White growth on lip.

Sir,

Orofacial traumas lead to tooth injury in the form of tooth loss or its fracture commonly in children.[1] Extruded teeth or their fragments are usually lost at the time of injury. There are high chances of the tooth or its fragment getting embedded into the soft tissue when it is lacerated. In cases with significant trauma to other vital areas like eyes, nose or head injury, the dental trauma and surrounding soft tissue damage may get overlooked. There are several reports of tooth fragments embedded into soft tissues becoming symptomatic later.[2-5] The fate of the embedded fragments, if missed initially, is variable. Few of these patients might present to the dermatologists with skin and/or lip swelling. We report an unusual evolution of a tooth fragment embedded in the lower lip following trauma.

Our patient was a 14-year-old girl who presented with complaints of an asymptomatic white, hard exophytic growth in the center of her lower lip for last 4 months [Figure 1]. Her mother told that 4 months back, a white small speck appeared over the lip and subsequently it erupted to form a white protruding growth. There was no history of discharge from the lesion or its surrounding skin. On examination, there was a single white hard exophytic lesion measuring 2×3 mm in size firmly attached to the lower lip. There was mild swelling of the adjacent part of the lip. On palpation, it was bony hard with no tenderness.

Figure 1

Small, white exophytic growth over the lower lip

On further interrogation, the mother also told that the child had orofacial trauma 10 months back following a fall from a ladder. At that time, she had broken her two upper central incisor teeth associated with tear and bleeding from the upper and lower lips. Laceration was repaired by a private practitioner but no radiographs were obtained and no attempt was made to locate fractured tooth fragments. With this significant history, we suspected that the white hard growth could be the embedded tooth fragment which has spontaneously extruded onto the surface of the lip. Radiographs showed a solitary radio-opaque shadow overlying the lower lip. The excisional biopsy of the lesion was done and the examination of the excised lesion confirmed that the growth was tooth fragment only [Figure 2].

Figure 2

Retrieved tooth fragment and primary closure of the mucosal defect with the suture

There are several reports of the embedding of tooth fragments in the surrounding damaged soft tissues including tongue and lips following trauma.[2-5] This group of patients present after a variable period of interval following trauma because of secondary infection or present with swelling due to the foreign body immune response mounted by the body resulting in chronic inflammation, fibrosis and encapsulation of the tooth fragment.

Our patient was interesting as she presented with the spontaneous extrusion of the tooth fragment. Such evolution of the tooth fragment embedded in the lip is not described in literature. In our patient, a single fragmented tooth got embedded into the lower lip and it remained embedded for around 6 months when it appeared beneath the mucosal surface in the form of a white speck. It eroded the lip mucosa and gradually almost the whole tooth fragment erupted out onto the surface of the lip. The tooth fragment was possibly considered foreign by the body and was therefore gradually extruded. Rao et al.[2] reported a spontaneous eruption of an occult incisor fragment from the lip after 8 months. Their patient had developed secondary infection and presented with intermittent purulent discharge. Our patient had no infection-related complications. Probably, there was insignificant inflammation and fibrosis in our patient and the continuous movement by the frequent contraction of the orbicularis oris muscle displaced the tooth fragment towards the surface and gradually extruded it in totality.

A fractured incisor accompanying a laceration involving the lip following trauma alerts us towards a possible displacement of the tooth fragments to the soft tissues. In case it is difficult to locate or completely rule out the presence of a foreign body in an oedematous and bleeding tissue, a quick soft tissue radiograph is a must before repairing the defect. If embedded tooth fragments are missed, they can result in the breakdown of the suture line, persistent chronic infection, discharge and disfiguring fibrosis. So, embedded tooth fragments can be one of the rare causes of lip swelling in a patient presenting to the dermatologists. The history of dental trauma should be sought in such patients.