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

Case Reports in Dentistry 2013.  Removal of a Maxillary 3rd Molar Displaced into Pterygopalatine Fossa via Intraoral Approach

JOMS 2013.  Displacement of Maxillary 3rd Molar Into the Lateral Pharyngeal Space

Dental Update 2020.  Displacement of Lower Third Molar into the Parapharyngeal Space during Extraction
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 7th November 2020
Last Updated 12th October 2011
Last Updated 12th October 2011