Surgical Management of Accidentally Displaced Mandibular Third Molar into the Pterygomandibular Space: A Case Report

拔除智齒是牙科門診常見的手術之一，但一如其他的手術，也都有產生後遺症的可能，例如常見的感染、出血、神經傷害與張口受限等。然而整顆牙齒或是牙根部分，被推入翼顎間隙中，則較為罕見，但卻可能產生較嚴重的組識傷害，甚至引起醫療糾紛。牙醫師應謹慎處理智齒，尤其是埋伏性智齒；也要了解智齒被意外推入翼顎間隙時，應如何因應與處理，以減少對病人的傷害及不必要的糾紛。由於有關下顎智齒被推擠到翼顎間隙的文獻報告與案例極少，本文提出此病例報告，以提醒牙醫師注意。病患為28歲男性，2006年一月，在牙科診所拔除智齒，牙醫師於切斷牙冠後，以牙根挺欲移除牙根時，牙根忽然不見了，牙醫師仔細檢查齒槽骨後，因未見牙根，而誤以為已拔除或被抽吸器吸走，便關閉傷口。病人因在國外唸書而未回診，於拔牙後三個月，開始有喉嚨異物感，並前往當地醫院檢查，在接受電腦斷層掃描後，發現有一牙根狀的影像在翼顎間隙裡，病人因學業關係，在2006年六月，至本院就診，希望進一步檢查，在照攝環口片與立體電腦斷層掃描，確定位置後，於全身麻醉下，經傳統式手術法，找到移位的牙根，並予以取出。術後傷口癒合正常，僅有暫時性舌尖麻木感。本病例提醒牙醫師，在拔除智齒前應仔細評估情況；拔牙時要正確使用器械及施力；並有良好的保護，如果牙根斷裂，要謹慎處理，萬一牙根或整顆牙被推擠到翼顎間隙，要確實檢查並照影像確定牙齒位置。如無把握，切勿任意嘗試拔除，以免使情況惡化，應立即轉介給口腔顎面外科醫師。一般而言，仔細定位與慎選手術方式是移除移位智齒的首要關鍵。當要立即移除異位牙根時，可用環口片攝影，配合水平向咬合片定位，如果是已經經過一段時問再要拔除的情況，或位置較深層時，則以立體電腦斷層掃描來定位較佳。

關鍵字

意外移位；下顎智齒；翼顎間隙；牙根斷裂

並列摘要

Surgical removal of the mandibular third molar is a regular surgical procedure in dental clinics, and like all operations, it may have some complications, such as infection, bleeding, nerve injuries, trismus and so on. An accidentally displaced lower third molar is a relatively rare complication, but may cause severe tissue injury and medicolegal problems. As few papers and cases have been published on this topic, we report this case to remind dentists on ways to prevent and manage this complication. The patient, a 28-year-old male, had his right lower mandibular third molar extraction in January 2006. The dentist resected the crown and attempted to remove the root but found that it had suddenly disappeared from the socket. Assuming that the root had been suctioned out he closed the wound. The patient was not followed up regularly because he studied abroad. About 3 months later, the patient felt a foreign body sensation over his right throat, and visited a local hospital in Australia. He was told after a computed tomography (CT) scan that there was a root-like radio-opaque image in the pterygomandibular space. The patient came to our hospital for further examination and management in June 2006. We rechecked with both Panorex and CT and confirmed the location of the displaced root. Surgery for retrieving the displaced root was performed under general anesthesia by conventional method without difficulty, and the wound healed uneventfully except for a temporary numbness of the right tongue. This case reminds us that the best way to prevent a displaced mandibular third molar is to evaluate the condition of the tooth carefully preoperatively, select adequate instruments and technique, and take good care during extraction. If an accident does occur, dentists should decide whether to retrieve it immediately by themselves or refer the case to an oral and maxillofacial surgeon, and should not try to remove the displaced root without proper assurance. Localization with images and proper surgical methods are the keys to retrieving the displaced fragment successfully. When immediate retrieval is decided on, Panorex and occlusal view are useful in localizing the displaced fragment. When the fragment moves into a deeper space or the retrieval has been delayed for months, three-dimensional CT seems to be a better choice.

並列關鍵字

accidental displacement ； mandibular third molar ； pterygomandibular space ； root fracture

國際替代計量

Surgical Management of Accidentally Displaced Mandibular Third Molar into the Pterygomandibular Space: A Case Report

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