INTRODUCTION

The extraction of the third molar is a common procedure that is performed in the oral and maxillofacial surgery units, the general rate of complications is low (4.6%), they can be trans and post-surgical, the majority inflammatory, with alveolitis being the most common¹.

This probability of complications is due to the varied pathology, anatomical region and systemic factors of the patients. Accidents and complications occur due to misdiagnosis, poor conditions, use of inappropriate instruments, application of excessive forces, lack of professional experience, lack of visualization of the operation area and can also be associated with the patient´s general condition².

The procedure for the extraction of third molars can be relatively simple, if it is carried out carefully and with the proper protocols, in most cases mild discomfort, moderate symptoms and recovery is rapid³.

The prevalence of trans and post-surgical complications after simple extractions is considered to be 9.3%⁴; in third molar surgery it has been established in 11%⁵, although there are reports of up to 17%⁶ and mandibular third molars from 8 to 11%³.

The presence of high-speed handpiece drills as a foreign body in hard or soft tissues, which should not be used for oral surgery, is a rare event. Serious complications can occur as a result of the use of incorrect instruments and inadequate surgical techniques⁷, the rupture of anesthetic needles in soft tissues is more common^8-9.

There is a probability that instruments such as drills or needles will break during the surgical procedure, it is necessary to help with an x-ray and discuss the complication with the patient10. If an unfortunate accident occurs, dentists must inform patients and take appropriate steps to resolve the problem without further injury to the patient. The retained fragments must be carefully studied before the extraction attempt¹¹.

The diagnosis of foreign bodies inside the tissues is often radiographic findings, on occasions they are associated with mild pain, edema, paresthesias or the presence of purulent discharge7. If retention of a broken instrument is suspected, a three-dimensional image will indicate the actual position and will help to avoid possible surgical complications¹².

With the authorization of a signed consent, the objective of this report is to describe an unusual case of a 2-fragment fracture drill, retained in the area of the left mandibular third molar, found as a radiographic finding.

 

Case report

A 21-year-old female mestizo old patient attended the FOUCE Surgical Center referred for the radiographic finding in the examination of a Dentist who requested a panoramic x-ray to plan the extraction of upper third and lower right molars.

The reason for the consultation was due to the extraction of a foreign body (drill), near the distal root of dental organ No. 37. As a surgical history, he reported extraction of the left lower third molar 5 years ago, a procedure that lasted approximately three and a half hours, He presented abundant intra-operation bleeding; in the post operation period he presented intense pain and edema for one week, for 3 months he maintained moderate pain, which is why he took anti-inflammatory drugs and pain relievers during that time (medication he does not remember); For a year, slight pain and discomfort were maintained when chewing, for four years, occasionally, he felt a slight numbness in the left hem and a slight swelling, especially in the morning when he got up.

In the panoramic x-ray, radiopaque shadow was observed in the distal region of the lower left second molar, which is confirmed in the periapical image, the shadow compatible with foreign body (drill) towards distal dental organ No. 37 (Figure 1).

Figure 1. A: Panoramic radiograph. B: periapical radiography; the foreign body separated into two segments is observed.

Fuente: Los autores

Upon extraoral and intraoral clinical examination of the affected region, tissues under normal patterns were observed, with slight palpation pain in the mucosa of the left retromolar region and lingual region near the floor of the mouth. Occlusal radiography (figure 3) and computed tomography of the mandible with sagittal cuts, transverse to 1mm were requested (figure 2).

Figura 2. A: Occlusal Radiography; B: tomography; C: axial section; D: cross section. Foreign body confirmation.

Fuente: Los autores

Both the inferior occlusal radiograph and the tomography showed that the direction of the foreign body was from vestibular to lingual, occupying a space of 19.23 mm, slightly vertical, from the cortical edge to near the basilar edge, near the distal root second molar. Two segments were verified in the same direction with the longest segment above the dental nerve canal and the smallest one below. The cross section showed that the upper end was separated 2.57mm from the vestibular-cortical. (figure 2). Due to the clinical and imaging characteristics, intra-osseous foreign body placed and divided into 2 fragments was diagnosed and surgery was planned to remove foreign body in its upper segment. It was decided to leave the lower segment due to being under the nervous-vascular pack, to avoid possible complications with the lower dental nerve.

 

Surgical procedure

Previous knowledge and authorization of the patient, after following the pre-surgical indications and under biosafety protocols, anesthesia was started for which 2% Lidocaine plus a vasoconstrictor 1: 80,000 was used with the mandibular trunk technique; Linear incision was made, followed by mucoperiosteal flap lifting, osteotomy with 703 burr at low speed and abundant irrigation with saline solution. After removing the burr, 000 silk and single stitches were cleaned and sutured (Figure 3).

Figura 2. A. fresa extraída como resultado del procedimiento quirúrgico. B: sutura. A. Drill removed as a result of the surgical procedure. B: suture.

Fuente: Los autores

Based on solid evidence of the use of paracetamol combined with Aines to efficiently control postoperative pain¹³, analgesic therapy was started with Keterolaco 30 mg / dl V.IM immediate and continued with Ibuprofen 400 mg combined with Paracetamol 500 mg PO. C / 12h. for 3 days, plus a regimen of Sultamicillin 375 mg PO. C / 12h. for 7 days, taking into account that antibiotics should be used only in selected cases¹⁴.

In the post-surgical control at 8 days, the clean and closed wound in the healing process was observed and the stitches were removed, clinical and tomographic controls were performed at fifteen days (figure 4), and controls after one month and 3 months, the patient reported that presurgical symptoms disappeared.

Figura 3. Control posquirúrgico; Post-surgical control

Fuente: Los autores

Discusion

Although rare, instrument breakage can occur during dental and surgical procedures. Therefore, dentists should always review the surgical tools for signs of breakage and be prepared to resolve a possible emergency¹⁵; In the case presented, it is probable that the accident has gone unnoticed by the clinician who caused it. The radiographic finding allowed guiding the diagnosis and treatment of the complication caused by the incorrect use of instruments in the surgical procedure.

Mishra et al. (2019)¹², mention that the rupture of an instrument during extraction is the result of excessive force and the improper use of the instruments. The foreign body removed was a high-speed hand piece bur, an instrument that should not be used in the extraction of third molars.

The rupture of the instruments or material can also occur due to sudden movements of the patients, it is important to determine the levels of anxiety regarding the treatment, the technique, the professional, the noise or the needles, in this case it will be necessary to find control mechanisms for anxiety or fear. Although needle rupture is more common⁹, the possibility in rotating instruments should not be ruled out in addition to the risk of tissue laceration.

The complication was located on the left side of the jaw, it has been reported that it is the most common side of complications; it is reasonable to assume that most surgeons are right-handed6. Therefore, extractions on the left side may be more difficult to visualize and perform, which may explain a higher complication rate.

One of the rare trans-surgical complications is the forgetfulness of some material or the fracture of the instruments, leaving fragments inside the oral cavity, defining it as "foreign body". Removing these remains of instruments can be easy for the surgeon if they are visible and if the elapsed time is short, but if they are found in relation to important anatomical elements such as the inferior alveolar canal or the encounter occurs after a few years, it can be difficult, taking more time to surgery and perhaps presenting other trans-surgical complications.

If an unfortunate accident occurs, dentists must inform patients and take appropriate steps to resolve the problem without further injury to the patient⁹.

To avoid such complications, the proper use of the low-speed part (micromotor) together with specific drills and other materials and instruments are what allow the surgical procedure to be carried out and successfully completed. Reyes⁸ mentions that the use of the high-speed part is safe in oral surgery if we carry out an adequate handling of the soft tissues, as long as the flap includes the periosteum and it is not torn. Instead, Tamashiro and colls.¹⁰, recommend using low speed and no turbines for the surgical removal of retentions, since there is a risk of causing emphysema.

Although the systematic use of antibiotics after surgery in the third molar area is controversial, there is evidence that supports this action to prevent infections and inflammatory complications^18-19; It was considered very important to avoid any complications after the history of the reported case.

 

Conclusions

In the case presented, image analysis has been essential to determine the diagnosis of the foreign body, and it has also allowed us to clearly establish position, direction, relationship with anatomical elements and risk of complications for the development of the treatment plan. Our report is a clear example of when it is possible to remove a foreign body and also when the decision should be made not to intervene to avoid post-operation complications. Instrument breakage can occur during dental and surgical procedures, all surgical materials and instruments must be of good quality and the condition of the instruments must be verified and deregistered when necessary to avoid ruptures, forgetting fragments and possible complications during surgery. The patient improved her quality of life and pre-surgical symptoms disappeared.

Bibliografía

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	Mayra Elizabeth Paltas Miranda; https://orcid.org/0000-0003-3441-6015
	Isadora Dourado Cardoso Alves; https://orcid.org/0000-0002-7992-6724
	Gabriela Moura Chicrala; https://orcid.org/0000-0001-6628-3048
	Paulo Sergio da Silva Santos; http://orcid.org/0000-0002-0674-3759