CLINICIAN'S CORNER

Submandibular-space abscess from loss of a bonded molar tube during orthognathic surgery
~ es Curioso,b Sormani Bento Fernandes de Queiroz,a Pedro Augusto Bulho Francisco Samuel Rodrigues Carvalho,b and Valthierre Nunes de Limab Fortaleza, Cear a, Brazil The use of bonded orthodontic molar tubes is becoming more prevalent in orthodontics because they have some advantages over conventional bonding. However, a bonded apparatus can become detached, leading to complications. This article presents the case of a submandibular-space abscess associated with a molar tube that detached during orthognathic surgery and became embedded in the soft tissues. The site became infected, and antibiotics were prescribed. Eventually, the molar tube migrated and could be removed under local anesthesia. (Am J Orthod Dentofacial Orthop 2013;143:735-7)

onded orthodontic molar tubes are often used because they have some advantages over conventional bonding, such as eliminating the need for orthodontic separation and subsequent cementation of bands, and better periodontal healing. Although these advantages indicate their use in patients requiring conventional orthodontics, bonded molar tubes should not be placed on terminal molars in patients undergoing orthognathic surgery because of the risk of detachment during surgery and the ensuing complications, including contamination and airway obstruction.1,2 This report presents a case of submandibular-space abscess after orthognathic surgery caused by a bonded molar tube lost during the surgery.
CASE REPORT

The patient, a 21-year-old man, was referred for surgical treatment of a skeletal Class III malocclusion with maxillary deciency and mandibular prognathism. After orthodontic preparation, a bimaxillary surgical procedure was planned and performed. The procedure was completed without incident, and the patient was
a Oral and maxillofacial surgeon; professor, Postgraduate Course in Orthodontics,  Fortaleza, Instituto Cearense de Especialidades Odontologicas (ICEO)-UNINGA, Cear a, Brazil. b Private practice, Fortaleza, Cear a, Brazil. The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article. Reprint requests to: Sormani Bento Fernandes de Queiroz, Rua Joaquim Lima, 1001 Apto 803, Papicu, 60175-005, Forteleza, Cear a, Brazil; e-mail, dr.sormaniqueiroz@hotmail.com. Submitted, December 2010; revised and accepted, March 2012. 0889-5406/$36.00 Copyright 2013 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2012.03.036

discharged from the hospital 2 days later. After 1 week, when the patient returned for a checkup, lateral and panoramic x-rays were taken. They showed a metallic artifact at the level of the inferior border of the mandible; it was compatible with an orthodontic bracket inside the soft tissues (Fig 1). Intraoral inspection conrmed the absence of the bonded tube on the maxillary second molar. There were no signs or symptoms of infection; we informed the patient, but because of intense postoperative swelling and limited mouth opening, no attempt was made to retrieve the appliance. After 2 months without complications, the patient reported that a painful yellowish tumor had formed below the mandible. Because he lived in another city, we instructed him to seek an evaluation from a local oral and maxillofacial treatment provider as soon as possible. The next day, he phoned to let us know that he had been diagnosed as having a submandibular-space infection; intravenous antibiotics were prescribed, and the site was drained. Ten days later, he returned to our clinic in Fortaleza, Cear a, Brazil, for examination. Mild swelling was observed in the mandibular region, with a small amount of secretion draining from the surgical site (Fig 2). Occlusion was normal, and no mobility of bone fragments was noted. A panoramic x-ray showed that the previously noted metallic artifact had migrated downward to a position compatible with the extraoral swelling. Under local anesthesia, an incision was made at the previous drainage site; after divulsion with hemostatic forceps, the orthodontic molar tube was identied in the subcutaneous tissue and removed with the forceps (Fig 3). After this procedure, the patient progressed well, with no further signs or symptoms of infection.
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Fig 3. Removal of the tube with the hemostatic forceps.

Fig 1. Lateral cephalometric and panoramic x-ray taken 1 week after the surgery, showing a metallic object at the level of inferior border of the mandible, compatible with a bonded molar tube.

Fig 2. Extraoral view of the patient 10 days after the surgical drainage, showing mild swelling of the submandibular region.

occlusion will be as planned when the plates and screws for bone xation are placed.1 With the improvements in bonding tools and techniques, the use of bonded molar tubes is becoming increasingly prevalent in orthodontic practices, but their use in orthognathic surgery patients should be avoided because of the risk of detachment of the tube with possible complications such as contamination of the surgical wound and airway obstruction.1,4 This case is a good example of a situation when an appliance bonded to a molar was lost and led to major complications. The surgical team did not realize that the tube had been lost, but even if they had, it would have been difcult or even impossible to identify the small piece of metal in a bloody surgical eld. Although this problem was resolved in a relatively propitious manner, infections in fascial spaces, such as the submandibular space, can have life-threatening complications, since the infection can take a downward path through the neck spaces and might even reach the mediastinum.4 In our patient, rapid diagnosis, intravenous antibiotics, and surgical drainage contributed to the good outcome. With regard to removal of the tube that was in intimate contact with the soft tissues, it was initially decided to perform clinical radiographic monitoring because of the patient's general condition, with swelling and limitation of mouth opening. Any attempt to remove the foreign body at that time would only have led to more pain and discomfort for the patient, with the possibility of failure to remove the tube from the soft tissues.
CONCLUSIONS

DISCUSSION

There is a relatively low incidence of postoperative complications after orthognathic surgery, including infection, mobility of fragments, sensory alterations, and malocclusion.3 Banding of terminal molars is important to provide good dental anchorage for transoperative maxillomandibular xation to ensure that the

Although the use of orthodontic bonded tubes in the molar region has become routine in orthodontic practice, their use in patients undergoing orthognathic surgery is contraindicated because of the risk of detachment during the surgical procedure, possibly leading to

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major complications, such as fascial space infections, as in the case presented here.
REFERENCES 1. Wenger NA, Atack NE, Mitchell CN, Ireland AJ. Peri-operative second molar tube failure during orthognathic surgery: two case reports. J Orthod 2007;34:75-9.

2. Laureano Filho JR, Godoy F, O'Ryan F. Orthodontic bracket lost in the airway during orthognathic surgery. Am J Orthod Dentofacial Orthop 2008;134:288-90. 3. Panula K, Finne K, Oikarinen K. Incidence of complications and problems related to orthognathic surgery: a review of 655 patients. J Oral Maxillofac Surg 2001;59:1128-36. 4. Pappa H, Jones DC. Mediastinitis from odontogenic infection. A case report. Br Dent J 2005;198:547-8.

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