Trauma in Primary/Young Teeth
Tooth embedded in lower lip following
dentoalveolar trauma: Case report
and literature review
Antonio Azoubel Antunes, DDS Thiago Santana Santos, DDS, MS Allan Ulisses Carvalho de Melo, PhD
Cyntia Ferreira Ribeiro, DDS, MS Suzane Rodrigues Jacinto Goncalves, PhD Sigmar de Mello Rode, DDS, MS
One of the most frequent consequences of trauma to the
maxillofacial region is damage to teeth and supporting structures.
Such damage can occur either in isolation or in conjunction with
other fractures and soft tissue lacerations. In emergency situations,
the harm caused to teeth could go unnoticed during the clinical
examination, depending on the nature and complexity of the
ne of the most frequent consequences of facial trauma is
damage to the teeth and supporting structures. Such traumas can
occur as a result of work- or sportsrelated accidents, physical violence,
automobile accidents, and, most
frequently, falls.1-3 Following a traumatic injury to the face, a thorough
examination of the soft tissues should
be systematically performed, including an evaluation of the hard tissues
(teeth and bone) through a clinical
inspection and radiographic examination, as well as pulp vitality, percussion, and mobility tests.4,5 When
examining soft tissues, both extraoral
and intraoral (lips, gums, cheeks,
tongue, oral mucosa, and palate)
examinations are necessary. X-rays
of tissues with signs of bleeding,
laceration, or swelling should always
be taken to determine the presence or
absence of a foreign body.6
Tooth fragments in the lower lip
are subject to constant movement
due to contractions of the orbicular
musculature and can end up distant
from the original site of perforation
at the time of trauma which can
make the diagnosis of such cases
trauma and the primary care team’s awareness of orofacial injuries.
Fractured incisors often cause lacerations to the soft tissues at the
time of trauma. During the diagnosis, particular care must be taken
when such a fracture is associated with a soft tissue injury.
Received: June 29, 2011
Accepted: August 15, 2011
more challenging. Fractured incisors
are often the cause of soft tissue
lacerations at the time of trauma.7
For this reason, special care must be
taken in cases of lacerations occurring with fractured or missing teeth.8
This report describes a case of
trauma to the maxillary incisors in
which tooth fragments remained
embedded in the interior of a lower
lip wound after primary care. The
authors also review and compare
similar cases cited in the literature.
Fig. 1. Clinical appearance of the fractured
A 17-year-old male came to the
clinic at the University of Tiradentes
School of Dentistry complaining of
a firm mass in the lower lip that was
sensitive to the touch. The patient
had been referred to the faculty with
a preliminary diagnosis of a tumor
in the lower lip by a general clinician. The patient’s history revealed
that he had fallen from a bicycle one
year earlier. At the time, he received
primary care at the emergency room
Fig. 2. Initial examination revealed a firm
nodule with normal pink color measuring
approximately 1 cm in diameter on the mucous
portion of lower lip.
Fig. 3. Radiograph revealing tooth fragments embedded in
the lower lip.
of a public hospital. The wounds,
including a laceration of the lower
lip, were sutured, and the patient
was discharged the same day.
The extraoral examination
revealed fractured maxillary central
incisors and visible scars on the
cutaneous portion of the lower lip.
Increased volume in the lip was
also noted (Fig. 1). The intraoral
examination revealed an inconspicuous scar on the mucous portion
of the lower lip. A firm nodule,
measuring approximately 1 cm in
diameter with a normal pink color,
was palpated in this region (Fig. 2).
The periapical radiograph revealed
radiopaque structures in the lower
lip similar to those of the incisal
region of the fractured maxillary
central incisors (Fig. 3). The history of trauma and the clinical and
radiological findings eliminated the
preliminary diagnosis of a tumor.
The patient underwent surgical
excision of the fragments under
local anesthesia; 1.0 cc of lidocaine
in a 2% solution with 1:100,000
epinephrine was administered to
the area of tumefaction. The lower
lip was incised along the existing
mucous scar line. The fragments
were identified and carefully
removed (Fig. 4). A 4-0 black
nylon thread was used to suture the
Fig. 4. Tooth fragments removed.
Fig. 5. Periapical radiograph confirming the
removal of the tooth fragments.
Fig. 6. Lower lip with satisfactory healing at
the six-month follow-up.
Fig. 7. Esthetic and functional integrity of the
teeth maintained at the six-month follow-up.
tissue. No antibiotic treatment was
prescribed after surgery, as there
were no signs of infection. During
the surgery, a periapical radiograph
was taken to confirm the complete
removal of the fragments (Fig. 5).
After suturing, the fragments were
reattached to the maxillary central
incisors using a composite adhesive
technique. The lingual sides of the
fragments were perfectly intact,
although the buccal aspect exhibited
a slight loss of enamel. After the
teeth were primed and etched, flowable resin was placed to match both
tooth fragments. The buccal gap
was microfilled with a composite
resin and polymerized. The teeth
were polished with rubber points
and polishing discs. Follow-up was
scheduled at two to four weeks and
three to six months to evaluate the
esthetic-functional integrity of the
At the six-month follow-up visit,
the lip exhibited satisfactory healing
and the repaired tooth was esthetically pleasing (Fig. 6). The vitality
test on both teeth was positive, and
neither tooth displayed any signs of
discoloration (Fig. 7).
The damage caused to teeth and
supporting structures is one of the
most frequent consequences of maxillofacial trauma. Such damage can
occur either in isolation or in conjunction with other fractures and
soft tissue lacerations. In emergency
Trauma in Primary/Young Teeth Tooth embedded in lower lip following dentoalveolar trauma
Table 1. Previous cases of tooth fragments embedded in lips reported
in the literature.
Cases Age/Sex since trauma Treatment
Gill & Fleming10
Schwengber et al
Removal and reattachment
Munerato et al 12
Naudi & Fung
Removal and reattachment
Pasini et al 6
Removal and reattachment
da Silva et al
Taran et al 7
de Santana Santos et al 25
Removal and reattachment
situations, the harm caused to teeth
may go unnoticed during the clinical exam, depending on the nature
and complexity of the trauma and
of the primary care team’s awareness
of orofacial injuries.6-13
A number of studies have reported
a greater frequency of dental trauma
to the incisors during childhood and
adolescence, with the prevalence
ranging from 10–20%, depending
on gender and age. These studies
attribute the greater vulnerability of
the incisors to their anterior projection and a shorter lip.14-17 Fractured
incisors often cause lacerations
to the soft tissues at the time of
trauma. It is not difficult to diagnose
tooth fracture, but particular care
must be taken when such a fracture
is associated with a soft tissue injury,
as tooth fragments embedded in soft
tissue can be overlooked during a
The authors searched for cases in
the literature documenting tooth
fragments embedded in lips. Nine
previous cases were discovered
The incorporation of a foreign
body into the wound healing
process increases the risk of infection and triggers foreign-body reactions and fibrous scar tissue. When
this reaction is chronic, it leads to
fibrosis, which encapsulates the
foreign body through the concentration of macrophages.18 In the present case, despite the absence of an
active infectious process, fibrous scar
tissue surrounding the fragments
was observed during the surgical
The differential diagnosis is of
utmost importance, especially
when patients are evaluated after
the original injury has already
healed. Radiographic findings of
tooth fragments in the floor of the
mouth could indicate sialolithiasis.8 In some cases, an increase in
lip volume could suggest the presence of a tumor during the initial
evaluation, as originally hypothesized in the present case prior to
referral to the dental clinic. Lin
et al reported a case of a foreign
body embedded in the tongue
following trauma that was initially
considered a tumor mass. That
hypothesis was promptly discarded
upon surgical excision.19
The bonding of a tooth fragment
after fracture was first described
by Chosack & Eidelman in 1964;
cementing was performed following
adequate endodontic treatment.20
Current methods range from simple
bonding, depending only on the type
of adhesive employed, to different
preparation methods for the tooth
and fragment.21-23 The advantage of
bonding is that it constitutes a more
conservative restoration of the tooth
injury without impeding the use of
a subsequent restorative material in
cases of unsuccessful treatment.24
Surgical excision is the treatment
of choice for tooth fragments embedded in the lip.25 Depending on the
size of the fragments and the length
of time they were embedded in the
tissue, it might be possible to use the
fragments to restore the remaining
fractured teeth.26 In the present case,
even one year after the cycling accident, it was possible to restore the
fractured teeth using the fragments
removed from the lower lip.
Knowledge of the patient’s injury,
a thorough clinical examination,
and a radiographic examination are
necessary whenever clinical signs of
dental trauma are observed during
primary care for trauma to the maxillofacial region. For such cases, an
analysis of the intra- and extraoral
tissues is critical, especially when
there is a laceration in which foreign
bodies might be present. These steps
will prevent the patient from having
to undergo additional surgical procedures for the subsequent removal
of remaining fragments.
Drs. Antunes and Santos are oral
and maxillofacial surgeons and
doctoral students in oral and
maxillofacial surgery, Ribeirao Preto
Dentistry College, Ribeirao Preto,
Sao Paulo, Brazil. Drs. de Melo and
Goncalves are in the School of Dentistry, University of Tiradentes, Aracaju, Sergipe, Brazil. Drs. Ribeiro
and de Mello Rode are postgraduate
students in oral rehabilitation,
University of Taubate, Taubate, Sao
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