From Volume 38, Issue 9, November 2011 | Pages 631-632
Lower third molar teeth can be dislodged into fascial tissue spaces when they are extracted or elevated out of their sockets. Thankfully, this rarely occurs. We present a case report on a lower right wisdom tooth dislodged into the right parapharyngeal space on its removal from the socket and the subsequent management of this rare complication.
Dislodgement of lower third molar teeth into the parapharyngeal space is rarely encountered. There have been cases reported1,2 which accurately describe displacement of the lower left third molar tooth into the parapharyngeal space, one of them whilst a General Dental Practitioner (GDP) was elevating the tooth under local anaesthesia (LA).2 Successful retrieval of the displaced tooth was achieved under general anaesthesia (GA) months later. The second case again describes the displacement of a lower third molar tooth into the lateral pharyngeal space during its elevation under LA. In this case, however, the displaced tooth was retrieved immediately without the need for a GA.
A 56-year-old man, accompanied by his GDP, attended the Hospital's Accident and Emergency Department following the displacement of the lower right third molar into the lingual and/or parapharyngeal space when the tooth was elevated out of its socket during its removal earlier on the same day. On initial presentation, the patient complained of difficulty in swallowing, pain and swelling of the right side of his neck. There was no respiratory distress or compromise. The patient was immediately transferred to the Resuscitation Department for close monitoring of his airway and IV antibiotics, IV steroid, IV fluids and analgesia were administered. The patient was kept nil by mouth.
A CT scan was done which demonstrated the displaced lower right third molar tooth to be lodged in the parapharyngeal space (Figure 1a), deep to the ramus of the mandible (Figures 1b and c). The tooth had displaced the right submandibular salivary gland inferiorly, and there was evidence of emphysema in the right submandibular space.
The following day, under a GA, the right lingual and parapharyngeal spaces were explored. An incision was made from the socket of the missing lower right third molar tooth to the external oblique ridge. The mucoperiosteal flap was raised and the right lingual nerve was identified and protected. There was pus exudate from the right parapharyngeal space and, on exploring this area, the lower right third molar tooth was visualized and retrieved with a pair of artery forceps. The surgical area was gently irrigated with normal saline and the flap repositioned and sutured with resorbable sutures. After an uneventful recovery, the patient was discharged home the following day.
At follow-up 1-week post-operatively, the patient had localized osteitis of the lower right third molar socket and paraesthesia in the distribution of the right inferior dental nerve. Two weeks post-operatively, the paraesthesia had improved significantly and the localized osteitis was resolving. The patient failed to attend subsequent follow-up appointments.
This type of complication during tooth removal can be brought about by:
If it does happen, tell the patient and act appropriately and promptly.
It is always best practice to act to prevent potential complications such as this by being vigilant at all times, as even when the extracted tooth goes under the mucoperiosteum, it may be possible to milk it out before it goes further into any of the tissue spaces. It is always a good idea to grasp the loosened tooth after elevating it with forceps for the final extraction from its socket.
This case report highlights a rarely encountered, yet potentially life threatening, complication of extracting lower third molar teeth. We feel that it is appropriate for dental practitioners who perform such procedures to be aware of this complication and, more importantly, manage such a complication promptly and appropriately.
