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J Oral Maxillofac Surg 68:480-485, 2010

RETRIEVAL OF DISPLACED THIRD MOLAR

Retrieval of a Displaced Third Molar Using Navigation and Active Image Guidance

Andrew Campbell, DDS,* and Bernard J. Costello, DMD, MD†

Displacement of a third molar tooth during routine surgical extraction is a rare event and well-docu- mented in the literature. 1-6 Even the most experi- enced surgeons may have this occur on occasion. Maxillary third molar teeth can be displaced into a variety of locations including the buccal space, infra- temporal fossa, maxillary sinus, or other tissue planes. We report a technique of easy retrieval using an active navigation image guidance system. This specific indi- cation has not been well reported, and it is important for dentoalveolar surgeons to be aware of the capa- bilities of the latest technology.

Report of a Case

An 18-year-old healthy female patient had a consultation with another surgeon for removal of pathologically im- pacted 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 appropri- ately 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

After 6 weeks of healing the patient was scheduled for surgical removal of the displaced tooth and, now, foreign body. At 6 weeks, the diplopia had almost completely re- solved and was only present during extreme upward gaze. A computed tomography scan was obtained as per the protocol for use with the Stryker System II Navigation image guidance apparatus (Stryker, Kalamazoo, MI). The patient was brought to the operating theater and placed under general anesthesia with a nasal endotracheal tube. The Stryker System II uses a light emitting diode (LED) mask to register the CT data with the patient in the operating the- ater and correlates the data with the hand-held probe/ suction device ( Fig 3 ). An accuracy of 0.5 mm was antici- pated after calibrating the system. Multiple views allowed localization of the tooth within minutes ( Fig 4 ). A small vestibular incision was made beneath the zygomatic but- tress, and a suction/probe was used to determine the exact location of the medial and lateral aspects of the occlusal sur- face of the tooth. After precise localization the tooth was bluntly dissected free and removed (Fig 5). Blood loss was minimal, and the incision was closed with a running 3-0 chro- mic suture. The entire procedure was completed within minutes, and the patient was discharged several hours later.

Discussion

Complications from third molar removal are, thank- fully, 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 infe- rior 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 permanent 21-23 ), 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 displace- ment 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 with- out reporting the complications. The typical management of displaced third molar teeth involves an initial, conservative attempt to re- move 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

CAMPBELL AND COSTELLO

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CAMPBELL AND COSTELLO 481 FIGURE 1. Panoramic tomogram of the patient with pathologically impacted teeth before

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.

in 3 dimensions. Imaging is recommended soon after the event to determine whether displacement of the tooth may affect function of another anatomic area (eg, the orbit). If the tooth is displaced into a critical anatomic area such as the orbit, early removal may be indicated. In most other instances, the tooth is left in position until initial scarring occurs over several weeks. The authors prefer to wait approximately 6 weeks.

weeks. The authors prefer to wait approximately 6 weeks. FIGURE 2. Computed tomography images of the

FIGURE 2. Computed tomography images of the maxillary right third molar displaced lateral to the orbit, and medial to the zygo- matic arch.

Campbell and Costello. Retrieval of Displaced Third Molar. J Oral Maxillofac Surg 2010.

Iatrogenically, displaced teeth are traditionally ap- proached after careful planning using detailed imag- ing 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 con- tinue to migrate; this is particularly the case with underdeveloped teeth without roots. Difficult-to-ac- cess 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

of at least several weeks allows fibrous encapsulation FIGURE 3. Stryker LED mask positioned on patient

FIGURE 3. Stryker LED mask positioned on patient to allow regis- tration and active navigation.

Campbell and Costello. Retrieval of Displaced Third Molar. J Oral Maxillofac Surg 2010.

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RETRIEVAL OF DISPLACED THIRD MOLAR

482 RETRIEVAL OF DISPLACED THIRD MOLAR FIGURE 4. Multiplanar views of the displaced third molar using

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 inferior–anterior aspect of displaced third molar.

Campbell and Costello. Retrieval of Displaced Third Molar. J Oral Maxillofac Surg 2010.

of the displaced tooth to occur. This tends to resist further displacement into other anatomical planes. Correlation of the position of the tooth with a multi- plane CT scan makes this approach reasonable for most minimally displaced teeth. However, surgical dissection and manipulation of the tissues can change reference points for the operating surgeon, and further displace- ment of the tooth can occur. Although some retrievals may be easy, others can be difficult, with risk of hemorrhage or neurologic injury, and may even re- quire aborting the procedure if the tooth is not lo- cated. Failure to locate the displaced tooth then re- quires the surgeon to use additional approaches or technologies for retrieval. Orr 25 reported on the in- fratemporal displacement of a right maxillary third molar. In his technique an 18-gauge spinal needle was inserted above the zygoma and posterior to the orbital rim. The needle was used to exert pressure on the tooth from a superior direction while manipulating intraorally to retrieve the tooth. Additional methods reported for removing teeth from the infratemporal fossa include the combination of intraoral incisions with a standard Gilles approach, 26 a transantral ap- proach, 27 and use of intraoperative fluoroscopy. 28 Another technique reported for locating and re- moving a displaced third molar not retrieved with a

simple intraoral incision involves a coronal or hemi- coronal approach, dissection of the temporalis mus- cle off the lateral skull, and entrance into the infra- temporal 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 pro- vides maximal surgical exposure; however, the ag- gressive 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 Nav- igation techniques with image guidance for crani- omaxillo-facial procedures have been popularized by a number of individuals. 30-32,34-37 As the technology

CAMPBELL AND COSTELLO

CAMPBELL AND COSTELLO FIGURE 5. Removal of the third molar took just minutes using this technique.

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.

has been refined, its initially cumbersome nature has been supplanted with standard protocols that have become routine in most major medical centers. Head frames were originally used for stereotactic brain surgery and localization of lesions for other onco- logic therapies. For many craniomaxillo-facial proce- dures these may be inconvenient or cumbersome to use. External fiducials placed before CT scanning or the use of an external mask with multiple LEDs are more commonly employed for procedures in crani- omaxillo-facial surgery. The latter are more recent developments and do not require rigid immobilization in a stereotactic head frame. In image-guided surgery using an optical tracking system the LED mask is placed on the patient, and a camera system connected to the CPU localizes the position of these infrared- LEDs and then merges the radiographic images with the actual position of the patient. 30 The registration procedure using the mask is quick and highly accu- rate. Navigation systems are classified as either active or passive. Active navigation systems place infrared LEDs on the patient and a camera records their posi- tion; passive systems have no LEDs but rather use spheres to reflect infrared light emitted by the camera system. 30 Active systems avoid problems created by obstructing or soiling of the reflecting spheres and overlap of reflections that can occur with passive systems. 38 Various probes containing position sensors may be used, including several varieties of suction catheters. Tracking systems follow the position of the surgical instruments and the patient, the system then

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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 conver- gence 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. Improve- ments in navigation technology and availability have led to a drastic increase in its application over the last decade. Image-guided navigation in the craniomaxil- lofacial 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 osteoto- mies, 37 and removal of foreign bodies. 30,31,34 Limitations when using image-guided navigation ex- ist and are important to consider. Intraoperative ac- tivity 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 bod- ies 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 instru- ments relative to the patient the camera must con- tinue to have the markers in view. The surgeon must position both himself or herself and the patient ap- propriately 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 mark- ers 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 How- ever, this specific indication has not been well re- ported, and it is important for dentoalveolar surgeons to be aware of the capabilities of current systems.

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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 de- creased likelihood of complications, as well as in improved recovery and a better experience for the patient and family when compared with more ag- gressive techniques previously described. The use of navigation provided a safe and precise approach to the region without the need for extensive explo- ration 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 expe- rienced of surgeons. Using navigation allowed us to remove a displaced wisdom tooth in a minimally in- vasive fashion in minutes. This technique allows ex- ceptionally accurate localization and removal of dis- placed teeth, which provides a much better solution than the more aggressive approaches described in the literature. It also affords a margin of safety with dis- section 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 accu- racy of navigation provides a predictable road map for successful removal of significantly displaced third mo- lars.

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