Dentaltown July 2020 - 47

Fig. 2

Management

Discussion

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, p. 48), 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.

The management of a midline diastema
is best handled by a dental professional
with either a fi xed 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

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