eMedicine Specialties > Emergency Medicine > Ear, Nose, & Throat

Dental, Fractured Tooth

Author: Lynnus F Peng, MD, Assistant Clinical Professor, Department of Anesthesia, University of California at Irvine; Chairman of Anesthesia, Department of Surgery, St Jude Medical Center at Fullerton
Coauthor(s): A Antoine Kazzi, MD, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon; Willard Peng, MS, Doctor of Dental Surgery Candidate, Department of Oral Medicine, University of Southern California; Caleb Cheng, University of California at San Diego
Contributor Information and Disclosures

Updated: Aug 11, 2009

Introduction

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%).

Cross section of an Ellis III dental fracture.

Cross section of an Ellis III dental fracture.

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Cross section of an Ellis III dental fracture.

Cross section of an Ellis III dental fracture.

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. In trauma with mandibular fracture, the teeth in the upper jaw may be at higher risk than teeth in the lower jaw.1  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 varies. In youths, falls and sporting activities account for most injuries. In later teenaged years, motor vehicle collisions (MVCs) account for most injuries.

Clinical

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%)

More on Dental, Fractured Tooth

Overview: Dental, Fractured Tooth
Differential Diagnoses & Workup: Dental, Fractured Tooth
Treatment & Medication: Dental, Fractured Tooth
Follow-up: Dental, Fractured Tooth
Multimedia: Dental, Fractured Tooth
References
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References

  1. Lieger O, Zix J, Kruse A, Iizuka T. Dental injuries in association with facial fractures. J Oral Maxillofac Surg. Aug 2009;67(8):1680-4. [Medline].

  2. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. Oct 9 2007;116(15):1736-54. [Medline].

  3. Bakland LK, Andreasen JO. Examination of the dentally traumatized patient. J Calif Dent Assoc. Feb 1996;24(2):35-7, 40-4. [Medline].

  4. 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].

  5. Devlin DH. A historical review of dental and facial skeletal trauma. J Calif Dent Assoc. Feb 1996;24(2):29-34. [Medline].

  6. Gutmann JL, Gutmann MS. Cause, incidence, and prevention of trauma to teeth. Dent Clin North Am. Jan 1995;39(1):1-13. [Medline].

  7. Harwood-Nuss A, Linden C, Luten R, eds. Dental injuries. In: The Clinical Practice of Emergency Medicine. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 1996:418-421.

  8. Josell SD. Evaluation, diagnosis, and treatment of the traumatized patient. Dent Clin North Am. Jan 1995;39(1):15-24. [Medline].

  9. Josell SD, Abrams RG. Traumatic injuries to the dentition and its supporting structures. Pediatr Clin North Am. Jun 1982;29(3):717-41. [Medline].

  10. 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].

  11. Rosen P, Barkin R. Dental emergencies. In: Emergency Medicine Concepts and Clinical Practice. Vol 3. 3rd ed. St Louis: Mosby-Year Book; 1992: 2381-2398.

  12. Trope M. Protocol for treating the avulsed tooth. J Calif Dent Assoc. Mar 1996;24(3):43-9. [Medline].

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Further Reading

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Keywords

tooth fracture, broken tooth, traumatized maxillary teeth, postnormal occlusion, overjet, short upper lip, incompetent lip, mouth breathing, maxillofacial injuries, maxillofacial fractures, Ellis classification, Ellis I fractures, Ellis II fractures, Ellis III fractures, chipped tooth, chipped teeth, root fractures, dentoalveolar fractures, malocclusion, dental displacement, maxillary fractures, mandibular fractures, Panorex, zinc oxide, calcium hydroxide paste, Dycal, bone wax, Ethicon, gutta-percha filling, partial pulpotomy, tetanus prophylaxis

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Contributor Information and Disclosures

Author

Lynnus F Peng, MD, Assistant Clinical Professor, Department of Anesthesia, University of California at Irvine; Chairman of Anesthesia, Department of Surgery, St Jude Medical Center at Fullerton
Lynnus F Peng, MD is a member of the following medical societies: Alpha Omega Alpha and American Society of Anesthesiologists
Disclosure: Nothing to disclose.

Coauthor(s)

A Antoine Kazzi, MD, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon
A Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Willard Peng, MS, Doctor of Dental Surgery Candidate, Department of Oral Medicine, University of Southern California
Disclosure: Nothing to disclose.

Caleb Cheng, University of California at San Diego
Disclosure: Nothing to disclose.

Medical Editor

Michael Glick, DMD, Professor and Acting Chair, Department of Diagnostic Sciences, New Jersey Dental School, University of Medicine and Dentistry of New Jersey
Michael Glick, DMD is a member of the following medical societies: American Academy of Oral Medicine and American Dental Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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