Patients requiring orthognathic surgery for correction of their maxillo-mandibular disharmony will also have to undergo orthodontic treatment during both pre- and postsurgical treatment phases. Tooth alignment and preparation of the future predicted occlusion are required, so that the osteotomized jaws can be easily repositioned in the surgery in order to achieve stable results. This is followed by a period of fine-tuning and maintenance of the occlusion afterwards.
Among orthodontists, the use of bonded orthodontic molar tubes has gained popularity compared to the conventional molar banding because the former are easier to place, without the need for orthodontic separator, more friendly to the periodontium, and more comfortable to the patient [
Banks and Mcfarlane [
A 25-year-old gentleman presented to our clinic with a complaint of recurrent pain and swelling on his right cheek of three-month duration. He visited a general practitioner each time, and the condition was resolved with analgesic and antibiotics. However, his symptoms got worse and he attended our Oral Surgery Clinic for consultation.
The patient is a fit and healthy young man with no relevant medical history and no known history of allergy. Past surgical history revealed that he had underwent bimaxillary orthognathic surgery one and half year earlier in a local hospital. Although the postoperative period was uneventful, the surgical team informed him that there was a dislodged orthodontic appliance in his right cheek that must have occurred during the operation. The team explained to the patient that this accident was realized later on the next day after the surgery when the molar tube from the right maxillary second molar was found missing, and its presence was confirmed high up in the right maxillary-zygomatic buttress area shown in the postoperative X-ray image taken on the next day following the surgery. A series of further postoperative radiographs confirmed its location, lying outside the right maxillary antrum. Due to the pronounced postoperative facial oedema at that time, no attempt was made to remove the appliance. The absence of sign and symptoms during further follow-up sessions confirmed the decision to leave it in-situ with continuous clinical observation.
On examination, there was no extraoral swelling noted. The mandible and maxilla seemed firm indicating good healing following previous mandibular saggital split and maxillary Le Fort I osteotomy sites and a stable class I dental occlusion. Intraorally, there was a sinus with slight pus discharge on the upper right buccal sulcus region adjacent to the upper right first premolar. All teeth in that quadrant were firm and vital. Tenderness was elicited upon palpation on the upper right vestibular region. We suspected the sinus track may originate from the dislodged appliance embedded in the cheek soft tissue. A periapical view was then taken with gutta-percha inserted into the sinus for foreign body localization purpose. The radiograph revealed the gutta-percha pointed towards the site of titanium plate and screws placed used for rigid fixation, and with the molar orthodontic tube appliance in its vicinity (Figure
Periapical radiograph with gutta-percha (GP) in situ which had been inserted through the sinus. The GP pointing towards the area of plate and screws with the dislodged molar tube in its vicinity.
Cone Beam CT images showing the dislodged molar tube lying outside the right maxillary antrum, as indicated by the arrow in axial view (a), while its position in relation to the rigid plate and screws on the zygomatic buttress can be seen clearly in 3-D image (b).
The presence of the molar orthodontic tube foreign body reaction was suspected as the most probable cause of the recurrent right cheek pain and swelling associated with an intraoral discharging sinus. Exploration of the site was performed through the sulcular incision under general anesthesia. The dislodged molar tube was identified lying on the zygomatic bone just beneath the raised flap. It was removed by dividing some surrounding fibrous tissue strands. Just below it, one titanium straight bone plate with four screws used for fixing the previous Le Fort I osteotomy site was inspected and found to be rigidly embedded in normal bone. However, a decision was made to remove them based on the fact that they are present in an infected area. (Figure
Titanium plate and screws and the stainless steel molar tube removed in the surgery.
The incidence of dislodged orthodontic appliance during orthognathic surgery is rare but been recognized as one of its surgical complications. Failed orthodonthic appliances frequently occur in double jaw surgery, as in our patient who had Le Fort I and bilateral sagittal split osteotomy. It has become an accepted practice to place the wire using the cleats and hooks of molar tube or band both intraoperative and postoperatively. Intraoral manipulations during placing and removing intermaxillary fixation wire with the interim splint contribute to the appliance failure during surgery [
Surgeons may have different opinion with regard to the management of a dislodged orthodontic appliance. When the event occurred and notified intraoperatively, a thorough search for the foreign body till it is found is the norm, due to the fact that the dislodged orthodontic appliance is “nonsterile” and the risk of metallic ion leach deep in the tissue. However, when the foreign body is identified postsurgically, commonly during the subsequent postoperative days following routine postoperative check X-rays, there is less urge by the surgical team to search for it due to the presence of postoperative oedema, the risk of further compromising patient’s airway resulting from soft tissue dissections in the exploration site, and the already drop in postoperative hemoglobin concentration, thus increasing further morbidity. The surgeon in this case had opted to leave the molar band in situ with continuous observation to minimize those morbidities since experience has taught that searching for a 4 mm size foreign body in inflamed, oedematous, and blood oozing soft tissue may take several hours!
Lammers [
Despite that, the actual location of the foreign body in the face or neck also determine whether to advocate an urgent exploration or a wait and see policy. Metallic foreign bodies that have impacted into the maxillary sinus or in close proximity to major vessels or nerves or lying under the pharyngeal wall mucosa must be explored and removed in view of grave consequences. Such complications may end up with chronic maxillary sinusitis, risk of erosion and rupture of major arteries, nerve pain, and neck abscess. In the present case, the location of the molar tube high up at the zygomatic buttress, external to the maxillary sinus, seems to be less likely to cause life-threatening consequences, and it may preferably be left in situ. Reports by Teltzrow et al. and Wenger et al. supported this opinion. They found that displaced orthodontic brackets which were left in situ for longer periods had been without adverse sequelae [
On the other hand, de Queiroz et al. reported acute symptoms following loss of a bonded molar tube during orthognathic surgery [
Most orthodontic metal appliances such as brackets and tubes are generally made of stainless steel. They contain a mixture of iron, chromium, nickel, and a small amount of molybdenum together with small traces of other metals [
Preexploration localization X-ray of the molar tube demonstrated that it is positioned close to the titanium bone plates and screws which were used for rigid fixation of the Le Fort I osteotomy site. This interesting situation recalled the manufacturer’s advice on cautions against mixed metals in vivo [
Intraoperative surgical manipulations carry the risk of dislodging fixed orthodontic appliances during orthognathic surgery, in particular the bonded molar tube. An immediate search for the loss metal foreign body is recommended. However, when the loss is discovered postoperatively, it may be retained in situ in the wound but the length of symptom-free period can never be ascertained. It is prudent for the surgeon to perform a thorough preoperative intraoral examination on the integrity of orthodontic appliances and its count in the patient’s mouth at the beginning and at the end of the surgical operation. This mandatory practice should be part of the orthognathic surgery protocol (Table
Safety measures to reduce risk of appliance failure and complications.
1 | Thorough examination of orthodontic appliance in patient’s mouth prior to surgery and before closure of the surgical wound (appliance count and its integrity) |
2 | Use of molar band rather than molar tube for orthodontic treatment of patients undergoing orthognathic surgery |
3 | Being vigilant and cautious handling of intermaxillary fixation intraoperatively |
4 | Good communication with orthodontist to help prepare the patient for the scheduled surgery |
In this case report, the patient is sufficiently anonymized according to ICMJE guidelines.
The authors declare that there is no conflict of interest regarding the publication of this article.