*Corresponding author:Amarjothi JMV, Department of Surgical Gastroenterology, 500, Tower block II, Rajiv Gandhi Government General Hospital,
Chennai, Tamilnadu, India
How to cite this article:Amarjothi JMV, Karthikeyan M, Jeyasudhahar J, Naganath B O. Impact of Surgery on Impacted Dentures in the GIT -Case Series and Review of Literature. Adv Res Gastroentero Hepatol. 2019; 12(1): 555827. DOI:10.19080/ARGH.2019.12.555827.
Dentures are an important cause of impaction in the Gastrointestinal tract especially in the elderly. These impacted dentures may be
frequently overlooked due to their radiolucency and are frequently not amenable for endoscopic retrieval necessitating surgery for retrieval of
these foreign bodies. The aim of this study is to describe the type of impaction, site, consequences and time interval to therapeutic intervention
including the type of intervention and outcomes after accidental swallowing of dentures in a tertiary care referral hospital and assess the same
in published medical literature throughout the world. From our experience, it is seen that dentures impacted in the cervical esophagus present
earlier than those impacted in the thoracic esophagus as they are more symptomatic. Leaks at the primary closure site are more common in the
cervical than thoracic esophagus which fortunately are more self-limiting and easily managed than thoracic leaks.
Impaction of dentures occurs most commonly in elderly in
the oesophagus. Though most are non-impacted and amenable
to endoscopic retrieval, impacted dentures usually require
surgical retrieval. Delay in diagnosis of impacted dentures
occurs commonly and is associated with significant morbidity
The study was carried in a prospectively maintained database
in a tertiary care hospital in southern India (2008-2017) where
there is a large inflow of such impacted cases for management.
Also, a comprehensive study of databases like PUBMED was also
carried out to look for such cases and the inference of the study
was duly noted.
In our series, 13 patients presented (11 M:2F) (average age-
54.9 yrs) with endoscopic failed retrieval of partial, radiolucent
impacted dentures without clasps at a median of 4 days (range,
1day-7.5 yrs) with 7 impacted at level of thoracic oesophagus, 5
in the cervical oesophagus and 1 in the stomach. All the impacted
dentures in the cervical oesophagus were symptomatic with 71%
(5/7) in the thoracic oesophagus presenting with chest pain. In
view of previous failure with endoscopic retrieval, all patients
with dentures impacted in the cervical oesophagus underwent
cervical oesophagostomy by left cervical incision along the
anterior SCM, retrieval and primary closure. All endoscopically
refractory dentures impacted in the thoracic oesophagus (n=7)
underwent a right thoracotomy and retrieval with intercostal
drainage. The denture impacted at the OG junction was retrieved
by making a gastrotomy and primary closure.40%(n=2) of
patients who underwent cervical oesophagotomy and retrieval,
developed leak, which was managed conservatively over a mean
duration of 12 days. One of those who underwent thoracotomy
(14.2%) developed leak which subsided on conservative treatment
of 60 days and another patient (14.2%) developed severe
bleeding after surgery necessitating a relook surgery for arresting
the bleeding site. Both patients made a delayed recovery
(Table 1 & Figures 1-3).
Incidence of impacted dentures
According to current literature, the most common ingested
Foreign Body (FB) in children are coins . The frequency of
swallowed foreign body (FB) in adults varies widely. In one study,
the more commonly swallowed foreign bodies among adults are
fish bones (9–45 %), bones (other than fish bones) (8–40 %),
and dentures (4–18 %) . Dentures are the most common FB
among the elderly with a peak age incidence of 60 years .
The incidence of dentures as a source of impacted foreign
body in the oesophagus varies widely in literature from 0.6% in
a large series of over 2300 impacted oesophageal FBs to recent
series which vary from 11.5% to 38.6% [4-6]. This discrepancy
may be due to the sample size and reviewing of such cases from
tertiary care centres only (where more difficult cases are usually
Dentures as foreign bodies are overlooked  because
a) They are irregular and allow partial passage of food,
giving a false security
b) Radiolucent acrylic material is not picked up by conventional
c) Though most recent dentures lack metal wires or
hooks, the few that might have, may be overshadowed by
other radio opaque shadows.
The emphasis is on early removal of impacted dentures due
to the following reasons: a) Chance of spontaneous passage is
small, b) Oedema at the local site grips the object firmly making
later manipulation increasingly difficult c) Perforation of the
Oesophagus and other blood vessels may be detrimental
Dentures are nowadays made of acrylic radiolucent material
which is a far cry from the radiopaque metallic dentures of the
1940s . which has resistance to every day wear and tear .
They may be of two types- complete or partial, with or without
The most dangerous type of denture causing impaction is
the partial radiolucent acrylic denture without clasps which due
to its small size (3-4 cm) [11,7], colour and radiolucency make
diagnosis by endoscopy and x rays difficult. Dentures can be
classified as bridges, crowns, partial dentures and others which
includes cores and fractured clasps . The ingested dentures
are most commonly composed of crowns followed by bridges,
partial dentures, metal cores and fractured clasps . It is
to be noted that crowns and bridges are smaller and are more
amenable to endoscopic retrieval than other types of dentures.
The most common dentures associated with impaction are the
upper dentures though they are the ones most amenable to
retrieval due to their relatively larger size [6,7].
Pathophysiology of mastication with dentures
A removable denture is a foreign body in the oral cavity and
an ill-fitting denture can have negative effects on swallowing by
impairing sensation in the oral cavity and this in the elderly can
be compounded by a stroke which drastically increase the risk of
aspiration and dysphagia [13,8].
Level of impaction of dentures in the GIT
The level of impaction of dentures may be at either of the two
Physiological constrictions (most common): The most
common physiological constrictions causing impaction of
swallowed dentures include
a. Hypopharynx (level of vocal cords), which is amenable
to endoscopic retrieval
b. cervical oesophagus (level of upper oesophageal
sphincter which is between cricopharyngeus and thoracic
inlet). This is the most common site for impaction , and
can be retrieved by both endoscopy and surgery (cervical
c. Thoracic oesophagus (level of aortic arch and left
bronchus). Impacted dentures at this level are prone for
life threatening complications as they are in the vicinity of
the great vessels after esophageal perforation. These can be
retrieved by either a thoracotomy or thoracoscopy
d. Ileocaecal region: It is the most common site for
perforation [14,15], due to metallic clasps and can be
managed either by laparoscopically or open surgery.
e. Sigmoid colon , /Rectum  - These  can be
accessed either by colonoscopy or laparotomy.
Pathological strictures can also cause impaction of foreign
bodies necessitating retrieval
The incidence of stricture is reported to be 66.6% for the
esophageal orifice, 19% for the tracheal bifurcation, and 14.3%
for the esophageal hiatus . The doctrine of masterly inactivity,
once the foreign body passes the physiological constrictions, the
cornerstone of management of ingested foreign bodies, need not
necessarily apply to dentures due to their presence of clasps,
irregular shape, relatively larger size and impaction even in the
distal GIT like rectum.
The need for expeditious retrieval of impacted dentures is
paramount as it reported that more than 24 hrs after ingestion,
the rate of complications increases from 3.2% at 24 h to as high
as 23.5% after 48 hrs . In a study from Nigeria, only 54.5%
reported to medical centre in 48 hrs reflective of the role of late
compliance as a factor in complications due to impacted dentures
. dentures impacted at
The most common clinical features of dentures impacted
in the cervical oesophagus include throat pain, tenderness and
pooling of saliva . Other rare features include hoarseness,
fever and otalgia. (< 15%). Long standing dentures in the neck
can mimic malignancy and even thyroid gland .
Most cases of impaction at the thoracic level of recent onset
can present with retrosternal or back pain . Dentures impacted
in the thoracic oesophagus can be asymptomatic for long when
they mimic a malignancy and can present suddenly with features
of massive UGI bleeding due to involvement of great vessels after
oesophageal perforation [22,23].
Jackson  reported the factors that contribute to overlooking
of foreign bodies:
1) Failure to consider the possibility of a foreign object when
developing a differential diagnosis;
2) Absence of a history suggesting a foreign body which
is common in the elderly with dentures. Factors like
neurological impairment, stay alone, absence of caregivers
etc. may impair an accurate history; and
3) mimic of other diseases as asthma, pneumonia, or tumor.
especially most impacted thoracic dentures may mimic
oesophageal malignancy and even rare complications due
to impacted thoracic dentures like vocal cord paralysis,
bronchial and aortic involvement may mimic complications
due to oesophageal carcinoma .
Complications of impacted dentures can be described at the
Level of oesophagus
i. Aortic erosion 
ii. Broncho aortic fistula 
iii. Horners syndrome 
iv. Oesophageal migration with diverticulum 
v. Oesophageocarotid fistula 
vi. RLN palsy. which is an entrapment neuropathy due to
FB induced perioesophageal fibrosis .
vii. Tracheoesophageal Fistula (TEF) [31-33]
Below the level of the oesophagus
a) Enterocolonic fistula involving small bowel and
transverse colon .
Radioluscent dentures are rarely seen on lateral x-rays. Also,
it is to be noted that there is a decrease in the size of the foreign
body on radiological examination . And hence, they do not
significantly impact on subsequent management [7,37]. The
classical findings include prevertebral soft tissue shadow (45%),
and air entrapment around the denture (40 %) and wire clasps
The findings include mildly hyperdense curvature and air
around the dentures may be seen .
Rigid endoscopy: under ETGA/muscle relaxation can be done
with success rate of 80% . However, it is to be noted that
endoscopic retrieval of dentures is associated with lacerations
of the mucosa which are prone to perforation. Endoscopy,
in some cases of impacted dentures, is more or less a blind
procedure as vision is obscured by edematous mucosa, hidden
or perforated denture edges and imperceptible hue of denture
from surrounding mucosa
Manevours used to cause disimpaction and increase
yield of endoscopic retrieval
a) Grasping forceps are most commonly used to retrieve
dentures endoscopically . In a study from Japan, Mazuno
 described their success rate at > 90%. However, it
must be noted that 13/23 (56.25%) were crowns which are
smaller and amenable to easier endoscopic extraction
b) Retrieval nets can also be used to retrieve small dentures
like crowns . However, it must be used judiciously
since their irregular surface may injure the mucosa during
c) Shear forceps to fragment and dislodge dentures and
screw into the substance of FB to increase purchase before
d) Use of overcovering plastic incubators before extraction
e) Hd YAG laser to fragment denture [41,42].
f) Oral side balloon or transparent cap to disimpact
foreign body .
g) Cotton sliver soaked in saline to disimpact .
h) Long rotation of scope or sounding the foreign body
with cannula in case of suspicion .
Complications related to perforation during endoscopic
instrumentation include paraesophageal abscess, mediastinitis,
pericarditis, pneumothorax, pneumomediastinum,
tracheoesophageal fistula, and vascular injury .
Flexible fibreopric oesophagoscopy: are for use under topical
anesthesia, permitting safer inspection, biopsy and photography.
The standard technique using rigid oesophagoscope are not
superseded, nor are they likely to be, in the foreseeable future,
for foreign body removal .
Upper gastrointestinal tract radiography using a nonionic
water-soluble contrast medium may be used to rule out
perforations (especially when aspiration is a risk)  (Table 2).
There is a role for conservative management in the
treatment of ingested dentures. The indications include
asymptomatic patients, nonimpacted dentures, preferably small
(,2.5 cm in diameter, < 6 cm in length, , radio dense dentures
without clasps or irregular edges. The exact duration for such
management is unknown which may vary from 1 -6 weeks in
literature [45,46]. The advantage of such an approach is the
absence of morbidity due to an additional intervention which
must be balanced against the need for routine confirmatory
radiography and possibility of perforation during the waiting
The range of foreign bodies able to be removed with a flexible
gastroscope has expanded with the development of newer snares,
cages, and forceps. Removal of a foreign body with the flexible
gastroscope is more likely to be successful and atraumatic when
the foreign body does not have sharp or penetrating edges.
Glucagon has been used in impacted oesophageal dentures
which relaxes the esophageal smooth muscle effecting the
transition into the stomach. Ferrucci et al,  reported good
outcomes using this method. However, other authors have not
found glucagon to be as reliable, with success rates between
29- 50%. It is believed that use of smooth muscle relaxants/
promotility agents is contraindicated for removing all foreign
bodies except food boluses .
Since Markoe  demonstrated the feasibility of using the
cervical approach for esophagotomy to remove foreign bodies
from the esophagus, many articles have supported this as the
gold standard in impacted cervical oesophageal foreign bodies in
general and dentures, especially in those with failed endocopic
retrieval [40,50-52]. After surgical retrieval, the oesophagostomy
can be closed primarily or over a T tube in case of friable tissue
Posterolateral Thoracotomy over the right side is used to
access the oesophagus for retrieval of impacted dentures where
the oesophagus may perforate during retrieval increasing the
morbidity and mortality of the procedure.
Moghissi  reported that ten of 39 cases with oesophagus
perforation occurred during removal of the foreign body. This
author reported a mortality rate of 48% in cases of thoracic
oesophageal perforation. Some authors have described
thoroscopic approach to access the oesophagus with reduced
morbidity and mortality [56,57].
Both open gastrotomy and laparoscopy have been tried to
retrieve denture in the stomach after endoscopic failure where
gastrotomy can be tried after failed laproscopic retrieval .
Ileocaecal region is the most frequent site of perforation
especially when the swallowed object has sharp edges like clasps
of a removable denture If the dentures become impacted at these
sites, urgent laparotomy and Foreign body retrieval is to be done
to avoid perforation.
A survey of dentists in the U.S. revealed that identification
and retrieval of dental prostheses are complicated by the
radiolucency of the materials used in the manufacture of
some devices. Radiolucency in denture materials has been
addressed repeatedly by dental organizations with no standard
manufacturing protocol [58,59].
The mandatory incorporation of radiopaque material in
dental resins is still not feasible, as they cannot match the
physical properties, appearance and the ease of handling of
currently used radiolucent dentures. The incorporation of
heavy metal salts or glass fillers not only is unsightly, but also
weakens the material, thereby increasing the risk of fracturing
and swallowing a fragment . Use of 12% barium fluoride
 which maintains the mechanical and aesthetic properties
and radiopaque wires have not seen widespread use [5, 61-84]
A careful clinical history and a radiologic examination is
paramount in a suspected case of ingestion though it might not
be very useful. Partial radiolucent dental prostheses without
metal clasps, though not as common as those metal clasps to
get impacted, present a diagnostic challenge. Impacted dentures
the esophagus for greater than 24 hours cause oesophageal
damage necessitating rapid intervention to avoid perforation.
Endoscopic retrieval can be tried as first method for extraction.
If the impacted foreign body cannot be removed endoscopically,
surgical removal should be undertaken. Preventing the ingestion
of dental prostheses involves patient education (61) regarding
the potential risks of wearing broken or defective dentures.