Management of Dental Trauma

Dental trauma is relatively common and can occur secondary to falls, fights, sporting injuries, or motor vehicle accidents. Because many clinicians work in a community-based environment where there is no dentist on call for emergencies, they may find themselves forced to deal with acute dental injuries in such situations.

A study sought to determine whether oral cavity cancers occurred more commonly at sites of dental trauma. The study concluded that oral cavity cancers occur predominantly at sites of potential dental and denture trauma, especially in nonsmokers without other risk factors. A key finding of this study was that the location where oral cavity cancers arise is different in smokers and nonsmokers. Recognizing teeth irritation as a potential carcinogen should have an impact on prevention and treatment strategies. ^{[1, 2]}

Prevention

A position statement from the National Athletic Trainers' Association (NATA) recommends that athletic trainers, coaches, and parents should motivate all athletes to wear mouthguards that are properly fitted during any sports activity with an increased risk of orofacial injury. ^[3]

Clinical evaluation

Initial evaluation of a patient with dental trauma should include the following:

• Full physical examination of the head, neck, and face

• Assessment of possible injuries to adjacent areas and structures (eg, facial fractures or head and neck trauma)

Imaging modalities that may be considered include the following:

• CT of the head, neck, and maxillofacial bones

• Periapical radiography

• Panoramic radiography of the teeth

See Overview for more detail.

Management

Treatment of dental trauma varies according to the type of injury involved:

• Fracture

• Avulsion

• Luxation (tooth displacement)

Tetanus booster and antibiotics should be administered whenever a dental injury is at risk for infection. Arrangements should be made for prompt follow-up with a dentist or an oral and maxillofacial surgeon.

Dental fractures may be classified as follows:

• Ellis class I (superficial enamel only) – No emergency care is required; follow-up with a dentist is arranged as needed

• Ellis class II (enamel and dentin, with sensitivity to temperature, air, and palpation) – The exposed dentin is covered, preferably with dental cement; the patient is referred to a dentist within 24 hours

• Ellis class III (enamel, dentin, and pulp; a dental emergency) – The fracture is covered with dental cement; patients receive urgent and immediate dental follow-up; topical painkillers increase the risk of infection and thus should not be applied

• Root fractures – Extraction of the coronal segment is required; if no more than one third of the root is involved, a dentist may be able to perform a root canal and salvage the tooth

Principles of management for dental avulsions include the following:

• An adult tooth that is avulsed should be reimplanted in its socket as soon as possible

• If the tooth cannot be reimplanted, it should be placed in a protective solution; it should never be allowed to dry

• If the tooth has been dry for a significant period, it should be soaked in the appropriate solution (which depends on the length of the dry period)

• Some studies suggest that when a tooth has been out of the mouth for longer than 60 minutes, immediate reimplantation is not required, and a root canal of the tooth should be performed with the tooth outside the mouth before it is reimplanted

• After reimplantation, any other injuries are repaired

• In children with dental avulsions, primary teeth are never reimplanted, because reimplantation of a deciduous tooth can cause harm to the developing permanent tooth

Luxations may be classified as follows:

• Concussion - Mild injury to the periodontal ligament, with some clinical tenderness but no movement of the tooth

• Subluxation - More significant injury to the periodontal ligament, with clinical tenderness and movement of the tooth

• Extrusion - Partial removal of a tooth from its socket

• Lateral luxation - Lateral displacement of a tooth at an angle, with possible fracture of the alveolar bone as well

• Intrusion - Impaction of a tooth into its socket in the fractured alveolar bone

Treatment of luxations includes the following:

• Concussion and subluxation – A soft diet, administration of nonsteroidal anti-inflammatory drugs (NSAIDs), and referral to a dentist; subluxation is a more significant injury and is more often associated with pulpal necrosis

• Extrusion – Restoration of the tooth to its original position; splinting

• Lateral luxation – Repositioning of the tooth, often made more difficult by a fractured alveolar bone; splinting, done by a general practitioner only if the alveolar bone fracture is minimal and done by a dentist or an oral and maxillofacial surgeon if the fracture is more extensive

• Intrusion – Usually, the general practitioner can provide no emergency treatment; referral to a dentist within 24 hours is indicated

Associated injuries to the maxillofacial bones may be classified as follows:

• Le Fort I – Transverse fracture separating the body of the maxilla from the lower portion of the pterygoid plate and nasal septum

• Le Fort II – Pyramidal fracture of the central maxilla and palate; facial tugging moves the nose but not the eyes

• Le Fort III (ie, craniofacial disjunction) – Facial skeleton completely separated from the skull, with the fracture extending through the frontozygomatic suture lines and through the orbit, the base of the nose, and the ethmoid; on physical examination, the entire face shifts with tugging

The image below depicts the Le Fort classification of maxillary fractures.

Dental trauma can be highly challenging for a clinician to deal with. Because teeth are not an area of intensive study in medical school, clinicians often rely on dentists to treat dental injuries. However, many clinicians work in a community-based environment where there is no dentist on call for emergencies; thus, they may find themselves forced to deal with an acute injury in a largely unfamiliar area. Accordingly, the aim of this article is to discuss dental trauma in a way that will be accessible and useful to the general clinician in an emergency situation.

Dental trauma is relatively common and can occur secondary to falls, fights, sporting injuries, or motor vehicle accidents. Dental injuries often occur in children, and it must be kept in mind that treatment of these injuries in children with primary teeth differs significantly from treatment in adults. ^[4] Before initiating treatment, it is essential to determine whether the injury is to a primary tooth or a permanent one and to assess the extent of tooth, pulp, and gum involvement.

In addition, dental injuries may be associated with other injuries of the face that demand emergency attention and stabilization. Immediate follow-up with a dentist or oral surgeon is the best way of minimizing the damage sustained from these injuries.

A tooth is made up of enamel, dentin, and pulp. The enamel forms the outer layer of the tooth, the dentin constitutes the layer underlying the enamel, and the pulp is the central portion of the tooth, containing the nerves innervating the tooth and the blood vessels supplying it. The area of the tooth above the gumline is called the crown, and the area below the gumline is called the root (see the image below).

Radiographically, the layers are easily identifiable because they have different radiopacities. Enamel is the most mineralized of the calcified tissues of the body, and it is the most radiopaque of the 3 tooth layers. Dentin is less radiopaque than enamel and has a radiopacity similar to that of bone. The pulp tissue is not mineralized and appears radiolucent.

The adult mouth contains 32 teeth: 4 central incisors, 4 lateral incisors, 4 canines, 8 premolars, and 12 molars. They are numbered in order from 1 to 32, proceeding from the upper right third molar to the upper left third molar and then from the lower left third molar to the lower right third molar (see the image below).

Children have 20 primary or deciduous teeth. These teeth are designated by means of letters, with A-J used for the upper jaw and K-T for the lower jaw. The letter A is assigned to the upper right rear molar, and subsequent lettering proceeds in the same manner as for adult teeth, with the letter T assigned to the lower right rear molar (see the image below).

For more information about the relevant anatomy, see Tooth Anatomy.

The most common mechanism of dental injury is trauma from falls and sporting injuries; altercations and motor vehicle accidents account for most of the rest. Tracheal intubation has also been associated with dental trauma. ^[5] Approximately 70% of all dental injuries involve the maxillary central incisors.

Management of dental injuries depends on the age of the patient and the extent of tooth and alveolar involvement. Because children have larger amounts of pulp in their anterior teeth than adults do, most tooth fractures in children involve a fracture of the pulp. Fortunately, children also have a greater capacity to regenerate pulp. As patients age, their teeth include progressively more dentin and less pulp, which makes fractures through the pulp chamber increasingly unlikely. ^[6]

The initial evaluation of a patient with dental trauma should include a full physical examination of the head, neck, and face. Dental injury is often accompanied by injuries to adjacent areas and structures. The clinician should always be aware of the possibility of other facial fractures or head and neck trauma.

Computed tomography (CT) of the head, neck, and maxillofacial bones should be obtained whenever warranted. Usually, clinical assessment and radiographic evaluation (eg, periapical radiographs) are the most helpful measures for determining the severity of the injury. Panoramic radiography of the teeth may also be required and should be performed if available.

Treatment of dental trauma varies, depending on the particular injury involved (eg, fracture, avulsion, or luxation). Specific treatments are described below. If a dental service is available, it can be used to treat more serious injuries, although the general clinician is capable of treating most injuries.

Tetanus booster and antibiotics should always be administered when necessary (ie, whenever a dental injury is at risk for infection). ^[7] Arrangements should be made for prompt follow-up with a dentist or an oral and maxillofacial surgeon, even if the patient was already seen by these services at the time of injury. ^[8]

New American Academy of Pediatrics dental trauma guidelines for nondentists

The American Academy of Pediatrics has released guidelines for nondentists on the prevention, diagnosis, and treatment of dental trauma. Recommendations include the following ^{[9, 10]} :

• Before treatment is initiated, an abbreviated medical and dental history should be taken

• The face, lips, and oral musculature should be thoroughly examined for soft tissue lesions

• Traumatized regions should be checked for fractures, abnormal tooth position, and tooth mobility

• Age-appropriate neurologic assessment should be performed.

• Patients should be asked about sensitivity to heat or cold

• Intraoral dental radiography, rather than computed tomography (CT), should be used to image the injured tooth

• Clinicians should know dental trauma classifications and urgent care for concussion, subluxation, lateral luxation, extrusive luxation, intrusive luxation, avulsion, infraction, enamel-only (uncomplicated) crown fracture, enamel and dentin (uncomplicated) crown fracture, crown fracture with exposed pulp (complicated), root fracture, and alveolar fracture

• Caregivers should be informed that the patient should eat a soft diet and avoid digit-sucking for 10 days after injuring a permanent tooth and should be made aware of the potential for and signs of root resorption, ankylosis, or pulpal necrosis

• Clinicians should know the difference between treatments for primary teeth and those for permanent teeth

Dental fracture

Dental fractures are classified according to the Ellis classification system, as follows.

Ellis class I

Ellis class I fractures involve only the superficial enamel. They are painless and do not necessitate emergency care. Follow-up with a dentist is arranged as needed for cosmetic repair.

Ellis class II

Ellis class II fractures involve both enamel and dentin and are sensitive to temperature, air, and palpation. The fracture line has a yellowish appearance, indicating that dentin has been exposed. Exposure of dentin allows communication between the oral cavity and the pulp, which puts the patient at risk for infection. Emergency care is required to prevent the spread of infection. The treating clinician should cover the exposed dentin, preferably with dental cement, and refer the patient to a dentist within 24 hours.

Ellis class III

Ellis class III fractures involve enamel, dentin, and pulp and constitute a true dental emergency. These fractures are generally very painful, even when exposed only to air; however, if the neurovascular supply has been compromised, they may be painless. A reddish or pink hue to the fracture indicates that the pulp has been compromised.

Ellis class III fractures become infected and may form an abscess if early intervention is not taken. They should be covered with dental cement, and patients should receive urgent and immediate dental follow-up. No topical painkillers should be applied, because these will increase the risk of infection.

Root fractures

Root fractures account for 5% of all dental injuries. ^[6] Extraction of the coronal segment is required. If the fracture involves no more than one third of the root, a dentist may be able to perform a root canal and salvage the tooth.

Dental avulsion

A dental avulsion occurs when a tooth is completely displaced from its socket. An adult tooth that is avulsed should be reimplanted in its socket as soon as possible to optimize the long-term viability of the tooth. During reimplantation, the tooth should be handled by the crown only, and all loose dirt and debris should be gently rinsed away with normal saline or tap water. These measures will minimize damage to the ligament cells around the root of the tooth, which are crucial for successful reimplantation.

If the tooth cannot be reimplanted, it should be placed in a protective solution, such as Hank's Balanced Salt Solution (HBSS), milk, or saline. These solutions help protect, hydrate, and nourish the periodontal ligament cells in the root of the tooth, thereby facilitating successful reimplantation at a later time.

The tooth should never be allowed to dry. If it has been dry for 20-60 minutes, it is soaked in HBSS for 30 minutes. If it has been dry for more than 60 minutes, it is soaked in citric acid for 5 minutes, then in 2% stannous fluoride for 10 minutes, and finally in doxycycline for 5 minutes before reimplantation is attempted; this approach helps reduce root resorption and increases the success rate of reimplantation.

Alternatively, the necrotic tissue can be gently brushed from the root surface, and the root can be soaked in topical fluoride for 15 minutes. This process makes the root more resistant to resorption.

New studies suggest that when a tooth has been out of the mouth for longer than 60 minutes, immediate reimplantation is not required, and a root canal of the tooth should be performed with the tooth outside the mouth before it is reimplanted. ^{[11, 7]}

Once the tooth is reimplanted, it is gently compressed into the gumline, and any other injuries (eg, lacerations) are repaired. Radiography is performed to look for any accompanying fractures of the maxilla or mandible. A splint should be applied to the avulsed tooth on an urgent basis, preferably by a dentist or an oral and maxillofacial surgeon. ^{[11, 12]}

If a dentist or an oral and maxillofacial surgeon is not available, a suture may be used as a temporary splint for all avulsion and luxation injuries. A silk 2-0 dental suture is placed from the palatal soft tissue to the vestibular soft tissue, incorporating the involved tooth. The stitches are crisscrossed over the tooth, and a locking horizontal mattress suture is employed to keep the tooth in place.

In the treatment of children with dental avulsions, it is vital to remember that primary teeth are never reimplanted, because reimplantation of a deciduous tooth can cause harm to the developing permanent tooth.

A review of 166 dental trauma patients by Lin et al found that the most frequent complication seen in 34.2% of patients was pulp necrosis and the most frequent avulsion related complication was ankylotic root resorption seen in 50% of the patients in a median follow-up of 1.18 years. ^[13]

Tooth displacement injury (luxation)

There are 5 different types of luxation, as follows:

• Concussion - A mild injury to the periodontal ligament, with some clinical tenderness but no movement of the tooth

• Subluxation - A more significant injury to the periodontal ligament, with clinical tenderness and movement of the tooth (often accompanied by bleeding at the gumline)

• Extrusion - Partial removal of a tooth from its socket

• Lateral luxation - Lateral displacement of a tooth at an angle, with possible fracture of the alveolar bone as well

• Intrusion - Impaction of a tooth into its socket in the alveolar bone, which is also fractured (the blood and nerve supply to the tooth is often disrupted as well)

Concussion and subluxation are generally minor injuries for which emergency treatment is unnecessary. Treatment typically consists of a soft diet, administration of nonsteroidal anti-inflammatory drugs (NSAIDs), and referral to a dentist for identification of any further damage that may have been missed on initial examination. In general, however, subluxation is a more significant injury than concussion and is more often associated with pulpal necrosis. ^[7]

For the treatment of extrusion, the tooth is restored to its original position, and a semirigid splint is placed by a dentist. Firm but gentle pressure usually allows the clinician to reposition the tooth. Local anesthesia, in the form of an alveolar nerve block, may be required. A temporary splint may be placed with a periodontal dressing until the patient can see a dentist. The patient should see a dentist for application of a more permanent splint within 24 hours. ^[7]

With lateral luxation, repositioning of the tooth can be more difficult, because the alveolar bone is also fractured. In most cases, however, application of firm pressure with the thumb and forefinger suffices for moving the tooth back into its original position. A general clinician should splint the tooth only if the alveolar fracture is minimal. If the fracture of the alveolar bone is more extensive, a dentist or an oral and maxillofacial surgeon must see the patient and splint the tooth. ^[7]

Intrusion is the most serious type of luxation. The entire tooth is impacted into the alveolar bone, and the alveolar socket fractures. The periodontal ligament is often crushed, and this disrupts the blood and nerve supply to the tooth. Usually, no acute treatment is possible. Patients are instructed to follow up with a dentist within 24 hours. The dentist may choose to reposition the tooth operatively, to reposition the tooth with gentle traction, or to allow the tooth to reposition on its own. Generally, a root canal must then be performed. ^[7]

Alveolar bone fractures often occur with various types of luxations. They may involve the socket wall, the alveolar process, or the supporting bone. For any fracture involving the alveolar bone, analgesics and antibiotics must be prescribed. The displaced teeth must be manually repositioned, and a dentist or an oral and maxillofacial surgeon must apply a rigid or semirigid splint, depending on the severity of the fracture; the patient generally wears this splint for 4-8 weeks.

Maxillofacial bone fracture

Many dental fractures are accompanied by injuries to the maxillofacial bones. When a patient is being evaluated for dental trauma, the threshold for performing a CT scan of the maxillofacial bones should be low so as to minimize the likelihood of missing any injuries to these bones. Maxillary and mandibular fractures are the types that are most likely to occur with dental injury.

Maxillary fractures are best assessed on physical examination by grasping and rocking the hard palate. They can be divided into 3 Le Fort classes as follows (see the image below):

• Le Fort I - A transverse fracture that separates the body of the maxilla from the lower portion of the pterygoid plate and nasal septum

• Le Fort II - A pyramidal fracture of the central maxilla and palate; facial tugging moves the nose but not the eyes

• Le Fort III (ie, craniofacial disjunction) - The facial skeleton is completely separated from the skull, and the fracture extends through the frontozygomatic suture lines and through the orbit, the base of the nose, and the ethmoid; on physical examination, the entire face shifts with tugging

  Le Fort I, II, and III maxillary fractures.

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Patients with complex fractures require admission and surgical repair. Even without surgery, most of these patients should receive intravenous (IV) antibiotics and be admitted to the hospital admission for advanced airway management, including intubation as necessary. ^[14]

Mandibular fractures often occur after assaults or falls on the chin, which can also cause dental injuries. They are generally multiple and involve the body, angle, and condylar process of the mandible. On physical examination, patients often have malocclusion and pain with jaw movement. Ecchymosis under the tongue is also a sensitive finding for mandibular fracture. Patients with open fractures require hospital admission and IV antibiotic therapy. ^[15]

A study by Magno et al reported that those with prior traumatic dental injuries are at greater risk for new episodes of traumatic dental injuries. ^[16]