Accidental displacement of a high-speed handpiece bur during

mandibular third molar surgery: a case report

Serhat Yalcin, DDS, PhD, Irem Aktas, DDS, Yusuf Emes, DDS, PhD, and
Belir Atalay, DDS, PhD, Istanbul, Turkey
ISTANBUL UNIVERSITY

Removal of third molars is one of the most common surgical procedures performed in oral and maxillofacial
surgery. This procedure may result in a number of major and minor complications. Accidental displacement of
impacted third molars is a complication that occasionally occurs during these operations, but accidental displacement
of a high-speed handpiece bur has never been reported in literature before. The aim of this article is to present a rare
and previously unreported case of a foreign body in the submandibular space and to review the possible
complications seen after third molar surgery. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:e29-e31)

Removal of third molars is one of the most common

surgical procedures performed in oral and maxillofacial
surgery.1 The surgical removal of third molar teeth may
result in a number of major and minor complications.
Major complications can be defined as complications
that need further treatment and may result in irreversible consequences. There have been many reports of
these complications, such as abscess formation, excessive bleeding, mandible fracture, and nerve injury.2
Minor complications can be defined as complications
that can recover without any further treatment, including pain, swelling, and bleeding.2 They are also termed
sequelae, because they occur often. The factors that
usually contribute to such problems are numerous and
include the patient, those which are tooth related, and
the surgeons operative experience.3
Accidental displacement of impacted third molars,
either a root fragment, the crown, or the entire tooth, is
a complication that occasionally occurs during these
operations.4-7 However, accidental displacement of a
high-speed hand piece bur has never been reported in
literature to our knowledge.
The purpose of the present article is to present a rare
and previously unreported case of a foreign body in the
submandibular space and to review the possible complications seen after third molar surgery.
CASE REPORT
A 35-year-old woman was referred to an outpatient clinic
for the removal of her right mandibular third molar. Three
Received from the Faculty of Dentistry, Department of Oral and
Maxillofacial Surgery, Istanbul University.
Received for publication Apr 6, 2007; returned for revision Aug 21,
2007; accepted for publication Sep 24, 2007.
1079-2104/$ - see front matter
2008 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2007.09.017

weeks after the operation she was referred to the Department

of Oral and Maxillofacial Surgery, Faculty of Dentistry,
Istanbul University, with the complaints of severe trismus,
swelling, and pain in the right submandibular space and
panoramic radiography of the region before the operation
(Fig. 1). In her dental history, she had her right mandibular
third molar extracted 3 weeks before with an operation lasting
more than 2 h. She had started antibiotics (oral amoxicillin,
1 g, 21) and analgesics after the operation but still had
severe trismus and pain.
After clinical examination, a panoramic radiograph was
taken. A part of the third molar and a foreign body were
observed in the socket (Fig. 2). To detect the exact localization of the foreign body, a computerized tomogram was taken
from the right mandibular third molar region. In the tomographic section, the foreign body was detected in the submandibular space (Fig. 3).
After informing the patient about her radiographic examinations, a signed consent form was taken from the patient,
and under local anesthesia (2% ultracaine with 1:100,000
epinephrine) the original wound was extended lingually to the
distal edge of the second molar, reflecting the mucoperiostal
flap carefully so as not to damage the lingual nerve. The
remaining part of the tooth was extracted (Fig. 4). Then the
foreign body was taken out from the submandibular space by
constant upward external pressure in the submandibular region to push the foreign body toward the oral cavity. It was a
20-mm long diamond bur (Figs. 4 and 5).
After the operation, the patient was prescribed antibiotics
and analgesics. After a week, all of the patients complaints
had dissipated.

DISCUSSION
Impacted mandibular third molars may be pushed
through a perforation in the lingual surface of the
mandible into the region of the submandibular fossa.
The thin lingual plate can be fractured during the attempt to remove the tooth.4 There have been many
cases reporting displaced lower third mloars (tooth,
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Yalcin et al.

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March 2008

Fig. 1. Preoperative panoramic radiograph of the patient.

Fig. 3. Postoperative computerized tomography showing a

foreign body.

Fig. 2. Postoperative panoramic radiograph showing the remaining tooth and the foreign body.

crown, or roots) in the literature,7 but we could find no

report about a bur displaced in submandibular or sublingual spaces. Huang et al.7 reported a review of 19
displaced lower third molars (13 complete teeth, 1
crown, 5 roots) and compared the treatment protocols
of each case, but they did not mention a case with a bur
displaced in anatomic spaces. The important point of
the present case is that it is a diamond bur, not the third
molar tooth or root fragments being pushed lingually.
It is unclear why the surgeon decided to separate the
crown from the roots. However, he used a high-speed
handpiece with a diamond bur instead of a surgical bur.
One of the most important points in surgical procedures
is the use of proper surgical techniques and instruments. In our oral surgery unit, we only use straight
low-speed handpieces while we remove the bone
around the third molar teeth. High-speed dental handpieces can cause great heat in the bone, resulting in
serious complications, such as osteomyelitis. High-

Fig. 4. Remaining tooth and the foreign body taken out of the
submandibular space.

speed handpieces can also cause emphysema within the

tissues. In the present case, the surgeon the patient had
first consulted had probably tried to cut the tooth with
a high-speed dental handpiece and, perhaps because he
had not placed the bur properly, it got loosened from
the hand piece and slided lingually.
Although removal of third molars is a common operation, there are several complications that can occur
after the surgery, such as immediate or late mandibular
fractures, infections, and nerve injuries.8-11 If the complaints of the patient have not disappeared a week after
the operation, a panoramic radiograph is recommended.

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Volume 105, Number 3

Yalcin et al. e31

instructions may help to reduce the rate of complications.2 The important point here is to use the current
surgical techniques and surgical instruments and to see
the patient 1 week after the operation and start treatment immediately if the complaints have not disappeared in order to prevent an increase in the severity of
the complications.
REFERENCES

Fig. 5. Postoperative panoramic radiograph after removal of

the remaining tooth and foreign body.

In the present case, when the panoramic radiograph was

taken, the foreign body and a part of the tooth were
detected in the socket. After removal of the root fragment and the bur, the patients complaints ended.
But not all complications after the removal of impacted third molars are solved so easily. If special care
is not given to preserve the lingual nevre during the
operation, long-term paresthesia can be seen.10 Immediate or late mandibular fractures, pterygomandibular
and submandibular abscess, and osteomyelitis are also
listed in the complications of mandibular third molar
surgery.1,11
Another common complication of lower third molar
surgery is the displacement of the impacted teeth or
root fragments to anatomic spaces.7 The importance of
the present case is that the displaced object was not a
tooth. It was a diamond bur of a high-speed handpiece,
which should not be used for oral surgery. We have
thus reported a rare case and showed that serious complications can occur as a result of the use of wrong
instruments and improper surgical techniques.
It should be kept in mind that removal of impacted
third molars can result in severe complications. Careful
attention to surgical details, including proper patient
preparation, asepsis, meticulous management of hard
and soft tissue, controlled force when applying surgical
instruments, hemostasis, and adequate postoperative

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Reprint requests:
Irem Aktas
Istanbul University
Faculty of Dentistry, Department of Oral and Maxillofacial
Surgery
34093, Capa, Istanbul
Turkey
iremaktas@yahoo.com