480

RETRIEVAL OF DISPLACED THIRD MOLAR

J Oral Maxillofac Surg

68:480-485, 2010

Retrieval of a Displaced Third Molar

Using Navigation and Active
Image Guidance
Andrew Campbell, DDS,* and Bernard J. Costello, DMD, MD
Displacement of a third molar tooth during routine
surgical extraction is a rare event and well-documented in the literature.1-6 Even the most experienced surgeons may have this occur on occasion.
Maxillary third molar teeth can be displaced into a
variety of locations including the buccal space, infratemporal fossa, maxillary sinus, or other tissue planes.
We report a technique of easy retrieval using an active
navigation image guidance system. This specific indication has not been well reported, and it is important
for dentoalveolar surgeons to be aware of the capabilities of the latest technology.

Report of a Case
An 18-year-old healthy female patient had a consultation
with another surgeon for removal of pathologically impacted third molars, and surgical removal of the teeth was
recommended (Fig 1). The complete bony impactions were
approached in typical fashion using a small incision along
the lateral aspect of the alveolar crest in the area of the
impacted tooth. A subperiosteal dissection was appropriately completed, but during elevation the right maxillary
third molar was displaced beneath the flap. An immediate
exploration was performed to locate the tooth but was
subsequently terminated without success. Postoperatively,
the patient displayed diplopia on upward gaze, warranting
evaluation by an ophthalmologist. Visual acuity and all other
aspects of her examination were normal with the notable
exception of diplopia on extreme upward gaze. A CT scan
was obtained to localize the now foreign-body, and the
patient was referred to the senior author for treatment (Fig
2). A minor orbital disruption was noted on the scan, with
disruption of the tissues surrounding the inferior rectus.
Received from the Department of Oral and Maxillofacial Surgery,
University of Pittsburgh School of Dental Medicine, Pittsburgh, PA.
*Pediatric Oral and Maxillofacial/Craniofacial Fellow.
Associate Professor and Program Director, Chief, Craniofacial
and Cleft Surgery.
Address correspondence and reprint requests to Dr Costello:
Department of Oral and Maxillofacial Surgery, 3471 Fifth Avenue,
Suite 1112, Pittsburgh, PA 15213; e-mail: bjc1@pitt.edu
2010 American Association of Oral and Maxillofacial Surgeons

0278-2391/10/6802-0040$36.00/0
doi:10.1016/j.joms.2009.06.032

After 6 weeks of healing the patient was scheduled for

surgical removal of the displaced tooth and, now, foreign
body. At 6 weeks, the diplopia had almost completely resolved and was only present during extreme upward gaze.
A computed tomography scan was obtained as per the
protocol for use with the Stryker System II Navigation image
guidance apparatus (Stryker, Kalamazoo, MI). The patient
was brought to the operating theater and placed under
general anesthesia with a nasal endotracheal tube. The
Stryker System II uses a light emitting diode (LED) mask to
register the CT data with the patient in the operating theater and correlates the data with the hand-held probe/
suction device (Fig 3). An accuracy of 0.5 mm was anticipated after calibrating the system. Multiple views allowed
localization of the tooth within minutes (Fig 4). A small
vestibular incision was made beneath the zygomatic buttress, and a suction/probe was used to determine the exact
location of the medial and lateral aspects of the occlusal surface of the tooth. After precise localization the tooth was
bluntly dissected free and removed (Fig 5). Blood loss was
minimal, and the incision was closed with a running 3-0 chromic suture. The entire procedure was completed within
minutes, and the patient was discharged several hours later.

Discussion
Complications from third molar removal are, thankfully, rare. The most common complications occur
with regular frequency. These include infection (0.8%
to 4.2%),7-13 alveolar osteitis (0.3% to 26%),7-15 inferior alveolar nerve injury (0.4% to 8.4%),8,18,19 lingual
nerve injury (0% to 23%,10,18,20 with approximately
0.5% being permanent21-23), and clinically significant
hemorrhage (0.1% to 0.7%).7,10,24 Rare complications
of third molar removal include mandible fracture
(0.0033% to 0.0049%),16,17 osteomyelitis, and displacement of teeth during removal, for which the incidences
are unknown. It is likely that displacement of teeth
during removal of third molars is under-reported, as
most surgeons retrieve their own displacements without reporting the complications.
The typical management of displaced third molar
teeth involves an initial, conservative attempt to remove the tooth from the area in which it is believed
to be displaced. If initial retrieval fails then the region
is irrigated and closed, and the patient is placed on
antibiotics. Imaging is obtained to localize the tooth

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CAMPBELL AND COSTELLO

FIGURE 1. Panoramic tomogram of the patient with pathologically impacted teeth before displacement.
Campbell and Costello. Retrieval of Displaced Third Molar. J Oral Maxillofac Surg 2010.

in 3 dimensions. Imaging is recommended soon after

the event to determine whether displacement of the
tooth may affect function of another anatomic area
(eg, the orbit). If the tooth is displaced into a critical
anatomic area such as the orbit, early removal may be
indicated. In most other instances, the tooth is left in
position until initial scarring occurs over several
weeks. The authors prefer to wait approximately 6
weeks.

Iatrogenically, displaced teeth are traditionally approached after careful planning using detailed imaging in multiple planes followed by the use of extended
intraoral incisions. Difficulties may be encountered when
teeth are displaced into areas where the tooth can continue to migrate; this is particularly the case with
underdeveloped teeth without roots. Difficult-to-access areas include the buccal fat pad, infratemporal
fossa, sinus cavity, floor of mouth, masticator space,
or other areas of loose fascial planes. A waiting period
of at least several weeks allows fibrous encapsulation

FIGURE 2. Computed tomography images of the maxillary right

third molar displaced lateral to the orbit, and medial to the zygomatic arch.

FIGURE 3. Stryker LED mask positioned on patient to allow registration and active navigation.

Campbell and Costello. Retrieval of Displaced Third Molar. J Oral

Maxillofac Surg 2010.

Campbell and Costello. Retrieval of Displaced Third Molar. J Oral

Maxillofac Surg 2010.

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RETRIEVAL OF DISPLACED THIRD MOLAR

FIGURE 4. Multiplanar views of the displaced third molar using the suction probe to identify the precise location of the displaced tooth in
real time. Probe positioned at inferioranterior aspect of displaced third molar.
Campbell and Costello. Retrieval of Displaced Third Molar. J Oral Maxillofac Surg 2010.

of the displaced tooth to occur. This tends to resist

further displacement into other anatomical planes.
Correlation of the position of the tooth with a multiplane CT scan makes this approach reasonable for most
minimally displaced teeth. However, surgical dissection
and manipulation of the tissues can change reference
points for the operating surgeon, and further displacement of the tooth can occur. Although some retrievals
may be easy, others can be difficult, with risk of
hemorrhage or neurologic injury, and may even require aborting the procedure if the tooth is not located. Failure to locate the displaced tooth then requires the surgeon to use additional approaches or
technologies for retrieval. Orr25 reported on the infratemporal displacement of a right maxillary third
molar. In his technique an 18-gauge spinal needle was
inserted above the zygoma and posterior to the orbital
rim. The needle was used to exert pressure on the
tooth from a superior direction while manipulating
intraorally to retrieve the tooth. Additional methods
reported for removing teeth from the infratemporal
fossa include the combination of intraoral incisions
with a standard Gilles approach,26 a transantral approach,27 and use of intraoperative fluoroscopy.28
Another technique reported for locating and removing a displaced third molar not retrieved with a

simple intraoral incision involves a coronal or hemicoronal approach, dissection of the temporalis muscle off the lateral skull, and entrance into the infratemporal fossa.29 Although this is a viable approach, it
is aggressive in comparison with the incisions and
recovery expected after routine third molar tooth
removal. This technique works very well and provides maximal surgical exposure; however, the aggressive nature of the procedure has a number of
possible complications associated with it, including
trismus, a residual coronal scar with hair loss, facial
nerve palsy, temporalis wasting, temporal hollowing,
and significant blood loss. These factors limit this
approach to teeth that cannot be accessed in any
other manner. In rare instances a brow incision may
be used to work in concert with an intraoral incision
to manipulate the foreign body from 2 locations in a
minimally invasive fashion. Although this procedure
was not necessary in the current case, it could be
performed with a higher degree of accuracy with
active navigation if necessary.
Image-guided navigation applications for surgery
were first developed for use in neurosurgery.30-33 Navigation techniques with image guidance for craniomaxillo-facial procedures have been popularized by
a number of individuals.30-32,34-37 As the technology

CAMPBELL AND COSTELLO

FIGURE 5. Removal of the third molar took just minutes using this
technique.
Campbell and Costello. Retrieval of Displaced Third Molar. J Oral
Maxillofac Surg 2010.

has been refined, its initially cumbersome nature has

been supplanted with standard protocols that have
become routine in most major medical centers.
Head frames were originally used for stereotactic
brain surgery and localization of lesions for other oncologic therapies. For many craniomaxillo-facial procedures these may be inconvenient or cumbersome to
use. External fiducials placed before CT scanning or
the use of an external mask with multiple LEDs are
more commonly employed for procedures in craniomaxillo-facial surgery. The latter are more recent
developments and do not require rigid immobilization
in a stereotactic head frame. In image-guided surgery
using an optical tracking system the LED mask is
placed on the patient, and a camera system connected
to the CPU localizes the position of these infraredLEDs and then merges the radiographic images with
the actual position of the patient.30 The registration
procedure using the mask is quick and highly accurate. Navigation systems are classified as either active
or passive. Active navigation systems place infrared
LEDs on the patient and a camera records their position; passive systems have no LEDs but rather use
spheres to reflect infrared light emitted by the camera
system.30 Active systems avoid problems created by
obstructing or soiling of the reflecting spheres and
overlap of reflections that can occur with passive
systems.38 Various probes containing position sensors
may be used, including several varieties of suction
catheters. Tracking systems follow the position of the
surgical instruments and the patient, the system then

483
displays the 3-dimensional relationship of the probe
to the patients anatomy. Accuracy with the probes is
typically better than within 1 mm.30
This technology has become useful as the convergence of a variety of technologies including highly
accurate imaging, user-friendly software applications
for navigation, and systems to correlate these data in
real time with a high degree of precision. Improvements in navigation technology and availability have
led to a drastic increase in its application over the last
decade. Image-guided navigation in the craniomaxillofacial region has been used in oncologic biopsies
and resections,32,35 craniofacial reconstruction,36,39
facial trauma,40 dental implantology,37 arthroscopy of
the temporo-manibular joint,37,41,42 facial osteotomies,37 and removal of foreign bodies.30,31,34
Limitations when using image-guided navigation exist and are important to consider. Intraoperative activity is based on the preoperatively acquired image
data. Changes occurring at the surgical site during
manipulation are not represented on images viewed
by the surgeon.31,32 Performing surgical procedures
in highly mobile tissues, such as the tongue, may be
unreliable and limited.31 When retrieving foreign bodies any further iatrogenic displacement will make the
preoperative images less useful.
Registration accuracy is crucial for the accuracy of
navigation.43,44 The accuracy obtained depends on
the tracking system used; on the design, number and
arrangement of fidicial markers; and on the image
data. In reality, marker position on the patient always
differs slightly from positions displayed on the image,
but this difference is routinely reduced to less than 1
mm.30,31 A disadvantage to optical navigation systems
relates to the line of sight. A camera senses the LED
markers on the patient for registration; to track instruments relative to the patient the camera must continue to have the markers in view. The surgeon must
position both himself or herself and the patient appropriately at all times to avoid obstruction of the line
of sight. This is not difficult for most procedures but
must be considered during set-up of the equipment.
Many image registration systems require that markers be placed on the patient before image acquisition
or that images be acquired in a specific protocol that
is not routine during initial diagnostic radiography. To
determine the need for image guided navigation the
patient will have already received diagnostic imaging.
The patient would then need additional imaging for
appropriate registration. There is additional cost and
radiation exposure when CT scanning is used.30
Removal of foreign bodies using navigation has
been discussed in previous publications.30,31,34 However, this specific indication has not been well reported, and it is important for dentoalveolar surgeons
to be aware of the capabilities of current systems.

484
This technique allowed exceptionally quick removal
of the foreign body with precise localization. This
permitted us to avoid exploratory blunt dissection in
the infratemporal fossa and to limit postoperative
pain, swelling, and potential scarring for our patient.
This minimally invasive approach resulted in a decreased likelihood of complications, as well as in
improved recovery and a better experience for the
patient and family when compared with more aggressive techniques previously described. The use
of navigation provided a safe and precise approach
to the region without the need for extensive exploration while avoiding significant vasculature and
other structures of concern to remove the displaced
tooth. Given the disruption of the orbit and inferior
rectus from the previous procedure, we considered
this very important.
Iatrogenic displacement of a third molar during
routine surgical extraction occurs rarely and is likely
under reported. It can occur even to the most experienced of surgeons. Using navigation allowed us to
remove a displaced wisdom tooth in a minimally invasive fashion in minutes. This technique allows exceptionally accurate localization and removal of displaced teeth, which provides a much better solution
than the more aggressive approaches described in the
literature. It also affords a margin of safety with dissection in this region that has heretofore not been
possible with traditional techniques. In cases in
which surgical manipulation may affect the globe,
vasculature, or various nerves in the region, the accuracy of navigation provides a predictable road map for
successful removal of significantly displaced third molars.

RETRIEVAL OF DISPLACED THIRD MOLAR

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