Journal of Cranio-Maxillo-Facial Surgery

Computed Tomography versus Cone Beam Computed Tomography as a diagnostic

imaging in Retrieval of Displaced Mandibular Third Molar Teeth/Roots
--Manuscript Draft--

Manuscript Number:

Article Type: Original article

Keywords: Displaced third molar, CBCT, CT, submandibular space, lingual nerve paresthesia

Corresponding Author: Mohamed Kamal Eid, PhD Oral and Maxillofacial Surgery
Tanta University Faculty of Dentistry
EGYPT

First Author: Mohamed Kamal Eid, PhD Oral and Maxillofacial Surgery

Order of Authors: Mohamed Kamal Eid, PhD Oral and Maxillofacial Surgery

Mohamed Eldesouky Elkalyouby, PhD Oral and Maxillofacial Surgery

Eman Abdel Salam Yousef, PhD Oral and Maxillofacial Surgery

Abstract: Background: Displacement of third molar tooth or a tooth fragment into adjacent
anatomic regions can be attributed to the use of excessive manipulation, improper
surgical planning, or poor clinical and/or radiological assessment.
Purpose: The aim of the study was to compare CT and CBCT as pre-surgical
diagnostic imaging before surgical retrieval of iatrogenic displaced mandibular third
molar teeth/roots.
Patients and methods: Sixteen patients with displaced mandibular third molar teeth/
roots were randomly divided into two equal groups, each of eight patients: Group (I)
multi-slice spiral CT scan and Group (II) CBCT scan were performed. the sensory
disturbances were evaluated along the follow-up period of 3 months.
Results: Regarding sensory disturbances, one patient in group I and three patients in
group II experienced lingual nerve paresthesia, according to follow-up after one week.
After three months, the lingual paresthesia symptoms were totally resolved for all
patients. Regarding pain, swelling and trismus there were no statistically significant
differences between the two groups (P > 0.05) during the follow-up period.
Conclusion: CT and CBCT are important for preoperative planning of the surgical
retrieval of displaced mandibular third molars/roots in different anatomic spaces.

Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation
Cover Letter

Cover letter

November 25, 2022

Editorial Department of Journal of Cranio-Maxillofacial Surgery

Dear Editor of Journal of Cranio-Maxillofacial Surgery,

I am submitting a manuscript for consideration of publication in Journal of
Cranio-Maxillofacial Surgery. The manuscript is entitled “Computed
Tomography versus Cone Beam Computed Tomography as a diagnostic
imaging in Retrieval of Displaced Mandibular Third Molar Teeth/Roots”.
It has not been published elsewhere and that it has not been submitted
simultaneously for publication elsewhere.

Thank you very much for your consideration.

Best regards,

Dr. Mohamed Kamal Eid

Oral & Maxillofacial Surgery department, Faculty of dentistry, Tanta
University, Horus University, Egypt
Address: Omar Abdelazez st , Alzzaeafran district , Mansoura – Dakahila
(Postal code 35511) , Egypt
Telephone: 002 0502204302
Mobile: 002 01220033033
E-mail: mohamed.alam1@dent.tanta.edu.eg
Title Page (with Author Details)

Computed Tomography versus Cone Beam Computed Tomography as a diagnostic

imaging in Retrieval of Displaced Mandibular Third Molar Teeth/Roots

Author's names and affiliations

1. Mohamed Kamal Eid

Degree: PhD Oral and Maxillofacial Surgery
Affiliation: Associate professor of Oral and Maxillofacial Surgery, Faculty of
Dentistry, Tanta University, Egypt
E-mail: mohamed.alam1@dent.tanta.edu.eg

2. Mohamed Eldesouky Elkalyouby

Degree: PhD Oral and Maxillofacial Surgery
Affiliation: Lecturer of Oral and Maxillofacial Surgery, Faculty of Dentistry,
Horus University, Egypt
E-mail: meldesouky@horus.edu.eg

3. Eman Abdel Salam Yousef

Degree: PhD Oral and Maxillofacial Surgery
Affiliation: Associate professor of Oral and Maxillofacial Surgery, Faculty of
Dentistry, Mansoura University, Egypt
E-mail: moony_salam@mans.edu.eg

Corresponding author
Dr. Mohamed Kamal Eid
Oral & Maxillofacial Surgery department, Faculty of dentistry, Tanta University,
Egypt
Address: Omar Abdelazez st , Alzzaeafran district , Mansoura – Dakahlia
(Postal code 35511), Egypt
Telephone: 002 0502204302
Mobile: 002 01220033033
E-mail: mohamed.alam1@dent.tanta.edu.eg
Manuscript (without Author Details) Click here to view linked References

Computed Tomography versus Cone Beam Computed Tomography as a

diagnostic imaging in Retrieval of Displaced Mandibular Third Molar
Teeth/Roots

Introduction

The most frequent procedure performed by dentists , oral and

maxillofacial surgeons is the surgical extraction of mandibular third
molars, thus high frequency of complications is prone to occur. Along
with additional issues like infection, alveolar osteitis, dysesthesia,
bleeding, and anesthetic problems, third molar removal can also result in
the displacement of a tooth or a tooth fragment into crucial adjacent
anatomic regions ( Kamburoglu et al., 2010 ; Goldberg, 1985)

Displacement can typically be attributed to the use of uncontrolled or

excessive force, excessive manipulation, improper surgical planning, or
poor clinical and/or radiological assessment, with the exception of cases
with atypical anatomical considerations, such as a distolingual tooth
inclination or a thin lingual cortex. ( Aznar-Arasa et al., 2012 ; Esen et
al., 2000) Patients may report a variety of symptoms, as some are
completely asymptomatic while others experience discomfort, swelling,
and trismus and should have the displaced tooth/root surgically removed.
(Solanki et al., 2016)

Due to poor visibility and restricted access, removing a displaced root or

tooth from these deep anatomical spaces may be difficult. (Jolly et al.,
2014) Localization of impacted teeth can be confirmed radiographically
using a combination of perpendicular projected images (occlusal,
periapical, or panoramic radiographs). Some clinicians have employed
cone beam computed tomography (CBCT) or low-dose computed
tomography (CT) to obtain three-dimensional data due to the limitations
of using a two-dimensional image. (Guerrero et al., 2011)

There are only a few case reports of third molar displacement in the
literature, and there isn't much information available overall because the
occurrence of this ailment is so low.

Purpose
The aim of this study was to compare CT and CBCT as pre-surgical
diagnostic imaging before surgical retrieval of iatrogenic displaced
mandibular third molar teeth/roots.
 Patients and methods

The study was approved by the Ethical Review Board (M22011122) of

Mansoura University. To use clinical data for the research that was
carried out in accordance with the principles of the Helsinki Declaration
as updated in 1975 and amended in October 2003, informed written
consent was requested from each patient. Each patient signed full
informed consent for the procedure.
Study design (Patients’ selection):
Sixteen patients were referred to Oral and Maxillofacial Department,
faculty of Dentistry, Tanta University complaining of trismus, little
swelling on the floor of the mouth, discomfort during swallowing, and
pain. The patients' medical history revealed that they had previously had
a challenging and unsuccessful extraction of an impacted mandibular
third molar by a general dentist under local anesthesia.
Patients presented with pathologic lesions (dental cyst or tumor) around
the tooth to be retrieved were excluded.
Groups allocation:
First-level 2D radiological imaging (orthopantomography) on all patients
revealed the existence of a radiopaque mass that resembled a third molar
tooth or root. For detailed radiographic examination, when a displaced
tooth/root fragment was suspected the patients were randomly divided
into two equal groups, each of eight patients:
Group (I): Spiral CT* scans were performed, and axial slices were
produced. Along with 3 dimensional pictures, images were rebuilt to
provide sagittal and coronal slices of 2.5 mm thickness. (Figure 1)
______________________________
* Toshiba X Vision EX/42 Helical Slip Ring CT60Hz 1,400 Gantry and tube slices, 2 MHU X-Ray
Tube, Japan
Group (II): CBCT** scans were done with an exposure performed at 15
mA, 85 KV and at a field of view 7.5 cm x 14.5 cm x 14.5 cm. (Figure
2).

Image reconstruction & evaluation

Images were performed including axial, sagittal, and coronal axes, in
addition to three dimensional views to detect the position of displaced
third molar tooth or root in relation to the mandible and the mylohyoid
muscle.
It was intended for all patients to have their displaced tooth or root
fragments retrieved using an intra-oral approach while being under
general anesthesia following standard blood tests and pre-anesthetic
examinations.
Surgical procedure
All surgeries were performed in a standardized fashion, using the same
surgical and pharmacological protocols. All surgeons had at least 5 years
of experience in third molar teeth extraction. Before surgery, the patient
performed a mouth rinse of chlorhexidine 0.12% for one minute.
Dexamethasone 8 mg was given orally to the patient one hour before
surgery to promote the best possible postoperative results.
Under general anesthesia, a lingual envelope incision was performed to
access and remove the displaced third molar tooth or root, and a
mucoperiosteal flap was released from the retromolar trigone to the
medial surface of the mandibular first premolar. (Silveira et al., 2014) By
carefully retracting the lingual soft tissue, an envelope flap was raised on
the lingual side from the second premolar to the anterior boundary of the
ramus.
______________________________
* * I-CAT (15mA, 85 KVp) Imaging Sciences International, Hatfield, England.
This protected the lingual nerve from injury. With great caution, the
lingual flap was reflected up to the submandibular area so that the tooth
or root fragment could be identified. An extra-oral finger was used as
support. (Jolly et al., 2014) Through blunt dissection, the loose tooth or
root was located, grabbed using a pair of artery forceps, and extracted.
The operator's index finger was used in some instances to palpate the
displaced roots, which confirmed their location deep within the
submandibular region. A buccal envelope flap was raised from the
mandibular first molar to the external oblique ridge. A lingual flap was
raised mesially up to the first premolar and distally adjoined with the
buccal flap. With considerable caution, the lingual flap was raised to the
submandibular area so that the root fragment could be seen. An additional
finger was placed in the mouth to provide support. The roots were
expelled by pushing them outward with a curette. (Figures 3 &4)
The flaps were sutured using 3-0 Vicryl sutures after the wound was
irrigated with normal saline. Following surgery, all patients received an
an oral treatment which included: antibiotic tab (amoxicillin 875 mg +
clavulanic acid 125 mg 1 gm) one tablet every 12 hours, analgesic tab
(ketoprofen 75 mg) one tablet every 8 hours and anti-edematous
(chymotrypsin 300i.u. + trypsin 300i.u) two tablets on empty stomach
one hour before meal for seven successive days.

Post-operative evaluation
At the conclusion of the intervention, the same operators meticulously
filled out a data collection form for each patient. These documents were
momentarily kept in a secure location inside the operational unit. A
progressive numerical code was given to each patient as a means of
identification. Gender, birthdate, the anatomical location of the misplaced
tooth or root, and the duration of the operation (calculated from the
incision to socket cleaning) were all collected
On the seventh post-operative day, the sutures were removed, and the
patients were evaluated for the following:
Pain: The degree of pain was determined during the follow-up periods
according to the visual analogue pain scale (VAS) from 0 (no pain at all)
to 10 (most severe pain).( Wewers and Lowe , 1990)
Swelling: It was assessed utilizing a vertical and horizontal guide with a
tape on four reference points; outer canthus of the eye, angle of the
mandible, tragus, and outer corner of the mouth respectively. To obtain
the percentage of facial swelling, the difference between measurement of
post-operative and pre-operative periods will be divided by the value of
the pre-operative period. (Souza and Consone, 1992)
Trismus: evaluated as present or absent.
Sensory disturbances: Nerve dysesthesia was recorded using two-point
discrimination test. (Cashin and McAuley, 2017) If the response was
affirmative, the following issues were investigated into: the type of
disturbance, the symptoms encountered, and an anatomical extent of the
sensitivity impairment. Tablet of Neuroton (Amoun Pharmaceutical
Company S.A.E) (Thiamine HCl (Vitamin B1) 250 mg Riboflavine
phosphate (Vitamin B2) 15 mg Pyridoxine HCl (Vitamin B6) 150 mg
Cyanocobalamin (Vitamin B12) 250 mcg Folic acid 500 mcg) once daily
for 2weeks were administered.
Patients were followed up 2 weeks, 1 month and 3 months post-
operatively for signs and symptoms monitoring until their resolution.
Statistical analysis

All the data were collected and statistically analyzed at the end of the
study using Statistical Package for Social Sciences (SPSS version
26,25.0, Chicago, IL, USA). Chi – square test to compare between
categorical variables, T-test to compare and assess parametric data and
level of the significance will be set as p<0.05
 Results

In this study, 16 patients were included; 4 were females (25%) and 12

males (75%). Patient age at the time of diagnosis ranged from 25 to 38
years (means 30.75). A total of 7 (43.75%) third mandibular left
molars/root fragments and 9 (56.25 %) third mandibular right molars/root
fragments were retrieved. This study recorded displacement of 15
mandibular third molar teeth or roots in submandibular fascial spaces and
one case in pterygomandibular fascial space. (Table 1) The average
operation time for group I and group II are 20 and 35 minutes
respectively.

During the follow-up periods, pain was measured on a visual analogue

scale (VAS) from 0 (no pain at all) to 10 (most severe pain). Regarding
the CT group, pain measurements were 6.7±1.06, 5.6±1.7, 1.8±1.5 and
0.6±1.2 for the 1st week, 2nd week, 1st month and 3rd month respectively.
While in the CBCT group, pain measurements were 7.2±2.06, 6.1±1.9,
2.6±1.8 and 1.3±1.1 for the 1st week, 2nd week, 1st month and 3rd month
respectively. No significant difference was recorded between the two
groups (P > 0.05). (Table 2)

Swelling was recorded as 283±7.09 mm and 383±7.09 mm for the 1st

week, 110±12.1 mm and 210±12.1mm for the 2nd week, 60±3.4 mm and
80±4.6 mm after one month for the CT and CBCT groups respectively.
By the end of the 3rd month, no facial swelling was recorded for any of
the patients. There was no statistically significant difference regarding
swelling between the two groups. (P> 0.05) (Table 2)

By the end of the second week, no patient had complained of trismus.

One patient in the CT group and three patients in the CBCT group in the
current study experienced lingual nerve paresthesia, according to follow-
up after one week. After three months of follow-up, the surgical course
was uncomplicated, and the lingual paresthesia symptoms were totally
resolved. For each patient, all the displaced teeth and root fragments were
retrieved.
 Discussion

A rare but potential problem is the accidental displacement of

mandibular third molars or their root fragments into adjacent anatomical
areas. (Solanki et al., 2016; Lee et al., 2013) The estimated incidence is
1%. Mandibular third molars can be displaced into the submandibular,
sublingual, and lateral pharyngeal fascial spaces. (Alexoudi et al., 2020)
The present study recorded 15 displacements within the submandibular
fascial space and one case in the pterygomandibular space.

It is debatable when the fragment should be extracted. Several dentists

insist on removing the remaining tooth right away, while others
recommend extraction 3–4 weeks after the incident. (Esen et al., 2000;
Jolly et al., 2014) The formed fibrosis, according to those who favor
delaying extraction, will make it easier to stabilize the tooth in its
displaced location and facilitate retrieval. However, it's possible that the
tooth will move into a deeper plane, which could result in infection or
potentially fatal problems such airway obstruction, deep neck infections,
carotid artery or internal jugular vein erosion, and cranial nerve
implications. (Tamer and Pektas, 2018) This is in favors of the immediate
surgical retrieval. In this study, all patients have been referred and have
undergone surgical retrieval of the displaced tooth/ root fragment within
11 days of the displacement incidence. (Esen et al., 2000; Medeiros and
Gaffrée, 2008; Ogadako et al., 2011)

Additionally, the displaced tooth should be removed safely which

necessitates accurate locating of its position. In this investigation, the
displaced tooth/root and the mandible were overlapped in the
orthopantomograms that were unable to pinpoint the exact location of a
displaced tooth or the relationship between the tooth and surrounding
anatomical structures The displaced tooth's precise location was revealed
by the reconstructed CT as well as CBCT images, which were used to
guide the dislodging with a lower radiation dose than traditional CT.
(Jolly et al., 2014) However, the CBCT has not been used in the few
documented cases, despite the need for using advanced imaging
techniques to find a displaced tooth and its relationship to the surrounding
anatomic structures. (Esen et al., 2000; Ogadako et al., 2011; Ertas et al.,
2002; Wang et al., 2016)

The simplest and least invasive approach for removing displaced root
fragments from the soft tissue of the lingual pouch is the intra-oral
approach. In other circumstances, such as when the displaced piece is
positioned in the lateral pharyngeal or deep cervical area, an extra-oral or
even a mixed intra-oral/extra-oral method is preferred. (Solanki et al.,
2016; Yeh, 2002) In the current study, a lingual mucoperiosteal flap
raised to the premolar location provided for acceptable visibility.
However, in some instances it did not always provide enough visibility
and access, thus a buccal envelope flap was raised from the mandibular
first molar to the external oblique ridge to conjoin the lingual flap
distally.

Patient age was a significant determinant for postoperative neurological

symptoms when we took the 25-year cutoff, as described in the literature.
(Leung and Cheung, 2011; Jerjes et al., 2010; Barone et al., 2019) This
might be related to a different bone biodynamic or to diverse manners.
that young people cope with nerve injuries. In this study, the patient age
at the time of diagnosis ranged from 25 to 38 years According to various
works, operator experience was important. (Cheung et al., 2010;
Bataineh, 2001; Goldberg, 2005), but this variable was not considered in
this study as all surgeons had more than 5 years of experience.
Due to its proximity to the lingual nerve, inferior alveolar nerve, and
blood vessels, retrieving a displaced tooth or root fragment from the
sublingual area can result in several consequences, including paresthesia
and hemorrhage. (Ertas et al., 2002; Tumuluri and Punnia‐ Moorthy,
2002; Gay-Escoda et al., 1993; Huang et al., 2007; Iwanaga et al., 2022)
Consequently, before proceeding with removal, comprehensive treatment
plan should be created to minimize the risk of problems. (Jolly et al.,
2014; Lee et al., 2013) As noted on the follow-up, three of our CBCT
group patients and one patient from the CT group both experienced
postoperative lingual nerve hypoesthesia, all of which were reversible.
This comes in accordance with Alexoudi et al (2022) who reported 2
post-operative reversible cases of lingual hypoesthesia after retrieval
displaced mandibular third molars from sub-mandibular spaces.

There was no correlation between the availability of CBCT images and

the development of neurological disorders. This aligns with other
literature reviews. (Matzen and Wenzel, 2015; Guerrero et al., 2014; de
Toledo et al., 2020) Nevertheless, it is evident that radiographic signs
detected on 3D X-rays might offer helpful cues for planning the
procedure and lower the risks associated with the extraction of impacted
mandibular third molars. (Goldberg , 2005; Bozkurt and Görürgöz , 2020)

Once properly localised using radiography or a CT scan, a dislodged root

fragment should be swiftly extracted. In this study, manual palpation is
another helpful localization technique. This comes in agreement with
Jolly et al., (2014) who successfully retrieved a displaced root into
submandibular space by an intra-oral approach under local anesthesia.
Furthermore, they underlined that the best method for assessing the size
and position of a displaced root fragment is believed to be CT scanning.
According to other studies, CBCT can offer the benefits of minimal
radiation exposure and three-dimensional views without compromising
image quality.( Kamburoglu et al., 2010; Aznar-Arasa et al., 2012;
Tumuluri and Punnia‐ Moorthy , 2002; Huang et al., 2007; Damstra et
al., 2010; Selvi et al., 2011) The geometric accuracy of CBCT has been
proven by experimental research.(Honda et al., 2004; Hilgers et al., 2005)
In contrast to panoramic radiography, CBCT does not provide a precise
risk for perforation of the inferior alveolar nerve canal.(Valmaseda-
Castellón et al., 2001) It is worth noting that the use of CBCT as an
imaging modality is restricted by its relatively expensive cost.( Freisfeld
et al., 1998; Aryatawong and Aryatawong ., 2000)

Due to its high resolution, CT gives surgeons relevant anatomical

information. (Valmaseda-Castellón et al., 2001) It has been documented
that conventional CT is helpful in determining the topographic
relationship between the mandibular canal and the third molars. (Monaco
et al., 2004; Maegawa et al., 2003) There are, however, few studies that
have linked CT results to surgical outcomes with respect to nerve
damage. To accurately anticipate the risk of damaging the inferior
alveolar nerve during surgery, it is crucial to accurately determine the
neurovascular bundle's position and its relationship to wisdom tooth roots
in all three dimensions prior to operation. Additionally, when informing
the patient about the complications of surgery and obtaining informed
consent, this data is immensely useful. (Iwanaga et al., 2021)

The frequency of neurological problems was substantially correlated with

surgical operation duration. It is unclear whether the time factor has an
impact on postoperative variables like edema, whether it is directly
correlated with the difficulty of the surgery, or whether it impacts both. (
Benediktsdóttir et al.,2004) An extended surgery duration can be
considered a negative prognostic indicator regarding nerve injuries.
( Leung et al., 2011) In this study, the average operation time for group I
and group II are 20 and 35 minutes respectively.

The study has few limitations. The first issue is the small sample size,
which leads to a remarkably low frequency of nerve damage. Another
issue can be the variable clinical presentation and subjective expression
of nerve lesions, necessitating reliance on patient descriptions of
symptoms. Further research is urged in this regard.

Conclusion

This study confirmed the clinical usefulness of both spiral CT and CBCT
for preoperative evaluation and planning of the way of surgical procedure
of displaced mandibular third molars/roots in different anatomic spaces.
However, CT is more accurate in demonstrating the relationship between
the lingual nerve and the displaced tooth/root.

Funding
The authors received no specific funding for this work.

Conflicts of interest
The authors declare no conflicts of interest.
 References

Alexoudi VA, Tatsis D, Zamani K, Zelkas D, Paraskevopoulos K,

Vaxtsevanos K: Iatrogenic displacement of impacted mandibular third
molars or their roots into adjacent soft tissues and spaces: A report of
three cases. Natl J Maxillofac Surg 11(2):275-279, 2020.
DOI: 10.4103/njms.NJMS_95_19

Aryatawong S, Aryatawong K: Evaluation of the inferior alveolar canal

by cross-sectional hypocycloidal tomography. Implant Dent 9(4):339-
345, 2000. DOI: 10.1097/00008505-200009040-00010
Aznar-Arasa L, Figueiredo R, Gay-Escoda C: Iatrogenic displacement of
lower third molar roots into the sublingual space: Report of 6 cases. J
Oral Maxillofac Surg 70(2): e107-115, 2012.
DOI: 10.1016/j.joms.2011.09.039

Barone R, Clauser C, Testori T, Del Fabbro M: Self-assessed

neurological disturbances after surgical removal of impacted lower third
molar: a pragmatic prospective study on 423 surgical extractions in 247
consecutive patients. Clin Oral Investig 23(8):3257-3265, 2019.
DOI: 10.1007/s00784-018-2747-9

Bataineh AB: Sensory nerve impairment following mandibular third

molar surgery. J Oral Maxillofac Surg 59(9):1012-1017, 2001.
DOI: 10.1053/joms.2001.25827

Benediktsdóttir IS, Wenzel A, Petersen JK, Hintze: Mandibular third

molar removal: risk indicators for extended operation time, postoperative
pain, and complications. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 97(4):438-446, 2004. DOI: 10.1016/j.tripleo.2003.10.018

Bozkurt P, Görürgöz C: Detecting direct inferior alveolar nerve–third

molar contact and canal decorticalization by cone-beam computed
tomography to predict postoperative sensory impairment. J Stomatol Oral
Maxillofac Surg 121(3):259-263,2020.
DOI: 10.1016/j.jormas.2019.07.004
Cashin AG, McAuley JH: Measuring two-point discrimination threshold
with a caliper. J Physiother 63(3):186, 2017.
DOI: 10.1016/j.jphys.2017.04.005

Cheung L, Leung Y, Chow L, Wong M, Chan E, Fok Y: Incidence of

neurosensory deficits and recovery after lower third molar surgery: a
prospective clinical study of 4338 cases. Int J Oral Maxillofac Surg
39(4):320-326, 2010. DOI: 10.1016/j.ijom.2009.11.010

Damstra J, Fourie Z, Slater J, Ren Y: Accuracy of linear measurements

from cone-beam computed tomography-derived surface models of
different voxel sizes. Am J Orthod Dentofacial Orthop 137(1):16. e1- 6,
2010. DOI: 10.1016/j.ajodo.2009.06.016

Ertas Ü, Yaruz MS, Tozoğlu S: Accidental third molar displacement into

the lateral pharyngeal space. J Oral Maxillofac Surg 60(10):1217, 2002.
DOI: 10.1053/joms.2002.35802

Esen E, Aydoğan LB, Akçali MC: Accidental displacement of an

impacted mandibular third molar into the lateral pharyngeal space. J Oral
Maxillofac Surg 58(1):96-7,2000. DOI: 10.1016/s0278-2391(00)80024-5

Freisfeld M, Drescher D, Kobe D, Schüller H: Assessment of the space

for the lower wisdom teeth. J Orofac Orthop 59(1):17-28,1998.
DOI: 10.1007/bf01321552

Gay-Escoda C, Berini- Aytés L, Piñera-Penalva M: Accidental

displacement of a lower third molar. Report of a case in the lateral
cervical position. Oral Surg Oral Med Oral Pathol 76(2):159-60, 1993.
DOI: 10.1016/0030-4220(93)90197-c

Goldberg MH, Nemarich AN, Marco WP: Complications after

mandibular third molar surgery: A statistical analysis of 500 consecutive
procedures in private practice. J Am Dent Assoc 111:277-9,1985.
DOI: 10.14219/jada.archive.1985.0098

Goldberg MH: Frequency of trigeminal nerve injuries following third

molar removal. J Oral Maxillofac Surg 63(12):1783, 2005.
DOI: 10.1016/j.joms.2005.08.009
Guerrero ME, Shahbazian M, Elsiena Bekkering G, Nackaerts O, Jacobs
R, Horner K: The diagnostic efficacy of cone beam CT for impacted teeth
and associated features: a systematic review. J Oral Rehabil 38(3):208-
16, 2011. DOI: 10.1111/j.1365-2842.2010.02141.x

Guerrero ME, Botetano R, Beltran J, Horner K, Jacobs R: Can

preoperative imaging help to predict postoperative outcome after wisdom
tooth removal? A randomized controlled trial using panoramic
radiography versus cone-beam CT. Clin Oral Investig 18(1):335-42,
2014. DOI: 10.1007/s00784-013-0971-x
Hilgers ML, Scarfe WC, Scheetz JP, Farman AG: Accuracy of linear
temporomandibular joint measurements with cone beam computed
tomography and digital cephalometric radiography. Am J Orthod
Dentofacial Orthop 128(6):803-11, 2005.
DOI: 10.1016/j.ajodo.2005.08.034

Honda K, Arai Y, Kashima M, Takano Y, Sawada K, et al: Evaluation of

the usefulness of the limited cone-beam CT (3DX) in the assessment of
the thickness of the roof of the glenoid fossa of the temporomandibular
joint. Dentomaxillofac Radiol 33(6):391-5, 2004.
DOI: 10.1259/dmfr/54316470

Huang IY, Wu CW, Worthington P: The displaced lower third molar: A

literature review and suggestions for management. J Oral Maxillofac Surg
65(6):1186-90, 2007. DOI: 10.1016/j.joms.2006.11.031.

Jerjes W, Upile T, Shah P, Nhembe F, Gudka D, et al: Risk factors

associated with injury to the inferior alveolar and lingual nerves
following third molar surgery—revisited. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 109(3):335-45, 2010.
DOI: 10.1016/j.tripleo.2009.10.010

Iwanaga J, Kunisada Y, Masui M, Obata K, Takeshita Y, et al:

Comprehensive review of lower third molar management: A guide for
improved informed consent. Clin Anat 34(2):224-43,2021.
DOI: 10.1002/ca.23693

Iwanaga J, Kato T, Tubbs RS, Ibaragi S: Lingual nerve impairment/injury

after retrieval of the displaced mandibular third molar into the floor of the
mouth. J Oral Maxillofac Surg 80(9):S69,2022.
DOI: 10.1016/j.joms.2022.07.096
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 26(4):181-4, 2014.
DOI: 10.1016/j.sdentj.2014.05.004

Kamburoglu K, Kursun S, Oztas B: Submandibular displacement of a

mandibular third molar root during extraction: a case report. Cases J
3(1):1-3, 2010. DOI: 10.1186/1757-1626-3-8
Lee D, Ishii S, Yakushiji N: Displacement of maxillary third molar into
the lateral pharyngeal space. J Oral Maxillofac Surg 71(10):1653-7,2013.
DOI: 10.1016/j.joms.2013.05.018

Leung Y, Cheung L: Risk factors of neurosensory deficits in lower third

molar surgery: a literature review of prospective studies. Int J Oral
Maxillofac Surg 40(1):1-10, 2011. DOI: 10.1016/j.ijom.2010.09.005

Maegawa H, Sano K, Kitagawa Y, Ogasawara T, Miyauchi K, et al:

Preoperative assessment of the relationship between the mandibular third
molar and the mandibular canal by axial computed tomography with
coronal and sagittal reconstruction. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 96(5):639-46, 2003. DOI: 10.1016/s1079-2104(03)00356-1

Matzen L, Wenzel A: Efficacy of CBCT for assessment of impacted

mandibular third molars: A review–based on a hierarchical model of
evidence. Dentomaxillofac Radiol 44(1):20140189, 2015.
DOI: 10.1259/dmfr.20140189

Medeiros N, Gaffrée G: Accidental displacement of inferior third molar

into the lateral pharyngeal space: Case report. J Oral Maxillofac Surg
66(3):578-80, 2008. DOI: 10.1016/j.joms.2005.10.042

Monaco G, Montevecchi M, Bonetti GA, Gatto MRA, Checchi L:

Reliability of panoramic radiography in evaluating the topographic
relationship between the mandibular canal and impacted third molars. J
Am Dent Assoc 135(3):312-8, 2004.
DOI: 10.14219/jada.archive.2004.0179

Ogadako RM, Woods M, Shah N: Dislodged lower right third molar

tooth into the parapharyngeal space. Dent Update 38(9):631-2, 2011.
DOI: 10.12968/denu.2011.38.9.631
Selvi F, Cakarer S, Keskin C, Ozyuvaci H: Delayed removal of a
maxillary third molar accidentally displaced into the infratemporal fossa.
J Craniofac Surg 22(4):1391-3, 2011.
DOI: 10.1097/SCS.0b013e31821cc254

Silveira RJ, Garcia RR, Botelho TL, Franco A, Silva RF: Accidental
displacement of third molar into the sublingual space: a case report. J
Oral Maxillofac Res 5(3):e5, 2014. DOI: 10.5037/jomr.2014.5305

Solanki R, Khangwal M, Kumar D, Goel M: Retrieval of mandibular

third molar tooth accidentally displaced in submandibular space: Series of
two cases. Indian J Dent 7(2):105, 2016.
DOI: 10.4103/0975-962x.184653

Souza JAd, Consone DP: Método para medida do edema facial em pós-
operatório de cirurgias bucais. RGO 40:137–41, 1992.
DOI: 10.11606/d.23.2017.tde-12062017-165918

Tamer Y, Pektas ZO: Accidental displacement of mandibular third molar

roots into the pterygomandibular space. Niger J Clin Pract 21(8):1075-7,
2018. DOI: 10.4103/njcp.njcp_427_17

Telles-Araújo G, Peralta-Mamani M, Caminha RD, Moraes-da-Silva A,

Rubira CMF, et al: CBCT does not reduce neurosensory disturbances
after third molar removal compared to panoramic radiography: A
systematic review and meta-analysis. Clin Oral Investig 24(3):1137-1149.
2020. DOI: 10.1007/s00784-020-03231-6

Tumuluri V, Punnia‐ Moorthy A: Displacement of a mandibular third

molar root fragment into the pterygomandibular space. Aust Dent J
47(1):68-71, 2002. DOI: 10.1111/j.1834-7819.2002.tb00307.x

Valmaseda-Castellón E, Berini-Aytés L, Gay-Escoda C: Inferior alveolar

nerve damage after lower third molar surgical extraction: A prospective
study of 1117 surgical extractions. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 92(4):377-83,2001. DOI: 10.1067/moe.2001.118284

Wang C, Gu Y, He L: Removal of mandibular third molar accidently

displaced into the parapharyngeal space aided by cone-beam computed
tomography: A case report. J Clin Case Rep 6(786):2, 2016.
DOI: 10.4172/2165-7920.1000786
Wewers ME, Lowe NK: A critical review of visual analogue scales in the
measurement of clinical phenomena. Res Nurs Health 13(4):227-36,1990.
DOI: 10.1002/nur.4770130405

Yeh CJ: A simple retrieval technique for accidentally displaced

mandibular third molars. J Oral Maxillofac Surg 60(7):836-7, 2002. DOI:
10.1053/joms.2002.33257
 Tables

Table 1: Demographic patient’s data of Age, sex distribution, facial space

involved and time of displaced tooth / root retrieval

Patient Group I Group II

No (CT) (CBCT)

Age Sex Fascia Space involved Time of Age Sex Fascial Space Time of
retrieval involved retrieval
(1) 30 male (Rt) submandibular 5 day 34 female (Lt) 7 day
submandibular
(2) 27 male (Lt) submandibular 9 day 30 male (Lt) 4 day
submandibular
(3) 38 male (Lt) 3day 27 male (Rt) 10 day
pterygomandibular submandibular
(4) 25 male (Lt) submandibular 7 day 36 male (Rt)submandibul 5 day
ar
(5) 33 male (Rt) submandibular 3 day 34 male (Rt) 3 day
submandibular
(6) 32 female (Rt)submandibular 10 day 30 female (Rt) 11 day
submandibular
(7) 30 male (Rt)submandibular 3day 26 male (Rt)submandibul 4 day
ar
(8) 28 female (Lt) submandibular 5day 32 male (Lt) 3 day
submandibular

Table 2: Postoperative clinical results (Pain, swelling)

Post- Group I (CT) Group II (CBCT)

(Mean ± SD) (Mean ± SD) Significant
operative
test
clinical sign (P Value)

1st 2nd 1st 3rd 1st 2nd 1st 3rd

week week month month week week month
month

Pain 6.7±1.06 5.6±1.7 1.8±1.5 0.6±1.2 7.2±2.06 6.1±1.9 2.6±1.8 1.3±1.1 0.000*
Swelling(mm) 283±7.09 110±12.1 60±3.4 0 383±7.09 210±12.1 80±4.6 0 0.000*
⃰ Significant p ≤ 0.05
 List of figures

Figure 1: Pre-operative (A) coronal, (B) axial sections and (C) 3D reconstructed
images of computed tomography (Group I, case number 4) showing the lingually
displaced wisdom roots in left submandibular space.
Figure 2: Pre-operative (A)axial, (B) coronal sections (C) panoramic view and (D)3D
reconstructed images of cone beam computed tomography (Group II, case number 2)
showing the lingually displaced wisdom tooth in left submandibular space
Figure 3: (A&B): The lingual flap was reflected up to the submandibular region, (C):
The retrieved displaced mandibular third molar tooth. (Group I, case number 4)
Figure 4: (A): The lingual flap was reflected up to the submandibular region, (B):
The retrieved displaced mandibular third molar tooth. (Group II, case number 2)
Figure Click here to access/download;Figure;Figure1.jpg
Figure Click here to access/download;Figure;Figure2.jpg
Figure Click here to access/download;Figure;Figure3.jpg
Figure Click here to access/download;Figure;Figure4.png
Author Agreement