Introduction: Dislodgment of nasopharyngeal temperature probes and/or entrapment at the patient hypopharynex is rare complication after orthognathic surgery that may occur as a result of surgical manipulation itself or may be a consequence of factors related to the insertion and handling of the probe after extubation. However, the exact mechanism of this complication is not known. Presentation of the case:We report the case of a patient who suffered from the dislodgment of a 12-cm temperature probe after orthognathic surgery. The surgery itself was uneventful. At the end of the surgery, the probe was believed to have been completely removed from the nasal cavity. The nasopharyngeal cavity was visually inspected while the patient was anaesthetized, and the trachea was still intubated. Extubation was successful, and the patient was moved to the recovery area. The patient was discharged from the hospital one day after she managed to take an oral fluid diet. At the follow-up visit on the 4th postoperative day, the patient presented with mild symptoms of a sore throat and mild cough. At the follow-up visit in the 3rd postoperative week, the patient reported one episode of vomiting and severe coughing, and 12 cm temperature probe was retrieved from her mouth by the patient. Discussion and conclusion:After conducting a systematic literature review, we discuss surgical orthognathic surgery cases that have involved this rare complication. We also describe changes in our clinical practice after this event, and we envision that these modifications will have a positive influence on patient care.