Hazards of swallowing orthodontic appliances

Clinical examination of orthodontic patient
 Careful patient assessment
is the most important part
of treatment.
• A simple assessment should
include the following:
– • Medical history
– • Patient’s complaint
– • Extra-oral examination
– • Intra-oral examination
– • Radiographs
– • Orthodontic indices
– • Justification for treatment
– • Treatment aims
– • Treatment plan
D. Roberts-Harry and J. Sandy: Orthodontics. Part 2: Patient assessment and examination I. BRITISH DENTAL JOURNAL VOLUME 195 NO. 9 NOVEMBER 8 2003

Medical examination
starts when patient
first enter the clinic.

Medical conditions (such
as stroke, dementia and
Parkinson's disease), use
of local anesthetics,
altered states of
consciousness associated
with intravenous sedation
, and age (a decreased
gag reflex in elderly
patients) are all factors
contributes to increase
the possibility of foreign
bodies aspiration.

 The extra-oral examination is conducted first

The skeletal relationship must
be assessed three-
dimensionally.

Clinical examination of
orthodontic patient
 The teeth lie in a position
of soft tissue balance

 Habits such as thumb sucking can induce a
malocclusion

The Quad-Helix appliance
Haas Expander

Removable appliances
Removable appliance with expansion screw
Twin block removable functional appliance

Removable expansion
orthodontic appliance

Frankel's functional regulator

Prof. Sander's bite jumping appliance

RETAINERS
Wraparound Hawley retainer

Essix thermoplastic retainers Removable Hawley-Type Retainers
Spring Aligners

Acrylic retainers are worn during nights,
retainers with sharp wire projections should be
avoided as it can cause (laceration, perforation
and infection or make its removal very difficult)
if swallowed
Spring Aligners

The ingestion or aspiration of instruments
or materials used in treatment can occur in
every field of the dental profession.
Zitzmann et al : Foreign body ingestion and aspiration. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:657-60

Foreign bodies vary in size and shape and
range from endodontic instruments, burs,
posts, root copings, teeth, orthodontic
brackets, and impression materials to
temporaries, implant components, and
restorations. Some objects are made of
materials that lack radiopacity, which makes
it impossible to identify their position;
diagnostic bronchoscopy or computed
tomography for localization is then required.

Abdominal ComputedTomography showing the
presence of a toothpick

In a 33-year
retrospective review,
Limper and Prakash
reported that the
second most common
cause of foreign body
aspiration in the lungs
was of dental origin.
Limper AH, Prakash UB. Tracheobronchial foreign bodies in adults. Ann Intern Med 1990;112(8):604-9.
Orthodontic wire

It has been reported that the patients who most
often swallow foreign bodies form select groups; these
groups include prisoners, psychotic individuals, people
with alcoholism, the senile, mentally retarded
individuals, patients who are nervous or restless, and
patients with an excessive gag reflex .

Predisposing factors to be checked with
medical questionnaire, patient’s medical
history, and during examination
1. Is on medication and/or has used a sedative
2. Abuses alcohol and/or drugs
3. Is serving a long-term prison sentence
4. Is psychotic
5. Is senile (mentally confused because of age)
6. Is mentally retarded
7. Has experienced a traumatic loss of consciousness (eg,
during an accident)

8. Has a hiatal hernia and symptoms of reflux esophagitis
9. Is pregnant and/or overweight, with increased intra-
abdominal pressure
10. Is barrel-chested or obese, with difficult access sites
11. Is nervous and/or restless and may move unexpectedly
12. Has hyperactive gag-reflexes
13. Has limited mouth opening, a small oral cavity, or
macroglossia
14. Wears complete dentures
Predisposing factors to be checked with
medical questionnaire, patient’s medical
history, and during examination

A hiatal hernia occurs when part of the stomach protrudes up into
the chest through the sheet of muscle called the diaphragm. This may
result from a weakening of the surrounding tissues and may be
aggravated by obesity and/or smoking.

Barrel chested
appearance resulting
from air trapping that
sometimes occurs with
advanced chronic
obstructive pulmonary
disease. X-ray on the
right also
demonstrates the
increased A-P
diameter along with
flattening of the
diaphragms.

Foreign bodies
entering the alimentary
canal do not represent
such a serious medical
problem unless they
become impacted or
cause perforation of the
gut wall as the majority
pass through without
incidence (Webb et al.,
1984; Hinkle, 1987;
Ghori et al.,1999).

The incidence of reported cases of
aspiration or ingestion of orthodontic
appliances include swallowing of a trans-
palatal arch during its removal (Absi and
Buckley, 1995), a lower spring retainer
(Hinkle, 1987), an upper removable appliance
(Martinez et al., 1975), a fragment of an upper
removable appliance (Parkhouse, 1991), a
piece of archwire (Lee, 1992), and expansion
appliance keys (Nazif and Ready, 1983).

Lateral and P/A
radiographs of the
neck with the broken
transpalatal archwire
at the level of CV6 and
CV7
 H. M. Abdel-Kader:
Al-Azhar University

 Chest radiograph demonstrating dental bridge in
the stomach.
Fixed Partial Denture

Patient position
In a supine position there is an increased risk of
objects entering the oropharynx, although it has
been suggested that the supine patient is prevented
from swallowing, and hence there is less chance of
aspiration or swallowing of foreign bodies. However,
accidents are possible when treating patients in
either position.
Supine position
Reclined position

Foreign bodies at Oropharyngeal level
• 60% of cases
• cause a well
localised clear
sensation of
something being
trapped
• mild to quite severe
discomfort.
• Drooling of saliva and an inability
to swallow
• Airway compromise may occur if
large objects are trapped.
• if stuck may lead to infection or
perforation

Foreign bodies at Oesophageal level
 In adults: an acute presentation following ingestion of
an object or food item that gets stuck.
 a vague sensation of something being stuck in the
centre of the chest or epigastric region
 Dysphagia, salivary pooling/drooling
 Gagging, vomiting, retching, neck and/or throat pain

Foreign bodies at
Oesophageal level
 Children with partial
oesophageal obstruction
may present with a chronic
course featuring inability to
feed, failure to thrive, fever,
recurrent aspiration
pneumonitis/pneumonia or
respiratory
embarrassment/stridor (due
to tracheal impingement).

Signs and symptoms
About 75% of children who
have an impacted foreign body
will have it at the level of the
upper oesophageal sphincter
while roughly 70% of affected
adults having impaction at the
level of the lower oesophageal
sphincter.

Foreign bodies at Sub-oesophageal level
It depend on the level
through the gut. Vague
symptoms such as
abdominal distension and
discomfort, fever, recurrent
vomiting, passing rectal
blood/melaena (black, tarry feces
that are associated with gastrointestinal
hemorrhage) and/or other
symptoms of acute or
subacute intestinal
obstruction may be present.

Symptoms due to gastrointestinal perforation
If an object perforates
the oesophagus it tends to
cause acute pain and/or
infections (mediastinitis (
inflammation of the tissues in the mid-
chest, or mediastinum) ,
pneumonitis (inflammation of the
tissues in the lung) or peritonitis
(inflammation of the peritonium) ).

 Acute mediastinitis is
an infection of the
mediastinum which is
often fulminant and
fatal. The majority
result from
oesophageal
perforation (including
from impacted
foreign body)

Examination of the patient with
definite/suspected foreign body
ingestion/entrapment
• Assess the airway and respiratory function to
exclude/highlight any compromise

• Check vital signs to exclude
airway obstruction or acute
gastrointestinal perforation, or
fever in case of delayed
presentation

• Open the mouth and observe the oropharynx
with a bright light

The Heimlich Maneuver® for CHOKING ADULTS
• From behind, wrap your arms around the patient's waist.
• Make a fist and place the thumb side of your fist against the victim's upper abdomen, below
the ribcage and above the navel.
• Grasp your fist with your other hand and press into their upper abdomen
• with a quick upward thrust. Do not squeeze the ribcage; confine the force of the thrust to
your hands.
• Repeat until object is expelled.

When an adult is choking
inform the patient what you are going to do

Start with five back blow pushing

Go behind the patient
wrap your arms around the patient waist

First find the patient navel (umbilicus)

Make a fist with the thumb inside against the midline of the
patient abdomen

repeat treatment until the object is removed

Wrap your arms on the patients’ chest
Perform only backward thrusts until the object is removed

 Consider indirect laryngoscopy and/or
examination of the pharynx if dentist has
appropriate equipment and a sufficiently
experienced practitioner available
laryngoscopy

 Gently palpate the neck and assess tracheal
position/compression

 Formally examine the chest and listen to the
lungs

 Perform a cardiovascular examination

In emergency situations
can be performed. The
emergency surgeon makes a cut in a
thin part of the voice box (larynx)
called the cricothyroid membrane. A
tube is inserted and connected to
an oxygen bag. This emergency
procedure is sometimes called a
cricothyroidotomy

Risks
There are several short-term risks
associated with tracheotomies. Severe
bleeding is one possible complication.
The voice box or esophagus may be
damaged during surgery. Air may
become trapped in the surrounding
tissues or the lung may collapse. The
tracheotomy tube can be blocked by
blood clots, mucus, or the pressure of
the airway walls. Blockages can be
prevented by suctioning, humidifying
the air, and selecting the appropriate
tracheotomy tube. Serious infections
are rare

Abdominal and Chest X-rays:
When there is a history of a swallowed or
aspirated radio-opaque object, then abdominal x-ray
,posteroanterior chest x-ray and lateral chest x-ray
should be carried out to confirm or refute the
possibility of oesophageal entrapment.

Endoscopy
Urgent endoscopy is
mandatory in cases
where there is airway
obstruction or evidence
of other severe
complications.

Endoscopy is
definitely indicated
when ingested objects
are sharp, non-radio-
opaque, elongated, or
where there are
multiple swallowed
objects or a high-risk of
oesophageal injury.

Endoscopy is also
indicated for gastric or
proximalduodenal
foreign bodies that
have a diameter of
2cm, length of 5–7cm
or are eccentrically-
shaped and prone to
enlodgement and
perforation, such as
open safety pins.

 Endoscopy is a relatively
safe procedure in
experienced hands, but
costly, and should
therefore be avoided as a
routine intervention if
possible.

CT scans
CT scanning of thorax/abdomen
is highly useful at locating entrapped
objects of various types and
considered superior by many to plain
x-ray imaging.
CT scanning is the investigation
of choice if there is reason to suspect
perforation or abscess formation.
Tooth pick

 Endoscopic appearance of metallic foreign
body.

 Chest Radiography (PA
and lateral) with a
metallic foreign body in
the right lobe bronchus.

 X-ray of the neck and chest AP-view showing foreign body
marble atT1-T2 level

Complications due to ingestion/ aspiration

Oropharyngeal foreign bodies
 Scratches and lacerations of oropharyngeal
mucosa
 Perforation
 Retro-pharyngeal abscess
 Soft-tissue infection or abscess

Oesophageal foreign bodies
 Scratches, lacerations or
abrasions of mucosa
 Oesophageal necrosis
 Retropharyngeal
abscess
 Oesophageal stricture
 Oesophageal
perforation and
subsequent

Oesophageal foreign bodies
 paraoesophageal abscess
 Mediastinitis
 Pneumothorax and/or
pneumomediastinum
 Pericarditis/cardiac
tamponade
 Tracheoesophageal fistula
 Aorto-oesophageal
fistulae or other
mediastinal vascular injury

• Gastric/small-intestine
foreign bodies:
Entrapment of object within
Meckel’s diverticulum
Perforation leading to
peritonitis and advanced
sepsis
Acute or sub-acute small-
intestinal obstruction
foreign bodies in
Meckel’s diverticulum

MANAGEMENT OF SWALLOWED/
ASPIRATED DENTAL OBJECTS
MAINTAIN PATIENT IN RECLINED POSITION
Airwaynotcompromised Airwaycompromised

Askpatienttocough
Airwaycompromised
Object not retrieved (thrown out) and airway obstruction exists
Perform Heimlich manoeuvre
Immediate summon, Support including
cricothyroidotomy where necessary
Escort patient to hospital for clinical/ redigraphical examination
Summon: to arrange for the
emergency centre to be ready to
receive your patient

Examinationofmouthandlocalarea
Airwaynotcompromised
swallowed
Maintain airway
Reassure the patient
Not swallowed
Retrieve and identify the object
Escort patient to hospital for clinical/ redigraphical examination
Identify the location of object

Identify the location of object
Gastroinestinal
Refer to gastroenterologist
Oesophagus
Respiratory tract
Endoscopic removal
Arrangement for bronchscopy/ surgery

Gastroinestinal tract
Monitor 2 weeks, examination of stools
Object retrieved
Object not retrieved
Identify object, Reassurance patient

Object not retrieved
Radiographic examination
Object still present
Object no longer present
(assume object passed,
reassure patient)
Consider need for
endoscopy or surgery

Ingestion of a quadhelix appliance requiring surgical
removal: a case report
a 13-year-old Down’s syndrome boy was
treated with a removable quadhelix appliance
for maxillary arch expansion.
Allwork JJ, Edwards IR, Welch IM. Ingestion of a quad-helix appliance requiring surgical removal: a case report. J Orthod 2007;34:154-7.

The removable component of the appliance
dislodged from the sleeves welded to the
molar bands and was accidentally swallowed
while the patient was eating yoghurt for
breakfast at school.

He presented without
any signs or symptoms
of respiratory distress or
gastrointestinal tract
irritation. An erect
anterior–posterior chest
radiograph was taken to
determine the location
of the appliance. The
radiograph confirmed
that the quadhelix was
situated in the region of
the lower oesophagus.

The patient was
referred to the
general surgeon
who planned to
retrieve the foreign
body with the aid of
a gastroscope under
a general
anaesthetic.

The surgeon
considred that the
risk of visceral
perforation was
high if the
quadhelix were to
be retrieved (to be
removed through
the mouth) in a
retrograde manner
with grasping
forceps.

It was therefore mobilized and passed distally
into the stomach. A mini- laparotomy (small incision
through the abdomen wall) was then performed. Access to
the stomach was gained via a 5 cm epigastric
midline incision and the foreign body was
removed from the stomach via a small
gastrotomy incision.

His active orthodontic treatment was
subsequently concluded using a preadjusted
edgewise appliance and an auxiliary E-arch to
maintain the expansion. Retention is being
monitored and he has recovered well.

Peri-operative second molar
tube failure during orthognathic
surgery: two case reports

Intra-operative view of a sagittal split osteotomy.
Note the proximity of the anterior relieving incision
to the position of the molar band

The post-operative rotational tomogram revealed
that the second molar tube on the left-hand side
had debonded during the operation and remained
within the surgical wound site.
Case 1

Case 1
It was not possible to palpate the molar tube
due to the postoperative swelling. The patient
was fully informed of this at review and it was
decided to leave the tube in situ.

Case 1
There was no subsequent infection of the
wound site and the tube was not palpable
once the swelling had subsided..

The post-operative rotational tomogram and
posteroanterior skull radiographs revealed a
tube to be positioned within the surgical
wound site.
Case 2

Again this wound site
healed without any
infection or damage to
the inferior-alveolar
nerve. It was decided to
leave this in situ unless
problems arose in future.

A 17-year-old girl was referred for surgical
correction of a Class III dentoskeletal
deformity
After the sagittal osteotomies, the surgeon
noticed that the maxillary right second-molar
bracket had been debonded and lost.
Orthodontic bracket lost in the airway during orthognathic surgery

Intraoperative lateral and posteroanterior radiographs show a
metal bracket (arrows) in the anterior aspect of the fourth
cervical vertebra.

This position indicated that the bracket was most likely in the
piriform recess of the larynx just above the vocal cords and
cuff of the endotracheal tube..

The throat pack was carefully removed, and the
hypopharynx inspected by using a laryngoscope. The
bracket was identified and removed with a forceps.

• A 45-year-old man came to the pulmonary clinic
for evaluation of what he thought was a three-
year history of asthma.
• Chest radiographs did not show any aspirated
material, bronchoscopy located a foreign body in
the right lung and removed it with a flexible
fiberoptic bronchoscope.

A 42-year-old age
woman accidentally
swallowed her lower
denture, which was
composed of eleven
teeth.
Image of partial denture at left
upper quadrant of the plain
abdominal radiograph on
admission day.

• Image of partial denture
at right lower quadrant
The daily descent of
the denture was
followed by plain
abdominal radiography
and physical
examination. The
image was localized at
the left upper quadrant
on admission day, but
it stopped on its way at
the right lower
quadrant on day two
and three.

Image of partial denture at
ileocecal region at lower
computurizedc tomography.
Since the patient's complaints increased we planned
surgical removal of the denture.

• Partial denture at ileum
Since the patient's complaints increased we planned
surgical removal of the denture.

• Extraction of dental denture via ileotomy

Denture In Esophagus
Mimicking Carcinoma
Accidental ingestion of
dentures may escape detection in
oesophagus since they are
radiolucent.
This case reported an
unsuspected denture in
esophagus mimicking a
carcinoma on imaging studies,
which was detected and treated
after nearly 4yrs.
Barium swallow study reveals filling defects in
the cervical oesophagus

Axial post contrast CT
scan reveals concentric
wall thickening of
cervical oesophgus with
obliteration of the
lumen.

Follow up Barium
study 2 yrs later reveals
a tracheo oesophageal
fistula and persistence
of filling defects

Esophagotomy was
perfumed and a denture with
granulation tissue was
removed. The tracheo-
oesophageal fistula however
persisted post operatively
and was treated by
submucous fibrin glue
injection. There was
complete healing of the
fistula as seen on endoscopy.

An Iatrogenic esophageal perforation with dentures
CT scan of thorax shows a foreign body in esophagus with
multiple air pockets in different tissue plan.

CT scan of thorax shows right side
hydropneumothorax, pneumomdiastinum and
multiple air shadow in subcutaneous tissue.

Photograph shows perforation in mid esophagus.

Photograph of denture after removal

Precautionary measures to prevent
aspiration or ingestion of foreign bodies
1. Related to patient
• Identify high-risk patient
• Consider (1) treatment with patient under
general anesthesia or (2) alternative
treatment options
• Use gauze screen to protect oropharynx in
sedated or conscious patient
• Treat patient with swallowing or coughing
problem in upright position

2. Related to orthodontic treatment
 Check band retention when impressions are made for
banded teeth.
 Use custom impression tray to minimize amount of
impression material required that could flushed away.
 Check retention of removable appliances
 Take extra care during placement of small objects. Seal
off oropharynx if necessary.
 Use dental floss to tether movable parts.
 Patients in whom the coordination of the deglutition
and cough reflexes are affected or the intra-abdominal
pressure is increased should be treated in a more
upright position.

Bonded attachments are often used rather
than bands because it is easier to bond to
partially erupted teeth, there is no need for
orthodontic separation or cementation, and
they offer improved periodontal health and
patient comfort. However, bonded brackets
can fail during conventional orthodontic
treatment, and the chance of failure might be
greater during surgical procedures.

In spite of these advantages,
bonded molars have failure
rates of 33.7% vs 18.8% for
banded molars. These failure
rates in surgical patients
might result in displacement
of the appliance into the
surgical field, oral pharynx, or
even the airway.

These foreign bodies
were left in situ without
ensuing problems. puts
the patient at risk of
aspiration; Pneumonia,
pulmonary abscess
formation, empyema
(pus with feces), and
even death could
ensue.

Wire lost in the mouth
• Never use straight cutter to remove excess
wire, it may lost in the oral cavity

Wire lost in the mouth
• When cutting the ends of archwires with safety
distal end wire cutters, the pliers sometimes fails
to hold the cut fragment. A cotton wool roll placed
over the end of the arch-wire before it is cut will
prevent the piece of archwire becoming displaced
in the mouth, or embedded in the soft tissues

Loose bracket and bands
Use glass ionomer of good quality
Cinch back the wire distal to the band
Loose band could be ingested or inspirated

• Debonding should be done with wire in place
to prevent bracket losing.

Clinical suggestions in orthognathic case set-ups
Ideally both bonded first
and second molars should
be tied together or
banded before surgery to
avoid loss if failure,
another alternative is
annealing and cinching
the archwire

• During taking the cephalometric X-
ray ear rods should be in while the
patient is sitting to prevent injuries
in case of fainting
• New machines does not include
ear rods

• The use of a gauze dental napkin as a barrier
technique can be very useful when placed
behind the orthodontic appliance during its
adjustment

• Parts like rubber dam clamps,
molar bands , Keys for turning
fixed expansion appliances intra-
orally should be attached to floss
• An alternative key that is
attached to a plastic spatula is
now commercially available and
may be a preferable alternative

• Auxilliaries that are placed on archwires such
as coil springs can be temporarily stabilized on
the wire during its placement with wax

• All the components of removable appliances
should be smooth and rounded as far as
possible. Hooked or 'C clasps should be
avoided if possible.
• All removable appliances must be suitably
retentive and of an adequate size
• The use of different coloured acrylics, rather
than pink to avoid problems visualizing the
acrylic on bronchoscopy or endoscopy if
fragments are inhaled or swallowed

• All orthodontic instruments that are used
intra-orally should be regularly inspected for
signs of failure, and replaced or reconditioned
on a regular basis

• Ingested ultrasonic scaler tip (arrow) in the
patient’s large intestine.

• During the taking of impressions the
impression material used should have a high
viscosity and the tray should be the correct
size and fit

• If a piece of appliance is dropped in the mouth
during treatment, the availability of high
speed suction with a pharyngeal tip can help
with quick retrieval

Hazards of swallowing orthodontic appliances

Hazards of swallowing orthodontic appliances

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