The Hidden Tooth: A Case Report
We have described a case in which a fragment of a fractured incisor was embedded in the upper lip. This case report emphasizes the need for a thorough clinical and a radiographic examination in all cases of soft tissue injuries which accompany a dental trauma. An early diagnosis and the surgical removal of these fragments could prevent undesirable foreign body reactions and scarring.
Soft tissue trauma, Artery forceps
INTRODUCTION
Soft tissue injuries often occur in children during their play or during a quarrel among their peer group. The coexistence of avulsed teeth or coronal fractures should alert the clinician to their possible loss in deeply lacerated wounds.Tooth fragments may be embedded in any soft tissue. The lips are most often involved. Hence, a proper clinical and a radiographic examination of both the hard tissue and the soft tissue and taking the history of the trauma can help in the diagnosis as well as in the planning of the treatment.
The patient was a healthy, 14 year old boy who reported to the dental department with the chief complaint of broken upper front tooth and he sought help in its restoration. The patient revealed a history of trauma 5 years back, where he had fractured the right maxillary central incisor (#11). A laceration was present over the upper lip, with a profuse bleeding, during the time of the trauma, following which he had taken a first aid treatment in the casualty ward of a nearby hospital. The injury was examined and cleaned and suturing was done over the upper lip, at the site of the injury. The patient did not complain of any related problems except for the swelling which was present since the time of the injury. On clinical examination following the history taking, it was found that the patient had a scar along the previously sutured region, with minor asymmetry of the upper lip (Table/Fig 1). The intra-oral examination revealed a coronal fracture of the right maxillary central incisor (#11) which involved the enamel and the dentin. It was considered as an Ellis class III fracture, as there was discolouration of #11 (Table/Fig 2).
On palpation over the scar formation region, a hard swelling which was deeply seated, was felt. A radiograph of the upper lip was taken and it revealed the presence of a radiopaque mass (Table/Fig 3). Following the examination, the treatment planning was done, which included removal of the hard mass and root canal treatment, followed by the restoration of the tooth with a ceramic crown. Initially, the upper lip was anaesthetized and the hard mass was pressed against its mucosal surface. An incision was placedalong the area of prominence and it was carefully dissected, while simultaneously applying pressure from the labial surface of the lip (Table/Fig 4). This manoevour squeezed out a white hard mass which was carefully grasped and removed with the help of an artery forceps (Table/Fig 5).The removed mass was the fractured crown which had been entrapped in the upper lip at the time of the injury (Table/Fig 6). The area was thoroughly examined and by using a 5-0 suture, it was approximated. Post-operative medications and instructions were given and the patient was subsequently examined and followed up.
The dental related trauma in the paediatric population can be physically and emotionally stressful for the children and their families (1). Occasionally, a part of the fractured tooth may enter and be retained in the lip. When a patient has a swollen lip which is associated with trauma to the anterior dentition, one should always suspect embedded tooth fragments. A radiograph of the involved lip which was taken from a profile view, should be obtained to evaluate the possibility of penetration and retention of a piece of a fractured tooth (2). A soft tissue radiograph can well be an occlusal view or a radiograph film which was placed between the lips and the dental arch, with a low exposure. Falls are the most common aetiology of these traumas in males, in the first decade of life (3),(4),(5). Many factors contribute to the increased incidence of these injuries in permanent dentitions like an increased overjet (>6 mm), lip incompetence, and proclined upper anteriors (3),(6),(7). Several similar cases have been reported, with the comprehensive management for the same (8),(9),(10),(11).
This case report emphasizes the need for a thorough clinical and a radiographic examination in all cases of soft tissue injuries which accompany a dental trauma. An early diagnosis and the surgical removal of these fragments could prevent undesirable foreign body reactions and scarring.
ID: JCDR/2012/4027:2487
Date of Submission: Jan 21, 2012
Date of Peer Review: Apr 04, 2012
Date of Acceptance: Aug 20, 2012
Date of Publishing: Sep 30, 2012
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