Displacement of Tooth / Tooth Fragments / Foreign Bodies into Adjacent Anatomical Zones

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.

CT_coronal_view_show_the_palatal_root_lodged_in_the_ostium_of_the_L_maxillary_sinus-734x758

Maxillary Sinus Involvement

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.