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Case Report

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.
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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.
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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.