We have only encountered the complications mentioned above once, in the 1970s, when there was a case of an impacted third molar that moved to the left maxilla sinus during exodontia and required a Caldwell-Luc procedure to be carried out. However, this case made an impression on us and lead us to develop this safety device which, in spite of its obvious advantages, also prolongs surgery time, implies additional use of instruments and consequently greater expense.

References

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