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CASE REPORT
Year : 2011  |  Volume : 29  |  Issue : 2  |  Page : 171-175
 

Retrieval and reattachment of an elusive tooth fragment


Department of Pedodontics, Government Dental College, Rohtak, India

Date of Web Publication9-Sep-2011

Correspondence Address:
Savita Sangwan
474 Model colony, Yamunanagar-135001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.84694

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   Abstract 

Traumatic dental injuries of uncomplicated nature are a common finding and upper central incisors are the most commonly affected teeth. Sometimes, the fractured fragment or the tooth gets embedded in the surrounding soft tissues and is often missed. There are few case reports regarding the retrieval and reattachment of tooth fragment. This report presents the case of an 8-year-old girl who came with the chief complaint of pain, irritation, and tingling sensation in the lower lip since one year when her upper central incisors got fractured due to trauma along with lip laceration. A soft tissue radiograph of lower lip revealed the presence of fractured tooth fragment which was then surgically removed and reattached to one of the fractured incisors. The patient was found to be asymptomatic after the procedure. This report further highlights the importance of proper radiographic diagnosis along with clinical examination immediately after trauma in order to prevent any complications in future.


Keywords: Lower lip, reattachment, tooth fragment


How to cite this article:
Sangwan S, Mathur S, Dutta S. Retrieval and reattachment of an elusive tooth fragment. J Indian Soc Pedod Prev Dent 2011;29:171-5

How to cite this URL:
Sangwan S, Mathur S, Dutta S. Retrieval and reattachment of an elusive tooth fragment. J Indian Soc Pedod Prev Dent [serial online] 2011 [cited 2019 Aug 20];29:171-5. Available from: http://www.jisppd.com/text.asp?2011/29/2/171/84694



   Introduction Top


Dental traumas are one of the most frequent facial traumas, especially in children and adolescents. These traumas may result from various factors like falls, being the most common, followed by assaults, sports, work accidents, and others. [1],[2],[3]

A proper diagnosis and treatment planning of dental injuries is a major determinant for the prognosis of these traumas. Maxillary incisors are the most frequently involved teeth, especially in class II division I malocclusion case where a short upper lip fails to adequately protect the teeth. [2] Prevalence of these traumas also varies according to the sex and age of the patients. [4],[5],[6]

The incisors, in particular, when fractured are often accompanied by the laceration of the soft tissue, especially the lower lip. Attention should be paid to the fractured or missing teeth. This fragment may lead to scarring and irritation of the soft tissue. In case of any laceration or bleeding, a soft tissue radiograph helps in the detection of included tooth fragments.

This paper describes a patient with facial trauma who concomitantly suffered dental trauma. The aim of this case report was to point out the importance of initial clinical and radiographic examination of the patient for carrying out a proper diagnosis of the possible tooth fragment being embedded in the lip tissues consequent to dental trauma and its subsequent reattachment if feasible.


   Case Report Top


A 9-year-old girl came to the Department of Pedodontics, Government Dental College, Rohtak, with the chief complaint of pain, irritation, and tingling sensation in the lower lip since 8 to 9 months. Her mother revealed history of trauma one year back, when patient had a fall from bed and fractured her both upper central incisors (11, 21) with concomitant lip lacerations. Patient's mother accounted that since the incident of trauma, her daughter often bites and plays with the lower lip. They reported to a private dental clinic immediately after trauma where only antibiotics and analgesics were prescribed and no other treatment was done or radiographs taken because of laceration and bleeding from the lower lip.

On extraoral examination, lower lip was normal in color, size, shape and no scar mark was observed [Figure 1]. Upon palpation, a firm movable nodule was felt on the right side of the lower lip. Intraoral examination revealed Ellis class II [7] fracture of both permanent right and left upper central incisors (11, 21) with no discoloration or sinus formation [Figure 2]. IOPA confirmed the absence of any pulpal involvement or periapical pathology [Figure 3]. Furthermore, corelating the history of trauma with the symptoms of irritation and biting of lower lip, a soft tissue radiograph of the lower lip was taken by placing the IOPA X-ray film between lower lip and lower incisors.
Figure 1: Preoperative view of lower lip showing normal findings

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Figure 2: Preoperative examination revealed fracture of permanent maxillary central incisors

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Figure 3: Preoperative IOPA X-ray of maxillary central incisors showed no root fracture or any periapical pathology

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Radiograph showed the presence of a radio-opaque foreign body suggestive of the coronal fragment of one of the fractured incisors [Figure 4]. The patient was scheduled subsequently for surgical removal of the fractured tooth fragment under local anesthesia. For this procedure, lower lip was scrubbed with betadine and 1 ml of lignocaine in a 2% solution with 1 : 100 000 epinephrine was administered in the lower labial vestibule. A horizontal incision was made on the right inner aspect of the lower lip and the dental fragment was gently removed [Figure 5],[Figure 6],[Figure 7]. Immediately after the surgical procedure, another soft tissue radiograph was obtained to confirm that the lower lip was free of any other remaining fragments [Figure 8]. 3-0 silk sutures were placed to reapproximate the tissues and analgesics were prescribed.
Figure 4: Preoperative X-ray of lower lip showed a radio-opaque image suggestive of tooth fragment

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Figure 5: Horizontal incision given on the lower lip

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Figure 6: Tooth fragment identified and removed

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Figure 7: Tooth fragment after its removal from the lower lip

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Figure 8: Postoperative X-ray of lower lip showed no radio-opaque mass

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The tooth fragment removed from the lower lip was cleaned and stored in saline until it was reattached to the upper left central incisor (21), using composite Scotchbond Multi-Purpose TM 3M (St. Paul, MN, USA). A groove was made into the dentine of the fragment removed from the lip with a round diamond bur. Acid etching was done for 30 seconds and Scotchbond Multi-Purpose TM primer was applied and dried for 5 seconds. The adhesive was applied and light cured for 10 seconds. The groove was then filled with composite resin matched to the tooth shade (B2). The tooth fragment was attached to the upper left central incisor, which had also been treated in a similar manner. The restoration was then light cured for 40 seconds from both labial and palatal surfaces. Care was taken to ensure that some composite was applied over the junction of the fracture so that the fracture site was not visible once the composite was cured [Figure 9]. Furthermore, for the restoration of upper right central incisor, the enamel margins were beveled using tapered fissure diamond bur and were acid etched with 35% phosphoric acid for 30 seconds. Thereafter, the primer and adhesive were applied and light cured for 10 seconds (Scotchbond Multi-Purpose TM 3M, St. Paul, MN, USA). Crown shape was formed by incremental placement of the composite resin matched to the tooth shade (B2) [Figure 9]. The restorations were further polished with a series of fine abrasive disks (Soflex, 3M- ESPE, Seefeld, Germany).
Figure 9: Right maxillary central incisor was restored with composite resin and fragment reattachment was done in left maxillary central incisor

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The patient was recalled after one week for suture removal and improved with uneventful healing [Figure 10]. The patient was reviewed after 3 months and she was found to be free of all the symptoms of irritation, pain, and tingling of lower lip. The teeth were neither tender to percussion nor mobile and were responsive to pulp testing. The appearance of the teeth and patient's feedback on the result of the procedure was satisfactory.
Figure 10: Follow-up after 15 days shows healed lower lip

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   Discussion Top


Trauma to the teeth as well as their supporting tissues corresponds to one of the most frequent traumas to the maxillofacial region. Mostly, these traumas occur separately but sometimes can be associated with other structures and soft tissue lacerations.

Falls account for most common etiology of these traumas with males, in the first decade of life, [8],[9],[10] more frequently affected. Many factors contribute to increased incidence of these injuries in permanent dentition like increased overjet (>6 mm), lip incompetence, and proclined upper anteriors. [2],[6],[8]

Normally, fractured or missing incisors are not difficult to diagnose but when associated with a soft tissue laceration, the condition requires a thorough examination for confirming the presence of the lost fragment/tooth which might have been embedded in the soft tissue. Tooth fragments embedded in the soft tissue may not be easily detectable. Dentists have a considerable role to play in the diagnosis of these foreign bodies, especially in cases of fractured incisors with lip lacerations, failure of which can lead to harmful sequelae. A simple soft tissue radiograph can help in detection of the included tooth fragments in the oral regions.

Radiographic examination has a major role to play after a maxillofacial trauma involving fracture of teeth/missing teeth since the later may act as foreign body, have risk of being ingested, aspirated, or included in the surrounding tissues. The worst complication is the aspiration of these foreign bodies that can lead to chronic airway infection and death, if not precociously diagnosed. [11] Another problem is in cases where patient gives history of long-standing trauma, the radiographic picture of tooth fragment embedded in the floor of the month may seem to be similar to sialolithiasis of salivary glands. However, the sum of clinical data along with radiographic findings leads to a conclusive diagnosis.

The treatment of choice in these cases is surgical excision. Immediately after excision, the soft tissue radiograph is mandatory to ensure the complete removal of fragments, as the failure to remove them totally may lead to breakdown of the suture line, persistent chronic infection, pus discharge, and a disfiguring fibrosis. [12],[13],[14]

In case the fragment is intact, it can be used to restore the remaining fractured tooth. [14] A number of advantages have been cited in favor of tooth fragment reattachment. It is a conservative restoration and aesthetics achieved by tooth fragment reattachment are far more superior to those achieved by any other type of restoration. [15] This is because the color matching and the incisal translucency are maintained. Also, the original tooth contours and the occlusal contacts are preserved. But, if the tooth fragment is allowed to dehydrate, the aesthetics achieved is less than ideal. [15],[16]

Finally, our case displays a good example of elusiveness of a broken fragment embedded in the soft tissue. The general dentist and even the patient failed to notice the presence of broken tooth fragment. As the healing of the laceration took place, the fragment was covered by fibrous tissue. The fragment could only be felt by careful palpation and confirmed by radiological examination.

Thus, this paper emphasizes the importance of an accurate clinical and radiographic examination of these patients, especially in the cases of dental traumas along with facial injuries. In these patients, both hard and adjacent soft tissues should be examined carefully, even if sutured and treated by another professional in the emergency.


   Acknowledgement Top


Special thanks to Dr. Sanguida A. for her contribution.

 
   References Top

1.Andreasen JO. Aetiology and pathogenesis of traumatic dental injuries. A clinical study of 1,298 cases. Scand J Dent Res 1970;78:329-42.  Back to cited text no. 1
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2.O'Neil DW, Clark MV, Lowe JW, Harrington MS. Oral trauma in children: A hospital survey. Oral Surg Oral Med Oral Pathol 1989;68:691-6.  Back to cited text no. 2
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3.Andreasen JO, Andreasen FM. Textbook and color atlas of traumatic injuries to the teeth. 3 rd ed. Saint Louis: C. V. Mosby; 1997. p. 170-88.  Back to cited text no. 3
    
4.Forsberg CM, Tederstam G. Traumatic injuries to the teeth in Swedish children living in an urban area. Swed Dent J 1990;14:115-22.   Back to cited text no. 4
    
5.Hunter ML, Hunter B, Kingdon A, Addy M, Dummer PMH. Traumatic injuries to maxillary incisor teeth in Swedish children. Endod Dent Traumatol 1990;6:260-4.   Back to cited text no. 5
    
6.Dearing SG. Overbite, overjet, lip-drape and incisor tooth fracture in children. N Z Dent J 1984;80:50-2.  Back to cited text no. 6
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7.Bastone EB, Freer TJ, McNamara JR. Epidemiology of dental trauma: A review of the literature. Aust Dent J 2000;45:2-9.  Back to cited text no. 7
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8.Kaban LB. Diagnosis and treatment of fractures of the facial bones in children 1943-1993. J Oral Maxillofac Surg 1993;51:722-  Back to cited text no. 8
    
9.Dewhurst SN, Manson C, Roberts GJ. Emergency treatment of orodental injuries: A review. Br J Oral Maxillofac Surg 1998;36:165-75.   Back to cited text no. 9
    
10.Luz JG, Di Mase F. Incidence of dentoalveolar injuries in hospital emergency room patients. Endod Dent Traumatol 1994;10:188-90.  Back to cited text no. 10
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11.Kimberly DR. Unrecognized aspiration of a mandibular incisor. J Oral Maxillofac Surg 2001;59:350-52.  Back to cited text no. 11
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12.Laskin DM, Donohue WB. Treatment of human bites of lip. J Oral Surg (Chic) 1958;16:236-42.  Back to cited text no. 12
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13.Goldstein EJ. Bite wounds and infection. Clin Infect Dis 1992;14:633-8.  Back to cited text no. 13
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14.Chu FC, Yim TM, Wei SH. Clinical considerations for reattachment of tooth fragments. Quintessence Int 2000;31:385-91.  Back to cited text no. 14
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15.Maia EA, Baratieri LN, De Andrada MA, Monteiro S Jr, De Araujo EM, Jr. Tooth fragment reattachment: Fundamentals of the technique and two case reports. Quintessence Int 2003;34:99-107.   Back to cited text no. 15
    
16.Worthington RB, Murchison DF, Vandewalle KS. Incisal edge reattachment: The effect of preparation utilization and design. Quintessence Int 1999;30:637-43.  Back to cited text no. 16
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]


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