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DISPLACED TEETH
Arguably, the most commonly misplaced object in
oral maxillofacial surgeries are teeth, both of
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SINUS DISPLACEMENT
The most commonly associated space with a displaced impacted maxillary third molar is the maxillary sinus. If the impacted tooth or root tip is lost in
the maxillary sinus, it is worth trying to visualize the
tooth through the site from which it came. Small
suction tips may be able to bring the object back
into view so that an instrument such as a small
hooked scaler or root tip pick can be used to
retrieve it. The hole into the sinus may need to be
enlarged to suction out the tooth or root tip. If all
else fails, a Caldwell luc procedure can be used
to access the displaced tooth or root tip (Fig. 2A, B).
This can be done in the traditional canine fossa
approach or through an osteotomy above the
second molar. The anterior Caldwell luc approach
makes for easier visualization through the osteotomy, as well as easier closure following retrieval of
the displaced object. Displaced root tips from
other posterior maxillary teeth can also be
retrieved in a similar fashion. The patient should
be informed of what has occurred and be placed
on sinus precautions and appropriate prophylactic
antibiotics. In addition to teeth, a poorly planned
implant can be lost in the sinus either from iatrogenic forces or physiologic complications (see
Fig. 2C). In the case of lost implants or other
instrumentation for that matter, retrieval can be
accomplished with a similar Caldwell luc
technique.
Fig. 2. (A, B) Impacted #1 displaced into the maxillary sinus during extraction. View of the tooth through a Caldwell luc approach and removal. (C) Panorex showing displaced dental implant in the maxillary sinus.
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Fig. 3. (A) illustration of K wire through a supra-temporal approach while manually guiding the tooth back
through an intraoral incision. Sketch and technique. (B) Demonstrates the Kirshner wire entrance point. This
entrance point is made by drawing a line straight down from the zygomaticofrontal suture line, and extending
another line 35 from the point of the zygomaticofrontal suture line posteriorly. Approximately l.5 cm from the
distal border of the zygoma and l.0 cm above the zygomatic process of the temporal bone and anterior to this
35 angle is the entrance point made by a stab incision in the skin. This entrance point is where the Kirshner wire is
introduced. (Courtesy of Allan Malkasian, DDS, Fresno, CA.)
to locate and identify the tooth should be performed (Fig. 7). Once located, the patient should
be taken to the operating room so that a secured
airway via intubation can assure safety during the
retrieval process. Using imaging, a small vertical
incision should be made over the anticipated location of the tooth (Fig. 8). Then, using blunt dissection with a curved Kelly, the operator can explore
the region for the tooth. Once observed, it is
Fig. 5. Computed tomography scan illustrating displaced mandibular third molar in the submandibular
space.
Fig. 6. Illustrating the anatomy of lingually displaced mandibular third molars. (A) Displaced root tip through
lingual plate of the mandible as compared with lingual nerve and mylohyoid muscles. (B) Incision is made along
the lingual border for access. (C) Dissection is made with periosteal elevator subperiosteal and beneath the mylohyoid muscle for access to root tip.
Implant Misplacement
Implant misplacement is another problem that is
prevented with good treatment planning and technique. Severe consequences of misdirected
Fig. 7. Computed tomography image of mandibular third molar displaced into the lateral pharyngeal space.
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Fig. 8. (A) Incision over anticipated location of a displaced mandibular third molar into the lateral pharyngeal
space. (B) Using blunt dissection to expose the displaced third molar followed by retrieval.
implants have been reported. One such consequence involved the inadvertent placement of
a zygomatic implant into the cranial vault.7 Paresthesias, anesthesia, and dysthesias can occur with
cranial nerve V division 3 encroachments. Sinus
encroachment can occur usually with fewer
consequences but is nevertheless not desired.
The use of preoperative models and imaging
should be standard. Preoperative imaging,
including cone beam CT, is highly recommended.
The location of vital structures and available bone
needs to be carefully surveyed. Proper use of
guiding stents and intraoperative periapical
imaging with paralleling pins will save many misdirected implants. Intraoperative occlusal assessments with guiding pins are the sine qua non of
a functional and esthetic implant placement.
Good control of the implants and instruments
along with proper throat pack protection will
greatly reduce the loss of such things down the
pharynx (Fig. 9).
is lost, the operator is advised to immediately discontinue the procedure and make an attempt at
visualizing and retrieving the material before it is
further dislodged and becomes inaccessible.
Simple precautions can be used to avoid this
situation. When a needle is lost during injection it
is likely due to operator error. Burying the needle
to the hub during a block is not advised, because
it surely guarantees difficult retrieval should it
break at its weakest point. Repeated use of the
same needle increases the risk of breakage and
should be avoided. If a needle is lost, intervention
radiology-guided localization can be helpful,
should local exploration fail. The insertion of
a directional guide wire (ie, spinal needle) in
The blade of an oscillating saw used during an intraoral vertical ramus osteotomy can break and get
dislodged between the edges of an incomplete cut.
Avoiding undue strain on the blade and overuse is
advised. Retrieval of a broken blade can be accomplished by simply installing a new blade and manually rotating the blade without power within the
incomplete osteotomy out of the cut (Fig. 13).8
The teeth of the new blade and the broken blade
should engage like the gears of the mechanical
watch and allow for rotation of the displaced blade
out of the bone.
If all attempts to remove a biocompatible needle, bur, or screw are a failure, it is not unreasonable to leave the material and follow up with the
patient. The analogy can be made to a bullet
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REFERENCES
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Fonseca: Saunders Elsevier; 2009. p. 21222.
3. Orr DL 2nd. A technique for recovery third molars
from the infratemporal fossa: case report. J Oral Maxillofac Surg 1999;57:145961.
4. Oberman M. Accidental displacement of impacted
third molars. Int J Oral Maxillofac Surg 1980;15:7568.
5. Huang I, Wu C, Worthington P. The displaced lower third
molar: a literature review and suggestions for management. J Oral Maxillofac Surg 2007;65:118690.
6. Yeh CJ. A simple retrieval technique for accidently
displaced mandibular third molars. J Oral Maxillofac
Surg 2002;60:8367.
7. Reychler H, Olszewski R. Intracerebral penetration of
a zygomatic dental implant and consequent therapeutic dilemmas: case report. Int J Oral Maxillofac
Implants 2010;25(2):4168.
8. Tabariai E, Alexander G. An approach to retrieve
a broken saw blade in an intraoral vertical ramus
mandibular osteotomy. J Oral Maxillofac Surg 2008;
66(11):24123.