J Oral Maxillofac Surg 58:96-97, 2000

Accidental Di sp lacement of an Impacted Mandibular Third Molar Into the Lateral

Pharyngeal Space Emin Esen, DDS, PhD, * Li~fti Barlas Aydo~an, MD, t

and Mehmet ~a~,atay Akvall, MDg"

Displacement of impac ted teeth is a rarely repor ted compl i ca t ion ) -3 The most c o m m o n sites of dislodg- men t are the maxillary sinus and submandibular space. 4

Because there is of ten deh iscence of the overlying lingual bone, and the mandibu la r third molar roots may be actually sitting in the submandibu la r space, root fragments or the ent i re tooth may be displaced into it dur ing extraction. 5,6 This repor t describes an

unusua l case of an impacted mandibu la r third molar that was displaced into the lateral pharyngeal space.

Report of Case

A 24-year-old woman was referred to the Department of Oral Surgery of the (~ukurova Dental School with a com- plaint of pain and discomfort during swallowing and restric- tion in mouth opening. She had undergone an unsuccessful surgical procedure under local anesthesia performed by a general practitioner for removal of impacted lower left third molar months before. She had had progressive limitation of mouth opening (15 mm), slight swelling on the left side of the neck, and difficulty swallowing despite antibiotic therapy during the last few weeks. A panoramic radiograph showed the presence of the tooth in what appeared to be the pterygomandibular region (Fig 1). Frontal and transverse computed tomography (CT) scans were obtained to deter- mine the exact location of the tooth in the mediolateral and anteroposterior directions. These showed that the tooth was located at the anterior border of the lateral pharyngeal space underlying the left tonsillar region (Figs 2, 3).

The tooth was retrieved via a transoral approach after tonsillectomy under general anesthesia by the Department

of Otolaryngology. A vertical incision starting from the tonsillar fossa was extended to the retromolar triangle, and blunt dissection was used to reach the lateral pharyngeal space. An abscess was drained during retrieval of the tooth, which indicated the presence of a localized infection. The postoperative course was uneventful, and the patient re- mained asymptomatic during the follow-up period. A rapid improvement in mouth opening was achieved by physical therapy (3 cm by the 2nd week).

Discussion Displacement of an ent i re tooth dur ing extract ion is

rarely encoun te red . Besides anatomic considerat ions,

such as a distolingual angulat ion of the tooth or dehiscence in lingual cortical plate, 5,6 excessive or

uncon t ro l l ed force, imprope r manipu la t ion due to lack of exper ience , and inadequate clinical and radio- graphic examina t ion are impor tan t factors that can lead to tooth displacement . In the cur ren t case, efforts made to retrieve the tooth after its initial d is lodgment and b l ind p rob ing appear to be the possible reasons

for fur ther d i sp lacement from the p teaygomandibula r

space into the lateral pharyngeal space. Advanced imaging t echn iques are often required to

locate a displaced tooth and its relat ion to the adjacent

*Assistant Professor, Department of Oral Surgery, Faculty of Dentistry, University of (~ukurova, Adana, Turkey.

tAssistant Professor, Department of ENT, Faculty of Medicine,

Gukurova University, Adana, Turkey. ~:Professor, Department of ENT, Faculty of Medicine, (~ukurova

University, Adana, Turkey. Address correspondence and reprint requests to Dr Esen: (~uku-

rova University, Faculty of Dentistry, Department of Oral Surgery, 01330 Balcah Adana, Turkey. © 2000 American Association of Oral and Maxillofacial Surgeons 0278-2391/00/5801 ©01553.00/0

FIGURE I . Panoramic radiograph showing the displaced tooth apparently in the pterygomandibular region.

96

ESEN, AYDOG~dq, AND AK~ALI 9 7

FIGURE 3. Frontal CT scan shows slight distortion of the lateral pharyngeal walk

FIGURE 2. Transverse CT scan shows the displaced third molar at the anterior border of the lateral pharyngeal space. Note the distolingual angulation of the contralateral third molar.

anatomic structures. 3 In this case, conven t iona l radio- graphs, inc lud ing posteroanter ior , lateral skull, and panoramic radiographs, were inadequate . CT showed :he exact locat ion of the displaced tooth and its :elation to the su r round ing soft tissues. Because the :ooth was located almost u n d e r the left tonsil, re- :rieval f rom tonsillar fossa seemed to be more conve- 1lent and less t raumatic than using an incis ion over

:he anter ior bo rde r of the ramus, and dissect ion

nedial to the medial p terygoid muscle. Some authors prefer to pos tpone surgery for several

reeks to al low fibrosis to occur and stabilize the tooth n a firm posit ion. 4~ However, delayed in te rven t ion nay increase the risk of infect ion and result in a

oreign body react ion or migrat ion of the tooth. 3 One hould be aware of the potent ia l risk of serious

infect ion involving adjacent fascial spaces, inc luding the cervical fascial spaces. Invo lvement of the lateral

pharyngeal space also may have serious life-threaten-

ing sequelae, inc lud ing thrombosis of the internal jugular vein, erosion of the carotid artery or its branches , or in ter ference wi th cranial nerves IX

through XII. 6 In this case, infect ion was control led by aggressive ant ibiot ic therapy before surgical interven- tion, and the pa t ien t recovered wi thou t any sequelae.

References 1. Patel M, Down K: Accidental displacement of impacted maxiUary

third molars. Br DentJ 177:57, 1994 2. Oberman M, Horowitz I, Ramon Y: Accidental displacement of

impacted maxillary third molars. Int J Oral Maxillofac Surg 15:756, 1986

3. Gay-Escoda C, Berini-Aytes L, Pinera-Penalva M: Accidental dis- placement of a lower third molar. Oral Surg Oral Med Oral Pathol 76:159, 1993

4. Pedersen GW: Oral Surgery. Philadelphia, PA, Saunders, 1988, pp 89-90

5. Laskin DM: Oral and Maxillofacial surgery. St Louis, MO, Mosby, 1985, pp 79-80

6. Peterson LJ: Contemporary Oral and Maxillofacial Surgery (ed 2). St Louis, MO, Mosby, 1993, pp 279-280, 442-443