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Basics ⬇

Author(s): ChristopherBossart, MD and ChristopherMcGrew, MD, FACSM, CAQSM

Description

Dentoalveolar injuries include dental avulsion, dental luxation, extrusion and intrusion, enamel and crown fractures, root fracture, and alveolar bone fracture.

Epidemiology

  • 25% of all respondents in the United States between the ages of 6 and 50 yr reported suffering at least one traumatic dental injury to their anterior teeth (1).
  • ~30% of children have experienced dental injuries (2).
  • The peak period for trauma to the primary teeth is 18 to 40 mo of age because this is a time of increased mobility for the relatively uncoordinated toddler. Injuries to primary teeth usually result from falls and collisions as the child learns to walk and run (2).
  • With the permanent teeth, school-aged boys suffer trauma almost twice as frequently as girls.
  • Sports accidents and fights are the most common cause of dental trauma in teenagers.
  • Data show that these orofacial injuries occur primarily during recreational sports and organized athletic events. Individuals who incur facial trauma during noncompetitive sporting events go vastly underreported, which skews the reporting. A large retrospective study shows that 69% of the injuries were incurred by males. The age group between 11 and 18 yr was the most commonly affected (3).
  • 90.3% of crown fractures or crown-root fractures occur from direct trauma (3).
  • The most commonly involved teeth were the central incisors (58.3%), and the second most commonly involved teeth were the maxillary lateral incisors.
  • There seems to be a seasonal variation in incidence of orofacial trauma. Many data demonstrate the probable correlation between outdoor activities and predominance of dental trauma during warmer times of the year (in the northern hemisphere) (1).
  • 5–35% of the population; 75% <15 yr of age
  • Predominant gender: male > female (3:1); equal or higher rates sometimes reported for females than males when corrected for exposure rates

Etiology and Pathophysiology

  • Etiology (2):
    • Falls made up 49% of cases (including uncoordinated childhood falls).
    • Traumatic dental injuries account for 18–30% of all oral injuries (4).
    • Sports-related injuries occurred in 18% of cases.
    • Bicycle and scooter accidents accounted for 13% of cases.
    • Assaults made up 7% of cases.
    • Road traffic accidents resulted in 1% of cases.
    • All others 12%
  • Pathophysiology:
    • Enamel fracture only (Ellis class I), 15.8%:
      • Roughness of chipped tooth on tongue
      • May go unnoticed by athlete
      • Not a dental emergency
    • Enamel and dentin fracture (Ellis class II), 39.9%:
      • Exposure of yellow dentin
      • Pain with dentin exposure to air, cold drinks, or touch
      • Not a dental emergency
    • Enamel, dentin, pulp exposed (Ellis class III), 25.7%:
      • Dental emergency (within 3 hr)
      • Exposure of red-pink dental pulp
      • Vital with closed root apex: less complex treatment
      • Vital pulp with open root apex: more complex but viable
      • Dental pulp opening appears dry or oozes putrescent exudates and no pain:
        • Nonviable
    • Root fractures (Ellis class IV):
      • Dental emergency (within 3 hr)
      • Middle (1/3) root fractures have a good prognosis depending on time of evaluation and treatment. This root fracture can be identified by its longer visible coronal segment and it being partially extruded compared with other teeth. The tooth is likely to bleed from the gingival sulcus, and with gentle finger pressure, it may be rotated in the socket. As long as the tooth is not visibly markedly loose, the athlete may finish sporting event with mouth guard in place and seek follow-up care in emergency department (ED) within 24 hr (5).
      • Cervical third fractures have the worst prognosis of all root fractures.
      • Apical root fractures have the best prognosis for maintaining viability, especially if lacking segmental mobility.
    • Extrusion, intrusion, lateral luxations:
      • Displacement (not fracture) involving periodontal ligament (i.e., stretch, compress, rupture ligament)
      • Lateral luxation involves movement of tooth in anterior/posterior plane: Follow up with dentist within 24 hr for splinting or immediately if tooth cannot be repositioned.
      • Intrusion involves movement of tooth inward:
        • May be extremely painful, painless, or numb depending on the extent of nerve root injury
        • Dental emergency (within 3 hr)
      • Extrusion is movement of the tooth out of the socket: Follow up with dentist within 24 hr for splinting or immediately if tooth cannot be repositioned.
    • Avulsion (tooth exarticulation): dental emergency (immediate): Time to definitive treatment is inversely related to viability.
    • Associated soft tissue injury (abrasions, lacerations, contusions):
      • Lacerations of the lip: 55.8%
      • Abrasions of face constituted 34.2%.
      • Abrasions of lip constituted 30.2%.
      • Abrasions of mentum constituted 21%.
      • Abrasions of nose constituted 13%.
      • Abrasions of other regions constituted 1.5%.

Risk-Factors

  • Protection: Large meta-analysis showed that athletes are 1.6 to 1.9 times more likely to have orofacial injuries playing sports not traditionally associated with mouth guard use compared to those sports mandating mouth guards (6).
  • Sports: baseball, basketball, cycling, hockey, soccer, skiing, rugby, football, wrestling, boxing, and martial arts
  • Anatomy: protruding maxillary incisors, lip incompetence, class II malocclusion
  • Previous injury

General Prevention

  • Face masks, in sports such as hockey and football, provide protection against trauma to the mouth and face.
  • Mouth guards reduce oral lacerations and tooth fractures and cushion impacts that could result in condylar displacement and subsequent injury.
  • Stock mouth guards are the most inexpensive but lack customized fit. The athlete has to continuously bite down on mouth guard for it to not become loose and free in the mouth. These mouth guards come with the risk that if the patient becomes unconscious, the mouth guard may be extruded from the oral cavity or obstruct the airway. They are often bulky and may interfere with speech and breathing.
  • Mouth-formed or boil-and-bite mouth guards are the most commonly commercially sold mouth guards, and many types are available. These mouth guards are best fit by a dentist but may be fit at home. Inconsistent retention, fit, and quality make these mouth guards still not the most desirable option, although they are better option than stock mouth guards. They are molded to the mouth after being placed in boiling water and then are set in cold water after being placed in the athlete’s mouth.
  • Custom-fitted mouth guards are fit in a two-stage process by a dentist for maxillary (class I or II occlusion) or mandibular (class III occlusion) arches. They provide increased comfort, compliance, and protection. They may last several years but are impractical for children <13 yr of age owing to rapid dental changes. They may be formed by vacuum or pressure lamination (preferred) processes. These mouth guards exhibit the most reliable retention rates and limit the incidence of dental trauma. The high cost of these mouth guards can be easily justifiable economically relative to the cost of cosmetic or restorative dentistry.

Commonly Associated Conditions

  • Facial contusion, laceration, fracture
  • Mandible fracture
  • Intraoral laceration (tongue, buccal mucosa, gingiva)
  • Concussion

Diagnosis ⬆ ⬇

Suspicions for dental trauma:

  • Impact to jaw, face, or any part of skull or neck leaving bruising or ecchymosis, diffuse or focal
  • Facial swelling, bleeding from mouth or gums
  • Patient complains of ear, jaw, or neck pain or headache.
  • Patient intolerant of drinking hot or cold fluids ± inability to chew
  • Prehospital:
    • Evaluate patient for signs of shock or acute blood loss.
    • Determine the extent of injury because this dictates how quickly action must be taken.
    • Response time is paramount when discussing viability of teeth affected by dental trauma. Better outcomes result from proper interventions done early in the time course.
    • Assess all lacerations for severity and necessity of intervention by dentist or oral maxillofacial surgeon.

History

  • Mechanism of injury and associated injuries (7)
  • Force and vector of injury: This is paramount to identify all injuries visible or potentially concealed by soft tissue injury and swelling.
  • Time since injury, time tooth was out of mouth, method of storage and transport
  • Past dental history, past general medical and surgical history
  • Medications and allergies
  • Last tetanus shot

Physical Exam

  • Signs and symptoms include:
    • Pain and tenderness to percussion or palpation.
    • Temperature sensitivity.
    • Color changes.
    • Tooth loosening.
  • Physical examination includes:
    • Assess levels of consciousness, and ensure that airway, breathing, and circulation are intact.
    • Begin with general examination of the head and neck, including skull, eyes, ears, nose, cervical spine, and anterior neck.
    • Proceed with extraoral exam. Palpate the mandible, zygoma, temporomandibular joint (TMJ), and mastoid region. Check for any mandibular or maxillary fractures that are present. Find mandibular fractures by feeling the lower border of the mandible for a step-down fracture. Identify any extraoral lacerations, bruises, or swelling. If a laceration is present in the upper or lower lip, the area must be inspected for foreign bodies such as gravel or tooth fragments. Any foreign bodies must be débrided from the soft tissue.
    • The mandibular condyles and maxilla should be carefully palpated. Check jaw movements for normal range of movements. Chin lacerations require careful evaluation of the cervical spine and mandibular condyles. Indications of condylar fractures include an anterior open bite, a malocclusion, or limited mandibular opening. Confirmation of condylar fractures requires a panoramic radiograph with closed- and open-mouth views.
    • Follow this with a detailed intraoral exam. Identify and account for all missing teeth, if possible. Explore oral cavity to identify extent of dental and oral mucosa damage. The labial and buccal mucosa, maxillary frenum, gingival tissues, and tongue should be examined for bruising or lacerations. All intraoral lacerations must be cleaned and explored, looking for any foreign bodies. Palpate the alveolus to detect any fractures. Have the patient clench the teeth so that the dental occlusion can be evaluated. Each tooth should be examined for damage or mobility. Multiple types of injuries to each tooth must be suspected. Excess mobility suggests root and alveolar fractures; this is also seen with luxation injuries to a lesser degree. Malalignment may indicate luxation injury or fracture. Modular movement of adjacent teeth suggests alveolar fractures.

Differential Diagnosis

  • Associated trauma: ruled out by history, physical examination, and radiography
  • Mandibular fractures and TMJ damage: Check occlusion, limitation of jaw motion, mobility of multiple teeth or jaw fragments, maxillary/hard palate mobility, anesthesia/paresthesia of the cheek and lip as well as radiography.
  • Soft tissue injuries: Include radiographs if not all tooth fragments are accounted for.

Diagnostic Tests & Interpretation

  • Radiographic examination: For evaluating injuries to the maxillary or mandibular teeth, an occlusal radiograph is the film of choice:
    • Two periapical views at different angles if a root fracture is suspected are required for a definitive diagnosis.
    • For deep tooth structure evaluation (i.e., Ellis class III, root, jaw fractures, intruded teeth), a lateral anterior radiograph provides additional useful information.
    • Chest radiograph if dyspneic, hemoptysis, or missing tooth to evaluate for aspirated tooth fragment
    • Panorex (panoramic radiograph) helps to evaluate suspected mandibular or condylar fractures.
  • Routine radiographs may not show root fractures; dental films (panoramic film with selected periapical views at multiple angles) are indicated with a low index of suspicion. Fractures may not be evident initially; negative films may be repeated 1 to 2 days after injury.
  • Postreduction views are needed to rule out root or alveolar fractures and confirm placement after reimplantation or splinting of an avulsed tooth.
  • Photographic documentation: The use of preoperative and postoperative photography may be useful for documentation purposes.

Treatment ⬆ ⬇

  • Treatment depends on rapid identification of injury type.
  • Initial stabilization:
    • Establish airway, breathing, and circulation.
    • Control soft tissue bleeding: pressure from gauze, fabric, or any other moldable material
    • Provide analgesia:
      • Injection of 1 to 2 mL lidocaine (0.5 to 1 mL for primary teeth) into the buccal gingival mucosa over the injured tooth and root apex, with epinephrine if not contraindicated; less effective with mandibular teeth
      • Inferior alveolar nerve block may be required for pain relief of mandibular teeth, with 2 to 4 mL lidocaine injected just superior to the lingula of the mandible.
      • Orthodontic wax may be applied to protect exposed dentin or pulp and sharp edge.
      • Oral pain medications are not recommended initially owing to the possibility of ingesting blood and fragments of teeth.
  • Tooth avulsions (8):
    • Avulsed primary teeth should not be replaced owing to the risk of injury to permanent teeth.
    • Locate all teeth or tooth fragments, and prepare to replace and reposition tooth immediately.
    • Handle the tooth only by the crown. Any contact with the root may render the tooth nonviable.
    • Inspect the tooth to ensure that no foreign material is left on the surface (especially at the root). If any foreign material is present, flush or swish the tooth in a sterile balanced salt solution (Hank balanced salt solution, Earl balanced salt solution) or milk for 10 sec. Do not brush.
    • Replantation should be performed as soon as possible (good prognosis within 20 min but poor after 2 hr) (9). No successful reimplantation has been performed if avulsed tooth has been out of mouth and dry for >60 min (10).
    • Do not attempt to replace tooth in obtunded patient.
    • After exam, flush socket with saline, and prepare to replace tooth.
    • Firmly (but not forcefully) reinsert tooth into the socket after local anesthesia and saline irrigation. Have patient bite gently on gauze to seat tooth in socket. Patient may feel a click or a give and then increased resistance. Once the tooth is firmly implanted in the alveolar socket and is anatomically consistent (labial and lingual surfaces align) with adjacent teeth, place an oversized piece of gauze atop the reimplanted tooth and have the patient bite down firmly on the gauze.
    • Transport immediately to dental office or ED with on-call dentistry, whichever is available at that time.
    • Place nonimplantable teeth or tooth fragments in preserving system such as sterile balanced salt solution (Hank balanced salt solution, Earl balanced salt solution) or milk if available.
    • Tooth may be stored in milk for 3 to 6 hr and even longer in sterile balanced salt solution and in saliva for up to 2 hr. If low risk for aspiration and no other alternatives are available, store sublingually or in buccal vestibule to prevent drying.
    • Do not store in plain water because this causes osmotic lysis of periodontal ligament cells.
    • Do not allow tooth to dry.
    • Dental treatment:
      • 5 to 10 days of antibiotics (penicillin V or alternatives) reduce the risk of root resorption.
      • Because there have been reported treatment failures with oral penicillin, other antibiotics that may be used are ampicillin-sulbactam (intravenous [IV]) or penicillin G (IV) with metronidazole (IV or PO) (11).
      • Splinting/immobilization: Acid-etch resin is used with wire along the labial surface to passively splint the injured tooth.
      • Duration of splinting varies with injury: Semirigid splints should be applied for 7 to 10 days after avulsion.
  • Tooth fractures (12):
    • Enamel only (Ellis class I): Locate fragment, if possible. If fragment cannot be reattached or securely replaced, place the fragment in a balanced salt solution. May be reattached up to 48 hr later by a dentist with resin or bonding. If nonviable, smoothing and contouring the rough edge are tactilely therapeutic and aesthetically pleasing; nonurgent referral to smooth rough edges, with cosmetic repair 4 to 8 wk later if needed
    • Enamel and dentin (Ellis class II): Fragment may be reattached with bonding agent or composite resin materials. Transport tooth fragments in tooth-preserving system. Arrange dental referral as soon as possible for best results (same day). Dentist may place composite resin or glass ionomer bandage. Exposed dentin should be sealed as soon as possible; delay may allow bacterial contamination of the pulp via dentinal tubules, especially in immature teeth. Acid-etch composite is used (possibly with tooth fragments) for definitive restoration.
    • Enamel, dentin, and pulp (Ellis class III):
      • Emergent evaluation within 3 hr before proceeding with treatment by dentist. Treatment based on pulp status and dental age of tooth. Direct pulp capping may allow pulp vitality with small pulp exposures. Partial pulpotomy with calcium hydroxide treatment may be indicated in immature teeth to delay root canal treatment until after apex maturation (if pulp remains vital). Teeth with moderate pulp exposure and closed apices necessitate root canal treatment.
    • Crown-root fractures (cleave fractures): Fractures near the alveolar crest rarely heal without either root canal therapy and post/crown placement or extraction and prosthodontic treatment.
    • Root fracture (Ellis class IV): Coronal portion should be repositioned after local anesthesia with radiographic confirmation and rigid immobilization for 2 to 3 mo (shorter for more apical fractures) (13).
    • Root fractures, as mentioned previously, have poorer prognosis the more distal from the apical segment. Apical root fractures may heal by cementum union alone.
    • Middle third fractures require urgent care. Immediate intervention includes using gentle pressure coupled with instructing the athlete to bite down on sterile gauze after repositioning. Subsequent dental evaluation emergently as well as periodically over the next 6 to 8 wk is necessary. The patient may require a root canal if indicated by a dentist.
    • Urgent management remains the same as for middle third injuries, but a dentist’s evaluation will determine viability of affected tooth and possible need for extraction and replacement with a dental implant.
  • Luxation:
    • For lateral luxation (subluxation of the dentoalveolar joint), if minor, it may be appropriate to attempt reduction if possible.
    • If reduction is possible and successful, provider may approximate and suture any gingival injury; splint for 2 to 4 wk, and follow up with pulp vitality testing, local anesthesia, firm repositioning, and splinting with close follow-up
    • Urgent referral (same day) only if repositioning cannot be done
    • Extrusion injuries: repositioning and splinting with anesthesia as needed
    • Urgent referral (same day) only if repositioning cannot be done
    • Intrusion injuries are dental emergency. Record the distance of intrusion, use local anesthesia, and luxate the tooth with gentle twisting if it is not already slightly mobile. Do not splint. Intrusive luxation with deciduous teeth may need to be extracted or may be left in and may reerupt. Teeth also may ankylose. Urgent repositioning is necessary.
    • Refer within 3 hr to ED or dentist’s office for treatment.
  • Alveolar fractures:
    • Immediate reduction with manual pressure after clinical diagnosis followed by radiographs and rigid splinting for 1 to 2 mo reduces pulp necrosis.
    • Empirical antibiotic therapy against oral flora is recommended to reduce contamination.

Medication

  • Immunizations: tetanus. Consider administration of immunization in cases of lacerations or tooth injuries with exposed pulp or for avulsions in patients for whom immunizations are due (last immunization >5 yr).
  • Antibiotic therapy: Consider prophylactic antibiotics in cases of exposed pulp or avulsion. Penicillin VK or clindamycin may be used (14).
  • Pain medications: Consider use of nonsteroidal anti-inflammatory drugs (NSAIDs) (ibuprofen) and/or analgesic (acetaminophen, tramadol, codeine, hydrocodone) as needed.

Issues for Referral

  • Patients should be advised to see their dentist in the time frame outlined earlier.
  • Urgent oral surgical referral may be necessary owing to associated injuries.

Additional Therapies

  • Photographs and meticulous documentation are particularly important in cases of assault or motor vehicle accidents.
  • Aspiration: If an avulsed tooth is not accounted for, a chest film may be indicated. Swallowed teeth rarely require treatment and should not be retrieved unless there is concern for gastrointestinal (GI) obstruction.
  • Damage to primary teeth may result in damage to permanent teeth in 25–70% of injuries.

Surgery/Other Procedures

  • Dental splinting is used as an initial treatment for subluxed or avulsed teeth that are replaced.
  • Root canal might be considered as delayed treatment in cases of injury resulting in damage to the root.

Admission, Inpatient, and Nursing Considerations

Hospital admission or observation is rarely required. Criteria may include:

  • Multiple, complicated trauma.
  • Vital signs instability.
  • Abuse or violence suspected in injury history.
  • Concern for aspirated tooth.

Ongoing Care ⬆ ⬇

  • Tooth avulsion:
    • Endodontic treatment is usually required at 1 to 2 wk in teeth with a closed apex (after pulpal ischemic necrosis, before infection) to prevent periapical abscess formation and root resorption. Teeth with an open apex may reestablish blood supply; thermal sensitivity testing is performed every 3 to 4 wk, with root canal treatment delayed until clinical or radiographic signs of disease. Calcium hydroxide treatment also may be considered to prevent inflammatory root resorption.
    • Follow-up is essential at least every 6 mo for several years; potential root resorption must be monitored and alveolar bone optimized for prosthetic implantation considerations.
  • Tooth fractures:
    • Crown fractures: Definitive restoration should be performed as soon as possible, especially if the arch is crowded, because delay may allow encroachment of adjacent teeth and necessitate orthodontic treatment before restoration. Root canal treatment may be required in 1 to 2 wk in cases of pulp exposure.
    • Root fractures: Monthly clinical and radiographic evaluation should be performed during splinting and then every 3 to 6 mo for at least 2 yr; 20–45% have pulpal necrosis and require pulpotomy, root canal treatment, or prosthesis. Hard tissue union is more likely with pulpal vitality, younger patients, closer fragment opposition, and increased root diameter.
  • Tooth luxation:
    • Intrusion: Radiographic monitoring for pulp necrosis or root resorption should occur every 3 wk. Orthodontic extrusion is required if reeruption is not satisfactory after 3 mo. Root canal treatment is required in 2 to 3 wk for 95% of teeth with mature roots and 65% of teeth with immature roots owing to pulp necrosis.
    • Lateral luxation requires follow-up with radiographs every 3 mo for 2 yr to ensure that root resorption or loss of pulp vitality is not evident.

Diet

Soft or liquid diet may be necessary for a time to further protect teeth and allow for healing.

References ⬆ ⬇

American Academy of Pediatric Dentistry. Guideline of Management of Acute Dental Trauma. http://aapd.org/media/Policies_Guidelines/G_Trauma.pdf. Adopted 2011. Revised 2011. Accessed 2011.

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Clinical Pearls ⬆

  • If the pulp becomes devitalized, the tooth will rapidly change color, along with associated symptoms. If root canal treatment is needed, a slight and gradual darkening may be noticed.
  • Depending on the type of injury and promptness of care, chances are good for a successful recovery.