CASO CLÍNICO

 

A rare complication during the extraction of the included inferior third molar. Case report

Una rara complicación en la extracción del tercer molar inferior incluido. Caso clínico

 

 

S. Aboul-Hosn Centenero¹, R. Sieira Gil², A. Monner Diéguez³

1 Jefe de la Unidad de Cirugía Maxilofacial del Hospital Plató, Barcelona.
2 Médico Residente del Servicio de Cirugía Maxilofacial del Hospital de Bellvitge, Hospitalet de Llobregat, Barcelona.
3 Jefe del Servicio de Cirugía Maxilofacial del Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona.

Correspondence

 

 

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ABSTRACT

We present a rare complication that appeared after an attempt to extract the included third molar with local anaesthesia at the odontologist office. The patient was admitted to the emergency room to have the tooth removed cervically under general anaesthesia and nasotracheal tubation because of its movement towards the submandibular fossa during the ambulatory extraction attempt. The patient showed evident signs of swelling in submandibular region and the airway was displaced towards the opposite side. The resulting complications from the third molar surgery are, in some cases, mortal and can occur after an apparently low risk surgery. These complications have been thoroughly described in literature. Still, we consider it important to describe infrequent complications of third molar surgery because it will allow us to know more about them and offer the best solution in every case.

Key words: Third molar complications; Third molar surgery.

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RESUMEN

Presentamos una rara complicación ocurrida tras el intento de extracción del tercer molar incluido en una consulta odontológica bajo anestesia local. El paciente requirió ingreso en el servicio de urgencias para la extracción, de forma urgente, de la pieza a través de un abordaje cervical bajo anestesia general e intubación nasaotraqueal por desplazamiento de la pieza hacia la fosa submandibular durante el intento de extracción ambulatoria. El paciente presentó signos evidentes de inflamación en la región submandibular con desplazamiento de la vía aérea hacia el lado opuesto. Las complicaciones derivadas de la cirugía del tercer molar son, en algunos casos, mortales y pueden aparecer tras un acto quirúrgico aparentemente de bajo riesgo. Estas complicaciones han sido ampliamente descritas en la literatura. Aún así consideramos importante el presentar complicaciones poco frecuentes en la cirugía del tercer molar ya que esto nos permitirá conocerlas y ofrecer la mejor solución en cada caso.

Palabras clave: Complicaciones tercer molar; Cirugía del tercer molar.

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Introduction

The pathology of the included third molar is well known among oral and maxillofacial surgeons because it is a common procedure. Its symptoms have been described in detail, different variations in the surgical technique for extraction and complications that extracting or not extracting can cause.^1-4 That is why, at the moment, there is little scientific literature on the included third molar that provides new information.

Regarding the morbidity, we present a case that is outstanding because it is unusual and also because of the potential seriousness it involves.

 

Case report

Thirty-four year old patient with no medical history of interest comes to our emergency service 12 hours after his odontologist unsuccessfully attempted to extract the lower right included third molar. The patient presents moderate trismus with signs of inflammation in the left submandibular region with no fever or other relevant symptoms. Upon intra oral exploration we find an open distal surgical wound of the inferior right second molar with evident inflammation of the surrounding mucosa, the third molar is not visible even though the patient informs us that his odontologist could not extract it.

An orthopantomogram is done where the third molar appears (Fig. 1). We try to perform an extraction through the surgical wound under local anaesthesia. The third molar can not be extracted because of difficult access and symptoms of pain and trismus that the patient has. We decide to perform a CT-Scan (Fig. 2) and to take the patient to the operating room to extract the third molar under general anaesthesia and nasotracheal intubation. We attempted to extract the third molar through the oral cavity but when trying to extract it, the piece moves even more toward the submaxilar fossa. As a result we decided to perform a right submandibular cervical approach through a 1,5 cm incision and careful dissection until reaching the sub maxilar fossa, track the lower right third molar and perform the extraction through the cervical incision.

 

 

 

The patient was moved to the Maxillofacial Surgery floor where endovenous antibiotic therapy was prescribed.

The patient is released 48 hours after the procedure, once a clear clinical improvement was confirmed.

 

Discussion

Even though it is a common surgical procedure, included third molar surgery is not exempt from risk during and after the surgical procedure. Infection is among the most common complication that we can find and can potentially become very serious if it is complicated with a cellulitis of the floor of the mouth or even with a mediastinitis if the purulent material progresses towards the mediastinum.⁵ Bleeding during this kind of surgery is usually self-controlled but it can be very unpleasant and create a significant state of anxiety in the patient when it is not supervised at home. Another relatively common complication is partial or total lesion of the dental nerve and/or the lingual nerve with the resulting hypoesthesia of parts of the tongue and lip. We have to let the patient know all of these possible complications when signing the informed consent as well as the post surgical inflammation that may come with haematomas, trismus, and pain.

We consider it very important to always take into consideration the typical complications that this surgery may involve but we want to emphasise that infrequent complications, ^6-10 like the one that we see in this case report, are complications that we may find during our habitual practice and we must know how to solve them.

In our opinion, in the case that we present there was an internal cortical fracture or lingual cortical fracture of the adjacent third molar. This is more frequent when the third molar is near the tongue with a thin cortical that tears when pressure is applied from the buccal side. The fact that we sometimes deal with erupted teeth can cause us to falsely trust the maxillofacial surgeon or odontologist. In this case, the odontologist´s attempt to recover the third molar caused the tooth move more towards the right sub maxilar fossa between the internal mandible side and the oral mucosa that covers the mandible area.

In every attempt to extract the third molar using different instruments in the oral cavity, the tooth would penetrate even deeper. That is why an extraction using a cervical approach was performed. We also want to highlight the importance of extracting the tooth as soon as possible, like we did with our patient, because the tooth behaves like a foreign body which can cause an infection in the surrounding tissues. We also consider it very important to perform antibiotic coverage in order to prevent the progression of a possibly infectious process from the patient's first visit and during two weeks after the procedure.

In the case of crown fractures during third molar outpatient surgery performed by the odontologist, we think that when faced with doubt about the best option it is best to refer the patient to a health center where a specialist in maxillofacial surgery is available.

We believe that the possibility of knowing about a rare complication, like the one that we present in this case, can give assure the surgeon about how to proceed during a habitual daily procedure. Although it may not be risk free like included third molar extraction.

 

Acknowledgements

Marcella Frediani for the translation work.

 

Correspondence:
Samir Aboul Hosn Centenero
c/ Diputación 345, 2-1
08009 Barcelona
E-mail: samiraboul@hotmail.com

Recibido: 28.01.2008
Aceptado: 24.09.2009

 

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