| Exodontia.Info |
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| Displacement of Tooth / Tooth Fragments / Foreign Bodies into Adjacent Anatomical Zones |
Suction can be applied to the opening immediately after
the tooth / root has been displaced into the maxillary
sinus. If this manoeuvre is unsuccessful, the maxillary
sinus can be irrigated via the oral opening and suction
reapplied to try to remove the foreign body. If this
second manoeuvre is unsuccessful, however, the
procedure should be aborted, and the patient started on
antibiotics and nasal decongestants.
The foreign body should be removed via a Caldwell-Luc
antrostomy as a secondary procedure coupled with
surgical closure of the oro-antral opening and a
temporary intra-nasal antrostomy to aid surgical drainage
of the sinus.
Tissue Spaces
Unerupted upper wisdom teeth in particular, are at risk
from being displaced into adjacent tissue spaces but no
tooth is immune.
When, for instance, the upper wisdom tooth is unerupted
and a flap has been raised (find OPG), the tooth may slip
behind the maxillary tuberosity and into the
pterygomaxillary space, from where it may migrate into
the deep structures of the neck.
Lower teeth are less prone to displacement than uppers
but they can be so affected. Lingually placed (teeth
tilted in the direction of the tongue) lower wisdom teeth
and their roots may occasionally be pushed through a thin
/ absent lingual plate into the floor of the mouth or below
the mylohyoid from where they can migrate into the neck.
Similarly, lingually placed lower premolars (find OPG),
particularly when unerupted, may be displaced into the
lingual tissues. The latter situation is prone to occur if
these teeth are “tapped out lingually” using a mallet and
elevator.
the tooth / root has been displaced into the maxillary
sinus. If this manoeuvre is unsuccessful, the maxillary
sinus can be irrigated via the oral opening and suction
reapplied to try to remove the foreign body. If this
second manoeuvre is unsuccessful, however, the
procedure should be aborted, and the patient started on
antibiotics and nasal decongestants.
The foreign body should be removed via a Caldwell-Luc
antrostomy as a secondary procedure coupled with
surgical closure of the oro-antral opening and a
temporary intra-nasal antrostomy to aid surgical drainage
of the sinus.
Tissue Spaces
Unerupted upper wisdom teeth in particular, are at risk
from being displaced into adjacent tissue spaces but no
tooth is immune.
When, for instance, the upper wisdom tooth is unerupted
and a flap has been raised (find OPG), the tooth may slip
behind the maxillary tuberosity and into the
pterygomaxillary space, from where it may migrate into
the deep structures of the neck.
Lower teeth are less prone to displacement than uppers
but they can be so affected. Lingually placed (teeth
tilted in the direction of the tongue) lower wisdom teeth
and their roots may occasionally be pushed through a thin
/ absent lingual plate into the floor of the mouth or below
the mylohyoid from where they can migrate into the neck.
Similarly, lingually placed lower premolars (find OPG),
particularly when unerupted, may be displaced into the
lingual tissues. The latter situation is prone to occur if
these teeth are “tapped out lingually” using a mallet and
elevator.
If lower molar roots are fractured during removal, it is
important that they are lifted out of the socket rather
than displaced further.
Over zealous use of the Cryers elevator in particular, can
gouge out the roof of the Inferior Dental (ID) Canal into
which the root can be subsequently pushed. As in all
situations, adequate exposure and illumination so as to
afford good surgical access is a pre-requisite. A fine
round bur should be used to remove a channel of bone
adjacent to the retained root sufficient to allow its
elevation upwards out of the socket.
If a root fragment is displaced and not readily visualised
X-rays in 2 planes should be taken. Once localised,
judicious removal of the roof of the ID canal is
undertaken until the retained fragment is found.
Thereafter, a blunt instrument such as a curved Warwick
James elevator can be insinuated beneath the fragment
which is carefully lifted off the neuro-vascular bundle.
Aero-Digestive Tract
It is all to easy for an extracted tooth or dislodged
fragment to be swallowed or worse still inhaled. Teeth
with single conical roots are sometimes ejected from
their sockets unexpectedly during exodontia and patients
will occasionally move violently just as a tooth is being
delivered (especially if they are nervous and / or the
depth of analgesia is inadequate).
In these circumstances, the tooth may disappear over
the dorsum of the tongue into the pharynx upon which
the patient's gag reflex is activated compounding the
problem.
If a tooth is dislodged into the unprotected pharynx, with
any luck, the patient will swallow it and it will pass
naturally in several days time.
However, it may well be inhaled and due to the manner
in which the trachea branches at the carina, not
infrequently becomes lodged in the right main bronchus.
This situation will usually be greeted by violent fits of
coughing but may be silent. If such a situation occurs or
the tooth cannot be immediately accounted for an urgent
chest and abdominal X-ray should be ordered.
If the patient is being treated outside of a hospital
environment, they should be immediately referred via
telephone to the local A&E or OMFS Department.
If the tooth is seen to be lying in the lung the patient is
urgently referred to either a cardio-thoracic surgeon or
respiratory physician for bronchoscopy. If the tooth is
seen within the stomach, the patient is reassured that all
should be well and is recalled for repeat abdominal x-ray
in a weeks time. If the tooth has failed to pass, a
general surgical opinion should be obtained as soon as
possible.
Instead of the tooth being safely removed from its
socket, it may be displaced into any one of a number of
potentially hazardous areas (that adjoin the socket)
including:
• Maxillary Sinus
• Tissue Spaces (such as the pterygomandibular
space, pterygopalatine fossa, lingual space)
• Inferior Dental Canal
• Aero-Digestive Tract
Maxillary Sinus Involvement
Teeth, roots and other foreign bodies can occasionally be
displaced into the maxillary sinus. Although they are
sometimes seen as a chance asymptomatic finding on
routine X-rays, such foreign bodies are generally
removed because of the possible complication of sinus
infection or polyp formation.
