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References

Ozalp B, Kuvat SV, Emekli U. Conservative treatment of displacement mandibular third molar. J Craniofac Surg. 2010; 21:1314-1316
Yeh CJ. A simple retrieval technique for accidentally displaced mandibular third molars. J Oral Maxillofac Surg. 2002; 60:836-837
Ertas U, Yaruz MS, Tozoglu S. Accidental third molar displacement into the lateral pharyngeal space. J Oral Maxillofac Surg. 2002; 60:1217-1219
Huang IY, Wu CW, Worthington P. The displaced lower third molar: a literature review and suggestions for management. J Oral Maxillofac Surg. 2007; 65:1186-1190

Letters to the Editor

From Volume 47, Issue 2, February 2020 | Pages 170-171

Authors

Awais Ali

BDS, MJDF (Eng)

Dental Core Trainee 2 University Dental Hospital of Manchester

Articles by Awais Ali

Mohammed Miah

General Dental Practitioner, Manchester

Articles by Mohammed Miah

Article

Root displacement into the lingual space: a rare occurrence

I wish to report a rare but clinically important risk during removal of lower third molar teeth. A 71-year-old female attended surgery for the removal of the lower left wisdom tooth (LL8) under local anaesthesia. The tooth had a history of pain and unrestorable subgingival caries. There was no relevant medical history. A pre-operative periapical radiograph was used to plan removal (Figure 1).

Figure 1. Pre-operative periapical radiograph of the lower left wisdom tooth. Distally curved root(s) noted.

Procedure

Routine simple elevation was carried out on the mesial aspect of the LL8. The majority of the tooth was removed, however, a third, lingually positioned root had separated and remained mobile in the socket. A curved clip was used to attempt retrieval but became caught on septal bone, which broke away, leading to the root disappearing into the lingual space. The socket was rechecked following copious irrigation confirming no root in sight.

The procedure was stopped immediately, haemostasis achieved and the patient informed in an open and honest manner. OPG facility allowed approximation of the position of the root (Figure 2). A maxillofacial on-call DCT was called for further management, who advised sending an urgent referral via FDS to an OMFS outpatient unit, antibiotic prophylaxis and monitoring following discharge. The patient was called in the afternoon. She explained that she was completely asymptomatic and had regained feeling following anaesthesia. A follow-up appointment found no complaints or signs of infection or swelling in surrounding tissues. The patient was assessed in an OMFS outpatient setting one week later and awaits a CT scan for locating the root.

Figure 2. Post-operative sectional orthopantogram of the displaced root at a position lingual and parallel to the tooth socket.

Immediate management

Primarily management is based on symptoms. If the root remains asymptomatic, and is not at risk of travelling between spaces, then it can be left for long-term review, with the patient’s consent. In cases of persistent symptoms, such as pain, infection and swelling, a plan for retrieval is required. Following appropriate high quality imaging, CBCT, CT, OPG, or occlusal views, the location of the root can be estimated. Poor visualization and limited access are key considerations for planning surgical exploration. Intra-vs extra-oral approaches have been defined in case reports.1,2 Careful retrieval is carried out following discussion of risks and benefits, primarily including failure to retrieve the root fragment and lingual nerve injury.

Clinical significance

Root displacement is considered to be associated with various risk factors, including: patient age, tooth position, presence of a lingual plate fracture, abnormal lingual plate thickness, excessive or uncontrolled force, lack of operator expertise, and poor clinical and radiological assessment.3,4 It is important for the practitioner to recognize the challenges involved in removing lower third molars, in particular, and to appreciate when a timely referral to specialist services is likely to provide the patient with the most appropriate treatment outcome.