Case Report
Retrieval and reattachment of an elusive tooth
fragment
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.
Key words
Lower lip, reattachment, tooth fragment
Introduction
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.[1-3]
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.[4-6]
JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Apr - Jun 2011 | Issue 2 | Vol 29 |
Savita Sangwan, Shivani Mathur, Samir Dutta
Department of pedodontics, Government Dental College,
Rohtak, India
Correspondence:
Dr. Savita Sangwan, 474 Model colony, Yamunanagar-135001,
Haryana, India. E-mail: drsethisavita@gmail.com
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DOI:
10.4103/0970-4388.84694
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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
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,
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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
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
Figure 1: Preoperative view of lower lip showing normal findings
Figure 3: Preoperative IOPA X-ray of maxillary central incisors showed
no root fracture or any periapical pathology
172 JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Apr - Jun 2011 | Issue 2 | Vol 29 |
radiograph of the lower lip was taken by placing the
IOPA X-ray film between lower lip and lower incisors.
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 [Figures 5-7]. 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.
The tooth fragment removed from the lower lip was
Figure 2: Preoperative examination revealed fracture of permanent
maxillary central incisors
Figure 4: Preoperative X-ray of lower lip showed a radio-opaque
image suggestive of tooth fragment
 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
resin and fragment reattachment was done in left maxillary central
incisor
cleaned and stored in saline until it was reattached to
the upper left central incisor (21), using composite
Scotchbond Multi-PurposeTM 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
Figure 10: Follow-up after 15 days shows healed lower lip
etching was done for 30 seconds and Scotchbond Multi-
PurposeTM 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

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 Sangwan, et al.: Retrieval and reattachment of an elusive tooth fragment
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-PurposeTM 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).
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.
Discussion
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,[8-10] 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
174 JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Apr - Jun 2011 | Issue 2 | Vol 29 |
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.[12-14]
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,
 Sangwan, et al.: Retrieval and reattachment of an elusive tooth fragment
even if sutured and treated by another professional in
the emergency.
Acknowledgement
Special thanks to Dr. Sanguida A. for her contribution.
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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.
Source of Support: Nil, Conflict of Interest: None declared.
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