Exodontia.Info
Displacement of Tooth / Tooth Fragments / Foreign
Bodies into Adjacent Anatomical Zones
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.

Suction can be applied to the opening immediately after 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.
Inferior Dental Canal

If lower molar roots are fractured during removal, it is important that they are lifted
out of the socket rather than displaced further.

Overzealous 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.


Useful Articles:

Braz Dent J 1992.  Complications in Exodontia - Accidental Dislodgment to
Adjacent Anatomical Areas

J Oral Maxillofac Surg 2000.  Accidental Displacement of an Impacted Mandibular
3rd Molar Into the Lateral Pharyngeal Space

J Oral Maxillofac Surg 2002.  A Simple Retrieval Technique for Accidentally
Displaced Mandibular 3rd Molars

J Oral Maxillofac Surg 2002.  Accidental 3rd Molar Displacement Into the Lateral
Pharyngeal Space

Australian Dent J 2002.  Displacement of a mandibular third molar root fragment
into the pterygomandibular space

J Oral Maxillofac Surg 2007.  Endoscopic Surgical Treatment of Chronic Maxillary
Sinusitis of Dental Origin

J Oral Maxillofac Surg 2007.  The Displaced Lower 3rd Molar.  A Literature
Review & Suggestions for Management

J Oral Maxillofac Surg 2009.  Removal of a Maxillary 3rd Molar Displaced Into the
Infratemporal Fossa. Report of a Case.

Oral Surgery 2010. Case Report of a Displaced Wisdom Tooth.

British Dental Journal 2010. Unrecognised Displacement of Mandibular Molar Root
into the Submandibular Space.

BJOMS 2010.  Technical note.  Removal of a root from the maxillary sinus using
functional endoscopic sinus surgery.

BJOMS 2010.  Letter to Editor.  Re - Removal of a root from the maxillary sinus
using functional endoscopic sinus surgery.

Dental Update 2011.  Dislodged Lower Right 3rd Molar Tooth into the
Parapharyngeal Space

Oral Surgery 2012.  Case Report.  The Use of Cone Beam Computed
Tomography in the Management of Displaced Roots into the Maxillary Antrum

JOMS 2013.  Displacement of Maxillary 3rd Molar Into the Lateral Pharyngeal
Space
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.
Last Updated 27th November 2014
Last Updated 12th October 2011
Last Updated 12th October 2011