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Dental Trauma

What is Dental trauma?

Dental trauma is an injury to the mouth and teeth including oral structures such as lips, tongue and cheeks. The teeth may be broken, displaced or even knocked out from the socket. Tooth injury may lead to pulp necrosis. Dental trauma is usually very painful when it occurs.

Types

Dental trauma is classified into the following types:

  • Enamel fractures-involving enamel only
  • Enamel-dentin fractures- involving enamel as well as dentin
  • Fractures involving pulpal exposure
  • Crown-root fracture (uncomplicated): a fracture involving enamel, dentin and cementum but not the pulp
  • Crown-root fracture (complicated): a fracture involving enamel, dentin, cementum and also pulp
  • Root Fracture: a fracture involving cementum, dentin and pulp
  • Alveolar fracture: a fracture of the alveolar process, the bony portion of the jaw that supports the roots of teeth, that may or may not involve the teeth socket
  • Concussion: The supporting structures of the tooth are injured but the tooth is not loosened or displaced from its socket.
  • Subluxation: The supporting structures of the tooth are injured and the tooth is loosened but not displaced from its socket and there is bleeding from the gingival sulcus.
  • Lateral luxation: The tooth is displaced in a mesial, distal, lingual or labial direction and is accompanied by alveolar fracture.
  • Intrusion: The tooth is pushed into the bone.
  • Extrusion: The tooth is slightly displaced out of its socket.
  • Avulsion: The tooth is completely knocked out of its socket.

Causes of Dental Trauma

The following are the causes of dental trauma:

  • Falls and fights
  • Child physical abuse
  • Sports-related injuries
  • Chewing onto hard food substances
  • Automobile accidents

Symptoms

When you have a tooth injury you may experience the following signs and symptoms:

  • Discoloration of the injured tooth
  • Pain, redness and swelling in the area of injury
  • If a tooth is broken, the socket appears bloody and swollen
  • If the jawbone is broken, then there may be malocclusion where the upper and lower teeth will not fit together properly or you may not be able to move your jaw.

Risk Factors:

You may be more prone to suffer a tooth injury if you have:

  • Protruding upper front teeth
  • Inadequate lip closure
  • Badly decayed teeth
  • Multiple cavities
  • If you do not wear a properly fitting mouth guard while playing contact sports
  • Tooth injury is more common in boys than girls

Diagnosis:

Your dentist will gather the following information to diagnose the type of dental trauma.

Medical and dental history:

Information about the patient’s general health condition is collected. Your dentist will ask whether you are suffering from any heart ailments, bleeding disorders, seizures or allergies and when were you last vaccinated against tetanus.

  • History of the dental injury: The dentist will ask you about the injury, the cause, and where and when the injury took place.
  • Clinical examination of the head and neck: Your dentist will examine you for any extra-oral wounds. The jaw movements are also checked for any deviation.
  • Oral examination of soft and hard tissues: Your dentist will check for fractured, displaced and avulsed teeth. Also, you will be assessed for any bony fracture or alveolar process displacement along with the tooth.
  • Radiographic examination: Your dentist will obtain X-rays to check for the extent of damage to broken teeth.

Treatment

Treatment will depend on the type of trauma sustained. Following is a list of trauma types and the associated treatments.

Enamel Fracture

  • If the broken tooth piece is available it will be bonded to the tooth.
  • If the tooth portion is lost then the sharp edge is smoothed and restored with composite resin.

Enamel-dentin fracture

  • If the broken tooth piece is available, it will be bonded to the tooth.
  • If it is not available, provisional restoration such as glass ionomer is placed or else a permanent restoration is done using bonding agent and composite resin.

Enamel-dentin-pulp fracture

There are two options:

  • Pulp capping

    Local anesthetic is given.

    The fractured tooth is isolated with a rubber dam.

    The area is cleaned with air-water spray and saline irrigation and disinfected with sodium hypochlorite.

    The pulp-capping material-calcium hydroxide or mineral trioxide aggregate is applied.

    The exposed dentinal tubules are sealed with glass ionomer cement.

    Finally, the tooth is restored with composite resin.

  • Pulpotomy

    After the local anesthetic is given, the tooth is isolated, cleaned and disinfected.

    Pulpotomy is performed to a depth of 2mm using round diamond bur and water spray.

    Bleeding is controlled by placing saline-moistened cotton pellet upon the pulp.

    Calcium hydroxide or mineral-trioxide aggregate is placed.

    The dentinal tubules are sealed and the tooth is restored with composite resin.

Crown-root uncomplicated fracture

Treatment involves fragment removal as follows:

  • The tooth fragment is removed with forceps.
  • The area is cleaned and disinfected.
  • The gingival lacerations are sutured if present.
  • The gingiva is allowed to reattach to the exposed dentin.
  • The dentinal tubules are sealed and the tooth is restored with composite resin.

Complicated crown fracture

In the acute phase, the crown fragment is temporarily bonded to the tooth with a composite or resin and then the following treatment guidelines are followed:

  • Fragment Removal and Gingivectomy: The steps are same as fragment removal procedure as explained previously.
  • Orthodontic extrusion of apical fragment
  • Local anesthetic is given.
  • The fragment is removed with forceps.
  • The area is cleaned and gingival lacerations are sutured.
  • Pulpotomy procedure is done.
  • Steel arch wire is adapted to the front teeth.
  • The teeth sites are acid-etched to receive arch wire and brackets.
  • The arch wire and brackets are bonded to teeth with resin.
  • Elastic traction is applied.
  • Follow-up: The splint is removed after 4 weeks. Tooth restoration, root canal filling and a post-retained crown is done after labial gingivectomy.

Root fracture

  • Usually, local anesthetic is not indicated. The area is cleaned with water spray.
  • The tooth is repositioned with digital finger pressure.
  • The gingival lacerations are sutured.
  • Composite or resin splint is applied for about 4 weeks.

Alveolar fracture:

  • Local anesthetic is given.
  • The displaced alveolar segment is repositioned using finger pressure.
  • The area is cleaned and gingival lacerations are sutured.
  • Splint is applied for 4 weeks to stabilize the segment.

Concussion

This requires monitoring of the pulpal condition of the tooth for 1 year. No other treatment is required. Soft diet and good oral hygiene is advised.

Subluxation

After cleaning the area, gingival lacerations if present are sutured. In case of pain in relation to occlusion, slight grinding of opposing tooth is done. A splint is applied for about 2 weeks for comfort.

Lateral luxation

The steps of treatment are:

  • The exposed root surface is cleaned with saline before repositioning.
  • Local anesthetic is given.
  • The tooth is repositioned with forceps or with finger pressure. A flexible splint is placed to stabilize the tooth for 4 weeks.

Intrusion

There are three options to treat intrusion:

Spontaneous repositioning:

This is done for permanent teeth with incomplete root development. The area is cleaned, gingival lacerations are sutured and spontaneous repositioning is allowed to take place. Progress is evaluated after 4weeks. If eruption has not taken place, orthodontic traction is applied.

Orthodontic repositioning:

This is done for patients coming in for delayed treatment. The steel archwire is adapted to the front teeth and elastic is applied. Progress is evaluated after 10 days. If eruption has not begun, local anesthetic is administered and the tooth is luxated (dislocated) slightly with a forceps. Root canal treatment is initiated after 2-3 weeks.

Surgical repositioning:

After local anesthetic is given, the tooth and the displaced bone is repositioned with forceps. The area is cleaned and gingival lacerations are sutured. A flexible splint is applied for 4 weeks. Root canal treatment is initiated 2-3 weeks later.

Avulsion

First-aid for avulsed teeth:

To save a knocked out tooth, you should put it back in its socket as soon as possible, at least within 2 hours. You must follow these steps:

  • Rinse the tooth under running water by holding it by the crown.
  • Replace it into its socket.
  • Press the tooth down with your thumb till the crown comes in level with that of adjacent teeth.
  • Finally, bite down on a piece of cloth to stabilize the tooth until you see a dentist.

If you are not able to replace the tooth back in its socket, take the tooth along with you to the dentist as soon as possible, within 60 minutes.

Keep the tooth moist by storing it in a cup of milk or salt water. If milk is not available, you can even place the tooth in your mouth between the cheeks and gums.

Treatment at the Dental Clinic:

  • The tooth is cleaned with saline.
  • The socket is irrigated with saline.
  • Examination of the alveolar socket is done, if fractured it is repositioned.
  • Replantation of the tooth is done with gentle pressure.
  • Gingival lacerations are sutured.
  • The position of the replanted tooth is checked clinically as well as with x-rays.
  • A flexible splint is placed for up to 2 weeks.
  • Antibiotics are prescribed.
  • Root canal treatment is initiated after 7-10 days.
  • Follow-up-clinical checkup is done every week during the first month.

Post-operative instructions:

  • Your dentist will advise you to eat soft foods for up to 2 weeks.
  • Brush your teeth with a soft toothbrush after every meal.
  • Use a chlorhexidine (0.1%) mouth rinse twice a day for 1 week.

Prevention:

Always remember to wear mouth guards when you are involved in active contact sports such as cycling, wrestling and hockey to prevent tooth injuries. A mouth guard is a protective device for the mouth that covers the teeth and gums to prevent injury.

Always fasten your car seat belts when you travel

Awareness of this procedure will make the stress of undertaking the procedure easier for you to bear. The decision to proceed with the procedure is made because the advantages of the procedure outweigh the potential disadvantages. It is important that you are informed of these risks before the procedure.

Although every effort is made to educate you on Dental Trauma and take control, there will be specific information that will not be discussed. Talk to your Dentist or Oral And Maxillofacial Surgeon about any concerns you have about Dental Trauma.

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