3
J Oral Maxillofac Surg 69:1301-1303, 2011 First Report of Accidental Displacement of Mandibular Third Molar Into Infratemporal Space Reza Shahakbari,* Hamed Mortazavi,† and Majid Eshghpour‡ One of the most common procedures in the dental office is surgical removal of the maxillary or mandibular third molars. 1 Of the complications associated with third molar extraction, the most commonly mentioned have been dysesthesia, alveolar osteitis, infection, hem- orrhage, fracture of the mandible, and damage to the adjacent teeth. Accidental displacement of the fractured roots or teeth into the submandibular, pterygomandib- ular, and sublingual spaces is a less common complica- tion. 2,3 One of the very rare occurrences during man- dibular third molar extraction is displacement of the tooth into the infratemporal space, such as reported in the present study. A review of the published data re- vealed little information on the incidence, cause, and management of displaced tooth and root fragments. 2 Case Report A 23-year-old female patient was referred from her gen- eral practitioner to the clinic of oral and maxillofacial sur- gery of the Mashhad Dental School with a complaint of limited mouth opening and pain in the left temporal area after surgical extraction of the mandibular third molar 1 week prior from the left temporal area. The intraoral clinical examination revealed tissue damage in the left temporal site. She had a mouth opening of about 15 mm, making it difficult to perform intraoral examinations or take photo- graphs. A panoramic radiograph suggested the presence of a tooth apparently near the left coronoid process (Fig 1). This resulted in a decreased coronoid process range of motion and maximal mouth opening. The tooth socket could be seen in the left side of the orthopantomogram (OPG) (Fig 1). The presence of the tooth was clearly re- vealed, adjacent to the coronoid on the patient’s computed tomography scan, especially the 3-dimensional computed tomography scan (Figs 2, 3). Initially, physiotherapy was conducted for 10 days, to rectify the limitation in mouth opening if it had been caused by factors other than the mechanical obstacle of the tooth adjacent to the coronoid. However, after physiotherapy, no change in the mouth opening had occurred. The removal of the tooth was at- tempted with the patient under local anesthesia 20 days after the initial operation. Access was achieved by a high ramus incision, similar to a coronoidectomy incision, and the tooth was removed. Immediately after surgery, the ex- tent of mouth opening had increased. At 1 week after removing the tooth, her maximal mouth opening was 40 mm. At present, the patient has had no complaints. Discussion The incidence of complications associated with sur- gical removal of the third molar has been moderate (around 10%). However, trained experienced sur- geons have had a lower incidence of complication than general dentists. 3 Fenestration of alveolar bone, a poor selection of surgical methods, and incorrect use of an instrument could be some factors resulting in accidental displacement of a tooth into the anatomic spaces. Uncontrolled force during the use of elevators has been reported as the most usual cause of these complications. 2,3 In the present case, the computed tomography findings showed damage to the lingual cortex that might have been related to displacement of the tooth into the infratemporal space. However, because this entity is very rare, we could not explain the actual cause of the tooth displacement into the infratemporal space. The infratemporal space is at the intersection of the deep temporal space superiorly and the pterygomandibular space inferiorly. Infec- tions of the infratemporal spaces are most often asso- ciated with the contiguous spaces, specifically the buccal, pterygomandibular, deep temporal, lateral pharyngeal, and parotid spaces. 4 A review of the pub- lished data showed that all dislodged teeth into the infratemporal space were maxillary third molars. We could not find a case of mandibular third molar having been displaced into the infratemporal space. The ac- cepted treatment is removal of the displaced teeth or root fragments to prevent future infection. 3 There- fore, patients must be urgently referred to a maxillo- facial surgeon after the administration of prophylactic *Assistant Professor, Department of Oral and Maxillofacial Sur- gery, University of Medical Sciences Mashhad Dental School, Mash- had, Iran. †Assistant Professor, Department of Oral Medicine, University of Medical Sciences Hamadan Dental School, Hamadan, Iran. ‡Assistant Professor, Department of Oral and Maxillofacial Sur- gery, University of Medical Sciences Mashhad Dental School, Mash- had, Iran. Address correspondence and reprint requests to Dr Mortazavi: Department of Oral Medicine, University of Medical Sciences Hama- dan Dental School, Next to Mardom Park, Hamada, Iran; e-mail: [email protected] © 2011 American Association of Oral and Maxillofacial Surgeons 0278-2391/11/6905-0019$36.00/0 doi:10.1016/j.joms.2010.06.215 1301
