A C C I D E N TA L LY I N G E S T E D F I X E D O R T H O D O N T I C R E TA I N E R : A M A N A G E M E N T P R O T O C O L A N D A C A S E R E P O R T

K o n s t a n t i n a T s i r o n i 1 , G e r a s s i m o s A n g e l o p o u l o s 2 , I o s i f S i f a k a k i s 3

D e p a r t m e n t O f O r t h o d o n t i c s , N a t i o n a l A n d K a p o d i s t r i a n U n i v e r s i t y O f A t h e n s , G r e e c e1 P o s t g r a d u a t e S t u d e n t2 O r t h o d o n t i s t – R e s e a r c h A s s o c i a t e3 A s s i s t a n t P r o f e s s o r

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INTRODUCTIONAccidental swallowing/ingestion of an orthodontic object/appliance or fragment of an appliance although not often reported in the literature, can cause serious respiratory and/orgastrointestinal problems. A variety of incidents have been reported in literature, such as swallowing a transpalatal arch, a fragment of a twin-block appliance, a maxillary expansionappliance key, a piece of an arch-wire and retainers. Most ingested objects pass through the gastrointestinal tract (GIT) spontaneously, but approximately 10%–20% need to be removedendoscopically and 1% require surgery. The incident can either happen during the chair-side procedure or out-of-office. The aim of this paper is to report a case of an accidentallyingested fragment of a fixed orthodontic retainer and to develop a protocol on managing these incidents.

MATERIALS AND METHOD

RESULTS

DISCUSSIONAlthough uncommon, ingestion or inhalation of a foreign body is a recognized complication of various dental procedures. The foreign body is more likely to enter the GIT, rather thanthe respiratory tract. Respiratory reaction is most often immediate and severe and requires immediate action. When an orthodontic object enters the GIT the size and shape of theingested object and the presence of sharp edges influences the risk, management and outcome. Large or sharp objects are at risk of becoming impacted, but approximately 60% enter thealimentary canal without lodging in the esophagus. Additionally, most ingested objects pass through the GIT without problems (as in this case report), with 80%–90% passing within 2 to12 days2. Symptoms, if present, may include perforation, intestinal mucosal ulceration, obstruction, abscess formation, hemorrhage and fistula formation. The patient may experiencenausea, inability to swallow, hematemesis, vomiting, abdominal pain or may be asymptomatic. The treatment protocol depends on the signs and symptoms of the patient as well as on thelocation of the ingested object. When an object is accidentally lost irretrievably to the oropharyngeal area, radiologic evaluation is essential to determine the object’s exact location.According to the guidelines of the British Orthodontic Society6, an ingested smooth flexible object less than 5 cm in length is likely to pass through the GIT uneventfully, whilst largerobjects are more prone to obstruct or perforate the GIT. Removal of these larger objects may be recommended. Additionally, more than 50% of foreign bodies will evacuate in the stoolsunnoticed. A flow chart (Figure 5) summarizes all the diagnostic steps for the management of these cases. While in most cases management usually includes monitoring and dietary advice(soft diet including bananas), in only a few cases retrieval through bronchoscopy and esophagoscopy may be applied. Larger objects that have caused obstruction may need surgicalintervention through the neck, chest or abdomen. Recommendations on prevention and management of such incidents may include the following:

CONCLUSIONSProper management of swallowed / ingested orthodontic objects is crucial to the patients’ health and safety. The above-mentioned recommendations may provide a helpful tool for the clinician in order not only to prevent swallowing of orthodontic objects but also to be readily prepared to manage such incidents.

REFERENCES1.Park JH, Owtad P, Milde B. Incident management guidelines for an ingested orthodontic object. Int J Orthod Milwaukee. 2013 Fall;24(3):45-9. PMID: 24358659.2. Al-Wahadni A, Al Hamad KQ, Al-Tarawneh A. Foreign body ingestion and aspiration in dentistry: a review of the literature and reports of three cases. Dent Update. 2006 Nov;33(9):561-2, 564-6, 569-70. doi: 10.12968/denu.2006.33.9.561. PMID: 17176743.3. Puryer J, McNamara C, Sandy J, Ireland T. An Ingested Orthodontic Wire Fragment: A Case Report. Dent J (Basel). 2016 Aug 1;4(3):24. doi: 10.3390/dj4030024. PMID: 29563466; PMCID: PMC5806942.

An 18.2-year-old boy accidentally ingested a 20 mm fragment ofa 0.0215-inch twistflex retainer during lunch. The wire hadbeen bonded on upper six anterior teeth (Figures 1 & 2) 18months before the incident. A literature review was carried outusing the PubMed, Scopus and Science Direct databases for casereports relating to ingestion of foreign bodies of orthodonticorigin, written in English. The search was carried out using acombination of the keywords “ingested’’, ‘’foreign bodies’’,‘’orthodontic’’ and produced a total of 118 results. The titlesand abstracts of these 118 papers were examined. Duplicatesand review articles were excluded.

The patient reported abdominal pain and nausea after theingestion and was instructed to seek hospital emergency care.A posteroanterior chest x-ray and a posteroanteriorabdominal x-ray revealed that the wire was located in thelower third of the descending colon (Figures 3 & 4). Thebiochemical blood analysis data were normal. Dietaryinstructions were given. After 2 days the wire found its waythrough the small intestine to the large intestine, binded withfecal matter and was expelled.The literature search revealed 118 results. 35 different caseshave been reported, of which 2 were related toswallowed/ingested orthodontic retainers. Both of the latterwere related to removable retainers. The incidents reported inthe literature are depicted on Table I.

FOREIGN BODY AUTHOR YEARBracket Wilmott et al. 2016Bracket Sheridan 2009Bracket Fiho 2008Bracket Milton et al. 2001Archwire Hoseini 2013Archwire Absi et al. 1995Sectional Archwire Milton et al. 2001Archwire fragment Puryer et al. 2016Archwire fragment Park et al. 2013Archwire fragment Umesan et al. 2012Archwire fragment Milton et al. 2001Archwire fragment Nicolas et al. 2009Archwire fragment Lee 1992Archwire fragment Perry 1987Archwire fragment Tiwana et al. 2004Wire & coil spring Quick et al. 2002Ligature wire Tiller et al. 2014Orthodontic band Naragon et al. 2013Orthodontic band Al-Wahadni et al. 2006Expansion key Monini Ada et al. 2011Expansion key Tripathi et al. 20112 Expansion keys Nazif et al. 1983Transpalatal arch Abdel-Kader 2003TwinBlock appliance Rohida et al. 2011Quadhelix Allwork et al. 2007RPE Sfondrini et al. 2003Removable appliance Dibiase et al. 2000Part of appliance Parkhouse 1991Part of appliance Martinez et al. 1975Part of appliance Tiwana et al. 2004Molar band Kharbanda 1995Molar band Lanning 1988Retainer Klein et al. 2002Retainer Hinkle 1987

1. All clinicians should take into account the possibility ofsuch an emergency in their standard operating proceduresand must be well prepared to handle them.2. Every orthodontist must undergo a basic life supportand first-aid skills course including Heimlich maneuver andCPR and keep up to date with current recommendations.3. The archwires should be cinched back in order to avoidswallowing tubes and bands.4. Using a gauze pad as protection distal to the archwireor appliance will prevent injury to the mucosa as well astrap any stray wires that fail the “safety hold” of the pliers.5. High-volume suction should be used while attemptingprocedures such as banding and bonding.7. Removable quadhelix appliance and transpalatal archesmust be tethered by a floss during appliance placementand displacement.8. All bonded fixed appliances including fixed retainersshould be checked periodically for signs of bond failure2.

4. Allwork JJ, Edwards IR, Welch IM. Ingestion of a quadhelix appliance requiring surgical removal: a case report. J Orthod. 2007 Sep;34(3):154-7. doi: 10.1179/146531207225022131. PMID: 17761797.5. Cameron SM, Whitlock WL, Tabor MS. Foreign body aspiration in dentistry: a review. J Am Dent Assoc. 1996 Aug;127(8):1224-9. doi: 10.14219/jada.archive.1996.0415. PMID: 8803399. 6. British Orthodontic Society. Advice Sheet—Guidelines for the Management of Inhaled or Ingested Foreign Bodies;British Orthodontic Society: London, UK, 2011.

Swallowed orthodontic object

Caused obstruction Did not cause obstruction

Pulmonary obstruction

Instant management (such as Heimlich maneuver or CPR)Contact hospital emergencies / accompany patient to

hospital

Esophageal obstruction 1.Clinical observation, monitor and maintain airway2. Patient in reclined position

Retrieval attempt by patient or orthodontist

If not retrieved accompany patient to hospital for x-rays to identify location

Oral cavityOro-pharyngeal soft tissues

Pharyngeal spacesRespiratory tract

Stomach &

abdominal cavityEsophagus

Confirm that the object is intact

and reassure the patient

Immediate retrieval with surgical or non-surgical

methods (bronchoscope)

Monitor 2-12 days, dietary advice, examine stools, ask for possible

signs and symptoms

If not discharged, locate with x-rays, refer for retrieval with

surgical / endoscopic methods

Figure 1. The fixed retainer bonded on six anterior teeth.

Figure 2. The fixed retainer after the ingestion of a 20 mm fragment.

Figure 3. The chest posteroanterior x-ray. Figure 4. The abdominal posteroanterior x-ray.

Figure 5. A flow chart for the management of ingested orthodontic objects.

Table I