- Email: [email protected]
Access to the Mandibular Angle Using a Sagittal Split to Address Pathologic Displacement of a Mandibular Third Molar
Accepted Manuscript Access to the mandibular angle using a sagittal split to address pathologic displacement of a mandibular third molar Katrina L. Kontaxis, DMD, Derek M. Steinbacher, DMD, MD, FACS, FAAP PII:
S0278-2391(15)01200-8
DOI:
10.1016/j.joms.2015.08.016
Reference:
YJOMS 56951
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 3 August 2015 Accepted Date: 17 August 2015
Please cite this article as: Kontaxis KL, Steinbacher DM, Access to the mandibular angle using a sagittal split to address pathologic displacement of a mandibular third molar, Journal of Oral and Maxillofacial Surgery (2015), doi: 10.1016/j.joms.2015.08.016. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Title: Access to the mandibular angle using a sagittal split to address pathologic displacement of a
Katrina L. Kontaxis, DMD Resident - Oral and Maxillofacial Surgery
M AN U
Yale New Haven Hospital
SC
Authors:
RI PT
mandibular third molar
Derek M. Steinbacher, DMD, MD, FACS, FAAP
Chief - Department of Dentistry and Oral and Maxillofacial Surgery Associate Professor of Plastic Surgery
EP
Corresponding author:
TE D
Yale New Haven Hospital
Katrina L. Kontaxis, DMD
AC C
Yale New Haven Hospital Oral and Maxillofacial Surgery 330 Orchard Suite 202
New Haven, CT 06511 Tel: (203) 789-3156
Fax: (203) 789-3954 [email protected]
ACCEPTED MANUSCRIPT
Abstract: Access to the mandibular angle for removal of pathology poses a unique challenge to surgeons. Intra-oral approaches result in significant bone removal and potential damage
cutaneous scar and the potential for facial nerve damage.
RI PT
to the inferior alveolar nerve (IAN). Extra-oral approaches are associated with a
This report describes a 53 year old man with a deeply impacted third molar associated
SC
with a cystic lesion that was treated by enucleation via intra-oral sagittal split osteotomy. This approach allowed for complete access and visualization of the cyst and displaced 3rd
M AN U
molar, while making it possible to protect the IAN with minimal surgical morbidity.
Introduction:
Proximity to important structures such as the inferior alveolar nerve (IAN) has been
TE D
described as a relative contraindication to third molar removal. [1] In the presence of pathology, however, removal of deeply impacted teeth is necessary. Extra-oral approaches have been described as an alternative technique for third molar removal. [2,
EP
3] This technique creates an external scar and may result in facial nerve injury. Additionally, significant osseous structure must be removed and complete visibility,
AC C
while protecting the inferior alveolar nerve, may be limited. Intra-oral approaches can also carry significant morbidity and visibility is often decreased, especially when a lesion has displaced a tooth to the inferior border of the mandible. Removal of the tooth and associated pathology via this approach may result in a mandible fracture or permanent IAN injury. Third molars have been successfully extracted as part of bilateral sagittal splits for orthognathic surgery. [4] A sagittal split osteotomy allows the surgeon to
ACCEPTED MANUSCRIPT
directly visualize and protect the inferior alveolar nerve as well as complete access to the displaced tooth and surrounding lesion.
impacted 3rd molar with associated pathology.
Case Report:
RI PT
We present a case where a sagittal split osteotomy (SSO) was used to approach a deeply
SC
A 53 year old male presented with an expanding mass in his left mandible. He
complained of a pressure sensation and tinnitus but denied any pain or dysesthesia.
M AN U
He had no significant medical history. On physical exam, he had no swelling and cranial nerve V3 was intact bilaterally. Intra-orally, his occlusion was stable and he had no swelling or drainage.
His panoramic radiograph showed a deeply impacted lower left third molar with roots at
TE D
the level of the inferior border. A pericoronal radiolucency was also noted. (Figure 1) A cone-beam computed tomography (CBCT) was obtained and confirmed the presence of a pericoronal radiolucency and close proximity to the inferior alveolar nerve as well as
EP
bony expansion. (Figure 2).
An intra-oral biopsy was performed and was consistent with an inflamed dentigerous
AC C
cyst. (Figure 3) He was referred to our institution for further management. Due to the extent of the lesion and amount of displacement of the tooth, the decision was made to perform a sagittal split osteotomy to gain access for removal. He was brought to the operating room and nasally intubated. Local anesthesia was administered (10 mL lidocaine1% with 1:100 000 epinephrine, 4 mL bupivacaine 0.25% with 1: 200 000 epinephrine) and a dart incision was made. A sub-periosteal dissection
ACCEPTED MANUSCRIPT
was carried out on the buccal and lingual and the mandibular lingula was identified. A corticotomy was performed from the medial surface of the ramus down the external oblique ridge and the lateral surface of the mandible anterior to the antegonial notch. A
RI PT
sequence of osteotomes and a three prong spreader were used to propagate the split. The inferior alveolar nerve was identified and protected. The tooth was then visualized,
sectioned, and carefully separated from the nerve. The lesion was curetted from the nerve
SC
and submitted to pathology in its entirety. The nerve was confirmed to be intact. Fibrin glue and demineralized bone matrix were placed in the defect. Four intermaxillary
M AN U
fixation (IMF) screws were then applied and the patient was held in occlusion with wire fixation. A 6mm titanium plate was placed on the lateral border of the mandible and secured with 4 monocortical screws. The wires and IMF screws were then removed and the stability of the patient’s occlusion was confirmed. The surgical site was irrigated and
TE D
closed in a layered fashion with resorbable sutures.
The patient was discharged on the same day and completed a course of antibiotics and antiseptic mouth rinse post-operatively. He was instructed to maintain a soft, blenderized
EP
diet for 4 weeks.
Two weeks post-operatively, his surgical site was healing well and he was found to have
AC C
some left sided V3 hypoesthesia. Three months post-operatively, he had no signs of infection and V3 showed normal sensation. A post-operative CBCT showed the sagittal split osteotomy well repositioned and early signs of bone fill. (Figures 4, 5) The final pathology reading confirmed the diagnosis of an inflamed dentigerous cyst.
Discussion:
ACCEPTED MANUSCRIPT
In the present case, the presence of a severely displaced third molar was strongly suggestive of a pathologic process. Surgical treatment was indicated to address the mandibular lesion associated with the impacted tooth. When third molars are deeply
RI PT
impacted, intra-oral and extra-oral approaches may be considered. [3] Extra-oral
approaches allow for good surgical access, but carry a risk of facial nerve injury and may result in cosmetic defects from skin scarring. Conventional intra-oral approaches require
SC
extensive bone removal and could potentially lead to a mandible fracture. They also
provide poor visualization in cases of deep impactions, placing the IAN at a high risk of
M AN U
injury.
The SSO technique for removal of third molars has been described in the past. [5-7] This technique allows for direct visualization of the IAN with access to the tooth and surrounding pathology in a controlled environment. Post-operative morbidity is minimal
TE D
when compared to more conventional intra-oral or extra-oral approaches. Patients may experience post-operative hypoesthesia as in conventional SSO procedures. However, since the SSO approach offers control of the field and the nerve is protected, nerve
EP
dysfunction usually improves within the year following surgery. Some previously reported cases described techniques where a period of IMF was used after surgery. [5, 7]
AC C
The use of post-operative IMF was not necessary in this case. The patient’s occlusion was stable at the end of the procedure and he maintained a soft diet for 4 weeks. In cases where post-operative IMF is deemed necessary by the surgeon, it may be considered a disadvantage. However, the morbidity of 2 weeks of IMF should be weighed against the risks of scar, facial nerve damage, and inferior alveolar nerve damage. Other
ACCEPTED MANUSCRIPT
complications of SSO are rare and include infection (2.8%), hardware failure (1.4%), bleeding (1.2%), unfavorable split, (0.9%) and non-union of segments (0.5%). [8]
RI PT
Conclusion:
This case report illustrates how a sagittal split osteotomy can be a safe and effective
alternative to conventional intra-oral and extra-oral approaches for extraction of deeply
SC
impacted 3rd molars and surrounding pathology where there is concern for damage to the
AC C
EP
TE D
M AN U
inferior alveolar nerve.
ACCEPTED MANUSCRIPT
References: 1.
Miloro, M., et al., Peterson's principles of oral and maxillofacial surgery. 2nd ed. 2004, Hamilton, Ont. ; London: B C Decker. Milner, N. and A. Baker, Extraoral removal of a lower third molar tooth. Br Dent J, 2005. 199(6): p. 345-6.
3.
Abu-El Naaj, I., et al., Surgical approach to impacted mandibular third molars--operative
SC
classification. J Oral Maxillofac Surg, 2010. 68(3): p. 628-33. 4.
RI PT
2.
Mehra, P., et al., Complications of the mandibular sagittal split ramus osteotomy
59(8): p. 854-8; discussion 859. 5.
M AN U
associated with the presence or absence of third molars. J Oral Maxillofac Surg, 2001.
Jones, T.A., T. Garg, and A. Monaghan, Removal of a deeply impacted mandibular third molar through a sagittal split ramus osteotomy approach. Br J Oral Maxillofac Surg,
6.
TE D
2004. 42(4): p. 365-8.
Toffanin, A., A. Zupi, and A. Cicognini, Sagittal split osteotomy in removal of impacted third molar. J Oral Maxillofac Surg, 2003. 61(5): p. 638-40. Sencimen, M., et al., Extraction of a deeply impacted lower third molar by sagittal split
EP
7.
osteotomy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2009. 108(5): p. e36-8. Teltzrow, T., et al., Perioperative complications following sagittal split osteotomy of the
AC C
8.
mandible. J Craniomaxillofac Surg, 2005. 33(5): p. 307-13.
ACCEPTED MANUSCRIPT
Legends: Figure 1: Pre-operative orthopantomogram Figure 2: Sagittal cut of pre-operative CBCT
consistent with an inflamed dentigerous cyst Figure 4: Post-operative orthopantomogram reconstruction
RI PT
Figure 3: H&E stain, 4x magnification, showing cystic lining and inflammation
AC C
EP
TE D
M AN U
SC
Figure 5: Sagittal cut of post-operative CBCT with signs of bone fill
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S0278-2391(15)01200-8
DOI:
10.1016/j.joms.2015.08.016
Reference:
YJOMS 56951
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 3 August 2015 Accepted Date: 17 August 2015
Please cite this article as: Kontaxis KL, Steinbacher DM, Access to the mandibular angle using a sagittal split to address pathologic displacement of a mandibular third molar, Journal of Oral and Maxillofacial Surgery (2015), doi: 10.1016/j.joms.2015.08.016. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Title: Access to the mandibular angle using a sagittal split to address pathologic displacement of a
Katrina L. Kontaxis, DMD Resident - Oral and Maxillofacial Surgery
M AN U
Yale New Haven Hospital
SC
Authors:
RI PT
mandibular third molar
Derek M. Steinbacher, DMD, MD, FACS, FAAP
Chief - Department of Dentistry and Oral and Maxillofacial Surgery Associate Professor of Plastic Surgery
EP
Corresponding author:
TE D
Yale New Haven Hospital
Katrina L. Kontaxis, DMD
AC C
Yale New Haven Hospital Oral and Maxillofacial Surgery 330 Orchard Suite 202
New Haven, CT 06511 Tel: (203) 789-3156
Fax: (203) 789-3954 [email protected]
ACCEPTED MANUSCRIPT
Abstract: Access to the mandibular angle for removal of pathology poses a unique challenge to surgeons. Intra-oral approaches result in significant bone removal and potential damage
cutaneous scar and the potential for facial nerve damage.
RI PT
to the inferior alveolar nerve (IAN). Extra-oral approaches are associated with a
This report describes a 53 year old man with a deeply impacted third molar associated
SC
with a cystic lesion that was treated by enucleation via intra-oral sagittal split osteotomy. This approach allowed for complete access and visualization of the cyst and displaced 3rd
M AN U
molar, while making it possible to protect the IAN with minimal surgical morbidity.
Introduction:
Proximity to important structures such as the inferior alveolar nerve (IAN) has been
TE D
described as a relative contraindication to third molar removal. [1] In the presence of pathology, however, removal of deeply impacted teeth is necessary. Extra-oral approaches have been described as an alternative technique for third molar removal. [2,
EP
3] This technique creates an external scar and may result in facial nerve injury. Additionally, significant osseous structure must be removed and complete visibility,
AC C
while protecting the inferior alveolar nerve, may be limited. Intra-oral approaches can also carry significant morbidity and visibility is often decreased, especially when a lesion has displaced a tooth to the inferior border of the mandible. Removal of the tooth and associated pathology via this approach may result in a mandible fracture or permanent IAN injury. Third molars have been successfully extracted as part of bilateral sagittal splits for orthognathic surgery. [4] A sagittal split osteotomy allows the surgeon to
ACCEPTED MANUSCRIPT
directly visualize and protect the inferior alveolar nerve as well as complete access to the displaced tooth and surrounding lesion.
impacted 3rd molar with associated pathology.
Case Report:
RI PT
We present a case where a sagittal split osteotomy (SSO) was used to approach a deeply
SC
A 53 year old male presented with an expanding mass in his left mandible. He
complained of a pressure sensation and tinnitus but denied any pain or dysesthesia.
M AN U
He had no significant medical history. On physical exam, he had no swelling and cranial nerve V3 was intact bilaterally. Intra-orally, his occlusion was stable and he had no swelling or drainage.
His panoramic radiograph showed a deeply impacted lower left third molar with roots at
TE D
the level of the inferior border. A pericoronal radiolucency was also noted. (Figure 1) A cone-beam computed tomography (CBCT) was obtained and confirmed the presence of a pericoronal radiolucency and close proximity to the inferior alveolar nerve as well as
EP
bony expansion. (Figure 2).
An intra-oral biopsy was performed and was consistent with an inflamed dentigerous
AC C
cyst. (Figure 3) He was referred to our institution for further management. Due to the extent of the lesion and amount of displacement of the tooth, the decision was made to perform a sagittal split osteotomy to gain access for removal. He was brought to the operating room and nasally intubated. Local anesthesia was administered (10 mL lidocaine1% with 1:100 000 epinephrine, 4 mL bupivacaine 0.25% with 1: 200 000 epinephrine) and a dart incision was made. A sub-periosteal dissection
ACCEPTED MANUSCRIPT
was carried out on the buccal and lingual and the mandibular lingula was identified. A corticotomy was performed from the medial surface of the ramus down the external oblique ridge and the lateral surface of the mandible anterior to the antegonial notch. A
RI PT
sequence of osteotomes and a three prong spreader were used to propagate the split. The inferior alveolar nerve was identified and protected. The tooth was then visualized,
sectioned, and carefully separated from the nerve. The lesion was curetted from the nerve
SC
and submitted to pathology in its entirety. The nerve was confirmed to be intact. Fibrin glue and demineralized bone matrix were placed in the defect. Four intermaxillary
M AN U
fixation (IMF) screws were then applied and the patient was held in occlusion with wire fixation. A 6mm titanium plate was placed on the lateral border of the mandible and secured with 4 monocortical screws. The wires and IMF screws were then removed and the stability of the patient’s occlusion was confirmed. The surgical site was irrigated and
TE D
closed in a layered fashion with resorbable sutures.
The patient was discharged on the same day and completed a course of antibiotics and antiseptic mouth rinse post-operatively. He was instructed to maintain a soft, blenderized
EP
diet for 4 weeks.
Two weeks post-operatively, his surgical site was healing well and he was found to have
AC C
some left sided V3 hypoesthesia. Three months post-operatively, he had no signs of infection and V3 showed normal sensation. A post-operative CBCT showed the sagittal split osteotomy well repositioned and early signs of bone fill. (Figures 4, 5) The final pathology reading confirmed the diagnosis of an inflamed dentigerous cyst.
Discussion:
ACCEPTED MANUSCRIPT
In the present case, the presence of a severely displaced third molar was strongly suggestive of a pathologic process. Surgical treatment was indicated to address the mandibular lesion associated with the impacted tooth. When third molars are deeply
RI PT
impacted, intra-oral and extra-oral approaches may be considered. [3] Extra-oral
approaches allow for good surgical access, but carry a risk of facial nerve injury and may result in cosmetic defects from skin scarring. Conventional intra-oral approaches require
SC
extensive bone removal and could potentially lead to a mandible fracture. They also
provide poor visualization in cases of deep impactions, placing the IAN at a high risk of
M AN U
injury.
The SSO technique for removal of third molars has been described in the past. [5-7] This technique allows for direct visualization of the IAN with access to the tooth and surrounding pathology in a controlled environment. Post-operative morbidity is minimal
TE D
when compared to more conventional intra-oral or extra-oral approaches. Patients may experience post-operative hypoesthesia as in conventional SSO procedures. However, since the SSO approach offers control of the field and the nerve is protected, nerve
EP
dysfunction usually improves within the year following surgery. Some previously reported cases described techniques where a period of IMF was used after surgery. [5, 7]
AC C
The use of post-operative IMF was not necessary in this case. The patient’s occlusion was stable at the end of the procedure and he maintained a soft diet for 4 weeks. In cases where post-operative IMF is deemed necessary by the surgeon, it may be considered a disadvantage. However, the morbidity of 2 weeks of IMF should be weighed against the risks of scar, facial nerve damage, and inferior alveolar nerve damage. Other
ACCEPTED MANUSCRIPT
complications of SSO are rare and include infection (2.8%), hardware failure (1.4%), bleeding (1.2%), unfavorable split, (0.9%) and non-union of segments (0.5%). [8]
RI PT
Conclusion:
This case report illustrates how a sagittal split osteotomy can be a safe and effective
alternative to conventional intra-oral and extra-oral approaches for extraction of deeply
SC
impacted 3rd molars and surrounding pathology where there is concern for damage to the
AC C
EP
TE D
M AN U
inferior alveolar nerve.
ACCEPTED MANUSCRIPT
References: 1.
Miloro, M., et al., Peterson's principles of oral and maxillofacial surgery. 2nd ed. 2004, Hamilton, Ont. ; London: B C Decker. Milner, N. and A. Baker, Extraoral removal of a lower third molar tooth. Br Dent J, 2005. 199(6): p. 345-6.
3.
Abu-El Naaj, I., et al., Surgical approach to impacted mandibular third molars--operative
SC
classification. J Oral Maxillofac Surg, 2010. 68(3): p. 628-33. 4.
RI PT
2.
Mehra, P., et al., Complications of the mandibular sagittal split ramus osteotomy
59(8): p. 854-8; discussion 859. 5.
M AN U
associated with the presence or absence of third molars. J Oral Maxillofac Surg, 2001.
Jones, T.A., T. Garg, and A. Monaghan, Removal of a deeply impacted mandibular third molar through a sagittal split ramus osteotomy approach. Br J Oral Maxillofac Surg,
6.
TE D
2004. 42(4): p. 365-8.
Toffanin, A., A. Zupi, and A. Cicognini, Sagittal split osteotomy in removal of impacted third molar. J Oral Maxillofac Surg, 2003. 61(5): p. 638-40. Sencimen, M., et al., Extraction of a deeply impacted lower third molar by sagittal split
EP
7.
osteotomy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2009. 108(5): p. e36-8. Teltzrow, T., et al., Perioperative complications following sagittal split osteotomy of the
AC C
8.
mandible. J Craniomaxillofac Surg, 2005. 33(5): p. 307-13.
ACCEPTED MANUSCRIPT
Legends: Figure 1: Pre-operative orthopantomogram Figure 2: Sagittal cut of pre-operative CBCT
consistent with an inflamed dentigerous cyst Figure 4: Post-operative orthopantomogram reconstruction
RI PT
Figure 3: H&E stain, 4x magnification, showing cystic lining and inflammation
AC C
EP
TE D
M AN U
SC
Figure 5: Sagittal cut of post-operative CBCT with signs of bone fill
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
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AC C
EP
TE D
M AN U
SC
RI PT
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AC C
EP
TE D
M AN U
SC
RI PT
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AC C
EP
TE D
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SC
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