| Abstract|| |
Accidental entry of foreign bodies into the oro-facial region could be due to trauma, therapeutic interventions or iatrogenic. Various foreign bodies and locations have been reported, for example, wood in the orbit, impression material in the maxillary sinus, tooth fragments in the orbit. All these cases presented with inflammatory reaction and formation of infected granuloma, pus discharging sinus and serious complications like intra-cranial abscesses. Foreign bodies sometimes migrate within the tissues and become symptomatic after a certain period of time. In these cases, it is very difficult to correlate the direct relation between the suspected foreign bodies with the present clinical symptoms. The removal of foreign bodies is often a surgical challenge due to a combination of difficulty in access and close anatomical relationship to vital structures. To prevent complications, foreign bodies should be diagnosed and removed on time.
Keywords: Foreign bodies, infected granuloma, pus discharging sinus
|How to cite this article:|
Mohanavalli S, David J J, Gnanam A. Rare foreign bodies in oro-facial regions. Indian J Dent Res 2011;22:713-5
Incidence of injuries due to road traffic accidents, fall, interpersonal assaults are increasing day by day throughout the world. The maxillofacial field demands the highest attention because of increased cosmetic needs. Traumatic and iatrogenic injuries can result in entrapment of foreign bodies like air gun pellets, stones, wood, metal, whole tooth, roots of teeth, dental cements and broken instruments, respectively. Thorough debridement of these wounds will clear all these foreign bodies. Investigations like radiographs, computed tomography (CT), magnetic resonance imaging (MRI), along with a good understanding of the nature of injury record will provide the surgeon with better diagnosis to completely retrieve all the foreign materials.
| Case Reports|| |
An 18 year old boy reported with a complaint of chronic discharge from the right angle region since 4 months. History revealed that he had met with an accident 6 months earlier and had got treated in a local hospital. Orthopantamograph (OPG) revealed no evidence of existing pathology. Patient's consent was obtained for surgical exploration under general anesthesia [Figure 1]. Incision was made through the existing scar tissue and all the infected granulation tissue was excised. Dissection was done carefully to protect the parotid gland and further exploration was made to rule out the presence of any foreign material. Surprisingly, a greyish black object was noticed embedded in the deeper tissues. On removal, it was found to be a piece of wood [Figure 2]. The wound was thoroughly cleaned with betadine and was closed in layers. After 10 days, the sutures were removed and the healing was satisfactory. Follow-up was done for the next few weeks. Wound healing was excellent except for an inconspicuous scar [Figure 3].
A 38 year old man reported with a complaint of swelling below the chin with the history of fall from a motorbike with loss of anterior teeth. On examination, there were missing upper anteriors and right lower anteriors. OPG revealed the presence of radioopacities in the submental region, which were suspected to be the missing teeth. The procedure was explained to the patient and exploration done under local anaesthesia. Sub-mental incision was made and dissected meticulously [Figure 4]. The foreign bodies (teeth) were retrieved using a hemostat [Figure 5]. Wound was closed in layers.
A 56 year old man complained of pus discharge from the upper back tooth region for the past 6 months. History revealed that the patient had undergone cyst enucleation in the right maxilla 1 year back in another hospital. On examination, a sinus opening close to the right upper first molar area was seen with purulent exudates. OPG and paranasal sinus (PNS) skull views were taken. Both radiographs showed radioopacities in the right maxillary sinus. CT reports revealed mucosal thickening of the right antrum [Figure 6]. Patient consent was obtained for exploration under local anesthesia. Vestibular incision was placed. On exploration, an infected gauze piece was found in the antrum. Complete retrieval of the gauze piece was done [Figure 7]. The wound was irrigated with betadine saline solution and an open dressing was given for 3 weeks. Wound healing was satisfactory.
|Figure 7: Gauze seen in right vestibular area; (inset) retrieved gauze piece|
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| Discussion|| |
Wood or bamboo foreign bodies are difficult to diagnose if they are placed very deeply. Radiological examination including three dimensional CT enables the surgeon to choose the optimal surgical approach to remove the foreign body, thereby avoiding purulent inflammatory complications.  Wooden or bamboo foreign bodies in both fat and soft tissues may present in CT patterns simulating as different as a gas bubble or a bone fragment.  CT was demonstrated to be superior to MRI in the evaluation of a wooden object in the orbit.  In case 1, there was a 10-month delay between the incidence of trauma and the removal of the wooden foreign body, due to the absence of earlier clinical symptoms. Foreign bodies may migrate within the tissues and become symptomatic after a certain time lapse. In these cases, it is very difficult to correlate the direct relation between the suspected foreign body and the present clinical symptoms. One should therefore suspect a foreign body when presented with a laceration due to a blow by a wood or bamboo stick. In this case, the patient gave a history of an accident with a wood laden vehicle, which gave us an idea for thorough exploration of the wound to rule out any remaining foreign body. Wooden or bamboo foreign bodies have to be removed to prevent complications. The choice of imaging studies in the evaluation of foreign bodies in oro-facial region is a controversial issue. Standard radiography fails to identify these retained foreign bodies. Although it is more costly, CT is the imaging study of choice for most foreign bodies. CT scans obtained within a day of the accident demonstrate wooden foreign bodies as of low density relative to the surrounding fat. In the acute stage, dry wooden foreign bodies mimic air bubbles. CT scans obtained 8-29 days after the accident demonstrate wooden foreign bodies as denser than the muscles. Therefore, such foreign bodies may be missed on CT when located in the fat layer. MRI should also be used when penetration by a wooden or bamboo foreign body is suspected and when other techniques have not shown the foreign body. MRI is also superior to CT in detecting the smallest pieces of wood. , Since our patient could not afford an MRI/CT, we planned for an exploration. The second case was interesting in its presentation in an unusual way. Since the patient had given a previous history of trauma, and on clinical examination there were missing anterior teeth, OPG and occlusal view radiographs revealed a tooth like appearance in the submental region. We were able to get an excellent outcome with good clinical correlation and good radiographic imaging. The third case was a rare occurrence of the presence of a gauze piece in the antral region. This was due to the failure of the patient to report to the hospital in which he had undergone enucleation. CT scan and radiographs were not able to show the exact picture of the foreign body. When we took pus for culture and sensitivity test, we found gauze threads in the discharge which triggered us to do the exploration. Surprisingly, the entire antrum was packed with the gauze. These types of foreign bodies in the oro-facial region definitely pose a challenge to the oral surgeon. So, a thorough understanding of the nature and cause of injury has to be taken into consideration with a good radiographic interpretation so that nothing will be left out which may cause hazardous complications.
| Acknowledgments|| |
Dr. K. Kamal Kannadasan, Professor and Head, Department of Oral and Maxillofacial Surgery., and Dr. P. Elavenil, M.D.S, Reader, Department of Oral and Maxillofacial Surgery, are gratefully acknowledged.
| References|| |
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|5.||Williams JL. Rowe and William's Maxillofacial Injuries. In: Williams JL. 2 nd ed, Vol. 1 and 2. New York: Churchill Livingstone; 1994. p. 186, 704,715,864. |
Department of Oral and Maxillofacial Surgery, S.R.M. Dental College, Chennai
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]