Successful endoscopic fragmentation and removal of an impacted esophageal denture: A case report

Abstract

BACKGROUND

Ingested dental prostheses are uncommon but clinically significant foreign bodies of the upper gastrointestinal tract. Their large size, rigidity, and metallic clasps increase the likelihood of mucosal embedding, failed en bloc extraction, and complications such as ulceration and perforation.

CASE SUMMARY

A 67-year-old man presented with acute-onset dysphagia that had persisted for 7 days after accidental denture ingestion. Contrast-enhanced computed tomography of the chest showed diffuse thickening of the mid-esophageal wall without any evidence of a foreign body. Upper gastrointestinal endoscopy revealed an impacted denture located 27 cm from the upper incisors, accompanied by surrounding edema. Initial extraction attempts using rat-tooth forceps, a snare, and alligator forceps were unsuccessful. Consequently, controlled fragmentation was undertaken. A thulium laser was used to cut approximately one-third of the denture, followed by further fragmentation with a clutch cutter. The resulting fragments were then removed with a retrieval basket. Repeat endoscopy showed a localized ulcer at the previous impaction site without signs of active bleeding or perforation. The patient recovered uneventfully.

CONCLUSION

For impacted dentures that cannot be safely removed en bloc, strategies such as endoscopic fragmentation and extraction can avoid surgery.

Key Words: Denture; Esophageal foreign body; Dysphagia; Endoscopic removal; Laser fragmentation; Clutch cutter; Case report

Core Tip: Impacted dentures represent high-risk esophageal foreign bodies because their metal clasps and irregular edges can become firmly embedded in the mucosa, making conventional retrieval with snares or forceps technically challenging and potentially hazardous. This case highlights a novel stepwise endoscopic strategy that incorporates thulium laser-assisted partial fragmentation, followed by definitive mechanical fragmentation using a clutch cutter and subsequent basket retrieval, thereby avoiding highly morbid surgical intervention. The findings demonstrate that the combined use of energy-assisted and mechanical fragmentation serves as an effective rescue technique for the management of complex denture impactions when standard retrieval techniques are unsuccessful.

INTRODUCTION

Foreign body (FB) ingestion is a common clinical problem, and the type of FB ingested varies across different age groups[1,2]. In adults, FB ingestion is commonly accidental. Patients with mental health disorders, learning difficulties, alcohol intoxication, those who wear dentures, and incarcerated populations are at increased risk of ingesting non-food FB[3]. In approximately 80%-90% of cases, ingested FBs pass without complications and are expelled through the anus within a few days. However, 10%-20% of cases may require endoscopic removal due to its complexity or risk, whereas fewer than 1% necessitate surgical intervention[1,4]. Nevertheless, FBs lodged in the esophagus, particularly sharp or irregular objects, warrant urgent endoscopic management due to the risks of obstruction, pressure necrosis, and perforation. Current guidelines issued by the European Society of Gastrointestinal Endoscopy and the American Society for Gastrointestinal Endoscopy support prompt endoscopic removal of esophageal FBs[5,6]. Cross-sectional imaging, such as computed tomography (CT), should be performed when perforation is suspected or when the ingested object is poorly characterized. Dentures constitute a distinctive subgroup of FBs as they are often large, rigid, and may contain metal clasps that anchor into the esophageal wall, leading to prolonged impaction. Owing to these features, dentures carry a high likelihood of impaction or perforation, with nearly 96% of cases requiring endoscopic or surgical intervention[7-10]. Furthermore, their removal presents considerable technical challenges during endoscopic removal[11]. This report describes the successful management of an impacted denture using a novel laser- and cutter-assisted endoscopic fragmentation and retrieval technique.

CASE PRESENTATION

Chief complaints

A 67-year-old man presented with a 7-day history of dysphagia following accidental denture ingestion.

History of present illness

The symptoms developed suddenly after the patient inadvertently swallowed a denture. He subsequently experienced dysphagia, characterized by the ability to tolerate only small volumes of liquids and an inability to swallow solid food, accompanied by retrosternal pain and a mild sensation of chest heaviness. No hematemesis, melena, fever, or respiratory distress was observed.

History of past illness

The patient has no documented history of esophageal disorders or relevant comorbidities.

Personal and family history

The personal and family histories were noncontributory.

Physical examination

Upon presentation, the patient’s vital signs were stable. No stridor, subcutaneous emphysema, or signs of aspiration or perforation were observed. Chest and abdominal examinations were unremarkable.

Laboratory examinations

Routine haematological and biochemical parameters were within normal limits.

Imaging examinations

Plain radiograph revealed no evidence of an FB. Contrast-enhanced CT of the chest demonstrated diffuse thickening of the mid-esophagus without signs of pneumomediastinum, paraesophageal collection, or pleural effusion; however, the FB could not be identified (Figure 1). Urgent upper gastrointestinal endoscopy subsequently revealed an impacted denture located 27 cm from the upper incisors, causing bilateral indention of the esophageal wall and associated surrounding edema (Figure 2).

Figure 1 Contrast-enhanced computed tomography chest showing diffuse oesophageal thickening at mid esophageal level (orange circle in A and orange arrow in B). No definite foreign or pneumomediastinum was identified. A: Cross-sectional image; B: Axial image.

Figure 2  Endoscopic view of an impacted denture (orange arrow) at 27 cm from the upper incisors.

FINAL DIAGNOSIS

Impacted denture in the mid-esophagus (27 cm from the upper incisors) associated with localized mucosal edema.

TREATMENT

Under endoscopic guidance, impacted denture was identified. Transparent distal cap was used for better visualization, maintain a stable working distance, and facilitate precise targeting of the denture. Multiple extraction attempts using rat-tooth forceps and a snare were unsuccessful due to the firm impaction of the denture. Subsequent retrieval attempts with alligator forceps and a snare after partial mobilization were also unsuccessful. Therefore, controlled fragmentation using a laser was attempted. Fragmentation was performed with the Quantino^® Thulium Fiber Laser (TFL) system (Biorad Medisys, Pune, India), operating at a central wavelength of 1940 ± 20 nm. A 273-µm laser fiber was placed within the outer sheath of the One-Action Stent Insertion System (Cook Medical, Bloomington, IN, United States), introduced via the working channel, and positioned in direct contact with the impacted denture. Fragmentation was carried out in pulsed mode with a pulse energy of 1 J at 10 Hz, corresponding to a power output of 10 W. These parameters enabled controlled fragmentation with minimal mechanical displacement, owing to the high absorption of TFL in aqueous media. Approximately one-third of the prosthesis was successfully sectioned (Figure 3); however, complete fragmentation could not be achieved using the laser alone. The denture was further cut with a clutch cutter (Fujifilm, Tokyo, Japan) (Figure 4A) and removed using a retrieval basket (Figure 4B). The removed denture fragments were examined to confirm complete retrieval (Figure 4C). Fragmentation was selected over forceful en bloc extraction because both ends of the denture were embedded within the esophageal wall, and uncontrolled traction was considered to carry a higher risk of deep mucosal injury or perforation.

Figure 3 Endoscopic images. A-C: Showing partial denture fragmentation using a Thulium laser.

Figure 4 Endoscopic denture fragmentation and removal of the denture. A: Endoscopic image showing denture fragmentation using a clutch cutter (orange arrow); B: Basket forceps (white arrow); C: Gross image of the removed denture fragments.

OUTCOME AND FOLLOW-UP

Repeat endoscopy demonstrated ulcerated mucosa at the site of the previous impaction, without evidence of active bleeding or perforation (Figure 5A). The patient received proton pump inhibitor therapy and was advised to follow a gradual dietary progression from liquids to soft solids. He remained clinically stable and was subsequently discharged. A follow-up endoscopy performed one week later showed partial healing of the ulcer with a reduction in mucosal edema (Figure 5B and 5C). At the outpatient follow-up visit, the patient reported complete resolution of dysphagia and chest discomfort.

Figure 5 Endoscopic appearance of esophageal mucosa after removal of dental prostheses. A: Immediate relook endoscopy showing ulceration at the impaction site after denture removal; B: Endoscopic image showing healing ulcer and decrease in mucosal edema; C: The healing condition after one week.

DISCUSSION

Denture ingestion is a clinically significant event and is not uncommon among high-risk groups. In a study by Liu et al[12], which analysed 275 patients with ingested FBs, denture impaction accounted for 4.3% of cases. Dentures are typically bulky and irregular in shape, and their metal clasps may become embedded in the esophageal wall, thereby increasing the risk of deep mucosal injury and perforation[13-15]. Most episodes occur accidentally, particularly in an intoxicated state, during sleep, or while eating[16].

Cross-sectional imaging can be valuable in cases of suspected denture ingestion, as some dentures are radiolucent on plain radiographs. CT can assist in confirming the location of the FB and assessing associated complications, such as pneumomediastinum or paraesophageal collections[5,8,13]. However, CT has limitations in the detection of dentures composed predominantly of acrylic resin, particularly when metallic components are absent or small[17,18]. In such cases, indirect findings including focal esophageal wall thickening, luminal narrowing, surrounding soft tissue edema, or proximal dilatation may be the only radiologic clues to the presence of an impacted FB. However, in the present case, CT showed only mid esophageal wall thickening and failed to detect the impacted denture. Subsequent endoscopy demonstrated firm bilateral mucosal embedding accompanied by edema, which likely accounted for the unsuccessful removal attempts using standard snares and forceps.

Endoscopic removal remains the primary approach for managing denture ingestion. A retrospective study involving 29 patients showed a high success rate (93%) for the endoscopic removal of ingested dental objects, with few complications, most of which were limited to minor mucosal injuries[13]. However, this study predominantly included small denture particles, such as crowns. Only one patient with an impacted partial denture was included; the denture was embedded in the cervical esophagus and could not be removed endoscopically, ultimately necessitating surgery[13]. Several innovative techniques, such as dual-channel endoscopy with balloon assistance, protective sheath methods, snare-assisted retrieval, overtube-assisted extraction, and combined laparoscopy–endoscopy approaches, have been described for the management of impacted dentures. These techniques facilitate safe disimpaction and may reduce the need for surgical intervention[19-21].

When en bloc extraction is unsafe or unsuccessful, controlled fragmentation can serve as an effective salvage strategy[5,6]. Yang et al[22] and Gupta et al[23] described holmium laser-assisted fragmentation of incarcerated sharp esophageal FBs, facilitating endoscopic removal and avoiding surgery. Likewise, Lopez et al[24] reported the successful fragmentation and removal of impacted dentures using a holmium laser in two patients. The authors also showed that the procedure was safe, quick (approximately 15 minutes), and not associated with postoperative complications. In the current case, a thulium laser was employed to fragment the dentures.

Laser-assisted techniques enable precise cutting of rigid FBs while minimizing mucosal traction; nevertheless, the potential risk of thermal injury and perforation mandates careful application and appropriate protective measures[5,6]. Following the failure of standard retrieval techniques, laser fragmentation was attempted. To the best of our knowledge, reports describing the use of a thulium laser for fragmentation and endoscopic removal of impacted esophageal dentures are lacking. While holmium laser-assisted denture fragmentation has been reported previously, the combined use of a thulium laser and a clutch cutter as a stepwise fragmentation strategy has not been described. In the present case, partial laser-assisted fragmentation followed by mechanical completion with a clutch cutter enabled successful endoscopic retrieval and avoided surgical intervention. Compared with the Holmium: YAG laser, the thulium laser provides a more precise cutting effect with a shallower depth of tissue penetration, potentially reducing collateral thermal injury. Although comparative data in esophageal foreign-body management are lacking, these characteristics may be advantageous when controlled fragmentation is required in close proximity to the esophageal wall.

In our patient, no procedure-related adverse events occurred, and repeat endoscopy demonstrated a healing esophageal ulcer consistent with pressure-related injury from prolonged impaction and local instrumentation[8,10,15]. Conservative management resulted in uneventful recovery. By contrast, patients who require surgical intervention may experience substantially greater postoperative morbidity[16]. This case supports a pragmatic algorithm for impacted dentures: (1) Confirm the location of the denture and exclude perforation, typically using CT/endoscopy; (2) Attempt retrieval using standard grasping devices and protective accessories; (3) If the prosthesis is firmly embedded or cannot be safely removed en bloc, consider controlled fragmentation using laser and/or mechanical cutting devices; (4) Involve surgical services early when perforation is suspected or when endoscopic extraction fails; and (5) Repeat endoscopy to look for mucosal healing.

The strengths of this case include the detailed step-by-step description of a surgery-sparing rescue strategy and endoscopic documentation of early mucosal healing following FB removal. The main limitations are the single-patient design and the lack of long-term follow-up beyond the early recovery period. This report also proposes the testable hypothesis that a stepwise approach combining energy-assisted and mechanical fragmentation may enhance the success of organ-preserving endoscopic management in selected patients with complex impacted dentures when conventional retrieval devices are unsuccessful.

CONCLUSION

Impacted dentures represent high-risk esophageal FBs that are often challenging to remove. This case highlights the effective use of a thulium laser and a clutch cutter for denture fragmentation and retrieval. When standard retrieval devices fail, controlled fragmentation with a laser and/or mechanical cutting devices, along with a staged endoscopic strategy, can facilitate safe removal and may obviate the need for surgery.