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

Dental, Fractured Tooth

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
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

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.

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%)

Differential Diagnoses

Dental, Avulsed Tooth
Dental, Displaced Tooth
Dental, Infections

Workup

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

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

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

Antibiotics

Therapy must cover all likely pathogens in the context of the clinical setting. Current recommendations by the American Heart Association 2007 for dental, oral, respiratory tract, or esophageal procedures, indicate prophylaxis if the patient has one of the following conditions:²

Prosthetic cardiac valve
Previous infective endocarditis
Congenital heart disease (CHD)
Unrepaired cyanotic CHD, including palliative shunts and conduits
Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure
Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
Cardiac transplantation recipients who develop cardiac valvulopathy

Penicillin VK (Veetids)

Inhibits biosynthesis of cell wall mucopeptide and is effective during active replication. Inadequate concentrations may produce only bacteriostatic effects.

Dosing

Adult

250-500 mg PO q6h

Pediatric

50 mg/kg/d PO divided qid

Interactions

Probenecid may increase effectiveness by decreasing clearance; tetracyclines are bacteriostatic, causing a decrease in the effectiveness of penicillins when administered concurrently

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal impairment

Erythromycin (EES, E-Mycin, Ery-Tab)

An alternative for patients allergic to penicillin. Because of possible GI irritation, advise patients to take this medication with food or milk if GI upset is noted.

Dosing

Adult

200-500 mg PO q6h

Pediatric

30-50 mg/kg/d PO divided qid

Interactions

Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis

Contraindications

Documented hypersensitivity; hepatic impairment

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur

Amoxicillin (Amoxil, Polymox, Trimox)

Interferes with the synthesis of cell wall mucopeptide during active replication, resulting in a bactericidal activity against susceptible bacteria.

Dosing

Adult

250-500 mg PO q8h

Pediatric

20-50 mg/kg/d PO divided q8h

Interactions

Reduces efficacy of oral contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment

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.

Fentanyl citrate (Duragesic, Sublimaze)

A more potent narcotic analgesic with a much shorter half-life than morphine sulfate. DOC for conscious sedation analgesia.
With short duration (30-60 min) that is easy to titrate, an excellent choice for pain management and sedation. Easily and quickly reversed by naloxone.
After the initial dose, do not titrate subsequent doses more frequently than q3h or q6h thereafter.

Dosing

Adult

0.5-1 mcg/kg/dose IV/IM q30-60min

Pediatric

<2 years: 2-3 mcg/kg/dose IV/IM q30-60min
2-12 years: 1-2 mcg/kg/dose IV/IM q60min

Interactions

Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants may potentiate adverse effects of fentanyl when both drugs are used concurrently

Contraindications

Documented hypersensitivity; hypotension or potentially compromised airway where establishing rapid airway control would be difficult

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade in order to increase ventilation

Meperidine (Demerol)

Narcotic analgesic with multiple actions similar to those of morphine. May produce less constipation, smooth muscle spasm, and depression of the cough reflex than similar analgesic doses of morphine.

Dosing

Adult

50-150 mg PO/IV/IM/SC q3-4h prn

Pediatric

1-1.8 mg/kg (0.5-0.8 mg/lb) PO/IV/IM/SC q3-4h prn; not to exceed adult dose

Interactions

Monitor for increased respiratory and CNS depression with coadministration of cimetidine; hydantoins may decrease effects of meperidine; avoid with protease inhibitors

Contraindications

Documented hypersensitivity; MAOls; upper airway obstruction or significant respiratory depression; during labor when delivery of premature infant is anticipated

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients with head injuries, since meperidine may increase respiratory depression and CSF pressure (use only if absolutely necessary); caution when using postoperatively and with history of pulmonary disease (suppresses cough reflex)
Substantially increased dose levels, due to tolerance, may aggravate or cause seizures even if no prior history of convulsive disorders; monitor closely for morphine-induced seizure activity with prior seizure history

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderate to severe pain. DOC for patients who are hypersensitive to aspirin.

Dosing

Adult

1-2 tab or cap PO q4-6h prn

Pediatric

0.05-0.15 mg/kg/dose oxycodone PO; not to exceed 5 mg/dose of oxycodone q4-6h prn

Interactions

Phenothiazines may decrease analgesic effects of this medication; toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4,000 mg/d of acetaminophen; higher doses may cause liver toxicity

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderate to severe pain.

Dosing

Adult

1-2 tab or cap PO q4-6h prn

Pediatric

<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen or 5 mg of hydrocodone bitartrate/dose
>12 years: 750 mg acetaminophen PO q4h; not to exceed 5 doses/d acetaminophen or 10 mg of hydrocodone bitartrate/dose

Interactions

Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants

Contraindications

Documented hypersensitivity; elevated intracranial pressure

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Tabs contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction

Acetaminophen (Tylenol, Panadol, Aspirin Free Anacin)

DOC for the treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, in those with upper GI disease, or in those who are taking oral anticoagulants.

Dosing

Adult

325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses/d

Interactions

Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity

Contraindications

Documented hypersensitivity; G-6-PD deficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose

Follow-up

Further Outpatient Care

Document arrangements for patients with repaired dental fractures to follow up with a dentist.
Advise patients with Ellis II and III fractures 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

Medicolegal 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

Multimedia

$Cross section of an Ellis III dental fracture.$

Media file 1: Cross section of an Ellis III dental fracture.

References

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].
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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].

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

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.

Further Reading