The coincidence of both soft tissue injury and traumatic tooth avulsion requires special consideration because of the possible projection of the tooth or its fragments into the soft tissue.
If it is undetected at the time of the emergency treatment, such fragments can lead to severe complications.
Here, we report a case of an initially-misdiagnosed embedded primary maxillary canine in the lower oral vestibule following traumatic tooth avulsion. This location is not frequent and only one case was reported in the literature. Diagnosis was based on the clinical and radiographic examinations. The tooth was successfully removed without any complication.
Nabiha Douki – Head of the Odontology department at the university hospital of Sahloul, Sousse, Tunisia
Dental trauma is common in children and adolescents, and it is caused by different factors, including falls, sports, school accidents, vehicle accidents, etc. 1.
Among these injuries, avulsion is often discussed in dental traumatology because of the various subsequent complications. The problem arises especially when the involved teeth are not found, as these teeth could be projected into the oral soft tissues. In addition, psychological and functional damage could also arise.
A tooth or its fragment may displace anteriorly, posteriorly, or vertically depending on the direction and the energy of the trauma. Also, the displacement of a tooth or its fragments into soft tissue usually involves the central and lateral incisor; but the canines are rarely involved 2.
In most cases, the embedded tooth or its fragments are found in the lips 3,4,5, the tongue 6, and the nasal cavity 2,7; but they are rarely found in the oral vestibule 8.
This case report presents the particularity characterizing the displacement of maxillary primary canine into the vestibule of the mouth, emphasizes the necessity to examine and explore all soft tissue wounds when missing teeth are present, and highlights the value of conventional intraoral radiographs in the detection of embedded teeth.
A 12-year-old boy was referred to the Department of Dentistry and Oral Surgery at Sahloul University Hospital by the emergency unit following a dentofacial trauma. His parents reported a fall associated with loss of consciousness 48 hours before their attendance. The patient had no general antecedents.
A CT-scan performed at the emergency unit revealed the avulsion of teeth 11, 21, 22, and 23 accompanied by a subcutaneous oblique embedded tooth opposite to the symphysis region. The tooth was not specified. No examination was performed for the missing teeth, the embedded tooth, or the oral soft tissue wounds and no treatment was provided. Only sutures were performed for the chin skin wound.
Antibiotic (Augmentin) and steroidal anti-inflammatory drugs (Unidex) had been prescribed. Then, the patient was referred to our department for the replacement of the avulsed teeth, which were not found by the parents.
Extraoral examination showed a lower lip laceration and facial abrasions, which were initially treated at the emergency unit using primary suture with black silk wound dressing (fig. 1).
A thorough intraoral examination revealed uninhabited alveoli of the 11, 21, 22, and 23, with an incomplete eruption of the 12 and the presence of the 53 on the dental arcade (fig. 1).
Examination of the 11, 21, and 22 alveoli with a curette and saline cleaning showed the presence of blood clots without any dental fragment, with the exception of the canine alveolus, where permanent canine germ was detected.
The intraoral view also revealed a lower lip edematous and a lacerated wound covered by fibrous tissues and which was painful during palpation (fig. 2.a). Moreover, a lacerated open wound was noted in the oral vestibular mucosa opposite to the mandibular anterior region, accompanied by pus discharge (fig. 2.b).
Cold and percussion tests, as well as periodontal probing were normal for all the mandibular anterior teeth.
The CT-scan confirmed the expulsion of the 11, 21, and 22, and showed the presence of the 13 and 23 germs with a root development exceeding half of the total root length (fig. 4).
A subcutaneous embedded canine was also noted in the mandibular anterior region with oblique direction. A radiograph of the soft tissues, performed by placing a peri-apical film in the lower labial sulcus, did not reveal a radio-opaque image near the wound site.
An intra-oral radiograph, carried out with a gutta-percha cone placed in the lower oral vestibule wound, showed the presence of an embedded missing canine, just opposite to the lower anterior teeth (fig. 3).
Based on the patient’s history and on the clinical and radiographic findings, diagnosis of embedded left maxillary primary canine in the lower oral vestibule following avulsion trauma was made.
The patient’s parents were informed about the presence of a primary canine in the lower vestibular mucosa and that this tooth could not be replanted.
The wound site and the surrounding tissues were cleansed with a betadine detergent.
Under local anesthesia, a horizontal incision was made in the lacerated vestibular mucosa, and the embedded canine was surgically removed (fig. 5, fig. 6).
The incision was sutured with 4.0 silk suture threads.
A favorable healing of the wound was noted and the sutures were removed on the tenth postoperative day.
After complete gingival healing, a temporary dental prosthesis was made to replace the three permanent avulsed teeth.
This prosthesis would not serve as a space maintainer for the 23, since the latter achieved half of its total root length.
Avulsion corresponds to a total displacement of the tooth out of its alveolar bone. It is accompanied by the rupture of the vascular-nervous bundle and the periodontal ligament fibers 9,10.
Prevalence of tooth avulsion varies from 0.5% to 3% 11, and from 6% and up to 16% 12 depending on studies. Maxillary central incisors are the most affected 13, probably because of an increased over-jet (greater than 6 mm) and an inadequate labial protection with a short upper lip 14,20. This is in line with our case involving anterior maxillary teeth avulsion.
When dental injuries are accompanied by surrounding soft tissue laceration, during the first consultation, the clinician should be attentive to a possible entrapment of a tooth or a tooth fragment into these wounds 3.
Cases involving displacement of a tooth or a tooth fragment into various soft tissues have been reported in the lower lip, which is the most common site, followed by the upper lip 3, 4, 5, tongue 6, 15, 16, and nasal cavity 2, 7. However, they are extremely rare in the oral vestibule. An extensive review of the literature reports only one case of traumatic displacement of a maxillary permanent canine into the upper vestibule of the mouth 8. Herein, we report a second case of a maxillary primary canine embedded in the lower oral vestibule following maxillary anterior teeth avulsion.
If they are undetected during the first consultation, such tooth fragments and foreign bodies may remain undiagnosed for longer periods. Long-term sequelae of an embedded tooth or tooth fragment include persistent chronic infection, pus discharge, formation of fibrous scar tissue leading to delayed healing, vascular and nervous sheath damages, spontaneous eruption or migration of the fragment in an unpredictable direction, in addition to medico-legal constraints 17, 18, 19.
A case of a tooth fragment embedded in the lower lip and that remained undiagnosed for 3 years was reported by Carson Mader. A firm, painless, and 1 cm mass in the lower lip, with a fractured crown of the maxillary left central incisor was the reason for the patient’s consultation 20.
This is the only report in the literature documenting the duration of a tooth embedded in the lip for this period of time. In 2010, Al-Jundi also reported a case of a 13-year-old child with a fractured tooth fragment embedded in the lower lip that remained overlooked for eighteen months 21. The patient consulted for esthetic restoration of his upper left incisor and he did not complain of any pain or discomfort.
There are also published cases of spontaneous eruption of undetected tooth fragments from the soft tissues, due to continuous movement and contraction of the muscles. However, this desired evolution remains exceptional. In 2006, Rao and Hegd reported a case of a spontaneous eruption, after eight months, of a tooth fragment impacted in the lower lip following trauma to the maxillary central incisor 22.
This finding shows the importance of an adequate cleansing of the oral mucosa wound prior to suturing during acute and subacute management of orofacial injuries. The usual recommendation is to detect and remove the embedded tooth to prevent immediate or delayed complications 3, 23.
In most of the times, failure in detecting an embedded tooth or a tooth fragment, and unsatisfactory emergency management by the medical practitioner may be related to the complexity and the nature of the dental injuries, as well as to unawareness of the importance of oral soft tissue examination 21, 24. Adequate collaboration between the involved medical and dental practitioners has a considerable value.
The present case indicates that intraoral examination, especially soft tissue inspection, during the acute step of oro-facial trauma management was not performed at the emergency department, thus leading to failure in detecting and removing the embedded tooth before consulting our dental department. In fact, clinically, a tooth embedded in the soft tissue may not be easily detected because of the lacerated and bleeding lesion. It can also be hidden by the contraction of orbicularis oris muscles 3.
Diagnosis is mainly dependent on the history of the trauma, and the clinical and radiographic examinations of both hard and soft tissues. A detailed history of the accident is important to determine the etiologic mechanism, the impact energy, the direction of the causal agent in order to suspect secondary fracture localization, the extra-oral dry time, and the missing teeth 19.
In this case, the patient consulted two days later with a soft tissue edema, laceration, and pus discharge after the wound debridement. It was so difficult to palpate the lacerated soft tissue accurately because of the painful and edematous wounds in the lower lip, covered by the fibrous tissue, and the pus discharge from the lacerated lower vestibular mucosa. So, a plain soft tissue radiograph should be performed, using a low radiation dose 25 to help detect and localize the embedded tooth in the oral soft tissues.
Radiographs are also essential tools to establish differential diagnosis between dental expulsion, full dental intrusion, or embedded tooth.
The choice of radiographs should be individualized to the unique needs of each case. It should therefore be based on the outcome of the detailed history-taking and the clinical examination, as well as the delivered radiation dose 25, 26.
In managing traumatic dental injuries, intra-oral radiographs with three different angulations, horizontal angle (90°) with central beam through the involved tooth, lateral view from the mesial and distal aspects of the involved tooth 27, are usually sufficient to assess most of the dento-alveolar injuries. They must therefore be used during the initial evaluation and follow-up visits.
For trauma in the anterior region, one occlusal film and three periapical exposures, using different angulations, are recommended 25.
They are important to identify the type, localization and extent of the injuries 25, and to eliminate the possibility of other diagnoses.
Recently, digital intra-oral radiographic systems are becoming increasingly used and are replacing traditional dental X-ray films for the diagnosis of dental diseases. In cases of traumatized teeth, no significant differences between the two techniques are detected, but the lower radiation in digital radiography favors this modality 25.
Soft tissue lacerations, with a possible embedded tooth or a foreign body, can be successfully evaluated using intra-oral radiographs with a very short exposure time 25.
Extra-oral radiographs are indicated in isolated cases of dental trauma. Panoramic radiography provides a global and non-detailed image of teeth. In cases of oro-facial trauma, it is usually indicated where a temporomandibular joint problem is detected or a jaw fracture is suspected 28, which is not the case in our report.
Three-dimensional imaging (both CT-scan and CBCT), despite delivering a higher radiation dose, has a great potential to help in the diagnosis and treatment planning of dental trauma associated with maxillofacial injuries 25,29. In fact, it allows better visualization of the traumatized dento-alveolar structures by eliminating superimpositions of the adjacent anatomic structures 27.
In the present case, the CT-scan, performed during the emergency consultation, confirmed the diagnosis of expulsion and revealed the subcutaneous oblique embedding of the left maxillary primary canine opposite to the mandibular symphysis. However, it did not specify the point of entry of this tooth because of the presence of two lacerated mucosa wounds in the mandibular symphysis, in the lower lip, and even in the lower oral vestibule. Intra-oral radiographs were therefore required.
In the emergency consultation, the medical practitioners focused on eliminating any vital complication and on detecting any other bone localized fracture. No attention was paid to the tooth embedded in the oral soft tissues.
Avulsion of permanent teeth is the most serious of all dental injuries. Prognosis depends on the measures taken at the accident site and the extra-oral time after avulsion 28.
In our case, complete removal of the canine was performed, but replantation could not be carried out. In fact, this act should not be performed when primary teeth are avulsed because of the risk to the underlying permanent tooth germ 28.
A literature search has not revealed any case with replantation of a tooth embedded in the oral soft tissue. However, some cases involving reattachment procedures of embedded tooth fragments have been reported, with a good long-term follow-up 30, 31, 32.
1. O’Neil DW, Clark MV, Lowe JW, Harrington MS. Oral trauma in children: a hospital survey. Oral Surg Oral Med Oral Pathol 1989; 68:691–6.
2. B. R. Chrcanovic, S. C. Bueno, D. T. da Silveira, and A. L.N. Cust´odio, “Traumatic displacement of maxillary permanent incisor into the nasal cavity, «Oral and Maxillofacial Surgery, vol.14, no. 3, pp. 175–182, 2010.
3. A. C. da Silva, M. DeMoraes, E. G. Bastos, R.W. F. Moreira, and L. A. Passeri, “Tooth fragment embedded in the lower lip after dental trauma: case reports,” Dental Traumatology, vol. 21, no.2, pp. 115–120, 2005.
4. A. A. Antunes, T. S. Santos, A. U. Carvalho De Melo, C. F. Ribeiro, S. R. J. Goncalves, and S. De Mello Rode, “Tooth embedded in lower lip following dentoalveolar trauma: case report and literature review,” General Dentistry, vol. 60, no. 6, pp. 544–547, 2012.
5. AGRAFIOTI, Anastasia, TSATSOULIS, Ioannis N., PAPANAKOU-TZANETAKI, Styliani I., et al. Primary inadequate management of dental trauma. Journal of Clinical and Diagnostic Research: JCDR, 2016, vol. 10, no 7, p. ZD12.
6. DE SANTANA SANTOS, Thiago, MELO, Auremir Rocha, PINHEIRO, Roberto Tiago Alves, et al. Tooth embedded in tongue following firearm trauma: report of two cases. Dental traumatology, 2011, vol. 27, no 4, p. 309-313.
7. A. H. B. Luna, R.W. F. Moreira, and M. de Moraes, “Traumatic intrusion of maxillary permanent incisors into the nasal cavity: report of a case,” Dental Traumatology, vol. 24, no. 2, pp. 244–247, 2008.
8. IWASE, Masayasu, ITO, Michiko, KATAYAMA, Hanon, et al. Traumatic displacement of maxillary permanent canine into the vestibule of the mouth. Case reports in dentistry, 2015, vol. 2015.
9. RAO, Dinesh et HEGDE, Sapna. Spontaneous eruption of an occult incisor fragment from the lip after eight months: Report of a case. Journal of Clinical Pediatric Dentistry, 2006, vol. 30, no 3, p. 195-197.
10. Naulin-Ifi C, Machtou P. Traumatismes dentaires : du diagnostic au traitement. Rueil-Malmaison, France : Editions CdP, impr. 2005 ; 2005. ix+165 p.
11. DE ANDRADE VERAS, Samuel Rodrigo, BEM, Jessica Silva Peixoto, DE ALMEIDA, Elvia Christina Barros, et al. Dental splints: types and time of immobilization post tooth avulsion. Journal of Istanbul University Faculty of Dentistry, 2017, vol. 51, no 3 Suppl 1, p. S69.
12. Andreasen JO, Andreasen FM, Andersson L. Textbook and color atlas of traumatic injuries to the teeth, 4th edn. 2007. p. 217–54, 444–88, 516–41.
13. Hecova H, Tzigkounakis V, Merglova V, Netolicky J. A retrospective study of 889 injured permanent teeth. Dental Traumatology 2010; 26:466-75.
14. Pektas ZO, Kircelli BH, Uslu H. Displacement of tooth fragments to the lower lip: A report of a case presenting an immediate diagnostic approach. Dent Traumatol 2007; 23:376-9.
15. Andersson L, Andreasen JO, Day P, Heithersay G, Trope M, Diangelis AJ et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries. 2.Avulsion of permanent teeth. Dental Traumatology 2012; 28: 88-96.
16. F. J. Hill and J. F. Picton, “Fractured incisor fragment in the tongue: a case report,” Pediatric Dentistry, vol. 3, no. 4, pp. 337–338, 1981.
17. D. G. McDonnell and E. X. McKiernan, “Broken tooth fragments embedded in the tongue: a case report,” British Journal of Oral and Maxillofacial Surgery, vol. 24, no. 6, pp. 464–466,1986.
18. Dent Traumatol 2010; 26:509-11. McDonnell DG, McKiernan EX. Broken tooth fragments embedded in the tongue: A case report. British J of Oral Maxillofacial Surg 24: 464–466, 1986.
19. T.-C. Tung, Y.-R. Chen, C.-T. Chen, and C.-J. Lin, “Full intrusion of a tooth after facial trauma, «The Journal of Trauma, vol. 43, no. 2, pp. 357–359, 1997.
20. SALAMA, Fouad S. et ABDELMEGID, Faika Y. MISSED DIAGNOSIS OF TOOTH FRAGMENTS IN THE LOWER LIP FOLLOWING DENTAL TRAUMA
21. MADER, Carson. Restoration of a fractured anterior tooth. Journal of the American Dental Association (1939), 1978, vol. 96, no 1, p. 113-115.
22. Al-Jundi SH. The importance of soft tissue examination in traumatic dental injuries: a case report
23. NAGAVENI, N. B. et UMASHANKARA, K. V. Tooth fragment embedded in the lower lip for 10 months following dentoalveolar trauma: A case report with literature review. Burns & trauma, 2014, vol. 2, no 3, p. 2321-3868.135652.
24. 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 PedodPrev Dent 2013; 31:52-5.
25. Marwaha M, Bansal K, Srivastava A, Maheshwari N. Surgical Retrieval of Tooth Fragment from Lower Lip and Reattachment after 6 Months of Trauma. Int J Clin Pediatr Dent 2015; 8:145-8.
26. KULLMAN, Leif et AL SANE, Mona. Guidelines for dental radiography immediately after a dento-alveolar trauma, a systematic literature review. Dental traumatology, 2012, vol. 28, no 3, p. 193-199.
27. Kim IH, Mupparapu M. Dental radiographic guidelines: a review. Quintessence Int 2009; 40:389–98.
28. FLORES, Marie Therese, ANDERSSON, Lars, ANDREASEN, Jens Ove, et al. Guidelines for the management of traumatic dental injuries. II. Avulsion of permanent teeth. Dental traumatology, 2007, vol. 23, no 3, p. 130-136.
29. Andreasen JO, Andreasen FM, Andersson L. Textbook and color atlas of traumatic injuries to the teeth, 4th edn. Oxford: Blackwell Munksgaard; 2007.
30. Greondahl G, Huumonen S. Radiographic manifestations of periapical inflammatory lesions. How new radiological techniques may improve endodontic diagnosis and treatment planning. Endod Topics 2004; 8:55–67.
31. 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.
32. Pasini S, Bardellini E, Keller E, Conti G, Flocchini P, MajoranaA. Surgical removal and immediate reattachment of coronal fragment embedded in lip. Dent Traumatol 2006; 22:165-8.
Original Article: Dental News Magazine – June 2021 Issue