Case Report

Retrieval and reattachment of an elusive tooth

fragment
Savita Sangwan, Shivani Mathur, Samir Dutta
Abstract Department of pedodontics, Government Dental College,
Rohtak, India
Traumatic dental injuries of uncomplicated nature are a
common finding and upper central incisors are the most Correspondence:
commonly affected teeth. Sometimes, the fractured fragment Dr. Savita Sangwan, 474 Model colony, Yamunanagar-135001,
or the tooth gets embedded in the surrounding soft tissues Haryana, India. E-mail: [email protected]
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 Access this article online
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chief complaint of pain, irritation, and tingling sensation in Website:
the lower lip since one year when her upper central incisors www.jisppd.com

got fractured due to trauma along with lip laceration. A DOI:

10.4103/0970-4388.84694
soft tissue radiograph of lower lip revealed the presence of
fractured tooth fragment which was then surgically removed PMID:
**********
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 The incisors, in particular, when fractured are often
trauma in order to prevent any complications in future. accompanied by the laceration of the soft tissue,
especially the lower lip. Attention should be paid to the
Key words fractured or missing teeth. This fragment may lead to
scarring and irritation of the soft tissue. In case of any
Lower lip, reattachment, tooth fragment
laceration or bleeding, a soft tissue radiograph helps in
the detection of included tooth fragments.
Introduction This paper describes a patient with facial trauma who
concomitantly suffered dental trauma. The aim of this
Dental traumas are one of the most frequent facial case report was to point out the importance of initial
traumas, especially in children and adolescents. These clinical and radiographic examination of the patient for
traumas may result from various factors like falls, being carrying out a proper diagnosis of the possible tooth
the most common, followed by assaults, sports, work fragment being embedded in the lip tissues consequent
accidents, and others.[1-3] to dental trauma and its subsequent reattachment if
feasible.
A proper diagnosis and treatment planning of dental
injuries is a major determinant for the prognosis Case Report
of these traumas. Maxillary incisors are the most
frequently involved teeth, especially in class II division A 9-year-old girl came to the Department of
I malocclusion case where a short upper lip fails to Pedodontics, Government Dental College, Rohtak,
adequately protect the teeth.[2] Prevalence of these with the chief complaint of pain, irritation, and
traumas also varies according to the sex and age of tingling sensation in the lower lip since 8 to 9 months.
the patients.[4-6] Her mother revealed history of trauma one year back,

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 Sangwan, et al.: Retrieval and reattachment of an elusive tooth fragment

when patient had a fall from bed and fractured her both radiograph of the lower lip was taken by placing the
upper central incisors (11, 21) with concomitant lip IOPA X-ray film between lower lip and lower incisors.
lacerations. Patient’s mother accounted that since the
incident of trauma, her daughter often bites and plays Radiograph showed the presence of a radio-opaque
with the lower lip. They reported to a private dental foreign body suggestive of the coronal fragment of
clinic immediately after trauma where only antibiotics one of the fractured incisors [Figure 4]. The patient
and analgesics were prescribed and no other treatment was scheduled subsequently for surgical removal of the
was done or radiographs taken because of laceration fractured tooth fragment under local anesthesia. For
and bleeding from the lower lip. this procedure, lower lip was scrubbed with betadine
and 1 ml of lignocaine in a 2% solution with 1 : 100 000
On extraoral examination, lower lip was normal in epinephrine was administered in the lower labial
color, size, shape and no scar mark was observed vestibule. A horizontal incision was made on the right
[Figure 1]. Upon palpation, a firm movable nodule inner aspect of the lower lip and the dental fragment
was felt on the right side of the lower lip. Intraoral was gently removed [Figures 5-7]. Immediately after
examination revealed Ellis class II[7] fracture of both the surgical procedure, another soft tissue radiograph
permanent right and left upper central incisors (11, 21) was obtained to confirm that the lower lip was free of
with no discoloration or sinus formation [Figure 2]. any other remaining fragments [Figure 8]. 3-0 silk
IOPA confirmed the absence of any pulpal involvement sutures were placed to reapproximate the tissues and
or periapical pathology [Figure 3]. Furthermore, analgesics were prescribed.
corelating the history of trauma with the symptoms
of irritation and biting of lower lip, a soft tissue The tooth fragment removed from the lower lip was

Figure 2: Preoperative examination revealed fracture of permanent

Figure 1: Preoperative view of lower lip showing normal findings maxillary central incisors

Figure 3: Preoperative IOPA X-ray of maxillary central incisors showed Figure 4: Preoperative X-ray of lower lip showed a radio-opaque
no root fracture or any periapical pathology image suggestive of tooth fragment

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 Sangwan, et al.: Retrieval and reattachment of an elusive tooth fragment

Figure 5: Horizontal incision given on the lower lip Figure 6: Tooth fragment identified and removed

Figure 7: Tooth fragment after its removal from the lower lip Figure 8: Postoperative X-ray of lower lip showed no radio-opaque
mass

Figure 9: Right maxillary central incisor was restored with composite Figure 10: Follow-up after 15 days shows healed lower lip
resin and fragment reattachment was done in left maxillary central
incisor
etching was done for 30 seconds and Scotchbond Multi-
cleaned and stored in saline until it was reattached to PurposeTM primer was applied and dried for 5 seconds.
the upper left central incisor (21), using composite The adhesive was applied and light cured for 10 seconds.
Scotchbond Multi-PurposeTM 3M (St. Paul, MN, USA). The groove was then filled with composite resin
A groove was made into the dentine of the fragment matched to the tooth shade (B2). The tooth fragment
removed from the lip with a round diamond bur. Acid was attached to the upper left central incisor, which had

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 Sangwan, et al.: Retrieval and reattachment of an elusive tooth fragment

also been treated in a similar manner. The restoration sequelae. A simple soft tissue radiograph can help in
was then light cured for 40 seconds from both labial detection of the included tooth fragments in the oral
and palatal surfaces. Care was taken to ensure that regions.
some composite was applied over the junction of the
fracture so that the fracture site was not visible once the Radiographic examination has a major role to play after
composite was cured [Figure 9]. Furthermore, for the a maxillofacial trauma involving fracture of teeth/
restoration of upper right central incisor, the enamel missing teeth since the later may act as foreign body,
margins were beveled using tapered fissure diamond have risk of being ingested, aspirated, or included in
bur and were acid etched with 35% phosphoric acid for the surrounding tissues. The worst complication is
30 seconds. Thereafter, the primer and adhesive were the aspiration of these foreign bodies that can lead to
applied and light cured for 10 seconds (Scotchbond chronic airway infection and death, if not precociously
Multi-PurposeTM 3M, St. Paul, MN, USA). Crown shape diagnosed.[11] Another problem is in cases where
was formed by incremental placement of the composite patient gives history of long-standing trauma, the
resin matched to the tooth shade (B2) [Figure 9]. The radiographic picture of tooth fragment embedded
restorations were further polished with a series of fine in the floor of the month may seem to be similar to
abrasive disks (Soflex, 3M- ESPE, Seefeld, Germany). sialolithiasis of salivary glands. However, the sum of
clinical data along with radiographic findings leads to
The patient was recalled after one week for suture a conclusive diagnosis.
removal and improved with uneventful healing
[Figure 10]. The patient was reviewed after 3 months The treatment of choice in these cases is surgical
and she was found to be free of all the symptoms of excision. Immediately after excision, the soft tissue
irritation, pain, and tingling of lower lip. The teeth radiograph is mandatory to ensure the complete
were neither tender to percussion nor mobile and were removal of fragments, as the failure to remove them
responsive to pulp testing. The appearance of the teeth totally may lead to breakdown of the suture line,
and patient’s feedback on the result of the procedure persistent chronic infection, pus discharge, and a
was satisfactory. disfiguring fibrosis.[12-14]

Discussion In case the fragment is intact, it can be used to restore

the remaining fractured tooth. [14] A number of
Trauma to the teeth as well as their supporting tissues advantages have been cited in favor of tooth fragment
corresponds to one of the most frequent traumas to reattachment. It is a conservative restoration and
the maxillofacial region. Mostly, these traumas occur aesthetics achieved by tooth fragment reattachment are
separately but sometimes can be associated with other far more superior to those achieved by any other type
structures and soft tissue lacerations. of restoration.[15] This is because the color matching
and the incisal translucency are maintained. Also, the
Falls account for most common etiology of these original tooth contours and the occlusal contacts are
traumas with males, in the first decade of life,[8-10] more preserved. But, if the tooth fragment is allowed to
frequently affected. Many factors contribute to increased dehydrate, the aesthetics achieved is less than ideal.[15,16]
incidence of these injuries in permanent dentition like
increased overjet (>6 mm), lip incompetence, and Finally, our case displays a good example of elusiveness
proclined upper anteriors.[2,6,8] of a broken fragment embedded in the soft tissue. The
general dentist and even the patient failed to notice the
Normally, fractured or missing incisors are not presence of broken tooth fragment. As the healing of
difficult to diagnose but when associated with a soft the laceration took place, the fragment was covered by
tissue laceration, the condition requires a thorough fibrous tissue. The fragment could only be felt by careful
examination for confirming the presence of the lost palpation and confirmed by radiological examination.
fragment/tooth which might have been embedded
in the soft tissue. Tooth fragments embedded in the Thus, this paper emphasizes the importance of an
soft tissue may not be easily detectable. Dentists have accurate clinical and radiographic examination of
a considerable role to play in the diagnosis of these these patients, especially in the cases of dental traumas
foreign bodies, especially in cases of fractured incisors along with facial injuries. In these patients, both hard
with lip lacerations, failure of which can lead to harmful and adjacent soft tissues should be examined carefully,

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 Sangwan, et al.: Retrieval and reattachment of an elusive tooth fragment

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