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Pediatric Nevus Sebaceous of the Scalp: A Reconstructive Challenge.

done. If the fractured root tip or the whole tooth is retained for a long time in its displaced space, infection and eventually abscess and a cutaneous fistula may develop. Here, we report a case of an cutaneous fistula which contains root particles of upper first premolar that was previously attempted to extract, and accidentally displaced into the deep buccal tissues. As we know, there is no such case in the literature. A 30-year-old male patient came to our clinic complaining about the pain, swelling, and cutaneous fistula on his right cheek. Tracing back the history, the patient had his upper right first premolar extracted approximately 8 months ago in a different hospital. He mentioned that the extraction was somewhat difficult for the dentist at that time, and after surgery he felt mild discomfort on the right side of his face. He said he had felt swelling and pain in the same region including under the right eye. The condition was resembling the canine space abscess. These schemes of symptoms repeated over and over again and medications provided only temporary relief. After that, white-colored pus was discharged from the swelling approximately 3 months before visiting our clinic. He told that the fistula has never healed since that time. Upon examining his oral condition, a mild swelling with tenderness on middle part of his right cheek and a cutaneous fistula with retracted skin were noted. On intraoral examination, healed upper first premolar area was evident and there was no sign of inflammation. The panoramic radiography showed the fractured root (Fig. 1A). Surgical intervention did not result in manifesting the particle. This finding suggested that the fractured root was actually in the soft tissues rather than in the alveolar bone or maxillary sinus floor. Afistulectomy and removal of the root particle were planned. Ring block anesthesia was performed, and after circumferential excision of the fistula margins, attempts were made to remove the dental particles through cutaneous fistula. In our first attempt, we managed to retrieve 2 fragments close to the external orifice of the fistula (Fig. 1B-C). Rest of the granulation tissues were removed and the fistula tract was irrigated. Then it was sutured in layers. Postoperative course was uneventful (Fig. 1D). When it comes to the issue of displacement complications during extraction, the literature often presents the cases of third molar. There have been many published case reports of displaced teeth, but these circumstances are still seen as rare complications. Despite the fact that we have little information about how the first extraction attempts were made, some clues let us make some predictions. The tooth whose root was fractured and displaced was the endodontically treated upper first premolar. Maxillary first premolar teeth generally have very thin 2 roots and are subject to fracture easily and, moreover, being endodontically treated makes it more likely to happen. These may be the reasons why the tooth was fractured, but it seems fractured root tip was further displaced into the deep buccal tissues. Excessive force and incorrect use of the elevator may lead to this type of complication. If the fragment is not visible and the dentist has lack of experience, we recommend that the practitioner should halt the procedure and refer the patient to an oral and maxillofacial surgeon. As we noted before, when we surgically seek the fragment in the alveolar bone, we could not find it. At this situation, we preferred to seek the particle in the cutaneous fistula but we recommend computerized tomography (CT) scan or at least occlusal radiography to identify the exact position. To the best of our knowledge, this is the first case report of a retrieval of the tooth fragment from the cutaneous fistula on the cheek.