the majority of tooth extraction procedures are performed using a handpiece accompanied by a thin bur to remove both the tooth and the bone . several articles have reported on the risk of percutaneous injuries to the surgeon caused by the bur , and injuries to the hand are the most commonly reported123 . in many cases , when the surgeons use the elevator to dislocate the third molar , they must stand beside the patient . thus , due to the proximity of the handpiece to the surgeon 's leg , the bur can accidently penetrate the lower limb , leading to an external injury . this report presents one such case and considers the precautions needed to avoid similar accidents . a 24-year - old male patient with no systemic medical history visited the department of oral and maxillofacial surgery of wonkwang university daejeon dental hospital ( daejeon , korea ) because of discomfort in his mandibular third molar . the tooth was extracted by creating an envelope flap and exposing the tooth and the bone , and a fissure bur connected to a handpiece was used to remove the bone of patient . after performing luxation using the elevator to dislocate the tooth , the surgeon , who was in a standing position , turned his body to pick up another instrument . at that moment , because the location of handpiece in a fixed upright position at the front of the instrument tray , the fissure bur broke and penetrated the surgeon 's right femoral region . the handpiece was immediately removed , but the head of the bur was not found . once the surgeon finished extracting the patient 's tooth , the injured area was disinfected with potadine ointment ( povidone iodine 450 g / bottle . ; samil , seoul , korea ) . radiographs of the right femoral region were then obtained at various angles to determine the location of the head of the bur , which was found in the upper medial area of the right vastus lateralis muscle.(fig . 1 ) under local anesthesia , a 1-cm incision was made to verify the radiographic findings , and the bur was removed.(fig . 2 ) subsequently , the area was dressed with potadine ointment and sutured using 5 - 0 nylon sutures . to prevent tetanus and bacterial infection , intramuscular hyper - tet injection ( green cross , yongin , korea ) was administered , and antibiotics and analgesics were also administered for 3 days . daily wound dressing was also performed for 10 days , and the treatment regimen was concluded with stitch removal . approximately 1 month after the incident , no postoperative complications had been observed . occupational injuries caused by sharp instruments such as needles , burs , blades and surgical wires occur frequently among dentists . previous studies have described the danger of percutaneous injuries to the hands and fingers of both the patient and the surgeon due to the tools used during dental treatment . however , percutaneous injuries caused by burs have rarely been reported . cleveland et al.2 reported in 1995 the percentage of percutaneous injuries associated with dental tools : endodontic files 1% , utility knives 5% , burs 2% , explorers 2% , needles 1% , pliers 1% , excavators 1% , and other instruments 1% . also in 2007 , a target study conducted with dental healthcare personnel reported that the percentage of percutaneous injuries associated with needles is 46% , burs 10% , scalpels 7% , scalers 5% , elevators 5% , explorers 4% , wires 3% , and other instruments 20%4 . even though instrument breakage in surgical procedures involving the bur is common5 , carlton et al.6 noted that puncture wounds occurred frequently in patients during oral maxillofacial surgery , but the proportion of such wounds occurring in the surgeon is low . to the best of our knowledge , this article is the first to report a case in which the surgeon suffered a percutaneous injury in the femoral area due to bur breakage . complications from cutaneous penetration of burs include infections through direct contact with patient blood , including viral transmission ( e.g. , human immunodeficiency virus , hepatitis b and c viruses ) and tetanus . a puncture wound from contaminated instruments carries the same health risks as a human bite7 . in this case , the injury was not serious , as it did not result in a severe soft tissue laceration , and the bur did not damage the bone or move to other parts of the body . we should have performed serological tests immediately , as blood - borne pathogens can lead to cross - infection . however , the patient did n't have a relevant medical history , so we thought that serological tests were not necessary . if a similar incident resembling our report occurs in the future , blood tests should be considered . the main treatment method in cases involving penetration of foreign substances is to completely remove the debris and to provide prophylaxis against potential infections with antibiotic treatment8 , as well as through tetanus immunoglobulin shots9 . similar to the case described in this report , numerous dentists experience light abrasions from the scaler tip because of the relatively close location of the dentist 's chair to the patient . although changing the design of the handpiece delivery system to that of the european dental unit ( continental dental unit ; adec inc . , bristol , in , usa ) could help prevent such injuries , several studies have reported no difference in the incidence of percutaneous injuries associated with these systems10 . in addition , the main reason for bur breakage is the reuse and repeated disinfection of the instrument5 . therefore , it is important to avoid overuse of the equipment . the most important factor , however , is to focus on prevention and care . through this article , we hope to have provided guidance for oral and maxillofacial surgeons regarding the procedures and precautions necessary to avoid ( or care for ) accidental penetration of the femoral region with a piece of equipment , which can occur during extraction of the third molar .
extraction of an impacted third molar is one of the most frequently performed techniques in oral and maxillofacial surgery . 
 surgeons can suffer numerous external injuries while extracting a tooth , with percutaneous injuries to the hand being the most commonly reported . in this article , we present a case involving a percutaneous injury of the surgeon 's femoral region caused by breakage of the fissure bur connected to the handpiece during extraction of the third molar . 
 we also propose precautions to prevent such injuries and steps to be undertaken when they occur .