Traumatic impaction of foreign body in the mucobuccal fold of lower anterior region in the oral cavity: A chance finding.

Foreign bodies may be ingested, inserted or deposited in the oral cavity. Iatrogenic foreign bodies such as impression material, amalgam, broken instruments, needles etc., are commonly encountered. These foreign bodies are generally symptomatic and show signs of inflammation pain and purulent discharge. An unusual case of asymptomatic traumatic foreign body (stone) impacted in the lower anterior region due to an accident 3 years back, which was diagnosed during routine oral examination is reported.

INTRODUCTION

Foreign bodies may be ingested, inserted into a body cavity, or deposited into the body by traumatic or iatrogenic injury. Motor vehicle accidents, assaults, and bullet wounds are a common cause for traumatic foreign bodies.[1] The more common iatrogenic lesions include apical deposition of endodontic materials, mucosal amalgam and graphite tattoos, oil granulomas, and traumatically introduced dental materials and instruments.[2] These foreign bodies and tissues reactions to foreign bodies are commonly encountered in the oral cavity. Most of the foreign bodies cause abscess formation, septicemia or lead to severe hemorrhage. They can also undergo distant embolization.[2] Those foreign bodies encountered in the oral cavity may present a diagnostic challenge due to many factors such as the size of the object, the difficult access, and a close anatomic relationship of the foreign body to vital structures.[3]

Complications caused by impacted foreign bodies include infections of peripheral nerve damage, pseudoneurysms and synovitis.[4]

This paper describes an asymptomatic presentation of a foreign body (stone) in the oral mucosa which clinically appeared like a soft tissue swelling on routine intra-oral examination.

CASE REPORT

A 32-year-old male patient presented to the Department of Periodontics with the chief complaint of pain and food impaction in relation to 16, the pain was continuous and dull in nature, on periodontal examination, bleeding on probing was present, with a probing pocket depth of 4 mm in the distobuccal region in relation to 16. Intra-oral periapical radiograph did not reveal any pathology and no evidence of furcation involvement, except a crestal bone loss distal to 16. Therefore, a provisional diagnosis of localized chronic periodontitis was made in accordance to the (Aap workshop 1999) and Phase I therapy was planned.

On routine dental examination, the patient had a swelling in the mucogingival area of lower anteriors. Extending from 32 to 42 and a miller's Class I recession in relation to 41 [Figure 1]. History revealed that the patient was involved in a car accident 3 years back. This resulted in cuts and bruises in the face and oral mucosa, emergency care was given with sutures placed externally over the chin and it had healed uneventfully.

Figure 1

Preoperative view

DESCRIPTION OF THE SWELLING

On inspection, the swelling measured 2 cm × 2 cm, extending to the mucogingival area apically from the apical region of the lower anterior teeth with no surface and vascular changes [Figure 1]. The swelling was hard, nontender and freely movable and was not attached to the underlying bone. The mass was soft to rubbery-firm on palpation, with no surrounding induration. It was minimally compressible, and margins were well defined. The nodule was mobile and could be easily moved to the back of a mouth mirror. The patient experienced no pain on palpation and was unaware of the presence or duration of the lesion.

RADIOGRAPHIC ASSESSMENT

An orthopantomograph showed a well-defined radio-opacity overlapping the roots in relation to 41 and 42 [Figure 2]. There was no periapical involvement and on assessment, the vitality of the tooth was intact. Therefore, the provisional diagnosis of a foreign body embedded in soft tissue was considered.

Figure 2

Radio-opacity overlapping the roots in relation to 41 and 42

SURGICAL PROCEDURE

Exploratory surgery was planned under local anesthesia, with Bard Parker blade no 15, a single vestibular incision was given extending from 32 to 42 for a depth of 3 mm into the area of swelling and a hard object was felt [Figure 3]. The overlying thick fibrotic tissue was explored, and a black stone was seen embedded in the soft tissue. The foreign body (stone) was removed in toto [Figures 4 and 5]. The fibrotic tissue surrounding the foreign body was excised completely, and a simple interrupted suture was placed [Figure 6] and the patient was put under analgesics with postoperative instructions.

Figure 3

Vestibular incision over the area of swelling

Figure 4

Black stone embedded in the soft tissue

Figure 5

Stone placed in the piece of gauze

Figure 6

Sutures placed

As there was also a Grade I recession in 41 [Figure 1], we planned to include root coverage using the bridge flap technique[5] along with the foreign body removal. However, the patient was not willing and, therefore, the procedure was not undertaken.

DISCUSSION

Foreign bodies may be deposited in the oral cavity either by traumatic injury or iatrogenically. Motor vehicle accidents and bullet wounds are common causes of traumatic injury. Glass pieces are the most frequently reported traumatic foreign bodies.[6]

Frequently, it is difficult to detect these impacted foreign bodies clinically, and they pose a diagnostic challenge. The visibility of different materials on plain radiographs depends on their ability to attenuate-rays. Foreign bodies may be visualized, depending on their inherent radio density and proximity with the issue in which they are embedded.[7] Metallic objects, unless made of aluminum, are opaque on radiographs. Plain radiograph and computed tomography are able to reveal foreign bodies such as stones, displaced pieces of teeth various metals and glass. In our case report, the foreign body (stone) was clearly visible in the orthopantomograph and was radio opaque [Figure 5].

Even if the patient is asymptomatic, removal of these foreign bodies is mandatory, since these objects usually lead to secondary infection, with abscess and fistula formation.[8] Depending on the type of trauma, the composition and location of the foreign bodies can vary considerably as superficial and penetrating foreign bodies. Superficial bodies are usually easy to remove if seen, and penetrating foreign bodies are more difficult to remove.[9] It is necessary to determine whether the foreign body is near vital structures or not. In most documented instances, patients present with oral pain and signs of inflammation with purulent discharge. Reports of asymptomatic foreign bodies are rarely reported in the dental literature.[1011]

In this case report, the foreign body (stone) was retained in the labial mucosa for 3 years after closure of the wound, and the stone was deeply embedded in fibrotic tissue. The patient was, however, unaware of the embedded stone and was completely asymptomatic. It was only observed on routine intra-oral examination. This case report highlights the importance of a thorough and systematic intra-oral examination. Though the lesion was asymptomatic at the time of examination, these retained foreign bodies are capable of causing inflammation, abscess formation as well as chronic pathologies including granulomatous tissue reaction, fistula formation and osteomyelitis if unnoticed and not removed.[12]

CONCLUSION

Though the patient's primary complaint was food impaction, routine intra-oral examination revealed a neglected, asymptomatic foreign body for over 3 years. This case report emphasizes the importance of a thorough and systematic dental examination, which would go a long way in avoiding local and systemic complications due to the foreign body.