Brief Clinical Studies The Journal of Craniofacial Surgery & Volume 23, Number 5, September 2012

10. McRae M, Frodel J. Midface fractures. Facial Plast Surg 2000;16:107Y113
11. Gruss JS, Phillips JH. Complex facial trauma: the evolving role of rigid
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1989;16:93Y104
12. Kelly KJ, Manson PN, Vander Kolk CA, et al. Sequencing LeFort
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13. Zide MF, Kent JN. Indications for open reduction of mandibular
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15. Biglioli F, Colletti G. Transmasseter approach to condylar fractures
by mini-retromandibular access. J Oral Maxillofac Surg
2009;67:2418Y2424
16. Ellis E 3rd, Throckmorton GS. Bite forces after open or closed treatment
of mandibular condylar process fractures. J Oral Maxillofac Surg
2001;59:389Y395
17. Throckmorton GS, Ellis E 3rd. Recovery of mandibular motion
after closed and open treatment of unilateral mandibular condylar
process fractures. Int J Oral Maxillofac Surg 2000;29:421Y427
18. Throckmorton GS, Ellis E 3rd, Hayasaki H. Masticatory motion after
surgical or nonsurgical treatment for unilateral fractures of the
mandibular condylar process. J Oral Maxillofac Surg 2004;62:127Y138
19. Hinds EC, Girotti WJ. Vertical subcondylar osteotomy: a reappraisal.
Oral Surg Oral Med Oral Pathol 1967;24:164Y170
20. Ellis E 3rd, McFadden D, Simon P, et al. Surgical complications
with open treatment of mandibular condylar process fractures.
J Oral Maxillofac Surg 2000;58:950Y958
remained lodged inside the lip. After fragment removal, the clinical
case showed a satisfactory repair emphasizing the importance of a
meticulous clinical examination to achieve a correct diagnosis and
an appropriate treatment plan, which is essential for a favorable
prognosis.
Key Words: Tooth fractures, soft tissue injuries, tooth injuries
C oronal fractures and lesions of the teeth-supporting structures
are the most frequent facial trauma. Dental trauma should al-
ways be considered an emergency and treated immediately to relieve
pain and improve the prognosis.1
The incisors, particularly fractured, can provoke soft tissue
lacerations at the moment of the trauma.2 When there is a soft tissue
laceration during a crown fracture, the clinician should make a
careful inspection because the possibility of such lacerations shel-
tering tooth fragments is large.3
Considering the observation above, the objective of this study
was to draw attention to the importance of a meticulous clinical
examination to reach the correct diagnosis aimed for appropriate
treatment and consequently a good prognosis through a clinical case
of tooth crown fracture, fragment of which remained lodged inside
the lip, compromising the healing process.

CLINICAL REPORT
A 9-year-old white male patient had a bicycle fall and immediately
sought attendance at the emergency office of the town, where his lip
Importance of Clinical that sustained injury was cleaned and sutured, and the patient was
instructed to make an appointment to a dentist.
Examination in Dentoalveolar The patient presented at the Faculty of Dentistry 24 hours after
Trauma the first presentation. Clinical examination showed that the lip injury
sutured was swollen (Fig. 1), and teeth 11 and 21 presented a coronal
Heloisa Fonseca Marão, DDS, MSc, fracture involving enamel and dentin with a mild mobility featuring
Sônia Regina Panzarini, DDS, PhD, a subluxation confirmed by radiographic examination. A split of
Gustavo Rodrigues Manrrique, DDS, teeth 11 and 21 was performed with a 0.5 steel wire (Morelli,
Eloá Rodrigues Luvizuto, DDS, PhD, Sorocaba, Brazil) and composite resin (A2 TPH Spectrum; Dentsply;
Petrópolis, Brazil) for 15 days. The exposed dentin was protected
Moriel Evangelista Melo, DDS*
with glass ionomer (Fuji II LC A2; GC Corporation, Tokyo, Japan).
A soft tissue radiography was performed because of the signif-
Abstract: Dental injuries are often the result of direct trauma. The
icant swelling of the lips and the presence of coronal fractures
most affected teeth are the upper incisors, and the most frequent
lesions are coronal fractures, contusions, and lip and alveolar mu-
cosa lacerations. The objective of this study was to draw attention to
the importance of the correct management of cases of crow fractures
associated with soft tissue lacerations when the fragment is not lo-
cated. This is a clinical case of crown fracture, the fragment of which
FIGURE 1. Lip injury, swollen and previously sutured.

From the *Division of Oral and Maxillofacial Surgery and †Department

of Surgery and Integrated Clinics, School of Dentistry of Araçatuba,
UNESPYSão Paulo State University, Araçatuba, São Paulo, Brazil.
Received December 2, 2011.
Accepted for publication April 22, 2012.
Address correspondence and reprint requests to Heloisa Fonseca Marão,
DDS, MSc, Rua José Bonifácio, no1193, Bloco 10A, Vila
Mendonça, Araçatuba, São Paulo, Brazil, CEP: 16015-050;
E-mail: heloisafonsecamarao@yahoo.com.br
The authors report no conflicts of interest.
Copyright * 2012 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0b013e31825bd2e5 FIGURE 2. Radiographic examination of the inferior lip.

e404 * 2012 Mutaz B. Habal, MD

Copyright © 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery & Volume 23, Number 5, September 2012
FIGURE 3. Removed tooth fragment.
without the location of the fragments. The radiographic examination
revealed a radiopaque structure compatible with a tooth fragment
within the soft tissue (Fig. 2).
The suture from the lip was then removed to explore the wound
and to remove the fragment (Fig. 3). The teeth were restored with
composite resin (A2 TPH Spectrum; Dentsply) after removal of the
contention. Periodic controls were performed, and 1-year follow-up
showed satisfactory results (Fig. 4).
DISCUSSION
A proper clinical examination depends on a careful inspection of all
the traumatized area, as well as the use of complementary exam-
inations and the basic knowledge of the healing process in dental
trauma.
The most common injuries that affect the teeth are the coronal
fractures, and those affect the lips and the alveolar mucosa are
contusions and lacerations.4 A combination of laceration and con-
tusion occurs in the penetrating injury on the lip wherein the teeth
are forced through the tissues. Under these conditions, the possi-
bility of tooth fragments hidden among the lacerations should be
considered, because it can cause acute or chronic infection and fi-
brosis.1,3 These fragments may not be evident on palpation, and a
helpful technique to diagnosis is soft tissue radiography.1
Crown fractures can also occur in association with periodontal
ligament injuries, depending on the type and intensity of the impact.
The most prevalent periodontal ligament injury is the subluxation.5
Treatment plan consists of an occlusal adjustment and sensitivity
testing at follow-up. The frequency of pulp necrosis is low in these
cases.
Because of the process of external root resorption, mainly as a
consequence of pulp necrosis, it is of great importance to proceed
to follow-up the teeth that have suffered traumatic dentoalveolar
injuries.6,7
Considering the aspects discussed on the diagnosis, treatment,
and prognosis of traumatic dental injuries, as well as the involve-
ment of different dental tissues, the need for a multidisciplinary
approach and a basic knowledge about the wound healing process
involved to ensure an adequate care with a minimum sequela
becomes clear.
Although the case report presented herein is simple, it is im-
portant to emphasize that failure during the clinical examination may
compromise the repair and interfere in the aesthetics, leading to
fibrosis in the area. Appearance of normality was observed at 1 year
of follow-up, pointing up the importance of an appropriate clini-
cal examination to allow a correct diagnosis and treatment.
FIGURE 4. One-year follow-up: radiographic examination.
* 2012 Mutaz B. Habal, MD
Copyright © 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
REFERENCES
1. Andreasen JO, Andreasen FM. Atlas of Dental Traumatology. Porto
Alegre, Brazil: Artmed Editora, 2001:770
2. Da Silva AC, De Moraes M, Bastos EG, et al. Tooth fragments
embedded in the lower lip after dental trauma: case reports.
Dental Traumatol 2008;24:487Y489
3. Munerato MC, Da Cunha FS, Tolotti A, et al. Tooth fragments
lodged in the lower lip after traumatic dental injury: a case report.
Dental Traumatol 2008;24:487Y489
4. Castro JC, Poi WR, Manfrin TM, et al. Analysis of the crown
fractures and crown-root fractures due to dental trauma assisted by the
Integrated Clinic from 1992 to 2002. Dent Traumatol 2005;21:121Y126
5. Panzarini SR, Pedrini D, Poi WR, et al. Dental trauma involving
root fracture and periodontal ligament injury: a 10-year retrospective
study. Braz Oral Res 2008;22:229Y234
6. Andreasen JO. Relationship between surface and inflammatory
resorption and changes in the pulp after replantation of permanent
incisors in monkeys. J Endod 1981;7:294Y301
7. Andreasen JO. External root resorption its implications in dental
traumatology paedodontics, periodontics, orthodontics and
endodontics. Int Endod J 1985;18:109Y118
Total Autogenous Mandibular
Reconstruction Using Virtual
Surgical Planning
Ryan Winters, MD,* Adam Saad, MD,Þ
Donald David Beahm, MD,þ Matthew Whitten Wise, MD,Þ
Hugo St. Hilaire, MD, DDSÞ
Abstract: Free fibula transfer has become the workhorse in man-
dibular reconstruction. Total mandibular reconstruction is an un-
common procedure with added complexity. Numerous techniques
have been described for such reconstruction, many requiring a tem-
poromandibular joint prosthesis. We present a novel method where
simultaneous bilateral free fibula transfer utilizing preoperative virtual
surgical planning was used to produce a total autogenous reconstruc-
tion. The virtual surgical planning allows to effectively quantify the
bone stock required preoperatively and facilitates intraoperative mod-
eling of the fibula. Therefore, a more anatomically correct reconstruc-
tion is obtained resulting in improved functional and aesthetic outcomes.
Key Words: Free fibular transfer, microvascular surgery,
total mandible reconstruction, virtual surgical planning
From the *Department of OtolaryngologyVHead & Neck Surgery, Tulane
University; and †Division of Plastic & Reconstructive Surgery and
‡Department of Otolaryngology-Head & Neck Surgery, Louisiana State
University, New Orleans, Louisiana.
Received March 24, 2012.
Accepted for publication April 22, 2012.
Address correspondence and reprint requests to Hugo St. Hilaire, MD, DDS,
Louisiana State University, 1542 Tulane Ave, Suite 700, New Orleans,
LA 70118, LA; E-mail: hugost1@gmail.com
Dr. Wise is a speaker for Life Cell, Inc. The company had no involvement,
financial or otherwise, in preparation, funding, or review of this
article. The other authors report no conflicts of interest.
Copyright * 2012 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0b013e31825bd302
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