Dental fracture

Background

Dental Numbering

Classic dental numbering.

• Adult (permanent) teeth identified by numbers
  • From the midline to the back of the mouth on each side, there is a central incisor, a lateral incisor, a canine, two premolars (bicuspids), and three molars
• Children (non-permanent) teeth identified by letters
• Common landmarks:
  • 1: Right upper wisdom
  • 8 & 9: Upper incisors
  • 16: Left upper wisdom
  • 17: Left lower wisdom
  • 24 & 25: Lower incisors
  • 32: Right lower wisdom

Clinical Features

Ellis class III fracture on tooth 9

• Localized tooth fracture
• History of oral trauma

Differential Diagnosis

Dentoalveolar Injuries

• Dental fracture
• Dental subluxation
• Dental avulsion
• Bleeding dental socket

Odontogenic Infections

• Acute alveolar osteitis (dry socket)
• Acute necrotizing ulcerative gingivitis (trench mouth)
• Dental abscess
  • Periapical abscess
  • Periodontal abscess
• Ludwig's angina
• Pulpitis (dental caries)
• Pericoronitis
• Peritonsillar abscess (PTA)
• Retropharyngeal abscess
• Vincent's angina - tonsillitis and pharyngitis

Other

• Scurvy
• Gingival hyperplasia
  • Phenytoin
  • Cyclosporine
  • Nifedipine, Amlodipine
  • Leukemia

Evaluation

• Clinical diagnosis
• Consider obtaining panorex to evaluate for associated bone fracture

Management

Diagram of the tooth displaying the enamel, dentin, and pulp

Enamel (Ellis Class I)

• Routine follow up only; nothing to do
• May consider filing down sharp edges with an emery board for comfort

Enamel + dentin (yellowish) (Ellis Class II)

• Patients experience sensitivity to hot/cold stimuli and air passing over tooth during breathing
• Cover exposed dentin with calcium hydroxide to decrease pulpal contamination
  • Greater than 2 mm of dentin offers more protection to pulp, can be covered with dental cement only. If dentin is less than 0.5 mm then cover with calcium hydroxide and dental cement over it.
    • Dermabond can be used if no other materials are available
• Next day follow up

Enamel + dentin + pulp (reddish) (Ellis Class III)

• On wiping fractured surface with gauze, blood is easily seen
• Immediate dental referral (dental emergency) - should be seen within 24 hours
• If not able to be seen immediately, cover exposed pulp with calcium hydroxide and dental cement.
• Discharge with penicillin or clindamycin as they have pulpitis by definition

Crown Root/Root fracture (not a common dental injury)

• Treatment for both is reduction, stabilization if fracture segment is stable and outpatient follow with dentist in 24-48 hours.
  • If fracture segment unstable/very mobile may need to extract to prevent aspiration.
• Crown Root fracture does not always involve pulp vs root fractures almost always involves pulp.

Disposition

• Discharge with dental follow-up

See Also

• Dental problems
• In-Training Exam Review

External Links

• Core EM Dental Trauma Page