Dental trauma refers to trauma (injury) to the teeth and/or periodontium (gums, periodontal ligament, alveolar bone), and nearby soft tissues such as the lips, tongue, etc. The study of dental trauma is called dental traumatology.Textbook and Color Atlas of Traumatic Injuries to the Teeth, Fourth Edition, edited by Andreason J, Andreasen F, and Andersson L, Wiley-Blackwell, Oxford, UK, 2007
Types
Dental injuries Dental injuries include: Enamel infraction Enamel fracture Enamel-dentine fracture Enamel-dentine fracture involving pulp exposure Root fracture of tooth
Periodontal injuries Concussion (bruising) Subluxation of the tooth (tooth knocked loose) Luxation of the tooth (displaced) Extrusive Intrusive Lateral Avulsion of the tooth (tooth knocked out)
Injuries to supporting bone
This injury involves the alveolar bone and may extend beyond the alveolus. There are five different types of alveolar fractures: Communicated fracture of the socket wall Fracture of the socket wall Dentoalveolar fracture (segmental) Fracture of the maxilla: Le Fort fracture, zygomatic fracture, orbital blowout Fracture of the mandible Trauma injuries involving the alveolus can be complicated as it does not happen in isolation, very often presents along with other types of tooth tissue injuries.
Signs of dentoalveolar fracture: Change to occlusion Multiple teeth moving together as a segment and are normally displaced Bruising of attached gingivae Gingivae across the fracture line often lacerated Investigation: Require more than one radiographic view to identify the fracture line.
Treatment: Reposition displaced teeth under local anaesthetic and stabilise the mobile segment with a splint for 4 weeks, suture any soft tissue lacerations.
Soft tissue laceration
Soft tissues injuries are presented commonly in association with dental trauma. Areas normally affected are lips, buccal mucosa, gingivae, frenum and tongue. The most common injuries are lips and gingivae. For lips, important to rule out presence of foreign objects in wounds and lacerations through careful examination. A radiograph can be taken to identify any potential foreign objects.
Gingivae lacerations that are small normally heals spontaneously and do not require any intervention. However, this can be one of the clinical presentation of an alveolar fracture. Gingivae bleeding especially around the margins may suggest injury to the periodontal ligament of the tooth.
The facial nerve and parotid duct should be examined for any potential damage when the buccal mucosa is involved.
Deep tissue wounds should be repaired in layers with sutures that are resorbable.
Primary teeth Trauma to primary teeth occurs most commonly at the age of two to three years, during the development of motor coordination. When primary teeth are injured, the resulting treatment prioritises the safety of the adult tooth, and should avoid any risk of damaging the permanent successors. This is because the root apex of an injured primary tooth lies near the tooth germ of the adult tooth.
Therefore, a displaced primary tooth will be removed if it is found to have encroached upon the developing adult tooth germ. If this happens, parents should be advised of possible complications such as enamel hypoplasia, hypocalcification, crown/root dilaceration, or disruptions in tooth eruption sequence.
Potential sequelae can involve pulpal necrosis, pulp obliteration and root resorption. Necrosis is the most common complication and an assessment is generally made based on the colour supplemented with radiograph monitoring. A change in colour may mean that the tooth is still vital but if this persists it is likely to be non-vital.
Permanent teeth
Dental injuries Dental injuryClinical findingsRadiographic findingsTreatmentFollow-up1) Enamel infractionA crack in enamel with no loss of tooth structure
Tooth is not tenderNo abnormalitiesGenerally no treatment needed
Discolouration of prominent cracks can be prevented by etching and sealing with resinNo follow-up required2) Enamel fractureFracture involving enamel only
Tooth not tender with normal mobility and pulpal responseLoss of enamel
May need lip or cheek x-ray to locate tooth fragments or other materialsIf available, tooth fragment can be bonded back onto the tooth
If not available, tooth can be restored with composite resin6–8 weeks: clinical and radiographic examination
1 year: clinical and radiographic examination3) Enamel-dentine fractureFracture involving both enamel and dentine without pulp exposure
Tooth not tender with normal mobility and pulpal responseLoss of enamel and dentine
May need lip or cheek x-ray to locate tooth fragments or other materialsIf available, tooth fragment can be bonded back onto the tooth
If not available, tooth can be restored with composite resin
If dentine is within 0.5mm of the pulp, calcium hydroxide placed and covered with glass ionomer6–8 weeks: clinical and radiographic examination
1 year: clinical and radiographic examination4) Enamel-dentine-pulp fractureFracture involving enamel and dentine with pulp exposure
Tooth not tender with normal mobility
Exposed pulp will be sensitive to stimuliLoss of enamel and dentine
May need lip or cheek x-ray to locate tooth fragments or other materialsIn developing teeth, preserve pulp vitality by pulp capping or partial pulpotomy using calcium hydroxide
In mature teeth, root canal treatment is usually performed6–8 weeks: clinical and radiographic examination
1 year: clinical and radiographic examination5) Crown-root fracture without pulp involvementFracture involving enamel, dentine and cementum without pulp exposure
Fracture extends below the gum margin
Tender tooth with mobile crown fragmentFracture line extending down the root may not be visibleEmergency:
aim is to stabilise the loose fragment by splinting it to adjacent teeth
Non-emergency:
removal of loose fragment (following gingivectomy, surgery or via orthodontics), root canal treatment and restoration with post-retained crown
In extreme cases (such as a vertical fracture), tooth may need to be extracted6–8 weeks: clinical and radiographic examination
1 year: clinical and radiographic examination6) Crown-root fracture with pulp InvolvementFracture involving enamel, dentine and cementum with pulp exposure
Tender tooth with mobile crown fragmentFracture line extending down the root may not be visibleEmergency:
aim is to stabilise the loose fragment by splinting it to adjacent teeth
In developing teeth, preserve pulp vitality by pulp capping or partial pulpotomy using calcium hydroxide
In mature teeth, root canal treatment is usually performed
Non-emergency:
removal of loose fragment (following gingivectomy, surgery or via orthodontics), root canal treatment and restoration with post-retained crown
In extreme cases (such as a vertical fracture), tooth may need to be extracted6–8 weeks: clinical and radiographic examination
1 year: clinical and radiographic examination7) Root fractureMobile or displaced crown segment
Tender tooth that may be bleeding from the gum
Tooth may be discoloured (red or grey)Fracture line involving the root will be seen as well as the directionIf displaced, reposition tooth and check the position with an x-ray
Flexible splint used to stabilise tooth for at least 4 weeks and then reassess tooth stability
Monitor healing for at least 1 year to assess the status of the pulp
Root canal treatment will be needed if pulp necrosis develops (this occurs in ~20% of root fractures)4 weeks: splint removal, clinical and radiographic examination
6–8 weeks: clinical and radiographic examination
4 months: splint removal in cervical third fractures, clinical and radiographic examination
6 months: clinical and radiographic examination
1 year: clinical and radiographic examination
5 years: clinical and radiographic examination
Periodontal injuries Periodontal injuryClinical findingsRadiographic findingsTreatmentFollow-up1) ConcussionTender tooth with no displacement and normal mobilityNo abnormalitiesNo treatment required4 weeks: clinical and radiographic examination
6–8 weeks: clinical and radiographic examination
1 year: clinical and radiographic examination2) SubluxationTender tooth with no displacement but increased mobility
May be bleeding from the gumNo abnormalitiesUsually no treatment required
Can use a flexible splint to stabilise the tooth for up to 2 weeks2 weeks: splint removal, clinical and radiographic examination
4 weeks: clinical and radiographic examination
6–8 weeks: clinical and radiographic examination
6 months: clinical and radiographic examination
1 year: clinical and radiographic examination3) ExtrusionTooth looks longer and is very mobilePeriodontal ligament space is increased apicallyTooth is repositioned gently in the socket
Tooth stabilised with a flexible splint for 2 weeks
Signs and symptoms of pulp necrosis indicates the need for root canal treatment to prevent root resorption2 weeks: splint removal, clinical and radiographic examination
4 weeks: clinical and radiographic examination
6–8 weeks: clinical and radiographic examination
6 months: clinical and radiographic examination
1 year: clinical and radiographic examination yearly
5 years: clinical and radiographic examination4) Lateral luxationTooth is displaced, most commonly towards the roof of the mouth/tongue or the lip
Tooth will be immobile
Tapping on the tooth will give a high-pitched, metallic (ankylotic) sound
Alveolar process fracturePeriodontal ligament space is widenedReposition the tooth using fingers or forceps to remove its "bony lock" and gently reposition it in the socket
Tooth stabilised with a flexible splint for 4 weeks
Signs and symptoms of pulp necrosis indicates the need for root canal treatment to prevent root resorption2 weeks: clinical and radiographic examination
4 weeks: splint removal, clinical and radiographic examination
6–8 weeks: clinical and radiographic examination
6 months: clinical and radiographic examination
1 year: clinical and radiographic examination
Yearly for 5 years: clinical and radiographic examination5) IntrusionTooth is displaced into the alveolar bone
Tapping on the tooth will give a high-pitched, metallic (ankylotic) soundAbsence of periodontal ligament space from part or entirety of the root
Cemento-enamel junction appears more apically for the traumatised toothIf incomplete root formation:
allow time for tooth to naturally erupt but if no movement after a few weeks then start orthodontic repositioning
intruded >7mm:
surgical or orthodontic repositioning
stabilise with flexible splint for 4 weeks after repositioning
If complete root formation:
intruded <3mm: allow time for natural eruption but if no movement after 2–4 weeks then reposition surgically or orthodontically
intruded 3-7mm:
surgical or orthodontic repositioning
intruded >7mm:
surgical repositioning
likelihood of pulpal necrosis in these teeth so root canal therapy with temporary calcium hydroxide filling in first instance and start root canal treatment 2–3 weeks after repositioning
stabilise with flexible splint for 4 weeks after repositioning2 weeks: clinical and radiographic examination
4 weeks: splint removal, clinical and radiographic examination
6–8 weeks: clinical and radiographic examination
6 months: clinical and radiographic examination
1 year: clinical and radiographic examination
Yearly for 5 years: clinical and radiographic examination6) AvulsionTooth completely removed from socketRadiograph required to ensure that missing tooth is not intrudedFor information on first aid procedures for avulsed teeth, see "Management" section of this page