Tooth fragment embedded in the lower lip for 10 months following dentoalveolar trauma: A case report with literature review
Burns & Trauma volume 2, pages 141–145 (2014)
Traumatic injuries to maxillary anterior teeth are a common finding in children because of falls while playing. Sequelae of trauma to dental hard tissue include broken, lost, aspirated and swallowed teeth. One additional hazard is the embedding of fractured tooth fragments in the soft tissues, particularly in the lip. A 10-year-old male patient complained of pain in the lower lip. There was a history of trauma to the upper anterior tooth 10 months previously. Clinical examination showed scarring and discoloration over the lower lip, and the presence of a hard mass was felt on palpation. Intraoral examination revealed an Ellis and Davey class II fracture of number 11. A radiograph of the lip was taken, which showed a radiopaque structure similar to the shape of the missing tooth fragment. Under local anesthesia, the tooth fragment was removed successfully, and the class II fracture was restored with composite. Therefore, proper clinical and complete radiographic examination of both hard and soft tissues following dental trauma is essential to rule out such occurrences.
Traumatic injuries to the maxillary anterior teeth are a common finding in children because of falls while playing. The reason for the increased vulnerability of the maxillary incisors to fracturing is because of the projection of anterior teeth and the short labial lip that does not adequately protect these teeth. Therefore, broken, lost, swallowed, or aspirated teeth can be a hazard in dental and medical practice. One additional hazard is the embedding of fractured tooth fragments in the soft tissues,[1–23] particularly in the lip. It is commonly observed that dental traumas are usually associated with damage to the surrounding soft tissues, varying from bruises to deep lacerations. From numerous case reports, it has been observed that an impact force toward the incisors leads to fracture and causes a laceration of the soft tissues, particularly of the lips, and may lead to embedding of tooth fragments in the lip [Table 1]. Such tooth fragments, if undetected at the time of emergency treatment, may remain undiagnosed for longer periods and lead to infection and disfiguring fibrosis in addition to medicolegal complications. The present article reports a case of scarring and foreign body reaction in the lip due to embedding of an occult tooth fragment for approximately 10 months after dentoalveolar trauma without patient awareness.
A 10-year-old male patient reported to the department of Pedodontics complaining of pain in the lower lip that began 15 days before. The patient’s medical history revealed traumatic injury to the upper anterior teeth in addition to a lower lip laceration due to a fall while playing approximately 10 months previously. However, at the time, no attempt was made to locate the fractured tooth fragment at the site of the accident neither by the patient nor by his parents. The patient consulted a nearby general medical practitioner for the soft tissue injury, and the lip laceration was sutured by the medical practitioner. Subsequently, the patient did not receive any treatment for the fractured upper teeth. For approximately 10 months, the patient did not feel any discomfort in the lip. Fifteen days before presenting at the clinic, the patient began to have pain in the lower lip. Clinical examination showed scarring and discoloration of the skin to the right of the midline of the external aspect of the lip [Figure 1]. On palpation, a small hard mass was felt in the lip mucosa. Intraoral examination revealed an Ellis and Davey class II fracture involving the permanent maxillary right central incisor. Suspecting a foreign body, a radiograph of the lip was taken, which showed a radiopaque structure similar to that of the fractured tooth fragment [Figure 2]. Based on the patient’s history and on clinical and radiographic findings, the present case was diagnosed as a case of embedded fractured tooth fragment in the lip following trauma. The embedding of the tooth fragment in the lower lip was explained to the patient, and its removal under local anesthesia was planned. A small incision was made under local anesthesia in the proximity of the hard mass, which exposed the embedded tooth fragment [Figure 3]. The tooth fragment was completely removed followed by suturing with 3−0 black silk suture [Figure 4]. Examination of the tooth fragment [Figure 5] confirmed that it was a tooth fragment that had been embedded and undetected in the lip for almost 10 months. The patient was reviewed regularly, and healing was uneventful. The fractured tooth fragment was discarded, as the patient did not agree to the reattachment procedure. Later, the fractured upper anterior tooth was restored with composite.
Traumatic injury to the upper anterior teeth is most commonly encountered in the first decade of life, with falls being the most frequent etiology. It has been reported that these injuries occur in association with soft tissue lacerations; as a result, the embedding of the fractured tooth fragment in the surrounding soft tissues is a common sequela.[1–23] An extensive review of PubMed literature revealed reports of tooth fragments embedded in various soft tissues [Table 1].[1–23] Among these, in most of the reported cases (16 out of 24 case reports), the lower lip was the most common site for the embedded incisor fragment.[1,3,4,9,11–17,19,20,22,23] However, Kalra et al., Cubukcu et al., and Agarwal et al. reported cases with tooth fragments embedded in the upper lip. McDonnell and McKiernan (in 1986) and Hill et al. published case reports of tooth fragments embedded in the tongue.
There are reports of spontaneous eruption of the undetected tooth fragments from the soft tissues. If the tooth does not erupt and remains within the soft tissues, persistent chronic infection with pus discharge and disfiguring fibrosis may occur. In 2010, Al-Jundi reported a case of a tooth fragment embedded in the lower lip that remained undiagnosed for 18 months. This is the only report in the literature documenting the duration of a tooth embedded in the lip for this length of time. In 2006, Rao and Hegde published a case report on the spontaneous eruption of the occult tooth after 8 months of entrapment in the lower lip. In the present case, the tooth remained within the lip for 10 months, leading to fibrosis and discoloration of the skin. A recent report published by Barua et al.  described a tooth fragment embedded in the lower lip for 5 months [Table 1].
Tooth fragments embedded in the soft tissue may not be easily detectable clinically. Therefore, every attempt should be made to locate the missing tooth structure before the wound is closed. If laceration and bleeding make clinical examination difficult, simple soft tissue and occlusal radiographs should be taken to help detect tooth fragments entrapped in the oral soft tissues.[2,18,23] Once the embedded tooth is diagnosed on radiographs, complete removal of the fractured tooth fragment is important to prevent infection, disfiguring, scarring and discoloration of the skin.
In the present case, it was noted that neither the patient nor the parents attempted to locate the tooth fragment at the site of injury. The medical practitioner who treated the patient also did not evaluate the possibility of embedded tooth fragments in the lacerated lip following the trauma. From this information, it is evident that there is a lack of knowledge among some health professionals regarding tooth embedding in soft tissues following trauma. Moreover, it has been reported that a majority of the skin wounds in children are often repaired in general medical hospitals. Additionally, it was found that the medical practitioners provided the treatment without detecting the foreign body or even seeking the opinion of a dental specialist (pediatric dentist) about the management of such injuries.[16,19] Therefore, collaboration between medical and dental professionals is essential in the management of such cases. Following retrieval of the embedded tooth fragment, the fragment can be used to restore the remaining fractured tooth. In the present case, the tooth fragment was discarded because the patient’s parents did not agree to the reattachment procedure. A literature search revealed 6 cases with reattachment procedures using the tooth retrieved from the soft tissues in addition to the long-term results.[1,3,13,15,16,19]
Finally, this paper emphasizes the importance of a detailed physical and radiographic evaluation of these patients following orofacial trauma. Particularly in cases of dental trauma that presents with soft tissue injuries such as lip laceration, both the hard tissue and the adjacent soft tissue should be carefully examined, even if the soft tissue has been sutured and treated by another health professional during the emergency care. Because of the magnitude of soft tissue trauma associated with a minor tooth structure, the pediatric dentist may often be the first health provider to see the child. Thus, the pediatric dentist should look for missed tooth fragments in a child with such injuries.
Lauritano D, Petruzzi M, Sacco G, Campus G, Carinci F, Milillo L. Dental fragment embedded in the lower lip after facial trauma: Brief review literature and report of a case. Dent Res J (Isfahan) 2012;9 (Suppl 2):S237–41.
Agarwal A, Rehani U, Rana V, Gambhir N. Tooth fragment embedded in the upper lip after dental trauma: A case report presenting an immediate diagnostic approach and complete rehabilitation. J Indian Soc Pedod Prev Dent 2013;31:52–5.
Lips A, da Silva LP, Tannure PN, Farinhas JA, Primo LG, de Araújo Castro GF. Autogenous bonding of tooth fragment retained in lower lip after trauma. Contemp Clin Dent 2012;3:481–3.
Wadkar MA, Dhusia HK, Narkhede PR. Foreign body in the lip: A case report. J Indian Dent Assoc 1986;58:147–8.
Snawder KD, O’Toole TJ, Bastawi AE. Broken-tooth fragments embedded in soft tissue. ASDC J Dent Child 1979;46:145–8.
Hill FJ, Picton JF. Fractured incisor fragment in the tongue: A case report. Pediatr Dent 1981;3:337–8.
McDonnell DG, McKiernan EX. Broken tooth fragments embedded in the tongue: A case report. Br J Oral Maxillofac Surg 1986;24:464–6.
Clark JC, Jones JE. Tooth fragments embedded in soft tissue: A diagnostic consideration. Quintessence Int 1987;18:653–4.
Taran A, Har-Shai Y, Ullmann Y, Laufer D, Peled IJ. Traumatic self-inflicted bite with embedded tooth fragments in the lower lip. Ann Plast Surg 1994;32:431–3.
Kalra N, Aggarwal A. Traumatically embedded deciduous tooth in the upper lip of a six year old child. J Indian Soc Pedod Prev Dent 1997;15:76–7.
da Silva AC, de Moraes M, Bastos EG, Moreira RW, Passeri LA. Tooth fragment embedded in the lower lip after dental trauma: Case reports. Dent Traumatol 2005;21:115–20.
Cetinkaya R, Ozcelik D, Kavak A. To the editor: Tooth fractures embedded in the lower lip. Dermatol Surg 2005;31:1375.
Pasini S, Bardellini E, Keller E, Conti G, Flocchini P, Majorana A. Surgical removal and immediate reattachement of coronal fragment embedded in lip. Dent Traumatol 2006;22:165–8.
Rao D, Hegde S. Spontaneous eruption of an occult incisor fragment from the lip after eight months: Report of a case. J Clin Pediatr Dent 2006;30:195–7.
Naudi AB, Fung DE. Tooth fragment reattachment after retrieval from the lower lip — a case report. Dent Traumatol 2007;23:177–80.
Schwengber GF, Cardoso M, Vieira Rde S. Bonding of fractured permanent central incisor crown following radiographic localization of the tooth fragment in the lower lip: A case report. Dent Tramatol 2010;26:434–7.
Al-Jundi SH. The importance of soft tissue examination in traumatic dental injuries: A case report. Dent Traumatol 2010;26:509–11.
Cubukcu CE, Aydin U, Ozbek S, Kahveci R. Delayed removal of a primary incisor embedded in the upper lip after dental trauma: A case report about the importance of soft tissue examination. Dent Traumatol 2011;27:314–7.
Sangwan S, Mathur S, Dutta S. Retrieval and reattachment of an elusive tooth fragment. J Indian Soc Pedod Prev Dent 2011;29:171–5.
Antunes AA, Santos TS, Carvalho de Melo AU, Ribiero CF, Goncalves SR, de Mello Rode S. Tooth embedded in lower lip following dentoalveolar trauma: Case report and literature review. Gen Dent 2012;60:544–7.
Goodson A, Bhangoo P. The importance of thorough oral examination and the value of soft tissue radiography in the management of embedded tooth fragments. Emerg Med J 2013;30:172.
Barua P, Chaudhary S, Kaur H, Mallikarjuna R. Treatment imprudence leading to missed tooth fragment. BMJ Case Rep 2013;2013:bcr2013009154.
Altundasar E, Demiralp B. The importance of soft tissue examination in post-traumatic decision-making: A case report. Aust Endod J 2013;39:35–8.
How to cite this article: Nagaveni NB, Umashankara KV. Tooth fragment embedded in the lower lip for 10 months following dentoalveolar trauma: A case report with literature review. Burn Trauma 2014;2:141–5.
Source of Support: Nil Conflict of Interest: None declared.
Fearured Articles on Wound Healing and Tissue Engineering in Burns & Trauma
Fearured Articles on Wound Healing and Tissue Engineering in Burns & Trauma
About this article
Cite this article
Nagaveni, N.B., Umashankara, K.V. Tooth fragment embedded in the lower lip for 10 months following dentoalveolar trauma: A case report with literature review. Burn Trauma 2, 141–145 (2014). https://doi.org/10.4103/2321-3868.135652
- Fractured incisor
- lip laceration
- tooth embedding