Aspiration of an impacted lower third molar during its surgical removal under local anaesthesia. The problem was recognized immediately during the surgical procedure. The aspirated tooth was detected in the right bronchus and eventually removed by rigid bronchoscopy.
Aspiration of an impacted lower third molar during its surgical removal under local anaesthesia. The problem was recognized immediately during the surgical procedure. The aspirated tooth was detected in the right bronchus and eventually removed by rigid bronchoscopy.
Aspiration of an impacted lower third molar during its surgical removal under local anaesthesia. The problem was recognized immediately during the surgical procedure. The aspirated tooth was detected in the right bronchus and eventually removed by rigid bronchoscopy.
Oral Surgery Aspiration of an impacted lower third molar during its surgical removal under local anaesthesia
R. F. Elgazzar, A. I. Abdelhady, A. A. Sadakah: Aspiration of an impacted lower third
molar during its surgical removal under local anaesthesia. Int. J. Oral Maxillofac. Surg. 2007; 36: 362364. #2006 International Association of Oral and Maxillofacial surgeons. Published by Elsevier Ltd. All rights reserved. R. F. Elgazzar a,b , A. I. Abdelhady a,b , A. A. Sadakah a a Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Tanta University, Egypt; b King Faisal University, KSA, Saudi Arabia Abstract. In this case of an aspirated impacted lower third molar during its removal under local anaesthesia, the problem was recognized immediately during the surgical procedure. The patient, a 23-year-old male, was subjected to urgent radiological examination. The aspirated tooth was detected in the right bronchus and eventually removed by rigid bronchoscopy. Oral surgeons should suspect any tooth that has been avulsed or extracted and not found as having been aspirated. Early diagnosis and management of such incidents is essential. . Accepted for publication 30 August 2006 Available online 15 November 2006 Aspiration of teeth, dental prostheses and other foreign bodies is recognized as a consequence of maxillofacial injuries and a complication during the provision of dental treatment. The outcome ranges from minimal symptoms, often unob- served, to respiratory compromise, fail- ure and even death. On reviewing the literature, the aetiology, nature of the aspirated objects, signs, symptoms and morbidity were found to be variable 3,7,8 . Meats, bones and dental appliances are the most commonly aspirated objects in adults. In children, eating while supine, especially just prior to falling asleep, increases the risk of aspiration. Peanuts, vegetable matter, such as watermelon seeds, and objects that tend to stay in the mouth for prolonged periods of time, such as gum and hard candy, are the most commonly aspirated objects in chil- dren 1,3 . Ingestion and/or aspiration of avulsed teeth was reported in various cases including maxillofacial trauma 25 , dental extractions 9 , patients with tra- cheostomy 8 , young children, and medi- cally, physically and mentally handicapped patients 7,11 . To the best of the authors knowledge, aspiration of an impacted mandibular third molar during its surgical removal under local anaesthe- sia has not been reported previously. Case report An otherwise healthy 23-year-old man was appointed for surgical removal of a mesioangular, symptomatic, partially impacted lower left third molar tooth. The procedure was undertaken under local anaesthesia with complete aseptic conditions. The tooth was routinely approached through a bucco-distal trian- gular ap, mesio-bucco-distal bone gut- tering and followed by angular sectioning of the mesial half of the crown. Upon elevation of the tooth using a straight elevator, applied mesiobuccally, the Int. J. Oral Maxillofac. Surg. 2007; 36: 362364 doi:10.1016/j.ijom.2006.08.011, available online at http://www.sciencedirect.com
This study was carried out in the Depart-
ment of Oral and Maxillofacial Surgery, Col- lege of Dentistry, King Faisal University, Saudi Arabia in collaboration with Faculty of Dentistry, Tanta University, Tanta, Egypt. 0901-5027/040362 +03 $30.00/0 #2006 International Association of Oral and Maxillofacial surgeons. Published by Elsevier Ltd. All rights reserved. patient had a gag reex provoked by the suction tip. There was an initial stiffness during its elevation followed by a dra- matic release and disappearance of the tooth. The socket and the surrounding soft tissue were immediately inspected, and the surrounding environment including the suction apparatus and surgical packs was examined, but the tooth was not found. The patient, who had a very mild cough, was asked if he had swallowed or aspirated a foreign body, but he could not be sure (Fig. 1). The patient was referred to the X-ray department and radiological examination (including lateral and postero-anterior head, neck, chest and abdominal views) was carried out. Chest plain X-ray views showed a small radioopaque shadowin the right bronchial tree, but this was not suf- cient to reach a consensus (Fig. 2a). Exam- ination of the chest computed tomography (CT) scan (Fig. 2b) showed a tooth sha- dow in the right bronchus that conrmed the suspicion of aspiration. A hard bronchoscopy under general anaesthesia was undertaken and the tooth was removed from the right middle bronchus. Preoperative steroids and antibiotics were prescribed to reduce oedema and infec- tion. The patient made an uneventful recovery and went home the next day with prophylactic broad-spectrum antibiotics, analgesics and a mouthwash. When the patient returned for suture removal, he was clinically examined to make sure that he was free of any signs or symptoms of chest infection. The patient reported that the cough had disappeared the day after the endoscopy. Discussion Although surgical removal of hundreds of impacted teeth has been undertaken by the authors during the last two decades, this case report of tooth aspiration during its extraction represents a rst for them. During elevation of the tooth under study, the patient had a sudden gag reex pro- voked by the suction tip followed by transient apnoea and immediate closure of the glottis (as in the case of deglutition) that was immediately followed by laryn- geal opening to allow inspiration. At that moment, the tooth was accidentally forced through the opened larynx down to the right bronchus. The tooth was not particularly large, and being further reduced with a surgical bur during its extraction facilitated its aspiration with- out choking or being stuck to the glottis. The only symptom in this case was a mild cough, but severe cough, dyspnoea, audi- ble wheezing and pain have been reported by some authors 1 . If severe airway com- promise or total obstruction occurs due to a larger foreign body, chest compres- sions, back blows, abdominal thrusts or the Heimlich manoeuvre may be attempted as rst aid until proper treat- ment is available. Due to its unique angulation, aspirated teeth or foreign bodies are usually (68 70%) found in the right tracheobronchial tree 2 , as in this case. Aspiration in both the left and right bronchial trees has been reported by others 10 . Radiographic studies of the chest can be of great help in diag- nosing the aspirated object, but can also be misleading 6 . In this case, the plain X-ray was not pathognomonic, but the CT scan conrmed the presence of the tooth in the right bronchus. Extraction of aspirated foreign bodies by bronchoscopy is the treatment of choice. Debate exists whether to use rigid or beroptic bronchoscopy; the decision depends on user preference, and foreign body location and size 10 . In the currently reported case, a rigid bronchoscope was successfully used for removal of the aspirated tooth through the vocal cords, and there was no need for tracheostomy. Oral surgeons should sus- pect any tooth that has been avulsed or extracted and not found, as possibly hav- ing been ingested or aspirated. Early diag- nosis and management of such incidents is essential. References 1. Athanassiadi K, Kalavrouziotis G, Lepenos V, Hatzimichalis A, Loutsi- dis A, Bellenis I. Management of for- eign bodies in the tracheobranchial tree in adults: a 10-year experience. Eur J Surg 2000: 166: 920923. 2. Dhanrajani PJ, Swaify GA. Aspiration of a bridge and a tooth. J Craniomaxillo- fac Surg 1992: 20: 9192. 3. Eren S, Balci AE, Dikici B, Doblan M, Eren MN. Foreign body aspiration in children: experience of 1160 cases. Ann Trop Paediatr 2003: 23: 3137. 4. Holan G, Ram D. Aspiration of an avulsed primary incisor. A case report. Int J Paediatr Dent 2000: 10: 150 152. Aspiration of impacted teeth during the surgical removal 363 Fig. 1. Postoperative orthopantomogram showing the empty extraction socket of the left lower third molar. Fig. 2. (a) Postero-anterior chest radiograph showing a radio-opaque shadow in the right bronchial tree (arrows) that was not convincing. (b) Axial CT showing denite tooth shadow in the right bronchus. 5. Kimberly DR. Unrecognized aspiration of a mandibular incisor. J Oral Maxillofac Surg 2001: 59: 350352. 6. Le Jr J. Foreign bodies in the tracheo- bronchial tree and esophagus. Surg Clin North Am 1966: 46: 15011512. 7. Schmidberger H, Juttner FM. Misin- terpreted expansive process of the middle lobe of the lung caused by unnoticed aspiration of a tooth. Rontgenblatter 1987: 40: 299301. 8. Steelman R, Steiner M, Millman E, Gustafson R. Aspiration of a tooth in a patient with a tracheostomy. Clin Pediatr (Phila) 1997: 36: 309 310. 9. Stoffers KW, Gobetti JP. The disap- pearing tooth: report of a case. J Mich State Dent Assoc 2002: 84: 3235. 10. Tal-Or E, Schwarz Y, Bloom Y, Klu- ger Y, Roodik V, Sorkin P. Aspirated tooth removal from airway through tra- cheotomy and exible bronchoscopy. J Trauma 1996: 40: 10291030. 11. Tiwana KK, Morton T, Tiwana PS. Aspiration and ingestion in dental practice: a 10-year institutional review. J Am Dent Assoc 2004: 135: 12871291. Address: Reda Fouad Elgazzar Department of Oral and Maxillofacial Surgery College of Dentistry King Faisal University Dammam P.B. 1982 P.C. 31441 KSA Saudi Arabia Tel: +966 3857 4161 Fax: +966 3857 2624 E-mail: reda_elgazzar@yahoo.co.uk, redaelgazzar@hotmail.com 364 Elgazzar et al.