Removal of the residual roots of mandibular wisdom teeth in the lingual space of the mandible via endoscopy

Abstract

In this study, we aimed to evaluate the reliability of the use of endoscopy for removal of the residual roots of mandibular wisdom teeth in the lingual space of the mandible. Seven patients with residual roots of the mandibular wisdom teeth remaining in the lingual space were treated via endoscopy, and the results of their treatments were reviewed retrospectively. The study found that the residual roots of the mandibular wisdom teeth in the lingual space were removed successfully via endoscopy. The average duration of surgery for each case was 5 min, and no complications were observed in any case. There is little risk involved with removing the residual roots of mandibular wisdom teeth in the lingual space via endoscopy and the procedure is safe and fast. We conclude that it is worth promoting this clinical procedure for current and future use.

Introduction

The removal of mandibular wisdom teeth is one of the most common outpatient oral and maxillofacial surgeries. The incidence of complications associated with this surgery, compared with those associated with common tooth extraction, remains high during and after the removal procedures. A serious complication of this procedure is that the residual roots of the mandibular wisdom teeth may break through the lingual bone walls and enter the neighbouring soft tissue space, such as the pterygomandibular, submaxillary, or parapharyngeal space or floor of the mouth. This type of complication is rare; however, removing the residual roots is a very difficult and intricate task and presents the risk of both physiological and psychological injury to the patient.

Removal of the mandibular wisdom teeth and the residual roots in the neighbouring space often results in considerable surgical trauma. Occasionally, a submandibular approach is required to remove the mandibular wisdom teeth or the residual roots. With developments in endoscopy, endoscopic instruments are now used widely in the oral area for diagnosis, orientation, surgeries, and so on. Nevertheless, the use of an endoscope in the removal of mandibular third molar residual roots in the lingual space has rarely been reported. In our department, seven patients with residual roots of the mandibular wisdom teeth in the lingual space of the mandible were treated via endoscopy between 2010 and 2013; the results of these procedures were reviewed retrospectively.

Patients and methods

In this study, data were collected from seven consecutive patients who had residual roots of the mandibular wisdom teeth in the lingual space following the removal of these wisdom teeth. All patients were treated in the department of oral and maxillofacial surgery of the study hospital between 2010 and 2013. The study patients had undergone previous procedures at other hospitals in an attempt to remove the residual roots via conventional methods using intraoral incisions and these had failed. Thus, the patients were referred to our department. The following information was collected retrospectively: patient age, sex, previous surgery date and treatment, radiographic data, therapy, and outcome.

Pantomography, multi-slice computed tomography (CT), and three-dimensional reconstruction (3D-CT) were performed in all patients to identify the presence and the location of the residual roots of the mandibular wisdom teeth in the lingual space. Surgery was performed on all patients to remove the residual roots within 1 week of the original procedure. Three cases were completed on the day of the extraction and three cases were completed the day immediately after the extraction. Surgery was performed on one patient on the seventh day (1 week) after the extraction; the delay was required to provide antibiotic treatment, as trismus was induced when the pterygomandibular space became infected.

Endoscopic system

A Karl Storz Endoskope system (Cat. No. 22201020) was used to perform the surgeries. A searching-unit medical endoscope with a cold light type Xenon Nova 300 (20134020) 3-Chip HD Camera (222220055-3) was used to record the surgery.

Surgical method

Four percent articaine hydrochloride with epinephrine 1:100,000 (Primacaine; Pierre Rolland, Bordeaux, France) in a cartridge ampoule syringe (Aspirating Syringes, KAS A; Shanghai Kangqiao Dental Instruments Factory, Shanghai, China) was slowly administered to the patient using a sterile dental needle (30 G, 0.3 × 21 mm; Pierre Rolland, France) to block the inferior alveolar nerve and the lingual nerve.

After making an extraction incision to the mandibular second molar mesial root of a mandibular wisdom tooth, we separated the lingual gingiva and mucoperiosteum and directed the detecting head and attractor through this incision.

The approximate location of the residual root was determined by pantomography ( Fig. 1 ), mandibular 3D-CT ( Figs 2–4 ), and intraoral parapharyngeal palpation. We placed a unilateral jaw-prop on the opposite side, restraining the tongue with a tongue spatula, to expose the surgical site in cases where the residual root location was deep and the parapharyngeal tissue could not be reached. An endoscopic light probe was introduced into the surgical area from the ipsilateral mouth corner at an angled mandibular occlusal plane of 45–60°. At the same time, we adjusted the angle according to the residual root position. Some blood clots could be observed with the endoscopic light probe, and an aspirator was placed in the surgical area.

Fig. 1
Panoramic radiograph showing a residual root located at the level of the inferior border of the mandible.

Fig. 2
CT image (sectional view) showing the residual root located interior to the mandible.

Fig. 3
CT image (coronal view) showing the residual root located interior to the mandible.

Fig. 4
3D-CT showing the lingual 3D location of the residual root.

Residual roots located in the pterygomandibular space were found easily by directing the endoscopic light probe towards the mandibular lingual surface. If the residual roots were located in the mouth floor space, it was necessary to break through the mylohyoid with an endoscopic light probe and enter the mouth floor space to find the residual tooth. It was also necessary to introduce an endoscopic light probe into the parapharyngeal space from the back of the pterygomandibular space if the residual roots were displaced into the parapharyngeal space. In some cases, when the endoscopic light probe was placed in the surgical area, the residual roots could not be found because of various muscle gaps in the lingual mandibular soft tissue. In these cases, it was necessary to re-insert the endoscopic light probe to find the residual roots. After locating the residual roots with the endoscope, the teeth were isolated from the surrounding muscle and were prepared for removal with an aspirator and a hook. The residual roots were easily removed with forceps by following visual images created by the endoscope ( Fig. 5 ; Supplementary Material Video 1). Seaming haemostasis was performed after successful removal of the residual roots. Routine postoperative prophylactic antibiotic treatment was administered to prevent swelling of the mandibular lingual soft tissue.

Fig. 5
Extraction of the residual root via endoscopy.

Patients and methods

In this study, data were collected from seven consecutive patients who had residual roots of the mandibular wisdom teeth in the lingual space following the removal of these wisdom teeth. All patients were treated in the department of oral and maxillofacial surgery of the study hospital between 2010 and 2013. The study patients had undergone previous procedures at other hospitals in an attempt to remove the residual roots via conventional methods using intraoral incisions and these had failed. Thus, the patients were referred to our department. The following information was collected retrospectively: patient age, sex, previous surgery date and treatment, radiographic data, therapy, and outcome.

Pantomography, multi-slice computed tomography (CT), and three-dimensional reconstruction (3D-CT) were performed in all patients to identify the presence and the location of the residual roots of the mandibular wisdom teeth in the lingual space. Surgery was performed on all patients to remove the residual roots within 1 week of the original procedure. Three cases were completed on the day of the extraction and three cases were completed the day immediately after the extraction. Surgery was performed on one patient on the seventh day (1 week) after the extraction; the delay was required to provide antibiotic treatment, as trismus was induced when the pterygomandibular space became infected.

Endoscopic system

A Karl Storz Endoskope system (Cat. No. 22201020) was used to perform the surgeries. A searching-unit medical endoscope with a cold light type Xenon Nova 300 (20134020) 3-Chip HD Camera (222220055-3) was used to record the surgery.

Surgical method

Four percent articaine hydrochloride with epinephrine 1:100,000 (Primacaine; Pierre Rolland, Bordeaux, France) in a cartridge ampoule syringe (Aspirating Syringes, KAS A; Shanghai Kangqiao Dental Instruments Factory, Shanghai, China) was slowly administered to the patient using a sterile dental needle (30 G, 0.3 × 21 mm; Pierre Rolland, France) to block the inferior alveolar nerve and the lingual nerve.

After making an extraction incision to the mandibular second molar mesial root of a mandibular wisdom tooth, we separated the lingual gingiva and mucoperiosteum and directed the detecting head and attractor through this incision.

The approximate location of the residual root was determined by pantomography ( Fig. 1 ), mandibular 3D-CT ( Figs 2–4 ), and intraoral parapharyngeal palpation. We placed a unilateral jaw-prop on the opposite side, restraining the tongue with a tongue spatula, to expose the surgical site in cases where the residual root location was deep and the parapharyngeal tissue could not be reached. An endoscopic light probe was introduced into the surgical area from the ipsilateral mouth corner at an angled mandibular occlusal plane of 45–60°. At the same time, we adjusted the angle according to the residual root position. Some blood clots could be observed with the endoscopic light probe, and an aspirator was placed in the surgical area.

Jan 17, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Removal of the residual roots of mandibular wisdom teeth in the lingual space of the mandible via endoscopy
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