Errant Elastic Extrudes 2 Teeth by Dr. Michael Daetwyler with Drs. Robert Julian and Brian Woo

A young patient’s case illustrates a risk of DIY orthodontics

by Dr. Michael Daetwyler with Drs. Robert Julian and Brian Woo

A 9-year-old patient was referred to the oral and maxillofacial surgery clinic at UCSF Fresno for urgent evaluation of Teeth 8 and 9, with Class III mobility and severe bone loss caused by a soft-tissue lesion. The patient and his mother both reported no past medical or surgical history or trauma to the area, and said that his teeth had been “normal” just one month before but gradually became more mobile, accompanied by significant inflammation to the gingiva between them.

The patient had been seen by dentists at two different dental offices, who had started him on amoxicillin and referred him to our clinic for evaluation of possible pathology. Over the week before their arrival, the patient’s mother reported increasing pain associated with teeth/soft tissue to anterior maxilla as well as increased mobility, and the presentation of a foul odor.

Evaluation revealed an erythematous, exophytic lesion between Teeth 8 and 9, resulting in their gross mobility (Figs. 1a and 1b). Radiographic evaluation (Fig. 2) appeared to show the teeth dislodging from their bony sockets, without any clear bony erosion of the lesion seen clinically. Both teeth lacked any response to cold testing, while remaining dentition, specifically Teeth 7 and 10, responded normally to cold testing and without any significant mobility. The patient was in mixed dentition stage appropriate for his age (Fig. 3), and no palpable cervical lymphadenopathy was present.

With no history of trauma to the region, infectious and pathologic concern was raised. The differential diagnoses for a pediatric patient with a rapidly advancing localized soft-tissue lesion causing displacement of teeth included juvenile aggressive periodontitis; aggressive necrotizing ulcerative gingivitis; Langerhans cell histiocytosis; pyogenic granuloma; rhabdomyosarcoma; lymphoma; and leukemia (Chart 1).

Management

Because the patient’s teeth were causing significant pain, and a thorough combination of clinical and radiographic exam had been deemed hopeless, we decided to remove Teeth 8 and 9 as well as the erythematous soft tissue between them for biopsy.

The patient was anesthetized with topical anesthetic, then 3.4ml 2% lidocaine with 1:100,000 epinephrine. The teeth and interpositioned gingiva were removed using a periosteal elevator, with little resistance or adherence to surrounding bone/soft tissue, and placed in formalin with the plan to submit for pathology evaluation.

Upon evaluation of the extraction socket, a small ring was noted to be embedded in the soft tissue apical to position of roots. A small elastic was retrieved from the extraction site (Fig. 4), and we asked the patient about its origin. He explained that his friends had been putting them on their teeth and he followed suit a few months ago, but thought that he had lost it. He failed to make the connection between the elastic and his developed symptoms, and didn’t mention it to his parents or the dentists who had seen him previously.

By the time he was seen in our clinic, the elastic had worked its way past the apices of the teeth and effectively extruded the central incisors from their sockets and devitalized them.

Discussion

The management of a midline diastema is best handled by a dental professional with either a fixed or removable appliance. Furthermore, in pediatric patients, midline diastemas of 2mm or less typically close spontaneously with the eruption of permanent canines.¹ In cases where elastics are planned to be applied directly to the teeth, such as orthodontic separators, it is imperative that the elastics are radiopaque.² Common orthodontic elastics lack this radiopacity, which would have likely enabled the patient to save his teeth because it would have been identified at his first dental visit. As weeks passed between his first dental visit until visiting our clinic on his third dental appointment since symptoms had started, the elastic was able to work itself past the apices of the teeth.

In instances where the elastic is quickly identified and removed, and the tooth is splinted into position, it is possible to save the affected dentition.³ Unfortunately, a missing history of elastic usage, a delayed presentation to our clinic, and the inability to visualize elastic clinically or radiographically ultimately led to the loss of Teeth 8 and 9.

The case allowed a review of pediatric pathology, a clinical entity that is much less common than in the adult population. It also highlights the need to take patient age into account when generating a differential diagnosis, because pediatric populations experience significantly different prevalence of different pathologic entities. Cancer of the oral cavity usually presents during the fifth and sixth decades of life; less than 5% of oral cancer occurs in patients younger than 30. This makes oral cancer in children extremely rare.⁴

In this case, for example, an erythematous, exophytic lesion of soft tissue with displacement of adjacent dentition would raise concern for malignancy. In a pediatric population, rhabdomyosarcoma might appear high on the differential while in an adult, squamous cell carcinoma would be a much more likely diagnosis. The inversion of those to pathologic entities would be very unlikely, given the age of this patient. Ultimately, however rare or common the entity, biopsy is necessary to obtain the accurate diagnosis.

The loss of teeth because of elastic migration is well described in the literature,^5,6 and it has even been used as a method to atraumatically extract teeth in bisphosphonate-treated patients to avoid osteonecrosis. In a small study, orthodontic elastics were placed around the roots of nonrestorable teeth, resulting in exfoliation of 15 teeth in an average of 5.8 weeks without any subsequent exposure of bone.⁷ In the past, elastics were also used for dental extractions in patients suffering from hemophilia.⁸ The usage of elastics to intentionally extract teeth remains an interesting area of potential development.

Conclusion

Unfortunately, this young patient lost both of his permanent maxillary central incisors because of a careless mistake and the inability of family or providers to identify the problem quickly enough to salvage his dentition. Because of his age, he was considered skeletally immature to receive dental implants, and returned to the care of his general dentist for fabrication of a removable prosthetic to allow improved aesthetics until further maturing and being considered for dental implants.

Fig. 1a

Fig. 1b

Fig. 2

Fig.3

Fig. 4

References
1. Wen-Jeng Huang, D.C. (1995). “The Midline Diastema: A Review of Its Etiology and Treatment.” Pediatric Dentistry (17:3):171–179.
2. Simona Dianiskova, C.C.-B. (2016). “Tooth Loss Caused by Displaced Elastic During Simple Preprosthetic Orthodontic Treatment.” World Journal of Clinical Cases, 4(9):285–289.
3. Al-Qutub, M. (2012). “Orthodontic Elastic Band-Inducing Periodontitis—A Care Report.” The Saudi Dental Journal, 24:49–53.
4. Stolk-Liefferink, S.A.; Dumans, A.G.; van der Meij, E.H.; Knegt, P.P; van der Wal, K.G. (2008). “Oral Squamous Cell Carcinoma in Children; A Review of an Unusual Entity.” International Journal of Pediatric Otorhinolaryngology, 72(1):127–31.
5. Monica Ghislaine Oliveira Alves, D.K. (2015). “Elastic Band Causing Exfoliation of the Upper Permanent Central Incisors.” Hindawi Case Reports in Dentistry, ID: 186945.
6. Dimitrios Konstantonis, R.B. (2018). “Torturous Path of an Elastic Gap Band: Interdisciplinary Approach to Orthodontic Treatment for a Young Patient who Lost Both Maxillary Central Incisors After Do-It-Yourself Treatment.” American Journal of Orthodontics and Dentofacial Orthopedics, (154)835–847.
7. Eran Regev, D.M. (2008). “Atraumatic Teeth Extraction in Bisphosphonate-Treated Patients.” Journal Oral Maxillofacial Surgery, 66:1157–1161.
8. Carroll La Fleur Birch, B.M. (1939). “Tooth Extraction in Hemophilia.” Journal of the American Dental Association, 12:1933–1942.