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 Table of Contents  
Year : 2021  |  Volume : 13  |  Issue : 1  |  Page : 40-42

Accidental displacement of third molar root into the lingual pouch: A case report and review of treatment approaches

1 Department of Oral and Maxillofacial Surgery, Seema Dental College and Hospital, Rishikesh, Uttarakhand, India
2 Department of Prosthodontics, Seema Dental College and Hospital, Rishikesh, Uttarakhand, India

Date of Submission30-Jul-2020
Date of Decision30-Aug-2020
Date of Acceptance18-Sep-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Mudit Agarwal
Department of Oral and Maxillofacial Surgery, Seema Dental College and Hospital, Rishikesh, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJDS.IJDS_121_20

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Third molar surgery is the most common procedure performed by oral and maxillofacial surgeons. A thorough understanding of the complications associated with this procedure will enable the practitioner to identify and counsel high-risk patients, appropriately manage more common complications, and be cognizant of less common sequelae and the most effective methods of management. We present a case of displaced third molar root into the lingual pouch (submandibular space) and ways to prevent and manage this rare complication. In this article, we have compared different surgical approaches for the removal of displaced root from the submandibular space.

Keywords: Displacement, lingual pouch, submandibular space, third molar root

How to cite this article:
Agarwal M, Muthunagai R, Agarwal A, Aeran H. Accidental displacement of third molar root into the lingual pouch: A case report and review of treatment approaches. Indian J Dent Sci 2021;13:40-2

How to cite this URL:
Agarwal M, Muthunagai R, Agarwal A, Aeran H. Accidental displacement of third molar root into the lingual pouch: A case report and review of treatment approaches. Indian J Dent Sci [serial online] 2021 [cited 2021 Jan 16];13:40-2. Available from: http://www.ijds.in/text.asp?2021/13/1/40/305970

  Introduction Top

Displacement of a third molar during routine surgical extraction is a rare event, but it is well-documented in the literature.[1],[2],[3],[4],[5],[6],[7] In about 1% of cases, complications, such as pain, swelling, dry socket, bleeding, paresthesia of the lingual or inferior alveolar nerve, and infection, occur. The application of uncontrolled or imprudent force, unrestricted manipulation, inappropriate surgical planning, poor clinical judgment, and radiological assessment results in the displacement of the tooth.[3]

Injury to tissues, pain, swelling, lockjaw, and foreign body reaction are some of the related complications, along with the medical-legal implications.[3] Thus, patient history and clinical and radiographic examinations must be rigorously evaluated to establish the best planning of the surgery and avoid the occurrence of accidents and possible surgical complications.

We report this case to elucidate ways to prevent and manage this complication. A brief overview of various treatment procedures for the treatment of this rare complication is done. Indications, advantages, and disadvantages of various treatment approaches have been compared to help make a right treatment decision.

  Case Report Top

A 50-year-old male patient was referred by a private practitioner to the oral and maxillofacial surgery unit of our institution with the chief complaint of pain and an inability to open his mouth 1 week after the extraction of his wisdom teeth. His mouth opening was reduced to 18 mm. A panoramic radiograph revealed a deep-seated root fragment overlapping the inferior alveolar canal below the distal root socket [Figure 1]. On intraoral examination, a hard swelling was palpated on the lingual side below the mylohyoid ridge and distal to the extraction socket. To precisely locate the root of the third molar, a cone-beam computed tomography (CBCT) scan was performed. The CBCT scan revealed a perforation in the lingual cortex. A hyperdense root fragment was found below the mylohyoid ridge just distal to the distal root socket [Figure 1]. We proposed surgical treatment under local anesthesia and explained the procedure and potential complications to the patient, who agreed with our proposal.
Figure 1: Preoperative orthopantomography and cone-beam computed tomography scan reveal displaced root fragment of the mandibular third molar (red arrow) and lingual plate perforation (black arrow)

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In preparation for the procedure, an inferior alveolar, lingual nerve block with long buccal nerve infiltration was undertaken by injection with 2% lidocaine with adrenaline (1:100,000). Under local anesthesia, the patient's mouth opening was increased manually and palpation of the displaced root fragment with the operator's index finger was done. The root fragment was confirmed to be located deep in the submandibular region. A lingual flap was raised mesially up to the first premolar and distally over the anterior border of the ramus. The full-thickness mucoperiosteal lingual flap was reflected up to the submandibular region with great care. The mylohyoid curtain was incised by blunt dissection near the medial surface. Despite adequate exposure, the fragment was not visible. With the help of a curette, the root was pushed outward and removed [Figure 2]. The wound was irrigated with normal saline and the flaps were sutured with 3–0 vicryl sutures [Figure 2]. An antibiotic and analgesic were prescribed for 5 days. On the 7th postoperative day, the patient reported with a complaint of limited mouth opening, his healing appeared to be satisfactory, and the sutures were removed. Lingual nerve function was tested and found normal. The patient was started on a combination of analgesic and muscle relaxant along with active mouth opening exercises for 5 days. One week later, the patient was able to open his mouth to 35 mm.
Figure 2: Postoperative image showing the conventional approach and the root fragment retrieved during surgery

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  Discussion Top

According to a review by Brauer,[1] this complication has an incidence lower than 1%. The first case of accidental displacement of a tooth dates to 1958 and was published by Howe[2] who described the removal of a third molar located in the lingual pouch. Since then, several isolated cases of displacement of third molars have been reported.

The movement of the root into deeper anatomic planes is most commonly caused by lingual plate fracture or perforation during extraction in addition to an inadequate pressure applied with the elevators.[3] In this case, the computed tomography (CT) findings showed damage to the lingual cortex [Figure 1] that might have been the major cause of displacement of the tooth into the submandibular space [Figure 1]. In 1964, Stacy and Orth reported a case that follows a lower third molar root dislodged apically through the lingual alveolar plate of bone with no more than finger pressure during the extraction of the tooth.[4] Inadequate visibility, lack of surgical skills, the axial inclination of a molar with a lingual or distal inclination of molar roots, thin alveolar plate, inappropriate instruments, and an inadequate examination also might be related to iatrogenic displacements.[3],[5]

Aznar et al. in 2012 gave a treatment algorithm for the management of displaced root into the submandibular space that defines the correct timing for the surgical intervention.[6] Several approaches have been described in the literature (intraoral and/or extraoral), but the most widely used technique consists of raising a lingual mucoperiosteal flap from the mandible ramus to the premolar region [mentioned in [Table 1] as conventional technique].[7] The intraoral approach under local anesthesia is the simplest and least invasive technique for the removal of displaced root from the lingual pouch. Local anesthesia is used commonly because it is considered to be simple and safe and it avoids complications related to the use of general anesthesia, which is relatively costly and may involve hospital admission.[8] In the present case, surgical access to the displaced root fragment was achieved by way of a lingual mucoperiosteal flap raised to the premolar site. However, this approach may not provide adequate visibility and access in other situations. This technique offers limited access and poor visibility of the area, owing to the presence of the mylohyoid muscle. Thus, some changes have been proposed, such as lingual plate fracture to allow access through the socket [[Table 1] modified conventional technique].[5] When a fragment is displaced within deep spaces, a combined intraoral and extraoral approach may be indicated.[9] In difficult to access areas and where the facility of surgical navigation technique is available, the computer-assisted navigation can be used in retrieval of accidentally displaced root or root fragment.[10] In a recent study by Huang et al., the residual roots of the mandibular wisdom teeth in the lingual space were removed successfully through endoscopy in seven cases. The average duration of surgery was 5 min, with no complications observed in any case. There is a minimal risk involved with the removal of residual roots of the mandibular third molar from the lingual space through endoscopy and the procedure is safe and fast.[11]
Table 1: Comparison of different surgical approaches for the management of displaced tooth or tooth fragment into the submandibular space[3]

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To prevent this complication, a thorough evaluation of all significant risk factors should be performed in advance. Proper visual access to the surgical area is paramount for third molar extractions. Excessive forces toward the lingual plate should be avoided and bone removal should be performed when necessary. Sometimes, it may be helpful to place the index finger on the lingual aspect to protect and prevent displacement of the third molar, particularly in cases in which the preoperative CT scan has depicted a very thin lingual plate.[5] This maneuver and the use of small diameter suction tips may be useful to pull back the displaced roots through the perforation in the lingual plate.

  Conclusion Top

Adequate clinical, radiological assessment, sound anatomical knowledge, and good surgical skills minimize the chances of complications. CT scan is paramount in identifying the exact location of the displaced root segment. Proper understanding of different surgical approaches for the removal of displaced root from the submandibular space helps in making the right decision. Recent reports on endoscopic and surgical navigation approach for retrieval of root fragment show promising results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Brauer HU. Unusual complications associated with third molar surgery: A systematic review. Quintessence Int 2009;40:565-72.  Back to cited text no. 1
Howe GL. Tooth removed from the lingual pouch. Br Dent J 1958;104:283.  Back to cited text no. 2
Figueiredo AA, Escoda G. Accidental displacement of third molar roots. J Oral Maxillofac Surg 2012;70:e107-15.  Back to cited text no. 3
Stacy GC, Orth D. Perforation of the lingual alveolar plate in association with mandibular third molars. Report of a case. Oral Surg Oral Med Oral Pathol 1964;17:586-91.  Back to cited text no. 4
Huang IY, Wu CW, Worthington P. The displaced lower third molar: A literature review and suggestions for management. J Oral Maxillofac Surg 2007;65:1186-90.  Back to cited text no. 5
Arasa, L.A., Figueiredo, R., Escoda, C.G. Iatrogenic displacement of third molar roots in to the sublingual space: report of 6 cases. J. Oral Maxillofac. Surg. 2012; 70, e107–e115.  Back to cited text no. 6
de Biase A, Guerra F, Giordano G, Salucci S, Solidani M. Surgical removal of a left lower third molar root after iatrogenic displacement in soft tissue. Case report. Minerva Stomatol 2005;54:389-93.  Back to cited text no. 7
Jolly SS, Rattan V, Rai SK. Intraoral management of displaced root into submandibular space under local anaesthesia: A case report and review of literature. Saudi Dent J 2014;26:181-4.  Back to cited text no. 8
Yeh CJ. A simple retrieval technique for accidentally displaced mandibular third molars. J Oral Maxillofac Surg 2002;60:836-7.  Back to cited text no. 9
Guo Y, Xu DD, Lv K, Wan QL, Li ZB, Li Z. The use of computer-assisted navigation in retrieval of accidentally displaced third molar. J Oral Maxillofac Surg 2016;74:5, 889-94.  Back to cited text no. 10
Huang ZQ, Huang ZX, Wang YY, Hu WJ, Fan S, Zhang DM, et al. Removal of the residual roots of mandibular wisdom teeth in the lingual space of the mandible via endoscopy. Int J Oral Maxillofac Surg 2015;44:400-3.  Back to cited text no. 11


  [Figure 1], [Figure 2]

  [Table 1]


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