Josep Maria Oliva Díez: MD; Stomatologist. ABS La Pau. Barcelona. Institut Català de la Salut.
Carlos López Sánchez: MD; Stomatologist. ABS Raval Nord. Barcelona. Institut Català de la Salut.
Cristina Gracia Ruiz: MD; Stomatologist. ABS Raval Sud. Barcelona. Institut Català de la Salut.
José María Segura Noguera: MD; Family physician. ABS Raval Nord. Barcelona. Institut Català de la Salut.
Noemí Escuder Ferrando: Dental hygienist. Centre de Referència d’Odontologia (CRO). Barcelona. Institut Català de la Salut.
Corresponding author: Dr. Jose M Oliva
Address: C) Casp 186, atic 3
Work phone: (34)932788660
Home phone: (34)932700638
Keywords: dentigerous cyst, ectopic eruption, expulsion, skin, third molar, transcutanous fistula.
The eruption and transcutaneous expulsion of teeth from the oral cavity is an extremely rare phenomenon, but one which should be known. We report the case of a 63 year old woman who presented with a lower third molar situated ectopically in the inferior mandibular angle with an associated follicular cyst. After several infectious episodes, the tooth was expelled from the oral cavity through a transcutaneous fistula at the lower edge of the mandible. This is a very uncommon complication that may occur in non-erupted teeth, and which probably has not been reported in the literature previously, as a PubMed search on the keywords “third molar, ectopic eruption, expulsion, tooth, skin, transcutaneous fistula” returned no cases similar to the one described here.
Ectopic teeth are a frequent finding in general dentistry and primary care. The tooth most frequently located ectopically is the lower third molar (35%), followed by the upper canine (34%), the upper third molar (9%), the second lower premolar (5%), the lower canine (4%) and the upper central incisor (4%) with other teeth being less frequently seen.
The lower third molar can be found ectopically in different locations on the jaw. They have been described in the mandibular angle1, ramus2,3, condyle4,5 and coronoid process6. Ectopic teeth can remain in place for the life of the patient, but eruptions in atypical places are also frequent, the most common being inside the oral cavity itself, near the dental arches. When the position of the tooth is inverted, they can occasionally erupt outside of the oral cavity in locations such as the maxillary sinus7-9, nasal cavity10-12, chin13-15, lower mandibular ramus16-18, lip19-20, etc.
The causes of these ectopic teeth are varied: abnormal position of the dental follicle originating in the embryonic period, crowding, supernumerary teeth, trauma, infections, cysts, tumors, endocrine disorders and hereditary factors21.
We present what is probably the first published report of the expulsion of a wisdom tooth through the skin (PubMed), after obtaining consent from the patient for the publication.
A 63-year-old woman, with no relevant medical history, who presented to her primary care clinic in May of 2010 with a fistulated abscess in the right mandibular angle, which had produced a foreign body through the fistula six days before. The patient was referred to the clinic dentist, who noted the presence of a large abscess on the floor of the mouth and right mandibular angle, with a cutaneous fistula and severe pain, and confirmed that the foreign body expelled through the fistula and brought by the patient was a tooth, specifically a lower third molar (Figures 1 and 2).
In the anamnesis, the patient reported periodic abscesses in this area over the last four years, with fistulas and purulent suppuration, treated in each case with antibiotics and anti-inflammatories. An orthopantomography from 10 years prior showed the presence of the lower right wisdom tooth in full inclusion, three centimeters mesial to the mandibular angle and under the roots of the second molar, in an upright position, at a 35-degree disto-angulation and with its roots perforating or passing through the lower mandibular cortex. A follicular cyst with a diameter greater than two centimeters enveloped the entire crown of the wisdom tooth and extended almost completely from the lower to upper cortex (Figure 3).
The maxillofacial surgeons who had treated the patient in the past had advised her against surgery due to the difficulty of the intervention and the possibility of injuring the inferior alveolar nerve.
A new orthopantomography was taken (Figure 4), showing the absence of the lower right wisdom tooth, as well as a 3 cm (height) by 2 cm (width) osteolytic lesion, which spanned the entire thickness of the jaw from the superior to the inferior cortex, with hyper-condensed edges. No involvement of the second molar was seen. Suspecting acute osteomyelitis, a mandibular CT and bone scintigraphy were done (Figures 5 and 6) which corroborated the existence of a large osteolytic cavity in the right mandibular angle, with signs of acute inflammation, but with very well defined osteocondensed edges, a sign of the evolution of a dentigerous cyst.
The clinical evolution of the case was excellent. The patient reported significant improvement in symptoms immediately after the expulsion of the molar, with complete disappearance of inflammation and pain after six weeks of treatment with antibiotics and anti-inflammatories (875 mg/125 mg amoxicillin/clavulanic acid and 600 mg ibuprofen). She was discharged.
Eight months later, the case was followed up. The patient was clinically asymptomatic, except for mild paresthesia in the fourth quadrant. The scar left by the fistula was evident, with the skin hyperpigmented and slightly withdrawn along 1.5 cm (Figure 7). A new follow-up orthopantomography showed the cystic lesion had not resolved completely, but there were clear signs of healing and new bone trabeculation (Figure 8).
The eruption of a tooth outside the oral cavity is a very rare event, and very few cases have been described in the literature13-20. In these cases, the common factor tends to be the slow eruption of a tooth through the skin, without accompanying inflammatory or infectious symptoms, although the majority of authors report episodes of mandibular trauma (Shah, Ebling,)13,15 or osteomyelitis (Gadalla, Dash)14,16 months or even years earlier. The cases described by Gadalla, Ebling, Dash and Shah13-16, were thoroughly alveolated teeth with typical dental-alveolar gomphosis, normal morphology and characteristics, with surrounding skin that were somewhat withdrawn and hyperpigmented but healthy and which formed a good union with the tooth. Ebling15, who did an anatomical and pathological study of this union, found two to three lines of cells that form a junctional epithelium, surrounded by tissue rich in collagen fibers and lymphocytes. Dash16 produced positive results from vitality tests on the pulp of two mandibular molars that had erupted through the skin, which indicates that these teeth were alive as well as being fully erupted. In the x-rays, all of these teeth were inverted, as could be expected.
The present case differed substantially from these others in the sense that the molar did not erupt through the skin in a typical physiological process (although outside the oral cavity), but was abruptly expelled through a chronic fistula in the context of an important acute infection of the dentigerous cyst, which had encapsulated it for over a decade. The case is, then, a pseudo-eruption, a process more similar to the expulsion of a foreign body, much like the slow expulsion of retained root remnants of the alveolar ridge commonly seen in clinical practice. In the first orthopantomography (Figure 3), the wisdom tooth can be seen in an upright, not inverted, position. Abu-El Naaj et al.1 describe a case very similar to ours in which a wisdom tooth associated with a dentigerous cyst and repeated infectious episodes and a transcutaneous fistula had perforated the lower mandibular cortex and probably would have been expelled in the same way if it had not been extracted surgically first. We should emphasize that there are numerous cases of incisor fragments housed in the labial tissues after traumas that are later expelled as foreign bodies19,20,22-26, but we have not found any published cases of a molar such as ours (PubMed).
The causes of these disorders are not clear, and we can only form a hypothesis. Published cases of transcutaneous dental eruption all present prior trauma or mandibular infections, which hypothetically could have caused the inversion of the dental bud at an early stage, when the roots had not yet formed, and result in its later inverted eruption. Our case appears to be the result of the infection of a large and growing dentigerous cyst, which eventually perforated the inferior mandibular cortex and expelled the affected tooth through the resulting fistula as a foreign body.
We therefore concluded, that the emergence or outcome of a tooth through the skin may be due to two different pathologic processes: 1) An authentic process of dental eruption, because of an inverted position of the dental bud, or 2) A process of foreign body expulsion after acute or chronic infection of the tooth and soft tissues with cutaneous fistula, with the possible presence of an associated dentigerous cyst.
The eruption or expulsion of teeth outside of the oral cavity, in the skin, maxillary sinus or nasal cavity are very unusual phenomena, but sufficiently frequent that a medical or dental practitioner may encounter them in clinical practice, and should be aware of them. A simple orthopantomography can provide a diagnosis in the majority of cases and should be done when alterations in the normal dental eruptive pattern are observed, as well as when there are antecedents of trauma or important infection of the jaws.
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We wish to express our gratitude to the Fundació IDIAP-Jordi Gol (Barcelona), for their help in the evaluation, translation and assessment of this manuscript.
Figure 1: Acute fistularized submandibular phlegmon, six days after the expulsion of the molar.
Figure 2: Wisdom tooth carried by the patient and which was expulsed through the fistula.
Figure 3: Orthopantomography of the patient from 10 years prior to resolution, where the wisdom tooth is visible next to the lower edge of the mandible, encapsulated by the follicular cyst.
Figure 4: Orthopantomography of the patient after the expulsion of the wisdom tooth, in which the absence of the tooth and the large osteolytic cavity that spans the space between the superior and inferior mandibular cortex are evident.
Figure 5: Mandibular CT showing the large osteolytic cavity left by the wisdom tooth and the cyst.
Figure 6: Scintigraphy showing increased uptade in the right mandibular angle, sign of an acute inflammatory process.
Figure 7: Current state of the patient, showing hyper-pigmented and indented scar left by the fistula.
Figure 8: Follow-up orthopantomography showing the state of healing and bone regeneration of the lesion.