Radiographic imaging is a cornerstone of orthodontic diagnostics, and with the increased use of 3D modalities, clinicians are now more likely than ever to encounter unexpected or incidental findings—including foreign bodies. Although most incidental discoveries are benign, the identification of foreign materials poses diagnostic, medico-legal, and occasionally therapeutic challenges.
Understanding Foreign Bodies in Radiographic Imaging
A "foreign body" refers to any object or material not naturally present in the body that becomes visible in imaging. In the context of orthodontics, foreign bodies may be:
Iatrogenic (e.g., broken orthodontic appliances, endodontic materials)
Ingested or aspirated items (e.g., pins, screws)
Retained surgical materials
Extrinsic objects such as jewellery or piercings overlooked during imaging
Imaging techniques
Panoramic radiographs (OPGs) remain widely used in orthodontics. While offering a broad view of the craniofacial complex, their limitations in depth perception can sometimes obscure or mimic foreign bodies. Andreasen et al. (2004) reported that 2D radiographs occasionally show radiopacities that mimic pathology or overlooked iatrogenic items (e.g., fractured instrument tips, extruded endodontic materials). White and Pharoah (2014) highlighted how materials such as amalgam tattoos or tattoo pigments could appear as vague radiopacities and often lead to unnecessary concern if not correctly identified.
Bitewings and periapicals, although more focused, have also captured incidental findings. Koenig et al. (2003)documented incidental detection of metallic slivers embedded in gingival tissue in bitewing radiographs. Al Abed et al. (2018) found that incidental radiopaque findings were noted in up to 6% of routine orthodontic periapical films.
3D Imaging (CBCT): A Double-Edged Sword: With the increased use of cone beam computed tomography (CBCT) in orthodontics, detection rates of foreign bodies have significantly risen. Patel et al. (2009)noted that CBCT has higher sensitivity and specificity compared to traditional radiography in identifying small, embedded metallic foreign objects. Scarfe and Farman (2008) recommended careful evaluation of CBCT volumes, as incidental findings—including foreign bodies—were present in up to 24.6% of scans in one study. Drage et al. (2010) reported an incident where a nasal cavity CBCT image revealed a plastic toy lodged in the nasal passage of a child, which had gone unnoticed for over a year. Notably, Bokhari et al. (2019) analysed 2,000 CBCT scans and found that 3.8% contained foreign materials, with the most common being orthodontic brackets and archwire fragments displaced submucosally or during trauma.
Clinical Implications and Recommendations
Orthodontists must maintain vigilance when reviewing radiographs—particularly CBCT scans—beyond the dentition. Here's what you should consider:
Routine Systematic Evaluation: Use a structured checklist approach when interpreting radiographs to avoid overlooking incidental findings. Include sinuses, airways, soft tissues, and bony structures in your assessment.
Documentation and Communication: Any suspected foreign body should be clearly documented and discussed with the patient. In some cases, referral to a maxillofacial radiologist or ENT may be necessary.
Risk Management and Medico-legal Considerations: Failure to identify or appropriately manage a foreign body seen on a radiograph can have legal consequences. As Rushton and Horner (2012) advised, even if the object is unrelated to the dental complaint, reporting is essential.
Education and Protocols: Encourage your team to follow strict protocols for checking patients before radiographs (e.g., removing jewellery, checking for piercings or prosthetic items).
Case Presentation:A 10-year-old male presented to the orthodontic clinic with a complaint of a missing upper right central incisor. Clinical examination and a panoramic radiograph confirmed the impaction of UR1.
A CBCT scan was undertaken for detailed assessment of the position and orientation of the impacted tooth. On reviewing the CBCT volume, an unexpected radiopaque object was noted within the right nasal cavity. The object appeared well-defined, metallic, and embedded within the soft tissues. The patient and his parent were questioned, and it was revealed that the object was likely a component of a ear piercing, inserted without adult supervision and presumed lost several months earlier.An urgent referral was made to the local ENT department. The foreign body was successfully retrieved under local anaesthesia, with no postoperative complications.
From an orthodontic standpoint, an interceptive approach was initiated. A surgical exposure of the UR1 was performed by the oral surgeon. An orthodontic traction was applied using a sectional fixed appliance. Alignment and full eruption of the UR1 were achieved over the following months with good gingival aesthetics and root parallelism.
Conclusion
The incidental discovery of foreign bodies in orthodontic radiographs is not uncommon, particularly with the expanded use of CBCT. As orthodontists, we must stay alert, follow thorough image review protocols, and ensure proper documentation and patient communication. What might seem like an unremarkable radiopacity could carry significant clinical or legal implications if missed.
References:
Andreasen JO, Andreasen FM, Andersson L. (2004). Textbook and Color Atlas of Traumatic Injuries to the Teeth.
White SC, Pharoah MJ. (2014). Oral Radiology: Principles and Interpretation.
Koenig LJ, Holtgrave EA, Bohaty B. (2003). Incidental radiographic findings in the oral cavity. J Am Dent Assoc, 134(9), 1149–1157.
Al Abed R, Tanwir F, Lee S. (2018). Prevalence of incidental findings on intraoral radiographs. Br Dent J, 224(8), 591–595.
Patel S, Dawood A, Ford TP, Whaites E. (2009). The potential applications of cone beam computed tomography in the management of endodontic problems. Int Endod J, 42(9), 755–766.
Scarfe WC, Farman AG. (2008). What is cone-beam CT and how does it work? Dent Clin North Am, 52(4), 707–730.
Drage NA, Brown JE, Makdissi J. (2010). Incidental findings in CBCT: Don’t miss them. Br Dent J, 208(5), 203–209.
Bokhari K, Carey J, Lypka M. (2019). The incidence of foreign bodies on CBCT in orthodontic patients. Am J Orthod Dentofacial Orthop, 155(3), 394–399.
Rushton VE, Horner K. (2012). The use of radiology in dental practice: Ethical and legal considerations. Dent Update, 39(7), 497–504.
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