Retrieval and reattachment of an elusive tooth fragment

Sangwan S,Mathur S, Dutta S JISPPD 2011;29 (2): 171-175

Ellis and Davey 1970 Class I-fracture of crown involving enamel Ellis and Davey 1970 Class II-extensive fracture of crown involving dentin but no pulp Ellis and Davey 1970 Class III-extensive involvement of crown with pulp exposure Ellis and Davey 1970 Class IV-Traumatized tooth becomes non vital or nonvital Ellis and Davey 1970 Class V-tooth lost as a result of trauma

Ellis and Davey 1970 Class VI-fracture of root with or without loss of crown structure Ellis and Davey 1970 Class VII-displacement of tooth without fracture of crown or root

Ellis and Davey 1970 Class VIII-fracture of crown en masse and its replacement
Ellis and Davey 1970 ClassIX-traumatic injuries to primary teeth

Rabinowitch 1956
1. 2. 3. 4. 5. 6. Primary teeth Fracture of enamel Fracture into dentin Fracture into the pulp Root fracture Comminuted tooth Displaced tooth

Ellis classification on primary tooth fracture

Enamel # Enamel &dentin # # involving pulp Crown # Root #

Soft tissue injuries of Oral mucosa

Lacerations : a shallow or deep wound in mucosa resulting from a tear & usually produced by a sharp object Contustion : a bruise produced by an impact from blunt object &not accompanied by a break of the continuity of in mucosa ,causing submucosal hemorrhage Abrasion : superficial woun produced by rubbing or scrapping of mucosa leaving a raw bleeding surface

ETIOLOGY
Incidence
0.5% to 16% of traumatic injuries

Main etiologic factors

Fights Sports injuries Automobile accidents

 Maxillary central incisor

Most commonly avulsed tooth

Mandibular teeth
Seldom affected

Most frequently involves a single tooth Most common age - 7 to 11

Permanent incisors erupting Loosely structured PDL

Demographic Details of the Patient

Age of patient :9 years

Chief Complaint:Pain, irritation, and tingling sensation in the lower lip since 8 to 9 months
History of Trauma :one year back, patient had a fall from bed and fractured her both upper central incisors (11, 21) with concomitant lip lacerations History from Patient's mother: since the incident of trauma, her daughter often bites and plays with the lower lip. Reported to a private dental clinic immediately after trauma where only antibiotics and analgesics were prescribed No other treatment was done or radiographs taken because of laceration and bleeding from the lower lip

Extraoral Examination

a. Lower lip was normal in color, size, shape and no scar mark was observed b. Upon palpation, a firm movable nodule was felt on the right side of the lower lip. Intraoral examination revealed Ellis class II fracture of both permanent right and left upper central incisors (11, 21) with no discoloration or sinus formation c. IOPA confirmed the absence of any pulpal involvement or periapical pathology

Figure 1: Preoperative view of lower lip showing normal findings

Figure 2: Preoperative examination revealed fracture of permanent maxillary central incisors

Figure 3: Preoperative IOPA Xray of maxillary central incisors showed no root fracture or any periapical pathology

Radiographic examination

Presence of a radio-opaque foreign body suggestive of the coronal fragment of one of the fractured incisors .

Figure 4: Preoperative X-ray of lower lip showed a radioopaque image suggestive of tooth fragment

Lower lip scrubbed with betadine L.A was administered in the lower labial vestibule Horizontal incision made on the right inner aspect of the lower lip and the dental fragment was gently removed

Steps in Surgical Removal of Fragment

silk sutures were placed to reapproximate the tissues and analgesics were prescribed Horizontal incision given on the lower lip Tooth fragment identified and removed

Tooth fragment after its removal from the lower lip

Postoperative X-ray of lower lip showed no radio-opaque mass

Tooth fragment removed from the lower lip cleaned and stored in saline until it was reattached to the upper left central incisor (21), using composite Acid etching for 30 seconds and primer applied ,dried for 5 seconds

Reattachment of Surgically Removed Tooth Fragment

Adhesive applied ,light cured for 10 seconds.Groove was then filled with composite resin matched to the tooth shade (B2) tooth fragment attached to the upper left central incisor (Treated in a similar manner). Restoration light cured for 40 seconds from both labial and palatal surfaces. Care 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

Upper right central incisor Enamel margins beveled using tapered fissure diamond bur and acid etched with for 30 seconds. Primer & adhesive applied & light cured for 10 seconds Crown shape formed by incremental placement of the composite resin matched to the tooth shade (B2) . The restorations were further polished with a series of fine abrasive disks

Right maxillary central incisor was restored with composite resin and fragment reattachment was done in left maxillary central incisor

Recall
Follow-up after 15 days shows healed lower lip Patient recalled after one week for suture removal and improved with uneventful healing . Patient was reviewed after 3 months was found to be free of all the symptoms of irritation, pain, and tingling of lower lip. No tender to percussion nor mobile and were responsive to pulp testing

fragment is intact, it can be used to restore the remaining fractured tooth. conservative restoration and aesthetics achieved by tooth fragment reattachment are far more superior to those achieved by any other type of restoration.

color matching and the incisal translucency are maintained.

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.

Positives of the reattachment of fractured segment