Oral Maxillofacial

Surge ry D isplacem ent

Complications
Gerald Alexander, DDSa,b,c,*, Hany Attia, DDSb

KEYWORDS
 Dentoalveolar complications  Maxillofacial complications
 Displaced surgical instrumentation

An iatrogenically displaced object, although traumatic or iatrogenic causes. In traumatic losses,

seldom anticipated and almost always inadvertent, unaccounted teeth must be located or, at
can present a challenge to the primary practitioner a minimum, documented of their negative locale.
or the secondary subsequent surgeon.1 Though It is not uncommon that trauma patients have loose
seldom life-threatening, the failure to resolve the or unaccounted for traumatically misplaced teeth.
problem in a timely fashion can have serious It is the duty of the oral maxillofacial surgeon prac-
psychological, physiologic, and medical legal titioner who evaluates these patients to account for
consequences. This discussion will emphasize possibly ingested or aspirated teeth via imaging.
the former and present cases of complications Imaging previously discussed can help either posi-
and the resolving treatment. No one sets out to tively or negatively confirm the location of these lost
displace an object, whether a tooth, instrument, teeth. If a tooth or object is thought to be lost
or ancillary equipment. Of course the paramount beyond the oral cavity during an in-office proce-
issues are anticipation and prevention. When the dure it is prudent to determine whether the object
event occurs, retrieval and repair, whether imme- was swallowed or aspirated. If it is obviously aspi-
diate or delayed, is the task at hand. rated and the patient is in airway distress, a simple
Modern imaging techniques can be both helpful finger sweep should first be attempted, followed by
and incriminating. Imaging can be as simple as a Heimlich procedure. Upper airway aspirations
a dental periapical or a panoramic radiograph may be retrievable with Magill forceps and the aid
and be as advanced as a 3-dimensional computed of a laryngoscope. If this is not successful, and
tomography (CT) reconstruction. In-office cone the patient begins to desaturate, a positive pres-
beam 3-dimensional imaging can be beneficial in sure bag connected to an oxygen source can aid
locating misplaced teeth or foreign objects. Their in ventilation. If all else fails, intubation or a crico-
availability is invaluable and may be, if not already, thyroidotomy may be indicated. Transfer of the
the standard of care. A chest radiograph or plain patient to the emergency room via ambulance
abdominal radiograph (KUB) film is often helpful should be initiated simultaneously.
in locating and or documenting negative findings The iatrogenic displacement of teeth occurs
of objects lost beyond the oral cavity. An intrao- most frequently in the attempted removal of
perative CT in a hospital operating room can be impacted third molars. It is wise to present this
very helpful in an anesthetized patient. possibility to the patient in the preoperative
informed consent discussion. Again anticipation
DISPLACED TEETH and prevention are key in management of this
oralmaxsurgery.theclinics.com

complication. Common places associated with

Arguably, the most commonly misplaced object in displaced third molars are the maxillary sinus,
oral maxillofacial surgeries are teeth, both of temporal space, infratemporal space, lateral

a
Private Practice, Fresno, CA, USA
b
Department of Oral Maxillofacial Surgery, University of California, San Francisco Fresno, Fresno, CA, USA
c
Veterans Affairs Medical Center Fresno, Fresno, CA, USA
* Corresponding author. 7025 North Maple, Suite 108 Fresno, CA 93720.
E-mail address: [email protected]

Oral Maxillofacial Surg Clin N Am 23 (2011) 379–386

doi:10.1016/j.coms.2011.04.001
1042-3699/11/$ – see front matter Ó 2011 Elsevier Inc. All rights reserved.
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380 Alexander & Attia

without saying that a gauze throat pack be appro-

priately placed to prevent losing the tooth in the
posterior pharynx. If the impaction is medial to
the second molar and cannot be surgically visual-
ized, it is better left alone than blindly reaching for it.

SINUS DISPLACEMENT
The most commonly associated space with a dis-
placed impacted maxillary third molar is the maxil-
lary 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
Fig. 1. Root tip lost in the buccal space.
to access the displaced tooth or root tip (Fig. 2A, B).
This can be done in the traditional canine fossa
pharyngeal space, submandibular space, and approach or through an osteotomy above the
buccal space (Fig. 1). second molar. The anterior Caldwell luc approach
In regards to maxillary third molar complications, makes for easier visualization through the osteoto-
if the surgeon is uncomfortable removing an my, as well as easier closure following retrieval of
unusually superiorly placed maxillary third molar, the displaced object. Displaced root tips from
then it should be left in place for further eruption. other posterior maxillary teeth can also be
The exception to this would be the presence of retrieved in a similar fashion. The patient should
any associated or obvious impending pathology. be informed of what has occurred and be placed
The most important preventative maneuver is to on sinus precautions and appropriate prophylactic
provide proper access. A high impaction is usually antibiotics. In addition to teeth, a poorly planned
apical and somewhat buccal to the second molar. implant can be lost in the sinus either from iatro-
A preoperative cone beam CT is invaluable in genic forces or physiologic complications (see
determining the medio–lateral location. If the tooth Fig. 2C). In the case of lost implants or other
is apical and reachable from a lateral approach, instrumentation for that matter, retrieval can be
then enough subperiosteal dissection should be accomplished with a similar Caldwell luc
achieved to visualize either a portion of the tooth technique.
or its overlying bone. This may require a buccal
Infratemporal Space Displacement
sulcular incision extending 2 to 3 teeth anteriorly
from the maxillary tuberosity or a vertical anterior The infratemporal space is also a possible
buccal releasing incision may provide excellent pathway for a displaced maxillary third molar. Its
access. Overlying bone is then removed with retrieval does not usually present any technical
a mono-beveled osteotome until enough of the problems once its location is established radio-
impacted tooth is visualized to permit placement graphically. Further displacement of teeth into
of a preferably curved elevator (eg, 190/191 or the temporal fossa may be more technically diffi-
a pots elevator). The elevator should be placed cult to access. It is sometimes helpful to place
mesial to the impaction and distal or superiorly to a finger over the temporal area (extraorally) to
the disto–buccal root of the second molar. The palpate or stabilize the ectopic tooth while the
force of the elevation should have a distal and retrieval is attempted through the extraction site
buccal vector. This may require the elevator to intraorally (Martin Bellenger, DMD, personal
engage more than half of the equator of the communication, 2009). It has also been suggested
impacted tooth. This will direct the tooth away that by waiting 10 to 14 days, enough fibrous
from the sinus cavity and the infratemporal space. growth will have developed around the tooth to
It may be helpful to place an instrument such as the help stabilize the tooth and facilitate its removal.2
rounded end of the #9 periosteal elevator distal to Another technique that has been described in
the impaction as it is elevated. Controlled force is the literature is to introduce a Kirshner wire lateral
applied when delivering the impaction. It goes to the orbital rim. With bimanual manipulation,

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 Oral Maxillofacial Surgery 381

Fig. 2. (A, B) Impacted #1 displaced into the maxillary sinus during extraction. View of the tooth through a Cald-
well luc approach and removal. (C) Panorex showing displaced dental implant in the maxillary sinus.

the Kirshner wire can be guided to the ectopic tooth the infratemporal space, a maxillary third molar
and pushed back through the extraction site (Allan can uncommonly find its way superiorly along
Malkasian, DDS, personal communication, 2010) side the condylar head (Fig. 4).
(Fig. 3).3 The Kirshner wire should be of a width Mandibular third molar teeth or, more frequently,
that can be flexed and, if necessary, a gentle curve their root tips, are sometimes displaced through
be placed at its tip. It is possible that the Kirshner the thin lingual plate of the mandible. This can
wire may require a blunt end so that it will not slip result in local displacement nearly subperiosteal
off the tooth when it is engaged in the temporal or through the mylohyoid muscle and into the
fossa. The index finger is placed at the incision submandibular space (Fig. 5). In this scenario,
site of the third molar socket. The tooth may or immediate stabilization of the tooth can some-
may not be palpable at this site. The Kirshner wire times be accomplished by placing a finger on the
is then introduced into the stab incision in the medial aspect along the angle of the mandible ex-
temporal region and passed in a direction that traorally. Following stabilization, the extraction site
angles toward the third molar socket. For orienta- can be widened with a small fissure bur, using
tion purposes, the Kirshner wire can be extended caution to avoid the inferior alveolar nerve. Manual
and used to palpate the maxillary tuberosity, then manipulation can then advance the tooth or root
retracted. At this point the goal is to palpate the tip back through the extraction site for retrieval. If
tooth with 1 index finger while using the tip (or a root tip is especially difficult to retrieve and is
curved tip) of the Kirshner wire to locate the tooth. at risk of dislodgement through the cortical plate,
When the tooth can be found and palpated with it is helpful to expose the root tip by removing
the fingertip, the Kirshner wire is pressed against the surrounding bone with a small fissure bur
the tooth, and the index finger is then used as rather than attempting to elevate the root tip with
counter pressure against the tooth. While pushing an elevator. Elevating the root tip between the
downward with the Kirshner wire and applying alveolus can lack control and accessibility, leading
counter pressure on the tooth, the tooth is moved to displacement.
downward and out of the temporal fossa. If all If the root tip finds its way through the lingual
else fails, a case report in the literature of a failed plate and below the mylohyoid muscle, a simple
removal of a displaced tooth in this area noted surgical approach can be used to dissect subper-
that there were no consequences.4 In addition to iosteal, to expose the root tip. This can be

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382 Alexander & Attia

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.)

accomplished by laying a full-thickness flap on the to locate and identify the tooth should be per-
lingual border of the alveolus and dissecting formed (Fig. 7). Once located, the patient should
subperiosteal, while maintaining digital pressure be taken to the operating room so that a secured
extraorally at the lingual aspect of the inferior airway via intubation can assure safety during the
border of the mandible (Fig. 6).5 Damage to the retrieval process. Using imaging, a small vertical
lingual nerve is avoided if dissection is maintained incision should be made over the anticipated loca-
subperiosteally. An extraoral incision can also be tion of the tooth (Fig. 8). Then, using blunt dissec-
used to approach the submandibular space. One tion with a curved Kelly, the operator can explore
surgeon reports making a 4 mm skin incision along the region for the tooth. Once observed, it is
the submandibular region and bluntly dissecting to
the lingual border of the mandible for stabilization
while retrieving the object. This should be done
as a last resort.6
A more serious, albeit rare, displacement of
mandibular third molars into the lateral pharyngeal
space can be daunting. When this may be
perceived as a possibility, immediate CT imaging

Fig. 4. Panorex of displaced mandibular third molar Fig. 5. Computed tomography scan illustrating dis-
along the condylar neck. (Courtesy of Dr Dennis- placed mandibular third molar in the submandibular
Duke R. Yamashita, Montebello, CA.) space.

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 Oral Maxillofacial Surgery 383

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 my-
lohyoid muscle for access to root tip.

a matter of properly grasping the tooth with an Implant Misplacement

instrument that will allow for clamping around the
Implant misplacement is another problem that is
diameter of the tooth so as to not allow the tooth
prevented with good treatment planning and tech-
to slip away during retrieval.
nique. Severe consequences of misdirected

Fig. 7. Computed tomography image of mandibular third molar displaced into the lateral pharyngeal space.

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384 Alexander & Attia

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 conse- is lost, the operator is advised to immediately dis-
quence involved the inadvertent placement of continue the procedure and make an attempt at
a zygomatic implant into the cranial vault.7 Pares- visualizing and retrieving the material before it is
thesias, anesthesia, and dysthesias can occur with further dislodged and becomes inaccessible.
cranial nerve V division 3 encroachments. Sinus Simple precautions can be used to avoid this
encroachment can occur usually with fewer situation. When a needle is lost during injection it
consequences but is nevertheless not desired. is likely due to operator error. Burying the needle
The use of preoperative models and imaging to the hub during a block is not advised, because
should be standard. Preoperative imaging, it surely guarantees difficult retrieval should it
including cone beam CT, is highly recommended. break at its weakest point. Repeated use of the
The location of vital structures and available bone same needle increases the risk of breakage and
needs to be carefully surveyed. Proper use of should be avoided. If a needle is lost, intervention
guiding stents and intraoperative periapical radiology-guided localization can be helpful,
imaging with paralleling pins will save many mis- should local exploration fail. The insertion of
directed implants. Intraoperative occlusal assess- a directional guide wire (ie, spinal needle) in
ments 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).

Other Displaced Objects

In addition to displaced teeth, loss of broken and
faulty instrumentation during a surgical procedure
can be an overwhelming complication. Instrumen-
tation at risk for loss include injection needles,
suture needles, packings, wires, plates, screws,
and broken burs. In all cases, when the material Fig. 9. Picture of poorly planned implant placement.

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 Oral Maxillofacial Surgery 385

Fig. 12. Bur lost in extraction site.

The blade of an oscillating saw used during an in-

Fig. 10. Picture of needle placement along rami of traoral vertical ramus osteotomy can break and get
mandible for reference in localizing a lost needle. dislodged between the edges of an incomplete cut.
Once needle is inserted, a radiograph is taken and Avoiding undue strain on the blade and overuse is
can be used for localization. advised. Retrieval of a broken blade can be accom-
plished by simply installing a new blade and manu-
ally rotating the blade without power within the
addition to a radiograph can assist in maintaining
incomplete osteotomy out of the cut (Fig. 13).8
a point of reference when exploring for the needle
The teeth of the new blade and the broken blade
(Fig. 10). Suture needles, when lost, can also
should engage like the gears of the mechanical
benefit from local exploration and radiographic
watch and allow for rotation of the displaced blade
localization. Maintaining counts, for all of the ancil-
out of the bone.
lary armamentarium, can be a simple precaution in
If all attempts to remove a biocompatible nee-
avoiding this complication.
dle, bur, or screw are a failure, it is not unreason-
Similarly, lost burs can be avoided by the previ-
able to leave the material and follow up with the
ously mentioned precautions. In addition, it is
patient. The analogy can be made to a bullet
advised to use a new bur on every surgical case,
as the savings of the minimal cost do not justify
the repercussions of a broken bur (Figs. 11 and 12).
Screws can also be easily lost during a procedure
due to the restricted field of vision with commonly
used magnification loops. Suctioning screws into
the suction canister can be avoided by using small
suction tips that are no bigger than the largest
screw head. Unaccounted wires lost during an
open reduction or osteotomy fixation with an
open incision site can be avoided by cutting 1
wire at a time and confirming its removal in
sequence. A postoperative panoramic image
should routinely be taken following arch bar
removal, as it is very easy to lose small fragments
within the interproximals of the dentition.

Fig. 13. Introduction of a new blade with the teeth of

the blade engaged in the teeth of the broken saw
blade. (From Tabariai E, Alexander G. An approach
to retrieve a broken saw blade in an intraoral vertical
ramus mandibular osteotomy. J Oral Maxillofac Surg
Fig. 11. Bur lost in maxillary sinus. 2008;66(11):2412–3; with permission.)

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386 Alexander & Attia

fragment left behind if inconsequential retrieval is complications that are beyond the ability or the
not an option. The only disadvantage to leaving comfort of the primary surgeon to another surgeon
this instrumentation can result in psychological as long as this practice is not habitual.
or medical–legal ramifications.
Loss of packings is different from loss of other REFERENCES
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