Radiology
Forum
Each month this section will bring the reader of ORAL SURGERY, ORAL MEDICINE, AND ORAL PATHOLOGY information of practical relevance to the art and scienceof diagnostic imaging and diagnostic images with unusual interpretive features. Practical notes and radiographs will be accompanied by an explanation or inquiry. Please submit 5 X 7 inch glossy black-and-white prints of your illustrations. All materials for publication should be submitted to Dr. Allan G. Farman, Department of Primary Patient Care, School of Dentistry, University of Louisville, Louisville. KY 40292.
lNTRANASALTEETtl:ACASEREPORT
T
he ectopic development of teeth has been reported in many locations in the oral cavity. Reported sites include the nasal cavity, maxillary sinus, palate, mandibular condyle, coronoid process, orbit, or through the shin. im7Ectopic teeth may be permanent, deciduous, or supernumerary. The ectopic eruption of teeth into the nasal cavity will be discussed, including signs and symptoms, diagnosis, and treatment, and a case will be reported. Fig. CASEREPORT
1.
Panoramic radiograph shows tooth in right nasal
floor.
A 22-year-old Latin American man complained of right facial pain and nasal stuffiness. The patient related a long history of facial pain in the right cheek area and also stated that he had great difficulty breathing through his left nares. Clinical examination revealed a white object in the right floor of the nose. The nasal septum was deviated to the left. Radiographic examination, which included a panoramic radiograph (Fig. 1) and occlusal radiographs (Fig. 2), revealed a tooth in the right nasal cavity. Because of the history of pain and congestion, the patient was taken to the operating room for removal of the tooth. After oral intubation and cocainization via the nose, the nasal cavity was inspected with a nasal speculum and then with a fiber-optic nasopharyngoscope (Fig. 3). The tooth in the right nasal floor was removed with elevators and a Kelly clamp. Granulation tissue was removed. Because of intranasal oozing, the anterior nasal cavity was packed. The patient declined correction of the septum at this time. The postoperative course was uneventful; the symptoms of right nasal stuffiness and facial pain completely resolved. DISCUSSION
Intranasal teeth are rare. In 1979 Smith and associates’ identified 27 cases of well-documented 804
Fig.
2. Occlusal radiograph shows intranasal tooth.
Volume 70 Number 6
Radiology forum
805
6. Shafer WC, Nine MK, Levy BM. A textbook of oral pathology. Philadelphia: WB Saunders Co, 1983. 7. Hiranandani LW, Melgiri RD. Supernumerary tooth in the floor of the nose. J Laryngol 1968;82:845-8.
MONOSTOTIC MANDIBLE
A
3. Intranasal view of tooth by basal pharyngoscope. Nasal septum on right. Inferior turbinate on left.
Fig.
intranasal teeth. The etiology of intranasal teeth is controversial. Many theories have been proposed, including developmental disturbances, trauma, infection, crowding, or dense bone. Symptoms of intranasal teeth range from none to such symptoms as pain, nasal obstruction, or epistaxis, and signs include deviation of the external nares and septum. The diagnosis of intranasal teeth may be made from either clinical examination or radiographic examination. Clinically, examination would reveal a tooth in the floor or lateral wall of the nasal cavity, with possible granulation tissue present. The tooth may or may not have dental caries. Radiographically, intranasal teeth may show up on panoramic x-ray films, occlusal x-ray films, or other facial x-ray films. Examination with fiberoptic assistance is helpful. Treatment of intranasal teeth is usually surgical removal, especially if there is a sign of infection or dental caries. If the tooth is not removed, close radiographic follow-up is recommended. Douglas D. Carver, DDS Sharon Peterson, DDS Terry Owens, MD 12121 Richmond, Suite 316 Houston, TX 77082 REFERENCES
1. Smith RA, Gordon NC, DeLuchi SF. Intranasal teeth: report of two cases and review of the literature. ORAL SURG ORAL MED
ORAL
PATHOL
1979;47:120-2.
2. Spencer MG, Couldery MG. Nasal tooth. J Laryngol Otol 1985;99:
1147-50.
Martinson FD, Cockshott WP. Ectopic nasal dentition. Clin Radio1 1972;23:451-4. 4. Thawley SE, LaFerriere KA. Supernumerary nasal tooth. Laryngoscope 1977;87:1770-3. 5. Murty PS, Hazarika P, Hebbar GK. Supernumerary nasal teeth Ear Nose Throat J 1988;67:128-9. 3.
PAGET’S
DISEASE
OF THE
76-year-old white man complained of left mandibular aching of several days’ duration. He also reported an increasing swelling in the area during the preceding 24 hours. His medical history included an allergy to penicillin, treatment of hypertension with hydrochlorothiazide and potassium, and removal of a basal cell carcinoma from his face 2 years earlier. His vital signs were within normal limits with the exception of an elevated temperature of 100” F. Clinically, the patient had a Class III jaw relationship with multiple diastemata. The moderate swelling in the body of the left mandible was warm to the touch but not fluctuant. Panoramic and periapical radiographs showed hypercementosis, loss of lamina dura, loss of normal trabeculation, osteolytic and osteosclerotic areas, and generalized loss of cortical bone limited to the mandible. Root resorption of the left mandibular second premolar was also nated (Figs. 1 and 2). The patient was referred to an internal medicine department for evaluation. The physician recommended radiographic examination of the skull, chest, and lumbosacral region after emergency dental treatment. The left mandibular second premolar and second molar were extracted in fragments. Pus from the extraction sites was cultured, and the tooth and bone fragments were sent for biopsy. The extraction sites healed well, and all symptoms resolved. The report on the culture stated “normal flora.” Microscopically, the description of the tooth and bone fragments was consistent with Paget’s disease of bone. Fibrous dysplasia and chronic osteomyelitis were thought to be less likely possibilities. A bone scan revealed “markedly increased activity” in the mandible and some activity in the great toe of the right foot that was attributed to “hammer toe.” No other areas of abnormal activity were seen in the skeleton, including the skull. A serum alkaline phosphatase test showed an elevated level of 182 U/L, with a normal adult range of 50 to 136 U/L. The incidence of monostotic Paget’s disease of the mandible with progressive resorption of the teeth is reportedly rare. l-3 In this case results of the bone scan,
Forum
Each month this section will bring the reader of ORAL SURGERY, ORAL MEDICINE, AND ORAL PATHOLOGY information of practical relevance to the art and scienceof diagnostic imaging and diagnostic images with unusual interpretive features. Practical notes and radiographs will be accompanied by an explanation or inquiry. Please submit 5 X 7 inch glossy black-and-white prints of your illustrations. All materials for publication should be submitted to Dr. Allan G. Farman, Department of Primary Patient Care, School of Dentistry, University of Louisville, Louisville. KY 40292.
lNTRANASALTEETtl:ACASEREPORT
T
he ectopic development of teeth has been reported in many locations in the oral cavity. Reported sites include the nasal cavity, maxillary sinus, palate, mandibular condyle, coronoid process, orbit, or through the shin. im7Ectopic teeth may be permanent, deciduous, or supernumerary. The ectopic eruption of teeth into the nasal cavity will be discussed, including signs and symptoms, diagnosis, and treatment, and a case will be reported. Fig. CASEREPORT
1.
Panoramic radiograph shows tooth in right nasal
floor.
A 22-year-old Latin American man complained of right facial pain and nasal stuffiness. The patient related a long history of facial pain in the right cheek area and also stated that he had great difficulty breathing through his left nares. Clinical examination revealed a white object in the right floor of the nose. The nasal septum was deviated to the left. Radiographic examination, which included a panoramic radiograph (Fig. 1) and occlusal radiographs (Fig. 2), revealed a tooth in the right nasal cavity. Because of the history of pain and congestion, the patient was taken to the operating room for removal of the tooth. After oral intubation and cocainization via the nose, the nasal cavity was inspected with a nasal speculum and then with a fiber-optic nasopharyngoscope (Fig. 3). The tooth in the right nasal floor was removed with elevators and a Kelly clamp. Granulation tissue was removed. Because of intranasal oozing, the anterior nasal cavity was packed. The patient declined correction of the septum at this time. The postoperative course was uneventful; the symptoms of right nasal stuffiness and facial pain completely resolved. DISCUSSION
Intranasal teeth are rare. In 1979 Smith and associates’ identified 27 cases of well-documented 804
Fig.
2. Occlusal radiograph shows intranasal tooth.
Volume 70 Number 6
Radiology forum
805
6. Shafer WC, Nine MK, Levy BM. A textbook of oral pathology. Philadelphia: WB Saunders Co, 1983. 7. Hiranandani LW, Melgiri RD. Supernumerary tooth in the floor of the nose. J Laryngol 1968;82:845-8.
MONOSTOTIC MANDIBLE
A
3. Intranasal view of tooth by basal pharyngoscope. Nasal septum on right. Inferior turbinate on left.
Fig.
intranasal teeth. The etiology of intranasal teeth is controversial. Many theories have been proposed, including developmental disturbances, trauma, infection, crowding, or dense bone. Symptoms of intranasal teeth range from none to such symptoms as pain, nasal obstruction, or epistaxis, and signs include deviation of the external nares and septum. The diagnosis of intranasal teeth may be made from either clinical examination or radiographic examination. Clinically, examination would reveal a tooth in the floor or lateral wall of the nasal cavity, with possible granulation tissue present. The tooth may or may not have dental caries. Radiographically, intranasal teeth may show up on panoramic x-ray films, occlusal x-ray films, or other facial x-ray films. Examination with fiberoptic assistance is helpful. Treatment of intranasal teeth is usually surgical removal, especially if there is a sign of infection or dental caries. If the tooth is not removed, close radiographic follow-up is recommended. Douglas D. Carver, DDS Sharon Peterson, DDS Terry Owens, MD 12121 Richmond, Suite 316 Houston, TX 77082 REFERENCES
1. Smith RA, Gordon NC, DeLuchi SF. Intranasal teeth: report of two cases and review of the literature. ORAL SURG ORAL MED
ORAL
PATHOL
1979;47:120-2.
2. Spencer MG, Couldery MG. Nasal tooth. J Laryngol Otol 1985;99:
1147-50.
Martinson FD, Cockshott WP. Ectopic nasal dentition. Clin Radio1 1972;23:451-4. 4. Thawley SE, LaFerriere KA. Supernumerary nasal tooth. Laryngoscope 1977;87:1770-3. 5. Murty PS, Hazarika P, Hebbar GK. Supernumerary nasal teeth Ear Nose Throat J 1988;67:128-9. 3.
PAGET’S
DISEASE
OF THE
76-year-old white man complained of left mandibular aching of several days’ duration. He also reported an increasing swelling in the area during the preceding 24 hours. His medical history included an allergy to penicillin, treatment of hypertension with hydrochlorothiazide and potassium, and removal of a basal cell carcinoma from his face 2 years earlier. His vital signs were within normal limits with the exception of an elevated temperature of 100” F. Clinically, the patient had a Class III jaw relationship with multiple diastemata. The moderate swelling in the body of the left mandible was warm to the touch but not fluctuant. Panoramic and periapical radiographs showed hypercementosis, loss of lamina dura, loss of normal trabeculation, osteolytic and osteosclerotic areas, and generalized loss of cortical bone limited to the mandible. Root resorption of the left mandibular second premolar was also nated (Figs. 1 and 2). The patient was referred to an internal medicine department for evaluation. The physician recommended radiographic examination of the skull, chest, and lumbosacral region after emergency dental treatment. The left mandibular second premolar and second molar were extracted in fragments. Pus from the extraction sites was cultured, and the tooth and bone fragments were sent for biopsy. The extraction sites healed well, and all symptoms resolved. The report on the culture stated “normal flora.” Microscopically, the description of the tooth and bone fragments was consistent with Paget’s disease of bone. Fibrous dysplasia and chronic osteomyelitis were thought to be less likely possibilities. A bone scan revealed “markedly increased activity” in the mandible and some activity in the great toe of the right foot that was attributed to “hammer toe.” No other areas of abnormal activity were seen in the skeleton, including the skull. A serum alkaline phosphatase test showed an elevated level of 182 U/L, with a normal adult range of 50 to 136 U/L. The incidence of monostotic Paget’s disease of the mandible with progressive resorption of the teeth is reportedly rare. l-3 In this case results of the bone scan,
