The ability to care for dental fractures in the emergency department or clinic setting is a skill required during the career of every clinic-based or emergency clinician. Although the procedures performed in these settings are largely temporizing measures, appropriate care in the acute setting is critical to avoid adverse outcomes.
In general, acute dental trauma is inadequately treated. In some patient populations, less than half of patients who need treatment receive it; of those who do receive treatment, over half receive inadequate treatment. Many patients with acute dental trauma require follow-up with a dentist or an oral surgeon within 24 hours; however, proper intervention should not be delayed. These procedures can improve cosmetic results, prevent tooth loss, and decrease the risk of infection following dental trauma.
Dental fractures are divided into categories based on the Ellis classification system.
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Ellis I: This level of injury includes crown fractures that extend through the enamel only. These teeth are usually nontender and without visible color change but have rough edges.
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Ellis II: Injuries in this category are fractures that involve the enamel as well as the dentin layer. These teeth are typically tender to the touch and to air exposure. A yellow layer of dentin may be visible on examination.
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Ellis III: These fractures involve the enamel, dentin, and pulp layers. These teeth are tender (similar to those in the Ellis II category) and have a visible area of pink, red, or even blood at the center of the tooth
The pulp of the tooth is very prone to infection. Infection of the pulp is termed pulpitis and can lead to potential tooth loss. The dentin of the tooth is very porous and is an ineffective seal over the pulp. In Ellis II and III fractures in which the dentin or pulp is exposed, the clinician caring for the tooth fracture in the acute setting must create a seal over these injured teeth to protect the pulp from intraoral flora and potential infection.
Other dental injuries that may or may not be associated with a dental fracture include the following:
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Dental avulsion – Complete extraction of the tooth (crown and root)
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Dental subluxation – The loosening of a tooth following trauma
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Dental intrusion – The forcing of an erupted tooth below the gingiva
In these situations, the goal is to return the tooth to its correct anatomical position as quickly and securely as possible, without causing further trauma to the tooth, gingiva, or alveolar bone.
An estimated 50% of children sustain a dental injury before age 18 years; most children are aged 7-14 years at the time of injury. Permanent teeth injuries make up 90% of the dental injuries to children; the most commonly injured teeth are the central incisors.
Dental trauma has a male predominance of almost 2:1. This predominance is evident in permanent dentition but not in the setting of primary dentition. Dental fractures are most common in children, youth, and young adults. Dental fracture is often a result of falls, play, altercations, sports, and motor vehicle accidents.[1, 2]
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