A Rare Complication of Maxillary Third Molar Extraction

ABSTRACT

The removal of tuberosity post extraction of the maxillary third molar is a very rare complication and there has not been ample discussion in the literature. Forceful extraction of a maxillary third molar can lead to soft and hard tissue loss. Various techniques have been used for the management of such defects such as local flaps, free soft tissue flaps, free bone flaps, and even tissue engineering. We present a case report of a large post-traumatic defect of maxillary tuberosity caused by forceful extraction of the maxillary third molar, which was managed conservatively by secondary healing, and the patient is on regular follow-up.

INTRODUCTION

Post-traumatic deformities following extractions particularly palate persist even after treatment. The maxilla is very important in maintaining the function of the oral cavity along with and aesthetics of the face[1] It is responsible for the separation of oral and orbital cavities, further providing support to maxillary contents. These defects affect mastication, deglutition, and phonetics. These deformities even after healing are among the most daunting challenges faced by oral and maxillofacial surgeons.[2] This paper presents a case of a post-traumatic defect of maxillary tuberosity that was managed by healing with secondary intention.

CASE REPORT

A 60-year-old male patient was referred to our department with a chief complaint of pain in the upper left back region of the jaw for 15 days. History dates back to 15 days when the patient got his upper left posterior tooth extracted, following which the patient started experiencing pain that was sharp, continuous, and radiating in nature. Pain aggravated on eating and relieved on taking medication. The patient had associated sensitivity to hot and cold. The patient also gave a history of loss of weight, which was approximately 12 kgs in the last 1.5 months. The patient was diabetic and had been on medication for the same for the past 2 years. The patient gave a history of angina pectoris for 5 years and had been on medication for the same. On extra-oral examination, there seemed to be a diffuse swelling present with respect to the middle one-third of the face, which was soft in consistency and tender on palpation extending anteroposteriorly from the corner of the mouth to 2 cm in front of the tragus and superoinferiorly from the line joining the ala of the nose to approximately the line joining the corner of the mouth to the lobule of the ear. Reduced mouth opening was also evident, which was around 2 finger breadths (approximately 25 mm). An area of erythema was also evident in the left corner of the mouth.

On intra-oral examination, there appeared to be a bony defect in the left maxillary tuberosity region of around 5 × 4 cm, extending anteroposteriorly from distal of 27 to beyond maxillary tuberosity region and mesiolaterally from 2 cm lateral to the mid palatal suture to the alveolar socket of 28. The surface appeared to be ulcerated and inflamed. The edges of the bony defect were covered by a necrotic slough. The buccal mucosa in the region of 28 showed an ecchymotic spot. On palpation, the posterior aspect of the palate was soft and extremely tender. On the basis of clinical examination, a provisional diagnosis of a post-traumatic intra-oral defect was made [Figure 1]. Taking into consideration the detailed history and clinical examination, the patient was sent for a Cone-beam computed tomography (CBCT). The CBCT report revealed an extensive bony defect involving the left maxillary posterior region and posterior wall of the maxillary sinus. Borders were ill-defined and the internal structure was radiolucent [Figure 2]. Antero-posteriorly, the lesion extended from the distal of 27 to the maxillary tuberosity region. There was a breach in the buccal and palatal cortical plates. The left maxillary sinus showed partial opacification.

Figure 1.

Patient lesion on first visit

Figure 2.

3D reconstructed CBCT image showing defect in maxillary tuberosity region

On the patient’s first visit, part preparation was done under strict aseptic conditions. Local anesthesia was achieved with 2% lidocaine with 1:80000 adrenaline by giving posterior superior alveolar and greater palatine nerve block. After achieving adequate anesthesia, the necrotic slough surrounding the defect was carefully removed followed by thorough intra-oral irrigation with povidone iodine and normal saline. Due to the lack of availability of soft tissue, a decision was made to heal the defect by secondary intention [Figure 3]. The patient was made aware of the complication and was reassured of the treatment modality. The patient was on follow-up every day and intra-oral irrigation with povidone–iodine and normal saline was performed daily followed by bactigrass (chlorhexidine gauze dressing) for the first week [Figure 4]. Thereafter, the frequency of visits was reduced to once in 4 days for the next 1 month [Figure 5]. Complete healing was observed within 1.5 months [Figure 6]. The patient was motivated to continue warm saline rinses throughout this healing period. Weight loss of the patient was addressed by motivating the patient to continue a good proteinaceous diet. Mouth-opening exercises were advised and were also promoted at every visit with the help of Hister’s mouth prop.

Figure 3.

After irrigation and removal of necrotic slough

Figure 4.

7^th Post-Operative day

Figure 5.

1 month Post-Operative day

Figure 6.

1.5 months Post-Operative day

DISCUSSION

Various oral and maxillofacial surgical procedures such as resections, reconstructive surgeries, benign and malignant pathologies, and oronasal and oro-antral fistulae warrant a need for the reconstruction of palatal defects, which is very complex and challenging. Primary closure of the defect is only possible if the tissue is elastic enough and there is minimal mucosal atrophy, which is not possible for palatal defects.[1,3]

Surgical and prosthetic techniques can be used for the closure of defects in which the primary closure is not possible, which includes local flaps such as buccal advancement, palatal flaps, buccal fat pad, and tongue flaps or tubed pedicled flaps from arms, neck, and abdomen, free non-vascularized grafts such conchal or dermis grafts.[4] Choosing an appropriate pedicled flap for the reconstruction of intra-oral defects is dependent upon the location of the defect and the size or extent of it. Pedicled flaps are only to be used taking into consideration the amount of flap tissue available and most importantly the point of the arc of rotation.[3,4] For anterior defects that include the lip, the anterior floor of mouth, or the anterior vestibulum, a facial artery musculomucosal flap (FAMM) or a platysma flap can be used. For defects of pre maxillae options can be FAMM and temporalis muscle flap (TMF). For posterior hard palate defects, buccal fat pad (BFP), FAMM, or TMF can be used for reconstruction. These flaps make dental rehabilitation difficult as the epithelization causes contraction and obliteration of the sulcus.[5]

The free soft tissue flaps described are radial forearm flaps, rectus abdominis, and anterolateral thigh flaps with the main objective of sealing the palatal defects. The advantage is obviously their long pedicle making the anastomosis of vessels easy but again, these tissue flaps do not have the ability to support the orbit or their ability to prevent the hollowing of the cheek. These flaps also make placing dental implants difficult.[3,5] Another possible solution is the use of tissue engineering, which can replace the use of these complex reconstruction methods. These engineered constructs need adequate vascularization, which can hamper this technique. Clinically usable methods of engineering these constructs are also lacking.[5] The reconstructive ladder is a system followed by surgeons to determine the most appropriate level of reconstruction and climb the ladder from simple to increasingly complex methods of reconstruction. The reconstructive ladder has been modified recently to start with the closure by secondary intention, followed by direct closure, local flaps, and distant flaps. The addition of tissue expanders has been made recently to include in the spectrum. However, healing by secondary intention has consistently proven to be one of the most successful methods of wound care for the management of large defects.[6] Healing by secondary intention is similar to the primary union in terms of events. The difference is that in secondary intention, there is a larger defect in which the edges have to be bridged. The healing takes place from the base upward as well as from the margins inward. The sequence of events includes cells from both margins proliferating and migrating into the wound until they meet in the middle and re-epithelialize the gap completely. Until the granulation tissue has filled the wound space from the base, the proliferating cells from the edges do not cover the surface fully.

In this case, after extraction of the maxillary third molar, the removed tuberosity segment was not retained by the practitioner and also no attempt was made to preserve the soft tissue, leading to a huge post-traumatic defect. Taking into consideration the reconstructive ladder, the co-morbidities, and the disadvantages of complex flaps, healing by secondary intention can be considered the most feasible treatment in such a case. The patient is on follow-up with no associated complications.

CONCLUSION

Tuberosity defects after maxillary third molar extractions are rarely observed. Dental professionals must inform the patients about the possible complications regarding third molar extraction.[7] Management of these post-traumatic defects can range from primary closure to a vascularized flap. Healing by secondary intention for small palatal defects in the posterior maxillary region is one of the most successful treatment options. Furthermore, careful extraction of the maxillary third molar must be carried out taking into consideration the preoperative status of the tooth and proper treatment planning to prevent the formation of these defects.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.