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eMedicine Specialties > Clinical Procedures > Otolaryngologic and Dental Procedures

Fractured Teeth

Jarred Jeremy Thomas, MD, Assistant Professor, Associate Program Director, Assistant Medical Director, Director of ED Chest Pain Evaluation Unit - Department of Emergency Medicine, University of Alabama at Birmingham
Andrew R Edwards, MD, Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, University of Alabama at Birmingham; Co-Director, Department of Resuscitation, University of Alabama at Birmingham Hospital; Medical Director of Jefferson County SWAT Team, Jefferson County Sheriff's Department; Melissa Moore,, University of Alabama School of Medicine

Updated: Mar 29, 2009

Introduction

The ability to care for dental fractures in the emergency department or clinic setting is a skill required during the career of every clinic-based or emergency clinician. Although the procedures performed in these settings are largely temporizing measures, appropriate care in the acute setting is critical to avoid adverse outcomes.

In general, acute dental trauma is inadequately treated. In some patient populations, less than half of patients who need treatment receive it; of those who do receive treatment, over half receive inadequate treatment. Many patients with acute dental trauma require follow-up with a dentist or an oral surgeon within 24 hours; however, proper intervention should not be delayed. These procedures can improve cosmetic results, prevent tooth loss, and decrease the risk of infection following dental trauma.

Dental fractures are divided into categories based on the Ellis classification system.

  • Ellis I: This level of injury includes crown fractures that extend through the enamel only. These teeth are usually nontender and without visible color change but have rough edges.
  • Ellis II: Injuries in this category are fractures that involve the enamel as well as the dentin layer. These teeth are typically tender to the touch and to air exposure. A yellow layer of dentin may be visible on examination.
  • Ellis III: These fractures involve the enamel, dentin, and pulp layers. These teeth are tender (similar to those in the Ellis II category) and have a visible area of pink, red, or even blood at the center of the tooth.

    Cross section of an Ellis III dental fracture.

    Cross section of an Ellis III dental fracture.


The pulp of the tooth is very prone to infection. Infection of the pulp is termed pulpitis and can lead to potential tooth loss. The dentin of the tooth is very porous and is an ineffective seal over the pulp. In Ellis II and III fractures in which the dentin or pulp is exposed, the clinician caring for the tooth fracture in the acute setting must create a seal over these injured teeth to protect the pulp from intraoral flora and potential infection.

Other dental injuries that may or may not be associated with a dental fracture include the following:

  • Dental avulsion - Complete extraction of the tooth (crown and root)
  • Dental subluxation - The loosening of a tooth following trauma
  • Dental intrusion - The forcing of an erupted tooth below the gingiva

In these situations, the goal is to return the tooth to its correct anatomical position as quickly and securely as possible, without causing further trauma to the tooth, gingiva, or alveolar bone.

An estimated 50% of children sustain a dental injury before age 18 years; most children are aged 7-14 years at the time of injury. Permanent teeth injuries make up 90% of the dental injuries to children; the most commonly injured teeth are the central incisors.

Dental trauma has a male predominance of almost 2:1. This predominance is evident in permanent dentition but not in the setting of primary dentition. Dental fractures are most common in children, youth, and young adults. Dental fracture is often a result of falls, play, altercations, sports, and motor vehicle accidents.1,2

Indications

The treatment of dental fractures should be performed in the setting of acute dental trauma.

  • Ellis I fracture
  • Ellis II fracture
  • Ellis III fracture
  • Subluxation
  • Avulsion-type injury

Contraindications

  • Consider the risk of aspiration following repair in the following specific subgroups of patients:
    • Intoxicated
    • Altered mental status
    • Decreased functional capacity
  • In multisystem trauma patients, always address the more critical issues and injuries first.
  • Tooth extraction may be a viable option in some cases of primary tooth injuries.

Anesthesia

Anesthetic options include the following:

  • Local anesthesia at the tooth apex
  • Mental nerve block
  • Inferior alveolar nerve block
  • Topical anesthetics should be avoided.

Equipment

Most essential equipment is available in a prepacked dental tray or dental box.

  • Local parenteral anesthetic agent (eg, lidocaine [Xylocaine], bupivacaine [Marcaine])
  • Zinc oxide topical ointment or cream
  • Calcium hydroxide composition (Dycal)
  • Glass ionomer composite
  • Cotton-tipped applicator or dental tools
  • Aluminum foil
  • Antibiotic agent (eg, penicillin V, clindamycin, erythromycin)
  • Tetanus toxoid vaccine booster dose

Positioning

  • Seat the patient in a reclined position at a 30-60° angle.
  • The patient’s neck should be slightly hyperextended.
  • A dental chair provides ideal support for the desired position.
  • The ability to position the patient may be limited because of the spine precautions necessary in patients with multisystem or isolated head or neck trauma.

Technique

Ellis class I

  1. File down sharp edges, if necessary, with a dental drill or emery board.
  2. Dental follow-up, as desired by the patient, is for cosmetic purposes only.

Ellis class II

  1. Cover the exposed surface with a calcium hydroxide composition (eg, Dycal), a glass ionomer, or a strip of adhesive barrier (eg, Stomahesive). 2-octyl cyanoacrylate (Dermabond) has been shown to be an acceptable alternative in the setting of a dental fracture if no other materials are available.3 The 2-octyl cyanoacrylate decreases tooth sensitivity and provides a protective barrier until dental follow-up.4
  2. Provide pain medications.
  3. Instruct the patient to avoid hot and cold food or drink.
  4. Arrange for a follow-up appointment with a dentist within 24 hours.
  5. Consider antibiotic coverage with penicillin or clindamycin.

Ellis class III

  1. Cover the exposed surface with a calcium hydroxide composition (eg, Dycal) or a glass ionomer.
  2. Provide immediate dental follow-up and analgesics as needed.
  3. Initiate antibiotics with coverage of intraoral flora (eg, penicillin, clindamycin).

Dental avulsion

  1. An avulsed tooth may be gently cleansed in either normal saline or sterile auxiliary solution (eg, Hank's balanced salt solution).
  2. Avoid scrubbing the tooth or any unnecessary delay before reimplantation.
  3. The tooth can be returned to its original position by applying firm finger pressure.
  4. Handle the tooth by the crown, and avoid trauma to the tooth root.
  5. Stabilize the tooth with a temporary periodontal splint.
  6. Provide early dental follow-up.
  7. Initiate antibiotics with coverage of intraoral flora (eg, penicillin, clindamycin).

Dental subluxation

  1. This type of injury may not require emergency treatment.
  2. Very loose teeth should be pressed back into their sockets.
  3. They should then be stabilized with wire or a temporary periodontal splint (eg, Coe-Pak).
  4. Patients with dental subluxation should maintain a soft or liquid diet to prevent further tooth motion.
  5. Provide early dental follow-up.
  6. Initiate antibiotics with coverage of intraoral flora (eg, penicillin, clindamycin).

Dental intrusion

  1. These injuries can be left alone and allowed to re-erupt.
  2. Provide early dental follow-up.
  3. Initiate antibiotics with coverage of intraoral flora (eg, penicillin, clindamycin).

Pearls

  • Pediatric patients (aged <12 y) have a thinner layer of dentin to protect the pulp. As a result, Ellis II fractures are more likely to become infected and should be treated as Ellis III fractures in this patient population.
  • Update the patient’s tetanus vaccination, if necessary.
  • Instruct patients to eat only soft foods following all injuries (except an Ellis I fracture).
  • Always consider the possibility of abuse (eg, child, spousal, or elder abuse) when patients present with dental fractures.
  • Complete a physical examination of the bony structures of the face when indicated to ensure that a more serious injury (eg, Le Fort fracture) is not missed.
  • Examine all intraoral lacerations for tooth fragments, which can result in chronic infections. For information on the treatment of intraoral lacerations, see eMedicine articles Complex Laceration, Lip and Complex Laceration, Tongue.
  • Avoid topical anesthesia, as it can increase the risk of a sterile abscess and irritation.
  • Dental blocks are very useful for pain control.
  • If teeth or partial teeth are missing, obtain a radiograph of the chest to rule out pulmonary aspiration or a CT scan of the face to rule out intrusion into alveolar bone or gingiva.
  • All dental fractures (except for Ellis I) require dental follow-up within 24 hours.

Complications

  • Loss of tooth
  • Infection or abscess
  • Aspiration of partial or whole tooth
  • Cosmetic deformity

Multimedia

Cross section of an Ellis III dental fracture.

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

References

  1. Gabris K, Tarjan I, Rozsa N. Dental trauma in children presenting for treatment at the Department of Dentistry for Children and Orthodontics, Budapest, 1985-1999. Dent Traumatol. Jun 2001;17(3):103-8. [Medline].

  2. Bruns T, Perinpanayagam H. Dental Trauma that require fixation in a children's hospital. Dental Traumatol. Dec / 2007;24:59-64.

  3. Hile LM, Linklater DR. Use of 2-octyl cyanoacrylate for the repair of a fractured molar tooth. Ann Emerg Med. May 2006;47(5):424-6. [Medline].

  4. Wiand D, DiNapoli D, Burkhartsmeyer A, et al. Tissue Adhesive, 2-Octyl Cyanoacrylate, is an Effective Emergency Department Treatment for Pain Associated with Dental Caries. Annals of Emergency Medicine. September, 2007;50:S36.

  5. Auerbach PS, ed. Trauma to the face and jaw. In: Wilderness Medicine. 4th ed. St Louis, Mo: Mosby; 2001.

  6. Buttaravoli P, Stair T, eds. Dental trauma (fracture, subluxation and displacement). In: Minor Emergencies: Splinters to Fractures. St Louis, Mo: Mosby; 2000.

  7. Flores MT, Andreasen JO, Bakland LK, et al. Guidelines for the evaluation and management of traumatic dental injuries. Dent Traumatol. Jun 2001;17(3):97-102. [Medline].

  8. Hamilton FA, Hill FJ, Holloway PJ. An investigation of dento-alveolar trauma and its treatment in an adolescent population. Part 1: The prevalence and incidence of injuries and the extent and adequacy of treatment received. Br Dent J. Feb 8 1997;182(3):91-5. [Medline].

  9. Roberts JR, Hedges RJ, eds. Dentoalveolar trauma. In: Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, Pa: WB Saunders; 2004:1320-30.

  10. Rosen P, Barkin R, eds. Dental emergencies. In: Rosen's Emergency Medicine Concepts and Clinical Practice. 3rd ed. St Louis, Mo: Mosby; 1992.

  11. Wilson S, Smith GA, Preisch J, et al. Epidemiology of dental trauma treated in an urban pediatric emergency department. Pediatr Emerg Care. Feb 1997;13(1):12-5. [Medline].

Keywords

fractured teeth, broken tooth, broken teeth, tooth fracture, cracked teeth, dental tooth, fractured tooth, tooth injury, dental fractures, dental injuries, dental trauma, dental avulsion, dental subluxation, oral trauma, facial trauma, tooth fractures, tooth injuries, tooth, dental, avulsion, subluxation, Ellis classification, Ellis I fracture, Ellis II fracture, Ellis III fracture, Ellis fractures, Ellis I, Ellis II, Ellis III, crown, dentin, pulp, calcium hydroxide, glass ionomer, gingiva

Contributor Information and Disclosures

Author

Jarred Jeremy Thomas, MD, Assistant Professor, Associate Program Director, Assistant Medical Director, Director of ED Chest Pain Evaluation Unit - Department of Emergency Medicine, University of Alabama at Birmingham
Jarred Jeremy Thomas, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Heart Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Andrew R Edwards, MD, Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, University of Alabama at Birmingham; Co-Director, Department of Resuscitation, University of Alabama at Birmingham Hospital; Medical Director of Jefferson County SWAT Team, Jefferson County Sheriff's Department
Andrew R Edwards, MD is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Melissa Moore,, University of Alabama School of Medicine
Melissa Moore, is a member of the following medical societies: Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Prajoy P Kadkade, MD, Assistant Professor, Department of Otolaryngology and Communicative Disorders, North Shore University Hospital-Long Island Jewish Hospital System, Albert Einstein College of Medicine
Prajoy P Kadkade, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Luis M Lovato, MD, Associate Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Gil Z Shlamovitz, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

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