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Journal of Trauma and Care

Cite this article: Gupta R, Thayath MN, Rana AS, Zaidi I, Nagaraj A, et al. (2017) Hide and Seek of Tooth Lost in Infra-Orbital Space. J Trauma Care 3(3): 1024.

*Corresponding authorRuchi Gupta, Department of Pediatric & Preventive Dentistry, Shree Bankey Bihari Dental College, 0.5 km Ahead Masuri Canal, NH-24, Masuri, Ghaziabad-201302, UP, India, Tel: 91-8587873929; Email:

Submitted: 22 April 2017

Accepted: 16 June 2017

Published: 19 June 2017

Copyright© 2017 Gupta et al.

ISSN: 2573-1246

OPEN ACCESS

Keywords•Dental trauma•Embedded tooth•Hidden•Infra-orbital space•Seeking•Standard protocol

Case Report

Hide and Seek of Tooth Lost in Infra-Orbital SpaceRuchi Gupta1*, Muhammad Nishad Thayath1, Amar Singh Rana2, Iram Zaidi1, Abhishek Nagaraj3, and Anubhav Jannu2

1Department of Pediatric & Preventive Dentistry, Shree Bankey Bihari Dental College, India2Department of Oral & Maxillofacial Surgery, Shree Bankey Bihari Dental College, India3Consultant Prosthodontist, Saudi Arabia

Abstract

Introduction: The purpose of this paper is to discussa rarest case of hidden maxillary tooth in infra-orbital space following trauma. Pediatric dental injuries leading to traumatic tooth displacement is common in children, although it very rare and sometimes challenging to diagnose and treat traumatically embedded tooth in vital tissue spaces which may lead to serious complications if ignored.

Case report: A 4-year old male child was brought with injuries on his face and mouth and swelling over theleft side of theface, resulting from fall. The intra-oral examination revealed theabsence of all maxillary incisors. The paranasal sinus view showed a vague tooth-like object embedded in the floor of theleft orbit. The correct location and type of tooth could not be ascertained till the end of theprocedure.

Comments: The above case is about the importance of seeking every tooth lost in trauma. It discusses complications of not following standard protocol for diagnosis and treatment in such rare cases.

INTRODUCTIONDento-alveolar trauma is a common problem in children and

represents a situation which demands immediate attention not only because of the injury which may be severe but also due to emotional distress to the child as well as to the parents [1]. Trauma to the oral hard and soft tissues is commonly seen in children. Among all facial injuries, dental injuries are the most common. As much as 18% of all injuries in children up to 6 years of age are seen in the oral region [2]. Injuries to the primary dentition are common, occurring with a significantly higher annual incidence than in the permanent dentition. One-third of all children in the primary dentition stage suffer from traumatic injuries to the mouth. This is possibly related to poor motor coordination and is sometimes due to the child’s inability to evaluate risks [3].

Dental trauma can result in a number of injuries involving the tooth and the supporting structures. Six types of luxation or displacement and seven types of tooth fracture have been described and are used to classify traumatic dental injuries [4].Traumatic tooth displacement is a common injury affecting children and adolescents. Although sometimes challenging to diagnose, tooth intrusion, aspiration and ingestion may lead to serious complications [5].

Intrusive traumas are mostly experienced in the deciduous

dentition with damage to anterior teeth; this kind of trauma is more common at age 1-3 years due to the high resilience and flexibility of the surrounding tissues around the deciduous teeth. Preschool children have wide medullar spaced bones; this situation leads to luxation and intrusion injuries instead of structural fractures [6,7]. The tooth most vulnerable to trauma is the primary maxillary central incisor, which sustains approximately 80% of all dental injuries. With a direct blow, a primary incisor can be completely intruded [8].

Deciduous teeth traumas may present with several visual signs: colour change of crown, pulp obliteration, pulp necrosis, resorption of root, inflammatory resorption, ankylosis, gingival recession, permanent displacement of the deciduous tooth, and pulp necrosis/premature loss [9,10]. The potentially most serious complications can occur when a tooth is displaced into another part of the body or when the tooth opens a communication from the oral cavity into an anatomical space [11]. Common spaces for displacement of teeth (traumatic or non-traumatic) include maxillary sinus, nasal cavity, temporal space, infratemporal space, lateral pharyngeal space, sub mandibular space and buccal space. There are many factors that increase the chance of tooth displacement. These include anatomic considerations, such as resilient and flexible tissues, medullar spaced bone, distolingual angulation of the tooth or dehiscence in lingual cortical plate,

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excessive or uncontrolled force of impact, improper manipulation and inadequate clinical and radiographic examination [12,13].

The treatment and prognosis of intrusive luxation can vary depending on the age of the patient, type of dentition, stage of root development, and time and severity of the trauma. There is no agreement in the literature for the ideal treatment for intruded primary or permanent teeth after trauma. A variety of treatment modalities suggested managing intrusive luxation. One option is to allow the tooth to re-erupt on its own. Another treatment is to reposition the tooth using orthodontic forces. Immediate surgical repositioning has also been recommended [14]. General anaesthesia (GA) may be indicated for paediatric dental patients with extensive restorative treatment or difficult treatment plans, uncooperative behaviour, severe anxiety or fear, physical or mental challenges, or for patients who are very young [15].

CASE REPORTA 4-year old boy was brought to the department of

Pedodontics and Preventive Dentistry, 1 day after suffering from dental trauma. The chief complaint was swelling over the left side of the face below eye and bleeding from the nose. The parents stated that child had a fall and after that they noticed the loss of upper front teeth, bleeding from mouth and nose. They could not count the number of teeth lost at the site of the accident as they were very anxious and immediately rushed to a local doctor for first aid. The child was very fearful and was crying continuously, the mother was also apprehensive. This was the first dental visit of child and first dental trauma experience, medical history was unremarkable. The patient had a high-grade fever of 103°C.

After the patient’s general, medical, and trauma history was recorded, a clinical examination was completed.

The initial examination was done with the child on the parent’s lap. This position was adequate as a child was very uncooperative for both the clinical and the radiological examinations and it allowed the parent to help restrain the child’s movements.

The extra-oral examination for hard and soft tissues revealed a contusion on the skin below lower lip, swelling and bleeding of the lower lip, bleeding from left nostril. The diffuse swelling was noticed on the left side of the face below the left eye till angle of the mouth, obliterating the nasolabial fold and difficulty in closing and opening left eye. On palpation, crepitation and some hard object felt below the inferior orbital ridge lateral to nose in the soft tissue.

The intraoral clinical examination was difficult as a child was very uncooperative and refused to open mouth, after alot of efforts we opened his mouth that revealed the loss of all four primary maxillary incisors, as well as agingival laceration. There was no evidence of traumatic injury to any other teeth.

Radiographic examination was done extra-orally only, due to inability to open child’s mouth to place films.

Adental panoramic tomography (DPT) and paranasal sinus view were done. On (DPT) complete loss of all primary maxillary incisors was noticed. No signs of damage to erupting tooth bud. Paranasal view revealed a radiopaque tooth-like object below the inferior orbital ridge, lateral to nasal bone, suggestive of

impaction of intruded tooth in infraorbital space. Parents were advised to go for 3- dimensional imaging like CBCT, but they were reluctant to go for further investigations due to lack of money and inability to understand the need for more investigations.

The image of intruded tooth implies that the tooth was displaced away from the developing tooth germ and perforated the muscle mass and entered the infraorbital space.

Due to the severity of intrusion, the position of the tooth and lack of patient cooperation it was decided to operate the child under general anaesthesia under antibiotic prophylaxis.

One of the most severe complications of an injury is an infection. The supporting apparatus of a healthy tooth is protected against invasion of oral microorganisms by the attached gingiva. As the tooth is pushed into the tissues, rupture of this attachment is unavoidable. Oral bacteria can now infiltrate and infect the wounded tissue. As there is no definite policy for antibiotic therapy in case of traumatic injury to primary teeth, the decision must be made by the clinician based on his or her own experience. Also, antibiotic prophylaxis is required for the reduction of oral bacteria, in children 2–4 years of age, unlike adults, as they are unable to rinse their mouth with a chlorhexidine preparation

[16]. Kenny and Yacobi (1988) and Spinosa (1990) advocated antibiotic therapy such as penicillin or erythromycin [17,18]. Hence, it was decided to wait till the patient is a febrile and ready for operation.

The patient was placed on oral Amoxicillin and Ibugesic for 5 days. The parents were also instructed to maintain good oral hygiene, with warm saline rinses, brushing with a soft brush after each meal, and a soft diet was prescribed. They were advised to bring the child in case of emergency.

After 3 days, despite antibiotic coverage, parents reported back with complaint of pus discharge from the left nostril and a punctum was noticed on the skin below the left eye lateral to nose at the expected site of impacted intruded tooth, suggestive of infraorbital space infection.

After preanesthetic check-up, the child was prepared for surgery next day. The surgery was performed by a team of paediatric dentists and oral surgeons with anaesthesia team. After preparation of the patient, general anaesthesia was given. The initial attempt was made to manipulate the extra-oral punctum, but only purulent discharge followed by bleeding was seen. The tooth was not palpable anymore, it might have moved deep into the muscle mass due to manipulation. An intra-oral incision was given high in the labial vestibule, followed by sharp and blunt dissection; further deepening of surgical site was done with sinus forceps. Every attempt was made to preserve the vitality of vital structures in infraorbital space while seeking the hidden tooth. When the tooth was not retrieved easily, bimanual manipulation was done in order to find the lost tooth in space. Finally, tooth moved through muscle mass and soft tissue, and felt again near the inferior orbital ridge. With more manipulation inside the infraorbital space tooth, an attempt was made to recover the tooth out of the anatomical space. This “hide n seek of the tooth in infraorbital space” continued for almost 30 minutes. Finally, with all possible attempts, we tried to recover the tooth from the extraoral sinus opening of punctum. The tooth was retrieved

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and was identified as a left maxillary central incisor. The cavity was irrigated with saline and antiseptic solutions. Vicryl sutures were given intra-orally and extra-oral sinus was also sutured. The patient was kept under observation for 24 hours after the weaning of general anaesthesia. Regular follow-up was done. Clinical examination was done on follow-up visits and there was no problem found. Parents were not interested in prosthetic rehabilitation of lost anterior teeth due to uncooperative child and behaviour and emotional trauma due to injury.

DISCUSSIONDental injury to the child patient is a traumatic experience

for both parents and child on a physical as well as emotional and psychological level. In view of the patient’s tender age and the likelihood that the dental visit will be the patient’s first, managing the child’s traumatic injuries is a demanding task.

Review of intrusive injuries

Intrusive luxation has been defined as dislocation of a tooth in an axial direction into the alveolar bone. This dislocation is considered complete when the tooth is enveloped by surrounding tissues or partial when the incisal border of the crown is visible [19]. Intrusion comprises 8–22% of all luxation injuries of primary anterior teeth [20]. Traumatic injuries are less frequent during the first year of life [21]. Their frequency increases during the toddler stage, due to the lack of motor coordination. One to 3 years is the most susceptible age group for intrusion injuries of primary incisors. In children above 4 years, other luxation injuries such as avulsion, extrusion, and lateral luxation become more frequent [20]. The teeth most frequently injured are the maxillary central incisors, ranging between 63% and 92% [20,22]. The predominant cause of dental injuries in younger age groups is falling, such as falling from baby carriages, falling down stairs, or falling against hard objects, and is mainly indoor injuries. Outdoor injuries are more common in elder children above 5 years. In addition, child abuse is highly associated with head and tooth injuries [2].The difference in the trauma pattern favouring luxation rather than fracture has been found to be typical for the primary dentition [23]. The surrounding bone is less dense and less mineralized (In older children, the probability of a root or crown fracture increases because of mineralisation and increased rigidity of the alveolar bone). Large bone marrow spaces, characteristic of growing skeletal tissues, imparts high elasticity to the alveolar bone This implies that a tooth hit by traumatic impact can easily be displaced instead of fractured. The short roots, resorbing roots, and the high crown-root ratio of primary teeth offer less resistance to intrusive displacement.

In falls wherein the impact has an axial component, the tooth will be intruded due to the labial curvature of the root; the intrusion will usually result in an axial and labial displacement in which the apex penetrates the labial bone plate. A case in which the impact direction has a strong lingual component typically occurs when the child falls with an object in the mouth (e.g., pacifier or toy). In these cases, the apex of the injured tooth may be forced into the follicle of the permanent successor, sometimes resulting in severe injury to the developing permanent tooth germ [2].

The degree of intrusion can be divided into 3 grades [24].

Grade I. Mild partial intrusion in which more than 50% of the crown is visible. Grade II. Moderate partial intrusion in which less than 50% of the crown is visible. Grade III. Severe or complete intrusion of the crown.

Examination protocol

The child’s medical history should always be discussed with the parents. The need for prophylactic antibiotic coverage should be determined. After a traumatic injury and contact with soil, a booster dose of DPT vaccine should be considered, if the patient has not received an immunisation within the prior 5 years. A dental history would indicate any past traumatic injury or other dental experience, which helps determine the child’s maturation and ability to cooperate during treatment. The history of the injury should be discussed with the parents. Children younger than 3 years have a limited vocabulary that restricts their ability to communicate. Separating these young children from the parents is not advised.

Clinical examination should commence with a neurologic assessment to detect signs of central nervous system damage. Cyanosis, nausea, vomiting, seizures, and loss of consciousness may be indicators of neurological damage. Other signs are unsteadiness, abnormal respiration, slurred speech, rhinorrhea, otorrhea, and abnormal eye movements [25].

The extra-oral examination includes assessment of temporomandibular joint, mandibular movements, facial asymmetry (indicating jaw fractures), swelling of the lips, skin lacerations/ cuts/ scars. Bleeding from the nostrils and subcutaneous haemorrhage near the nostrils may indicate fracture of the alveolar bone [2].

The Intraoral examination includes examining all intra-oral hard and soft tissues. Soft tissues (lips, oral mucosa, attached and free gingivae, and frenums) should be checked for lacerations and hematomas. Contusions of the lower lip and chin are more frequent with intrusion injuries [26]. A soft tissue radiograph may be helpful in detecting the presence of foreign bodies that may have been impacted within lip or tongue lacerations [27]. Hard tissue examination of traumatic and other teeth and surrounding alveolar bone: When the tooth is partially intruded, the orientation of displacement can be assessed. A labial crown orientation indicates a palatal intrusion of the root toward the permanent tooth germ. Conversely, a palatal crown inclination indicates a buccal intrusion of the root away from the successor germ [2]. Crushing and compression of the alveolar bone is an integral part of an intrusive luxation injury. Fracture of the alveolar socket may accompany intrusion injuries of high impact, such as falling down a staircase. Signs of alveolar fracture can be detected by gentle palpation of the mucosa in the traumatised area. In this case, the injured teeth and cortical bone will move as a unit [28].

Radiographic examination is an important adjunct to the clinical examination, providing valuable information that may affect the treatment plan for the injured primary tooth. It shows the degree of development of the primary tooth and its permanent successor and the relationship between the two. Furthermore, physiological and pathological root resorption and the position of displaced primary teeth can be seen. On the

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radiographic examination, if the tooth appears foreshortened, the tooth is labially displaced, if appears elongated radiographically, the tooth is most likely been intruded into the follicle of the permanent tooth and must be removed [29]. According to ‘‘Guidelines for the Management of Traumatic Injuries to Primary Teeth’’[30], the extra-oral lateral view of the tooth in question is useful to reveal the relationship between the apex of the displaced tooth and the permanent tooth germ as well as the direction of dislocation. Various extra-oral vies used are: anterolateral view, ortho-pantomograph, paranasal sinus view. 3-D imaging like cone-beam computed tomography (CBCT) can be more helpful in dento-alveolar trauma evaluation. Its advantages are shorter exposure time, high resolution, reduced image artefact, low radiation dose and high accuracy than 2-D radiography. However, the high cost of this technology prohibits its use in most dental offices. Moreover, multiple exposures restrict its use in pediatric patients routinely, as lower imaging dose should be a strict consideration in pediatric patients, in accordance with the principle of radiology, ALARA (as low as reasonably achievable) [31].

Displacement of intruded tooth

Traumatic or accidental iatrogenic displacement of teeth into tissue spaces is a well-recognized but a rare and potentially serious complication. Careful pre- operative planning/ evaluation, proper radiographs, adequate access and visibility, proper technique and controlled use of force should be utilised to retrieve a tooth displaced into vital spaces. In case of complication, proper management and timely referral to the oral and maxillofacial surgeon should be done to avoid un-necessary damage to both hard and soft tissues of the maxillofacial region. The displacement may be in the form of root or a whole tooth. Whether initial attempt should be made to retrieve the tooth vary from case to case. Early retrieval is favourable as delay of more than 24 hours lead to swelling, pain, trismus and psychological problems. However, some authors recommend waiting so that fibrosis and stabilisationhave taken place.

Common spaces for displacement of teeth (traumatic or non-traumatic) include maxillary sinus, nasal cavity, temporal space, infratemporal space, lateral pharyngeal space, sub mandibular space and buccal space [32,33].

Treatment regimens: The overall principle of treatment is not to take any risk of damage to the permanent successor, which usually implies a very conservative approach. Objectives of trauma management in the primary dentition, to comfort the child and parents during this trying episode,toavoid inducing dental fear and anxiety in young children who may be experiencing their first dental problem and tominimize the risk of further damage to the permanent teeth [2].

Use of topical anaesthetics, local anesthesia, sedation, general anaesthesia should be considered. Adequate oral hygiene and a soft diet should be prescribed [34].

Management of an intruded primary incisor depends on the following variables,

• The direction of intrusion.

• The degree of intrusion.

• The presence of alveolar bone fracture.

• Age and cooperation of child.

According to the current guidelines, a treatment regimen of the intruded primary incisor can be broadly of two types depending on the radiographic examination [2,30]. If the injury is grade I or apex is displaced towards or through the labial bone plate than the intruded tooth is left for a spontaneous eruption. But, if the intruded tooth is grade II or grade III, or has been forced into the follicle of the permanent tooth germ, extraction of the primary tooth is indicated. If an intrusion is complete and impacted or embedded in tissues or fascial spaces, surgical removal is mandatory.

Surgical protocol: Surgery performed on pediatric patients involves a number of special considerations unique to this population. Several critical issues deserve to be addressed [35] (Figures 1-3). These include Preoperative evaluation. medical; and dental

• Behavioural considerations.

• Growth and development.

• Developing dentition.

• Pathology.

• Perioperative care.

Follow up: Intrusion injuries of primary teeth should be carefully followed up. The follow-up schedule for traumatized primary teeth, according to the guidelines of the International Association of Dental Traumatology is as follows [30]:

• 1 week: Clinical.

• 3–4 weeks: Clinical, radiographic.

• 6–8 weeks: Clinical.

• 6 months: Clinical, radiographic.

• 1 year: Clinical, radiographic.

Figure 1 Pre operative.

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Summary of case

In this case report, we discussed a case of displacement of the tooth in infra-orbital space. The canine space (also termed the infra-orbital space), is a fascial space of the head and neck (sometimes also termed fascial spaces or tissue spaces) [36]. It is a thin potential space on the face, and is paired on either side. It is located between the levatorangulioris muscle inferiorly and the levatorlabiioris superiorly [36,37]. The term is derived from the fact that space is in the region of the canine fossa, and that infections originating from the maxillary canine tooth may spread to involve the space. Infra-orbital is derived from infra- meaning below and orbit which refers to the eye socket. According to some authors for the ease of understanding this space, it is also described as infraorbital triangle or triangle of contension [38], marked by upper boundary of infra-orbital rim, lower boundary by medial edge of nasolabial furrow, lateral edge by zygomaticus major muscle, the space of triangle contains muscle mass, soft tissues, and vital structures.

In this case, the complete intrusion of the primary maxillary left incisor occurred and the tooth was embedded in so-calledinfra-orbital triangle. All possible attempts were made with following the guidelines and given protocols for management of embedded tooth. CBCT would have been a better investigation for correct location diagnosis. Delay in procedure leads to the increase in the space infection, so early intervention would have been better.

CONCLUSIONTraumatised teeth present a clinical challenge with regard to

their diagnosis, treatment planning, and prognosis [14]. A patient presenting with facial trauma may be distracted by other injuries, and a missing tooth may be presumed to have been avulsed during the accident. All missing teeth should be accounted for to ensure that they have not dislodged inside the body. Complete displacement of the tooth can have life-threating complications, like an abscess, space infections, airway obstruction, anytime a tooth is not accounted, the possibility of complete intrusion should be considered [39,40].

Involvement of dental practitioners in the initial assessment of dental trauma, use of available diagnostic aids judiciously, following recommended treatment protocols could be alife saviour for the patient.

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Figure 2 Intra operative.

Figure 3 Post Operative.

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Gupta R, Thayath MN, Rana AS, Zaidi I, Nagaraj A, et al. (2017) Hide and Seek of Tooth Lost in Infra-Orbital Space. J Trauma Care 3(3): 1024.

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