Ectopically Positioned Tooth Piercing the Philtrum.

A variety of eruption disturbances arise during the transitional dentition period, which can be broadly classified as disturbances related to time and disturbances related to position. The occurrence of ectopic eruption is relatively common, but ectopically positioned tooth piercing the philtrum is a rare clinical presentation. This is a case report of a 70-year-old female who presented with the chief complaint of an abnormally positioned tooth piercing out from the upper lip to the Department of Oral and Maxillofacial Surgery, Karnavati School of Dentistry, Uvarsad, Gandhinagar, Gujarat, India. As per the patient's history, labially erupted tooth was piercing the philtrum for 60 years and it was visible extraorally from the philtrum and was painful. Copyright:

INTRODUCTION

The eruption process is a very complex phenomenon in which multiple factors act synchronously to achieve a normal eruption. However, the process might be altered by genetic, molecular, cellular, or tissue causes. Ectopic eruption is a broadly applied term that may indicate an abnormality of direction determining tooth eruption and/or final tooth position.

A variety of eruption disturbances arise during the transitional dentition period, which can be broadly classified as disturbances related to time and disturbances related to positions.[1] Ectopic development and eruption of the tooth into regions other than the oral cavity is rare, although there have been reports of teeth in the maxillary sinus, mandibular condyle, coronoid process, palate, chin, skin, and the nasal cavity.[2] Teeth have also been found in various unusual locations such as ovaries, testes, inferior mediastinum, retroperitoneal area, and the presacral and coccygeal regions.[3] Many cases of inverted tooth have been reported. In most cases, they have been found to be impacted in the maxilla, erupted into the nasal cavity, or found in the maxillary sinus.[4] Fewer cases have been reported in the mandible, and most of them are invertedly impacted third molar.[5]

There are very few reports of inverted mandibular premolar.[6] The occurrence of ectopic eruption is relatively common, but ectopically positioned tooth piercing the philtrum is a rare clinical presentation.

CASE REPORT

An old female reported to the Department of Oral and Maxillofacial Surgery, Karnavati School of Dentistry, Uvarsad, Gandhinagar, Gujarat, India, with the chief complaint of an abnormally positioned tooth piercing out from the upper lip and nose. As per the patient's history, labially erupted tooth was piercing the philtrum for 60 years and it was visible extraorally from the philtrum and was painful for 6 months. The patient was given a detailed explanation pertaining to the present state, i.e., only incisal one-third of the crown of tooth was visible extraorally and two-third of the crown of tooth was visible intraorally [Figure 1], and after radiographic [Figure 2] as well as clinical diagnosis, the patient was planned for tooth extraction under local anesthesia with adrenaline, followed by extraoral and intraoral closure of surgical site. The patient was explained about all possible complications and various outcomes pertaining to treatment along with written consent.

Figure 1

(a) Extraoral preoperative photograph. (b) Intraoral preoperative photograph. (c) Radiographic preoperative photograph

Figure 2

(a) Infiltration extraorally and intraorally block as well as infiltration was given. (b) Using blade no. 15, incision was carried out, and along with that, dissection was done. (c) Using anterior tooth forceps, extraction was tried, but due to thick vestibular attachments, it was not possible. (d) Crestal incision from the right side upper cabinets tooth region up to the left side upper canine tooth region was done. (e) Full-thickness mucoperiosteal flap was raised using molt no. 9 periosteal elevator, and the tooth was extracted using anterior tooth forceps. (f) Extraction socket after tooth extraction. (g) Extraoral presentation after tooth removal from philtrum. (h) Layer-wise layer dissection was done

Surgical procedure

The surgical procedure was performed under local anesthesia with adrenaline (1:200,000). Both sides local anesthesia was given as shown in Figure 2a. Incision was given using B. P handle no. 3 and blade no. 15 surrounding the tooth extraorally and intraooraly as shown in Figure 2b. Dissection was done along the periphery of the tooth crown which was visible. Then, using anterior tooth forceps, the extraction as shown in Figure 2c was tried, but due to thick vestibular attachments, the case was proceeded as crestal incision from the right side upper canine tooth region up to the left side upper canine tooth region, followed by releasing incision that was given distal to the left side upper canine tooth region, as shown in Figure 2d. Full-thickness mucoperiosteal flap was raised using Molt no. 9 periosteal elevator and the tooth was extracted using anterior tooth forceps uneventfully; along with it, Grade I mobile right side upper canine tooth and root stumps of left side upper canine were also extracted, as shown in Figure 2e. This was followed by the dissection using small mosquito/artery forcep in three different layers: i.e., extraorally skin layer dissection was done, intermediate muscle layer was dissected, and then, intraorally mucosal layer was dissected, as shown in Figure 2f. Extraoral presentation after tooth remoreremoval from philtrum.as shown in Figure 2g. Followed by the muscle layer, the mucosal layer was sutured using vicryl 4-0 suture material [Figure 2h], and skin layer was sutured using ethilon 3-0 suture material. Postoperative instructions were given, and antibiotics and analgesics were prescribed for 5 days.

Follow-up

The patient was recalled for follow-up on the 3rd [Figure 3a], 7th [Figure 3b], and 10th days and 1 month postoperatively [Figure 3c]. Hematoma was noticed on the left side of the upper lip on the 3rd postoperative day, but no infection and swelling were noticed extraorally or intraorally. On the 7th day, suture removal was done from the intraoral site, and on the 10th day, extraoral suture knots were removed, and hematoma was relieved on the 10th day. Healing was satisfactory intraorally and extraorally on the 1 month follow-up period.

Figure 3

(a) First follow-up. (b) Second follow-up. (c) Third follow-up

DISCUSSION

Many cases with intraoral or extraoral ectopic tooth position, earlier assessed as developmental anomalies, are frequently found to have a history of trauma. The effect of trauma and jaw fracture on the development and eruption of teeth has been found to be that in teeth in which root formation has started, erupt normally, or ill positioned, but their roots remain shorter compared to the contralateral teeth. The cause of the present condition might have been due to the teeth developed in an abnormal position since the beginning of the developmental stage and subsequently erupted labially positioned as the path of the eruption might have altered and ignored orthodontic treatment due to lack of awareness among the community. Whatever the cause may be, this type of extraoral tooth eruption piercing the philtrum is rare and this is first of its kind reported in the literature.

CONCLUSION

Regardless of the cause of such condition, this is a rare case. Clinicians while examining a patient should think of all possible factors and plan the treatment accordingly. Dental science has advanced a lot. However, there are thousands of conditions for which dental science cannot give any explanation. This case presents one such challenge to oral surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.