Table of Contents    
CASE REPORT
Year : 2018  |  Volume : 9  |  Issue : 2  |  Page : 294-296  

Unusual finding of molar tube embedded in the labial vestibule: A rare case of negligence


1 Department of Plastic Surgery, King George Medical University, Lucknow, India
2 Department of Periodontics, Dr. Ziauddin Ahmad Dental College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
3 Department of Orthodontics, Dr. R. Ahmed Dental College, Kolkata, West Bengal, India
4 Department of Orthodontics, Dr. Ziauddin Ahmad Dental College and Hospital, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Web Publication20-Jun-2018

Correspondence Address:
Abdul Ahad
Department of Periodontics, Dr. Ziauddin Ahmad Dental College and Hospital, Aligarh Muslim University, Aligarh - 202 002, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnsbm.JNSBM_156_17

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   Abstract 

Cases of negligence in orthodontics are not as frequent as in other dental or medical specialties. However, sometimes we come across a case of negligence that cannot be ignored. Here, we present a very uncommon finding of a molar tube embedded in the labial vestibule, between mandibular central and lateral incisors, for more than a month. The uniqueness of this finding is that a molar tube, as the name suggests, is supposed to be bonded on molars and if it gets dislodged due to any reason, it should have been embedded near the respective molar. With this dilemma in mind, this case offers many things to learn from errors.

Keywords: Orthodontic appliance, patient nonadherence, professional negligence


How to cite this article:
Ahmed R, Ahad A, Nakib AA, Tariq M. Unusual finding of molar tube embedded in the labial vestibule: A rare case of negligence. J Nat Sc Biol Med 2018;9:294-6

How to cite this URL:
Ahmed R, Ahad A, Nakib AA, Tariq M. Unusual finding of molar tube embedded in the labial vestibule: A rare case of negligence. J Nat Sc Biol Med [serial online] 2018 [cited 2018 Jul 20];9:294-6. Available from: http://www.jnsbm.org/text.asp?2018/9/2/294/234699


   Introduction Top


Regular follow-up of orthodontic patients should not be aimed at just activating the appliances or placing the next sequence of wires. It should serve a wider perspective of keenly observing the patient for any adverse treatment effects, compliance with oral hygiene instructions, and very importantly, any left outs in the oral cavity. Commonly, the extended archwire, cut by distal end cutter may be left in the oral cavity which may subsequently enter the esophagus or the trachea, causing the patient to land up in the emergency. If any orthodontic materials such as elastic separator, elastics module, bracket, band, molar tube, or temporary anchorage device get embedded in the soft tissue of oral cavity, it should be considered as an iatrogenic damage caused by the treating clinician.

Microbial plaque accumulation in the oral cavity is enhanced by various anatomic as well as iatrogenic factors.[1] Foreign body partially embedded in the gingiva or alveolar mucosa is a common niche of microbial biofilm, causing inflammation in surrounding area. Although clinical signs in such cases may mimic the features of gingivitis, it is less likely to resolve by conventional periodontal therapy.[2] Elastic separators and bands are most commonly left embedded interdentally thus causing severe inflammation and bone loss in that area.[3],[4]

To avoid pain caused due to elastic separators clinicians often use bondable molar tube instead of stainless steel (SS) bands. However, since the bond strength of bondable molar tube is much lesser as compared to spot welded molar tube on SS bands, former breaks much more frequently than latter.[5] Embedded elastic separators have been reported frequently in literature, but implantation of a molar tube or orthodontic bracket in soft tissue is a rare incidence.[6],[7],[8] We are reporting a peculiar case of the embedded bondable molar tube in the labial vestibule of the mandibular arch. Even after extensive search on various scientific databases, we could not find any report of such a case so far.


   Case Report Top


A 22-year-old systemically healthy female, reported with a chief complaint of dull pain in the lower anterior teeth region for 1 week. Pain used to get relieved on analgesic use but reappear after a few hours. She reported having been undergoing fixed orthodontic treatment for 1 year in a dental clinic. She also informed about some kind of “surgery” in the same region, performed on her last visit to the orthodontist, around 6-week back. No written details about the surgical intervention were available, and hence the exact type of surgery could not be ascertained.

Extraoral examination revealed no relevant findings. On intraoral examination, unsatisfactory oral hygiene clearly suggested that patient lacked good motivation toward dental treatment. A metallic structure was found to be partially embedded in the labial vestibule between central and lateral incisors (#41 and #42), surrounded by a zone of inflammation. Gingiva around mandibular incisors and canines was also inflamed along with a recession defect on tooth #41 [Figure 1].
Figure 1: A metallic structure partially embedded in the labial vestibule

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The metallic structure looked like an orthodontic bracket or molar tube whose maximum dimension could be no more than 8–10 mm. Without going into details of the cause of such a mishap, we decided to remove it immediately under local anesthesia. A small incision with a No. 11 Bard-Parker blade under local infiltration of 2% lignocaine was sufficient to retrieve the foreign body [Figure 2] and [Figure 3]. Now, it was clearly identified to be a bondable molar tube of mandibular right molar [Figure 3]. After hemostasis was achieved, a periapical radiograph was taken to rule out the presence of other foreign bodies. The patient was advised to take Ibuprofen 400 mg twice daily for 3 days. A Chlorhexidine mouth rinse was also prescribed twice daily for 1 week.
Figure 2: The metallic structure was removed under local anesthesia

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Figure 3: Bondable molar tube removed from the labial vestibule

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The patient reported after 5 days with complete relief from pain. Satisfactory healing of previously involved site was observed. Oral prophylaxis was performed and oral hygiene instructions were reinforced.


   Discussion Top


As already mentioned, many cases of embedded elastic separators have been reported which the patients carry in their oral cavity, for years, without even noticing them.[6],[7],[8] Patients hardly report until it turns out to be a painful abscess. However, in the present case, a metallic molar tube with a hook remained embedded for over a month, and the patient reported only when it pained. It was really surprising to find an appliance, used on molars, to be embedded in the anterior region. As the actual cause and time of this unfortunate incident could not be ascertained, only speculations and possibilities can be explained.

A possibility of negligence exists, wherein the treating orthodontist might have attempted mandibular anterior corticotomy for periodontally accelerated osteogenic orthodontics. A debonded molar tube might have got trapped inside the flap during surgery. This incident may also be associated with some mucogingival surgery attempted to cover the gingival recession in the right mandibular central incisor. Another speculation may be associated with the bonding of brackets and molar tubes, where the clinician might have lost the control and due to instrument slippage, the molar tube might have landed in there.

State rules and regulations which preserve the rights of practicing general dentists and specialists as well as to discourage the unauthorized practice by an untrained person are not strongly implemented in India.[9],[10] This contributes to spreading of malpractice, and hence, negligence toward patient's care. Most of the dental negligence cases go unreported as a majority of the population lack awareness.[11]

Although the patient was not maintaining proper oral hygiene and did not report to her orthodontist immediately after initiation of pain, nevertheless, it was responsibility of the treating clinician to motivate the patient and to make sure that she was compliant to instructions and satisfied with the treatment. Orthodontists need to see beyond their focused area. Complete oral examination on every visit is essential to prevent such unfortunate incidents.


   Conclusion Top


This peculiar case of a molar tube getting embedded in an unusual location is a clear example of negligence by the clinician and poor motivational status of the patient. It is the need of the hour to spread awareness about the negligence and to sensitize clinicians about possible iatrogenic damages during orthodontic treatment. It is advisable to do a thorough examination at each visit for any residual/dislodged material during orthodontic treatment. If found and managed at an early stage, damage to oral tissues can be prevented.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Jansson L, Ehnevid H, Lindskog S, Blomlöf L. Proximal restorations and periodontal status. J Clin Periodontol 1994;21:577-82.  Back to cited text no. 1
    
2.
Koppang HS, Roushan A, Srafilzadeh A, Stølen SØ, Koppang R. Foreign body gingival lesions: Distribution, morphology, identification by X-ray energy dispersive analysis and possible origin of foreign material. J Oral Pathol Med 2007;36:161-72.  Back to cited text no. 2
    
3.
Waggoner WF, Ray KD. Bone loss in the permanent dentition as a result of improper orthodontic elastic band use: A case report. Quintessence Int 1989;20:653-6.  Back to cited text no. 3
    
4.
Becker T, Neronov A. Orthodontic elastic separator-induced periodontal abscess: A case report. Case Rep Dent 2012;2012:463903.  Back to cited text no. 4
    
5.
Chung K, Hsu B, Berry T, Hsieh T. Effect of sandblasting on the bond strength of the bondable molar tube bracket. J Oral Rehabil 2001;28:418-24.  Back to cited text no. 5
    
6.
Tandon S, Ahad A, Kaur A, Faraz F, Chaudhary Z. Orthodontic elastic embedded in gingiva for 7 years. Case Rep Dent 2013;2013:212106.  Back to cited text no. 6
    
7.
Vishwanath AE, Sharmada BK, Pai SS, Nelvigi N. Severe bone loss induced by orthodontic elastic separator: A rare case report. J Indian Orthod Soc 2017;47:97-9.  Back to cited text no. 7
    
8.
Harrington Z, Darbar U. Localised periodontitis associated with an ectopic orthodontic separator. Prim Dent Care 2007;14:5-6.  Back to cited text no. 8
    
9.
The Dentist Act, 1948 (16 of 1948). Ch. 5. Available from: http://www.dciindia.org.in/Rule_Regulation/Dentists_Act_1948.pdf. [Last accessed on 2017 Oct 30].  Back to cited text no. 9
    
10.
Puroshottam S, Patil S, Rao RS, Agarwal A. Quackery in dentistry – An uncurbed menace. Int J Contemp Dent 2013;4:6-8.  Back to cited text no. 10
    
11.
Lal S, Paul D, Vashisht B. National Oral Health Care Programme (NOHCP) implementation strategies. Indian J Community Med 2004;29:3.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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