Introduction

It is very unnatural and rare for a tooth to be present in the nasal cavity. Approximately 50 cases of a nasal tooth have been reported so far in the literature (1). The etiology of nasal tooth is unclear. Theories explaining it include developmental disturbances, infections, genetic factors, trauma, crowding of dentition, cysts, persistent deciduous teeth or exceptionally dense bone (2) . The clinical manifestations are varied, however the intranasal tooth may also be completely asymptomatic and may only be noted on routine clinical or radiographic examination. The diagnosis of nasal tooth is made on the basis of clinical and radiographic findings. Computed tomographic scanning is helpful in diagnosing and treatment planning of intra nasal tooth apart from plain radiographs of the facial region (3). The differential diagnosis should include foreign bodies in the nasal cavity, rhinoliths, bony sequestra, neoplasms and exsostosis (2). The treatment involves surgical removal of the symptomatic intra nasal tooth. Asymptomatic tooth should preferably be removed or at least followed radiographically.

Case 1

A 20 year old female patient was referred to the Department of Oral and Maxillofacial Surgery, Vishnu Dental College and Hospital, Bhimavaram, A.P. India. for diagnosis and management of a radiopaque lesion in the left nasal cavity noted during routine dental radiographic examination. The patient was asymptomatic at the time of examination but gave a history of chronic left nasal congestion. She denied any history of trauma or swelling . No significant medical history was noted. On intra oral examination retained deciduous upper left canine was noted. A white mass resembling a tooth could be clearly visualized in the floor of the left nasal cavity away from the ostium (fig – 1). Radiographs included maxillary occlusal view as well as orthopantamogram (fig – 2 and 3) which revealed a radiopaque mass resembling a tooth (permanent canine) .

Figure 1

Figure 1 : Extra oral photograph showing a white mass in the left nasal cavity resembling a tooth.

Figure 2

Figure 2 : Maxillary occlusal radiograph reveals a left permanent canine tooth (black arrow) at the apex of the root of the left central incisor.

Figure 3

Figure – 3 : Pre operative orthopantamogram showing maxillary left canine (black arrow).

The patient was further questioned about the ectopic eruption of the tooth into the nasal cavity. She admitted having knowledge of its presence since 3 years when it was diagnosed by another dentist. The ectopically erupted permanent maxillary left canine (fig – 4) was surgically removed by an Oral and Maxillofacial surgeon via the trans nasal approach from the left nasal cavity as is evident from the post operative orthopantamogram (fig – 5). Under local anaesthesia (2% lidocaine with 1:1,00,000 adrenalin) and strict aseptic conditions the tooth in the nasal cavity was elevated with an ball end probe placed below it and retrieved using a forceps. Anterior nasal pack was placed. No intra operative complications were noted. Before being discharged the patient was advised oral medication of cap Amoxicillin 500 mg three times daily for 5 days along with tab Diclofenac sodium 75 mg three times a day for 5 days. The patient was reviewed 3 days after discharge. The anterior nasal pack was removed and the surgical area was inspected for wound healing which was satisfactory. There were no significant complaints during the follow up period which lasted 3 years .

Figure 4

Figure – 4 : Photograph of the surgically removed ectopic left maxillary permanent canine tooth

Figure 5

Figure – 5 : Post operative orthopantamogram

Case 2

A 35 year old male patient was referred to the Department of Oral and Maxillofacial Surgery, Vishnu Dental College and Hospital, Bhimavaram, A.P. India from another centre regarding his missing left maxillary central incisor. The patient had a history of trauma to the facial region two months earlier. His medical history was not significant but he complained that he could not breath freely from his left nostril and also has a sensation of foreign body lodged in the nostril. On intra oral examination there was a missing left maxillary central incisor . On examination of the left nostril , a tooth like structure could be clearly visualized (fig – 6). Lateral skull radiograph (fig – 7) demonstrated a radiopaque lesion that did not appear to be related anatomically but resembled a tooth like structure. The tooth (fig – 8) was removed surgically via trans nasal approach by an Oral and Maxillofacial surgeon. Under local anaesthesia (2% lidocaine with 1:1,00,000 adrenalin) and strict aseptic conditions the tooth in the nasal cavity was elevated with an ball end probe placed below it and retrieved using a forceps. Anterior nasal pack was placed. No intra operative complications were noted. Before being discharged the patient was advised oral medication of cap Amoxicillin 500 mg three times daily for 5 days along with tab Diclofenac sodium 75 mg three times a day for 5 days. The patient was reviewed 3 days after discharge. The anterior nasal pack was removed and the surgical area was inspected for wound healing which was satisfactory. The patient had a follow up period of 3 years during which he had no further complaints.

Figure 6

Figure – 6 : Extra oral photograph showing a white mass in the left nostril resembling a tooth

Figure 7

Figure – 7 : Lateral skull radiograph which reveals the intruded maxillary left central incisor (black arrow)

Figure 8

Figure – 8 : Photograph of the intruded left maxillary central incisor which was surgically removed

Discussion

Intra nasal tooth is an unnatural phenomenon and rare. It was originally described in 1897 (4). Smith .et.al in 1979 identified 27 cases of well documented intra nasal teeth (2). In 2008 Y.K Gupta and N. Shah have reviewed over 50 cases of teeth occurring in the nasal cavity (1). The etiology of intra nasal teeth is unclear and controversial. Theories explaining it include developmental disturbances such as cleft of the lip and palate, teeth displaced by trauma or cysts, maxillary infections either odontogenic or rhinogenic, genetic factors, obstruction to eruption secondary to crowding of the dentition, persistant deciduous teeth, exceptionally dense bone, supernumerary and ectopic teeth (2). Presence of a third tooth bud has also been implicated as one of the predisposing factors for the development of a nasal tooth (5).

The two cases which we have presented there is significant difference in the etiopathogenesis leading to the tooth in the nasal cavity. In case 1 the patient did not have a history of trauma or infection except that she suffered from chronic congestion of her left nostril. She was also aware of the fact that there was an ectopically erupted tooth in her left nasal cavity. Ectopic teeth are estimated to occur in 1 % of the general population (4). The presence of teeth have been reported in ovaries, testes, anterior mediastinum and pre sacral regions (1). In the maxillofacial region teeth have been found in the nose (2), maxillary sinus (6), mandibular condyle (5), coronoid process (7), chin, skin (8), orbit and even in patients with cleft of lip and palate (1). The cause of ectopic teeth is varied. Obstruction at the time of tooth eruption has been thought to predispose to ectopic growth. This obstruction may occur in conditions such as crowded dentition, persisting deciduous teeth, (our patient had retained deciduous upper left canine) or in exceptionally dense bone (9). Smith et al. in 1979 reported single as well as multiple ectopic teeth and described no predilection towards the right or the left nasal cavity (2).

In case 2 it was obvious that the patient had a history of trauma to the facial region which lead to the intrusion of the left maxillary permanent incisor into the nasal cavity. Intrusive luxation is one of the five different types of luxation injuries which comprises 15 – 61 % of dental traumas to the permanent dentition (10). It is represented by displacement of the tooth deeper into the alveolar bone and is usually accompanied by comminution or fracture of the alveolar socket, and the direction of dislocation follows the axis of the tooth. With increasing age the frequency and pattern of injury change. In the permanent dentition the number of intrusive luxation injuries is considerably reduced and is usually seen in the younger individuals (related to the resilience of the alveolar bone at this stage) (10), which is in contrast taking into consideration the age of our patient. Luna A.H.B et.al (11) and Martin B.S (12) ^{have reported traumatic intrusion of the maxillary permanent incisor into the nasal cavity in patients who were younger than 12 years of age.}

The diagnosis of intranasal tooth is made on the basis of clinical and radiographic findings. Clinically, intranasal tooth would present as a hard white mass and is usually surrounded by granulation tissue and debris (2). Radiographic examination including caldwells, waters, lateral view of the skull, panoramic radiographs may be helpful in confirming the diagnosis because the intranasal tooth may appear as a non specific radiopaque lesion in or near the nasal cavity (13). Albert C et al. are of the view that the computed tomographic findings of tooth equivalent attenuation and a centrally located cavity are highly discriminating features that help to confirm the diagnosis (3).

The differential diagnosis of nasal teeth should include radiopaque foreign body, rhinolith (calculus present in the nasal cavity) , inflammatory lesions due to syphilis, tuberculosis or fungal infection with calcification, benign tumours, haemangioma, osteoma, calcified polyps, enchondroma and dermoid and malignant tumours such as chondrosarcoma and osteosarcoma (2,14).

The intranasal tooth may present with a variety of symptoms or they may be completely asymptomatic. Symptoms include nasal congestion (15) (evident in case 1), unilateral nasal obstruction (15) (evident in case 2), chronic nasal discharge (8) , crusting of the nasal mucosa (16) , localized ulceration (17) , nasal pain and epistaxis (18,8) ^{, nasal septal abcess (19), nasal and oral fistula (2,5) , osteomyelitis of the maxilla (17,20) , facial pain and head ache (6) , cacosmia (21), and septal perforation (18). Thorali (22) in 2002 stressed the importance of first correct clinical and radiological examination so that the various complications can been prevented.}

The treatment of intranasal tooth is early surgical removal when diagnosed (as was done in our cases) because of the potential morbidity. Some authors (2,9) are of the view that asymptomatic patients can be observed with close radiographic follow up while others (4,6,15) recommend extraction of asymptomatic teeth their argument being that asymptomatic patients may become symptomatic with time. There is also a potential for more serious sequelae (eg; deep fascial space abcess) because the nasal tooth lies in the area of danger triangle of the mid face. Murthy et al. in 1988 recommended that the best time to remove these teeth is when the roots of the permanent teeth have completely formed so that possible injury to their development can be avoided (7).

The surgical procedures include a trans nasal or trans palatal approach (15), however if the tooth is associated with osteomyelitis, intra oral fistulae or septal deviation, then concomitant surgical procedures such as debridement, septoplasty (21) or septorhinoplasty (7) may be necessary. Endoscopic extraction of intranasal tooth has been advocated and recommended by some authors (15,23) . Even though it offers good illumination, clear visualization, precise dissection with preservation of neighboring structures (24,25) this technique requires specific instrumentation and training (26).

Conclusion

Two cases of maxillary teeth involving the nasal cavity are reported which were surgically extracted via the trans nasal approach without any intra operative or post operative complications. The authors recommend early surgical removal of the nasal tooth when diagnosed to prevent potential morbidity.