AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Dental fractures are commonly observed with other oral injuries. Early recognition and management can improve tooth survival and functionality. Approximately 82% of traumatized teeth are maxillary teeth. Fractures to the maxillary teeth are distributed among the central incisors (64%), lateral incisors (15%), and canines (3%).

Pathophysiology

The typical cause is severe force to the teeth sufficient to disrupt the enamel, dentin, or both of a tooth. In a study of 1610 children, predisposing factors included postnormal occlusion, an overjet exceeding 4 mm, a short upper lip, an incompetent lip, and mouth breathing.

Frequency

United States

More than 50% of physical trauma in child abuse occurs in the head and neck region.

International

In a study conducted in Sweden, approximately 7% of all physical injuries involved the oral cavity. In patients aged 0-19 years, 9% of injuries involved the oral cavity. During the Korean War, 3000 maxillofacial injuries occurred.

Mortality/Morbidity

Trauma to the teeth is not life threatening; however, associated maxillofacial injuries and fractures can compromise the airway. Morbidity to the teeth may be individualized to primary and permanent teeth. Fractures are more common in permanent teeth; primary teeth usually become displaced.

• Primary teeth - Failure to continue eruption, color changes, infection, abscess, loss of space in the dental arch, ankylosis, injury to the permanent teeth, abnormal exfoliation
• Permanent teeth - Color changes, infection, abscess, loss of space in the dental arch, ankylosis, resorption of root structure, abnormal root development

Sex

The male-to-female ratio is 2-3:1.

Age

The average age of injury is variable. In youths, falls and sporting activities account for most injuries. In later teenaged years, motor vehicle collisions (MVCs) account for most injuries.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Different physical and clinical findings present depending on where the tooth is fractured. Note the fracture's extent and the patient's age. The Ellis classification has been designed for evident fractures.
• • Ellis I fractures involve only the enamel; these injuries may show minor chipping with rough edges.
  • Ellis II fractures involve enamel and dentin; patients may complain of pain to touch and sensitivity to air. A pale yellow exposure of the dentinal processes, which communicates directly with the pulp, can occur. Patients younger than 12 years have immature teeth with much less dentin spanning the space between the pulp and enamel. The chance of infection and damage to the pulp in this age group is much greater because of larger pulp size and shorter dentin distance the infection has to traverse.
  • Ellis III fractures involve enamel, dentin, and pulp; patients complain of pain with manipulation, air, and temperature. Pinkish or reddish markings around surrounding dentin or blood in the center of the tooth from the exposed pulp may present.
• Root fractures are clinically difficult to diagnose; patients may notice abnormal mobility and sensitivity to percussion of the tooth.
• Dentoalveolar fractures may cause patients to complain of malocclusion and mobility with findings of a mobile group of teeth.

Physical

• Inspection
• • Evaluate surrounding soft tissue area for laceration, discoloration, ecchymosis, and embedded foreign bodies (eg, chipped teeth).
  • Evaluate teeth for fractures, chips, and other deformities. Embedded tooth fragments may lead to chronic infection or fibrosis.
• Palpation
• • Evaluate if the tooth is mobile or if an entire segment is mobile.
  • If possible, have the patient bite down to further localize suspect area.
• Percussion and sensitivity
• • Percuss with tongue blade to evaluate sensitivity.
  • Assess sensitivity to air and hot and cold solutions.
  • Percussion is necessary when an impact trauma with no fractures or displacement is involved. In apparently undamaged teeth, the neurovascular bundle that enters through the apical canal may have been damaged. The resulting damage can lead to pulp degeneration. These teeth are often sensitive to percussion.

Causes

• Unknown (17%)
• Altercations (17%)
• Contact sports (15.9%)
• Motor vehicle collisions (10.8%)
• Motorcycle accidents (10.4%)
• Ice hockey (2.3%)

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Imaging Studies

• Obtain 4 films (maxillary anterior and 3 periapical films from various angles) to evaluate a dental fracture or displacement.
• • In the ED, because such specialized films are often not available, use a limited facial series and a Panorex to evaluate maxillary and mandibular fractures, foreign bodies, and displacement.
  • A Panorex can be used to assess a mandibular fracture.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Emergency Department Care

Provide adequate pain management and tetanus vaccination, and ensure proper follow-up care.

• Ellis I fracture: Smooth rough corners with a dental drill or an emery board.
• • Treatment of fractures contained solely within the enamel alone requires no urgent care. The tooth can be repaired cosmetically at the convenience of the patient
• Ellis II fracture: Cover exposed dentin with a layer of zinc oxide or calcium hydroxide paste (Dycal).
• • Dycal requires the tooth to be absolutely dry for adherence. Cover the tooth with a small piece of dental or aluminum foil. Exposure to humidity increases the rate at which the Dycal will set.
  • In patients younger than 12 years, coverage is especially important to prevent infection.
• Ellis III fracture: Cover exposed dentin with a layer of zinc oxide or calcium hydroxide. Bleeding and moisture with this type of fracture usually makes it more difficult for these materials to adhere to the tooth. Cover with dental foil and expediently refer the patient to a dentist.
• Root and dentoalveolar fractures require splinting by a dentist for several weeks.
• Bone wax (Ethicon), which is a combination of beeswax and isopropyl palmitate, is not recommended for open dental fractures because it can cause inflammatory reactions of the surrounding soft tissues (eg, pulp).

Consultations

• Consult a dental or oral maxillofacial surgeon.
• Depending on the extent of the fracture, the dentist may do perform a root canal with calcium hydroxide followed by a gutta-percha filling or a partial pulpotomy.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Drugs used to treat fractures generally are nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, anxiolytics, and proper antibiotics.

Drug Category: Antibiotics

Therapy must cover all likely pathogens in the context of the clinical setting.

Drug Category: Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and enable physical therapy regimens. Many analgesics have sedating properties that benefit patients in pain.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Document arrangements to follow up with a dentist.
• Ellis II and III fractures: Advise patients to avoid eating solid foods to prevent loss of the adhesive dressing and to follow up with a dentist within 24 hours.

Complications

• Tooth loss
• Cosmetic deformity
• Infection

Patient Education

• For excellent patient education resources, visit eMedicine's Teeth and Mouth Center. Also, see eMedicine's patient education articles Broken or Knocked-out Teeth and When to Visit the Dentist.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to provide tetanus prophylaxis
• Failure to rule out aspiration of tooth chips if unable to recover the tooth in the field
• Failure to properly examine surrounding traumatized tissue for tooth chips
• Failure to recognize domestic and/or child abuse
• Failure to evaluate fully the temporomandibular joint, maxilla, mandible, and occlusion
• Failure to evaluate associated head and neck injuries
• Failure to recognize possible airway compromise
• Failure to warn patient that any trauma to teeth can disrupt the neurovascular supply and lead to long-term pulp necrosis or root resorption

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Bakland LK, Andreasen JO. Examination of the dentally traumatized patient. J Calif Dent Assoc. Feb 1996;24(2):35-7, 40-4. [Medline].
• Cvek M, Mejare I, Andreasen JO. Conservative endodontic treatment of teeth fractured in the middle or apical part of the root. Dent Traumatol. Oct 2004;20(5):261-9. [Medline].
• Devlin DH. A historical review of dental and facial skeletal trauma. J Calif Dent Assoc. Feb 1996;24(2):29-34. [Medline].
• Gutmann JL, Gutmann MS. Cause, incidence, and prevention of trauma to teeth. Dent Clin North Am. Jan 1995;39(1):1-13. [Medline].
• Harwood-Nuss A, Linden C, Luten R, eds. Dental injuries. In: The Clinical Practice of Emergency Medicine. 2^nd ed. Philadelphia: Lippincott Williams & Wilkins; 1996:418-421.
• Josell SD. Evaluation, diagnosis, and treatment of the traumatized patient. Dent Clin North Am. Jan 1995;39(1):15-24. [Medline].
• Josell SD, Abrams RG. Traumatic injuries to the dentition and its supporting structures. Pediatr Clin North Am. Jun 1982;29(3):717-41. [Medline].
• Krasner P, Rankow HJ. New philosophy for the treatment of avulsed teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. May 1995;79(5):616-23. [Medline].
• Rosen P, Barkin R. Dental emergencies. In: Emergency Medicine Concepts and Clinical Practice. Vol 3. 3^rd ed. St Louis: Mosby-Year Book; 1992: 2381-2398.
• Trope M. Protocol for treating the avulsed tooth. J Calif Dent Assoc. Mar 1996;24(3):43-9. [Medline].

Article Last Updated: Sep 27, 2007