Dental trauma

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Dental trauma
Fracturedtooth.jpg
A broken upper front tooth. The layers of tissue that make up the tooth are clearly visible, with the pink pulp standing out against the paler dentine and tooth enamel.
Specialty Oral and maxillofacial surgery   OOjs UI icon edit-ltr-progressive.svg

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. [1]

Contents

Types

Root fracture Dental x-rays 2010 pd 009.JPG
Root fracture
Simple mandible fracture Simple mandible fracture.jpg
Simple mandible fracture

Dental injuries

Dental injuries include: [2] [3]

Periodontal injuries

Injuries to supporting bone

3D CT of mandible fracture. 3D CT mandible fracture.jpg
3D CT of mandible fracture.

This injury involves the alveolar bone and may extend beyond the alveolus. [5] [6] There are five different types of alveolar fractures:

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:

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

Facial nerve branches. Facial nerve should be examined for any potential damage when buccal mucosa is involved. Head facial nerve branches TZBMC.jpg
Facial nerve branches. Facial nerve should be examined for any potential damage when buccal mucosa is involved.

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. [5] [6]

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. [7] When primary teeth are injured, the resulting treatment prioritises the safety of the adult tooth, [7] and should avoid any risk of damaging the permanent successors. [8] This is because the root apex of an injured primary tooth lies near the tooth germ of the adult tooth. [8]

Therefore, a displaced primary tooth will be removed if it is found to have encroached upon the developing adult tooth germ. [8] If this happens, parents should be advised of possible complications such as enamel hypoplasia, hypocalcification, crown/root dilaceration, or disruptions in tooth eruption sequence. [9]

Potential sequelae can involve pulpal necrosis, pulp obliteration and root resorption. [10] 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 injury [2] Clinical findingsRadiographic findingsTreatmentFollow-up
1) Enamel infractionA crack in enamel with no loss of tooth structure

Tooth is not tender

No abnormalities


Generally no treatment needed

Discolouration of prominent cracks can be prevented by etching and sealing with resin

No follow-up required
2) Enamel fractureFracture involving enamel only

Tooth not tender with normal mobility and pulpal response

Loss of enamel

May need lip or cheek  x-ray to locate tooth fragments or other materials

If available, tooth fragment can be bonded back onto the tooth

If not available, tooth can be restored with composite resin

6–8 weeks: clinical and radiographic examination

1 year: clinical and radiographic examination

3) Enamel-dentine fractureFracture involving both enamel and dentine without pulp exposure

Tooth not tender with normal mobility and pulpal response

Loss of enamel and dentine

May need lip or cheek  x-ray to locate tooth fragments or other materials

If 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 ionomer

6–8 weeks: clinical and radiographic examination

1 year: clinical and radiographic examination

4) Enamel-dentine-pulp fractureFracture involving enamel and dentine with pulp exposure

Tooth not tender with normal mobility

Exposed pulp will be sensitive to stimuli

Loss of enamel and dentine

May need lip or cheek  x-ray to locate tooth fragments or other materials

In developing teeth, preserve pulp vitality by pulp capping or partial pulpotomy using calcium hydroxide

In mature teeth, root canal treatment is usually performed

6–8 weeks: clinical and radiographic examination

1 year: clinical and radiographic examination

5) 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 fragment

Fracture 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 extracted

6–8 weeks: clinical and radiographic examination

1 year: clinical and radiographic examination

6) Crown-root fracture with pulp InvolvementFracture involving enamel, dentine and cementum with pulp exposure

Tender tooth with mobile crown fragment

Fracture 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 extracted

6–8 weeks: clinical and radiographic examination

1 year: clinical and radiographic examination

7) 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 injury [2] Clinical findingsRadiographic findingsTreatmentFollow-up
1) 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 examination

2) SubluxationTender tooth with no displacement but increased mobility

May be bleeding from the gum

No abnormalitiesUsually no treatment required

Can use a flexible splint to stabilise the tooth for up to 2 weeks

2 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

3) 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 resorption

2 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 examination

4) 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 fracture

Periodontal 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 resorption

2 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 examination

5) IntrusionTooth is displaced into the alveolar bone

Tapping on the tooth will give a high-pitched, metallic (ankylotic) sound

Absence of periodontal ligament space from part or entirety of the root

Cemento-enamel junction appears more apically for the traumatised tooth

If  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 repositioning

2 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 examination

6) 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

Treatment will depend on whether the tooth has an open or closed apex and how long the tooth has been out of the mouth prior to dental clinic arrival (see Dental Trauma Guide for full treatment details)

4 weeks: splint removal, clinical and radiographic examination

3 months: clinical and radiographic examination

6 months: clinical and radiographic examination

1 year: clinical and radiographic examination yearly

Risk factors

Prevention

Prevention in general is relatively difficult as it is nearly impossible to stop accidents from happening, especially in children who are quite active. Regular use of a gum shield during sports and other high-risk activities (such as military training) is the most effective prevention for dental trauma. [26] [27] They are mainly being fitted on the upper teeth as it has higher risk of dental trauma compared to the lower teeth. Gum shields ideally have to be comfortable for users, retentive, odourless, tasteless and the materials should not be causing any harm to the body. [28] However, studies in various high-risk populations for dental injuries have repeatedly reported low compliance of individuals for the regular using of mouthguard during activities. [29] Moreover, even with regular use, effectiveness of prevention of dental injuries is not complete, and injuries can still occur even when mouthguards are used as users are not always aware of the best makes or size, which inevitably result in a poor fit. [18]

Types of gum shield: [28] [30]

One of the most important measures is to impart knowledge and awareness about dental injury to those who are involved in sports environments like boxing and in school children in which they are at high risk of suffering dental trauma through an extensive educational campaign including lectures, leaflets, posters which should be presented in an easy understandable way. [32]

Management

The management depends on the type of injury involved and whether it is a baby or an adult tooth. If teeth are completely knocked out baby front teeth should not be replaced. The area should be cleaned gently and the child brought to see a dentist. Adult front teeth (which usually erupt at around six years of age) can be replaced immediately if clean. If a tooth is avulsed, make sure it is a permanent tooth (primary teeth should not be replanted, and instead the injury site should be cleaned to allow the adult tooth to begin to erupt).

When the injured teeth are painful while functioning due to damage to the periodontal ligaments (e.g., dental subluxation), a temporary splinting of the injured teeth may relieve the pain and enhance eating ability. [34] Splinting should only be used in certain situations. Splinting in lateral and extrusive luxation had a poorer prognosis than in root fractures. [35] An avulsed permanent tooth should be gently rinsed under tap water and immediately re-planted in its original socket within the alveolar bone and later temporarily splinted by a dentist. [4] Failure to re-plant the avulsed tooth within the first 40 minutes after the injury may result in very poor prognosis for the tooth. [4] Management of injured primary teeth differs from management of permanent teeth; an avulsed primary tooth should not be re-planted (to avoid damage to the permanent dental crypt). [8] This is due to the close proximity of the apex of a primary tooth to the permanent tooth underneath. The permanent dentition can suffer from tooth malformation, impacted teeth and eruption disturbances due to trauma to primary teeth. The priority should always be reducing potential damage to the underlying permanent dentition. [36]

For other injuries, it is important to keep the area clean by using a soft toothbrush and antiseptic mouthwash such as chlorhexidine gluconate. Soft foods and avoidance of contact sports is also recommended in the short term. Dental care should be sought as quickly as possible.

Splinting

A tooth that has experienced trauma may become loose due to the periodontal ligament becoming damaged or fracture to the root of the tooth. Splinting ensures that the tooth is held in the correct position within the socket, ensuring that no further trauma occurs to enable healing. [37] A splint can either be flexible or rigid. Flexible splints do not completely immobilise the traumatised tooth and still allow for functional movement. Contrastingly, rigid splints completely immobilise the traumatised tooth. [38] The International Association of Dental Traumatology (IADT) guidelines recommend the use of flexible, non-rigid splints for a short duration by stating that both periodontal and pulpal healing is encouraged if the traumatised tooth is allowed slight movement and if the splinting time is not too long. [39] [40]

Complications

Not all sequelae of trauma are immediate and many of them can occur months or years after the initial incident thus required prolonged follow-up. Common complications are pulpal necrosis, pulpal obliteration, root resorption and damage to the successors teeth in primary teeth dental trauma. The most common complication was pulp necrosis (34.2%). 50% of the tooth that have trauma related to avulsion experienced ankylotic root resorption after a median TIC (time elapsed between the traumatic event and the diagnosis of complications) of 1.18 years. Teeth that have multiple traumatic events also showed to have higher chance of pulp necrosis (61.9%) compared to teeth that experienced a single traumatic injury (25.3%) in the studies (1) [41]

Image shows a grey discoloured upper right front incisor, usually indicating that the tooth is non-vital Frontzahntrauma Zahn 11 Behandlungsschritte 20091215 009.JPG
Image shows a grey discoloured upper right front incisor, usually indicating that the tooth is non-vital

Pulpal necrosis

Pulp necrosis usually occurs either as ischaemic necrosis (infarction) caused by disruption to the blood supply at the apical foramen or as an infection-related liquefactive necrosis following dental trauma (2). Signs of pulpal necrosis include [42]

Treatment options will be extraction for the primary tooth. For the permanent tooth, endodontic treatment can be considered.

Radiographic signs of periapical inflammation is usually evident in a tooth with necrotic pulp Periapical radiolucency.jpg
Radiographic signs of periapical inflammation is usually evident in a tooth with necrotic pulp

Root resorption

Root resorption following traumatic dental injuries, whether located along the root surface or within the root canal appears to be a sequel to wound healing events, where a significant amount of the PDL or pulp has been lost due to the effect of acute trauma. [43]

Pulpal obliteration

4–24% of traumatized teeth will have some degrees of pulpal obliteration that is characterized by the loss of pulpal space radiographically and yellow discolouration of the clinical crown. No treatment is needed if it is asymptomatic. Treatment options will be extraction for symptomatic primary tooth. For symptomatic permanent tooth, root canal treatment is often challenging because the pulp chamber is filled with calcified material and the drop-off sensation of entering a pulp chamber will not occur. [44]

Damage to the successor teeth

Dental trauma to the primary teeth might cause damage to the permanent teeth. Damage to the permanent teeth especially during development stage might have following consequences: [45]

Epidemiology

Dental trauma is most common in younger people, accounting for 17% of injuries to the body in those aged 0–6 years compared to an average of 5% across all ages. [46] It is more frequently observed in males compared to females. [47] Traumatic dental injuries are more common in permanent teeth compared to deciduous teeth and usually involve the front teeth of the upper jaw. [48]

"The oral region comprises 1% of the total body area, yet it accounts for 5% of all bodily injuries. In preschool children, oral injuries make up as much as 17% of all bodily injuries. The incidence of traumatic dental injuries is 1–3%, and the prevalence is steady at 20–30%." [49]

Almost 30% of the children in pre-school have mostly experienced trauma to primary teeth. Dental injuries involving the permanent teeth happen to almost 25% of children in school and 30% of adults. The incident varies in different countries as well as within the country itself. Dental traumatic accidents depends on one's activity status and also the surrounding environment factor but these are the main predisposing risk factor compared to a person's age and gender. [50]

Trauma is the most common cause of loss of permanent incisors in childhood. Dental trauma often leads to complications such as pulpal necrosis, and it is nearly impossible to predict the long-term prognosis of the injured tooth; the injury often results in long-term restorative problems. [51] [52] [53]

See also

Related Research Articles

A subluxation is an incomplete or partial dislocation of a joint or organ. According to the World Health Organization, a subluxation is a "significant structural displacement" and is therefore visible on static imaging studies, such as X-rays. Unlike real subluxations, the pseudoscientific concept of a chiropractic "vertebral subluxation" may or may not be visible on x-rays.

<span class="mw-page-title-main">Endodontics</span> Field of dentistry

Endodontics is the dental specialty concerned with the study and treatment of the dental pulp.

<span class="mw-page-title-main">Mouthguard</span> Protective device for the teeth and gums to avoid injury to them

A mouthguard is a protective device for the mouth that covers the teeth and gums to prevent and reduce injury to the teeth, arches, lips and gums. An effective mouthguard is like a crash helmet for teeth and jaws. It also prevents the jaws coming together fully, thereby reducing the risk of jaw joint injuries and concussion. A mouthguard is most often used to prevent injury in contact sports, as a treatment for bruxism or TMD, or as part of certain dental procedures, such as tooth bleaching or sleep apnea treatment. Depending on the application, it may also be called a mouth protector, mouth piece, gumshield, gumguard, nightguard, occlusal splint, bite splint, or bite plane. The dentists who specialise in sports dentistry fabricate mouthguards.

<span class="mw-page-title-main">Periodontal fiber</span> Group of specialized connective tissue fibers

The periodontal ligament, commonly abbreviated as the PDL, are a group of specialized connective tissue fibers that essentially attach a tooth to the alveolar bone within which they sit. It inserts into root cementum on one side and onto alveolar bone on the other.

A dental emergency is an issue involving the teeth and supporting tissues that are of high importance to be treated by the relevant professional. Dental emergencies do not always involve pain, although this is a common signal that something needs to be looked at. Pain can originate from the tooth, surrounding tissues or can have the sensation of originating in the teeth but be caused by an independent source. Depending on the type of pain experienced an experienced clinician can determine the likely cause and can treat the issue as each tissue type gives different messages in a dental emergency.

Dilaceration is a developmental disturbance in shape of teeth. It refers to an angulation, or a sharp bend or curve, in the root or crown of a formed tooth. This disturbance is more likely to affect the maxillary incisors and occurs in permanent dentition. Although this may seem more of an aesthetics issue, an impacted maxillary incisor will cause issues related to occlusion, phonetics, mastication, and psychology on young patients.

Dens invaginatus (DI), also known as tooth within a tooth, is a rare dental malformation and a developmental anomaly where there is an infolding of enamel into dentin. The prevalence of this condition is 0.3 - 10%, affecting males more frequently than females. The condition presents in two forms, coronal involving tooth crown and radicular involving tooth root, with the former being more common.

<span class="mw-page-title-main">Tooth resorption</span> Medical condition

Resorption of the root of the tooth, or root resorption, is the progressive loss of dentin and cementum by the action of odontoclasts. Root resorption is a normal physiological process that occurs in the exfoliation of the primary dentition. However, pathological root resorption occurs in the permanent or secondary dentition and sometimes in the primary dentition.

Pulp necrosis is a clinical diagnostic category indicating the death of cells and tissues in the pulp chamber of a tooth with or without bacterial invasion. It is often the result of many cases of dental trauma, caries and irreversible pulpitis.

Dental subluxation is a traumatic injury to the periodontal tissue in which the tooth has increased mobility but has not been displaced from its tooth socket.

<span class="mw-page-title-main">Dental avulsion</span> Medical condition

Dental avulsion is the complete displacement of a tooth from its socket in alveolar bone owing to trauma, such as can be caused by a fall, road traffic accident, assault, sports, or occupational injury. Typically, a tooth is held in place by the periodontal ligament, which becomes torn when the tooth is knocked out.

<span class="mw-page-title-main">Regenerative endodontics</span> Dental specialty

Regenerative endodontic procedures is defined as biologically based procedures designed to replace damaged structures such as dentin, root structures, and cells of the pulp-dentin complex. This new treatment modality aims to promote normal function of the pulp. It has become an alternative to heal apical periodontitis. Regenerative endodontics is the extension of root canal therapy. Conventional root canal therapy cleans and fills the pulp chamber with biologically inert material after destruction of the pulp due to dental caries, congenital deformity or trauma. Regenerative endodontics instead seeks to replace live tissue in the pulp chamber. The ultimate goal of regenerative endodontic procedures is to regenerate the tissues and the normal function of the dentin-pulp complex.

<span class="mw-page-title-main">Tooth mobility</span> Medical condition

Tooth mobility is the horizontal or vertical displacement of a tooth beyond its normal physiological boundaries around the gingival (gum) area, i.e. the medical term for a loose tooth.

Tooth ankylosis refers to a fusion between a tooth and underlying bony support tissues. In some species, this is a normal process that occurs during the formation or maintenance of the dentition. By contrast, in humans tooth ankylosis is pathological, whereby a fusion between alveolar bone and the cementum of a tooth occurs.

Pulp canal obliteration is a condition which can occur in teeth where hard tissue is deposited along the internal walls of the root canal and fills most of the pulp system leaving it narrowed and restricted.

Root fracture of the tooth is a dentine cementum fracture involving the pulp.

<span class="mw-page-title-main">Enamel fracture</span>

An enamel fracture is when the outermost layer of the tooth is cracked, without damaging the inner layers including the dentine or pulp. This can happen from trauma such as a fall where the teeth are impacted by a hard object causing a chip to occur.

Dental intrusion is an apical displacement of the tooth into the alveolar bone. This injury is accompanied by extensive damage to periodontal ligament, cementum, disruption of the neurovascular supply to the pulp, and communication or fracture of the alveolar socket.

Tooth replantation is a form of restorative dentistry in which an avulsed or luxated tooth is reinserted and secured into its socket through a combination of dental procedures. The purposes of tooth replantation is to resolve tooth loss and preserve the natural landscape of the teeth. Whilst variations of the procedure exist including, Allotransplantation, where a tooth is transferred from one individual to another individual of the same species. It is a largely defunct practice due to the improvements made within the field of dentistry and due to the risks and complications involved including the transmission of diseases such as syphilis, histocompatibility, as well as the low success rate of the procedure, has resulted in its practice being largely abandoned. Autotransplantation, otherwise known as intentional replantation in dentistry, is defined as the surgical movement of a tooth from one site on an individual to another location in the same individual. While rare, modern dentistry uses replantation as a form of proactive care to prevent future complications and protect the natural dentition in cases where root canal and surgical endodontic treatments are problematic. In the modern context, tooth replantation most often refers to reattachment of an avulsed or luxated permanent tooth into its original socket.

Apexification is a method of dental treatment to induce a calcific barrier in a root with incomplete formation or open apex of a tooth with necrotic pulp. Pulpal involvement usually occurs as a consequence of trauma or caries involvement of young or immature permanent teeth. As a sequelae of untreated pulp involvement, loss of pulp vitality or necrotic pulp took place for the involved teeth.

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