Dentoalveolar Trauma

Ted Fields, DDS

Introduction
The importance of care for dentoalveolar trauma cannot be overestimated. A
traumatic episode is often very distressing for an entire family. Parents may often be so
distraught and upset that they present in a more fragile emotional state than their injured
children do. Prompt and proper treatment of dental injuries is a service that patients and
their families will greatly appreciate. A well-treated trauma patient is a patient for life - as
will be many of their family and friends.

The Current State of Affairs

Are dentists prepared to treat patients who have sustained dental trauma? While
this may seem like an embarrassingly simple question, the evidence may surprise you.
Hamilton et al.1 evaluated 332 teeth that were traumatized within the past year.
They rated 59% of the subsequent treatment inadequate.
Within 1 year most restorations were inadequate! These authors conclude
“primary care services currently available for the treatment of dental trauma are
inadequate.”
A retrospective study by Robertson et al.2 examines 488 traumatized teeth over a
15 year period. They found that of 106 uncomplicated crown fractures that were restored
with composite resin, 19% had been replaced more than 10 times and 25% of all the
restorations were still rated as unacceptable.
In a related follow-up paper by Hamilton et al.,3 more than 300 dentists
were interviewed and mailed questionnaires. For questions regarding acute care of
dentoalveolar trauma, the mean score was barely above 50%. The results were even
worse for questions regarding follow-up care. Only 19% knew how long traumatized
teeth should be splinted. The authors again conclude, “dentists in the primary care sector
have insufficient knowledge to treat dental trauma (Fig 1).”

Fig 1 - m9 This
direct composite veneer
fractured during
mastication before one
year of service. A properly
designed restoration
should clearly serve the
patient for more than one
year. These restorations
must not be in heavy
occlusion in centric
 relation, lateral excursions,
or protrusive movements.
Wide margins should be
prepared to provide
adequate surface area for
adhesion. Patients should
also be evaluated for
parafunctional

habits to help select the most appropriate type of restoration. Nightguards

may help protect veneer restorations and extend their longevity.

The Importance of Proper Trauma Care

Approximately 30% of all individuals sustain some form of dentoalveolar trauma
in their lifetime.1 Many of these injuries occur in children: toddlers learning to walk,
young boys aged 8-10 years old beginning to play team sports. Dental injuries also have a
higher prevalence in the elderly population since many elderly patients sustain falls
secondary to impaired vision, disorientation, and syncope. Epileptic patients with seizure
disorders are also at increased risk for dentoalveolar trauma. Dentoalveolar trauma is a
common problem that all dentists will be called to evaluate and treat.
Understanding prevention and management of these injuries is not an elective
service like veneering or bleaching. Mastering the prevention and management of
dentoalveolar trauma is a responsibility that all dentists owe to their patients. Besides
certain acute infections, dentoalveolar trauma is the only dental condition that requires
emergent care to eliminate pain, prevent infection, save teeth, and preserve optimal form,
function, and esthetics. The rapport and gratitude from a well-treated trauma patient can
form the foundation of a long and cherished relationship.

Wound Healing
Even a simple isolated episode of dental trauma initiates a complex cascade
of healing events that involves many diverse tissues. For example, one simple punch
to the mouth may appear to only lingually luxate the maxillary central incisors, but
closer examination will reveal that much more is involved. This injury will result in
disruption of the periodontal ligaments and neurovascular bundles, fracture of
alveolar bone, gingival laceration, possible tooth root fracture, possible lip
laceration or contusion, and possible TMJ injury from the transmission of force
through the mandible to the skull.
Even in this simple example, we see that many different tissue types are
involved. Each of these tissues has individual healing capabilities. Each tissue has a
unique healing sequence and schedule. Some tissues are capable only of repair
whereas others are capable of regeneration. Many tissues are initially repaired with
connective tissue, then remodeled through various degrees of regeneration.

Repair - injured tissue is restored by new tissue that does not reproduce the
original structure and function. Reparative tissue is usually less specialized and
serves primarily to obturate any injury-induced tissue defects.

Regeneration - the original tissue architecture and function is restored.

Wound healing for injuries like the example above, begins with control of
bleeding. Bleeding in the well-vascularized oral mucosa is tampanaded by local
vasoconstriction and coagulation. Platelets help mediate this clotting as they
directly participate in fibrin plug formation and initiate the clotting cascade by
activating clotting factors. Hemorrhage control is rapidly followed by an
inflammatory response in which leukocytes migrate to the wound site. Although
an oversimplification, polymorphonuclear leukocytes generally prevent infection
while macrophages scavenge foreign bodies and necrotic debris. Connective and
epithelial tissue migration and proliferation follow the inflammatory response.
There is actually significant overlap of these events as angiogenesis and the ingress
of endothelial cells into the wound site begins within 2 days of injury. Also in this
early healing period, epithelial cells marginally migrate into the wound site and
fibroblasts begin collagen production and secretion. Finally, there is tissue
remodeling in which connective tissue and epithelial reorientation of cell-to-cell
contacts and extracellular matrix results in tissue reorganization that increases the
tissue strength across the wound. This is seen clinically as the soft tissue scar
matures.
So, to recap the important steps in wound healing:
1. Vasoconstriction and bleeding control
2. Inflammatory response
3. Connective and epithelial tissue migration and proliferation
4. Tissue remodeling
The dentist's mission is to provide favorable conditions so that each of these
tissues may achieve their optimal healing capabilities without contamination,
infection, or delay. Fortunately, this diverse group of tissues has many similar
healing requirements.

What Is Dental Trauma?

It’s amazing that studies such as those by Hamilton et al. show such poor
management and understanding of dentoalveolar trauma. After all, what is
dentoalveolar trauma? If you think about it, virtually every procedure that dentists
perform produces some form of trauma. Restorative dental procedures and dental
surgery involve controlled injury, where the benefit to the patient outweighs the
insult (Figs 2-4).
 Fig 2 Clearly a full-mouth extraction such as this is
both physically and psychologically traumatic for any patient.
During this elective surgical procedure in which 11 mandibular
teeth were removed, the exact same treatment principles were
followed as are required to treat dentoalveolar trauma. Local
anesthetic was given to palliate discomfort. The wounds were
thoroughly debrided and then cleansed with sterile saline and
high-speed suction to minimize the risk of contamination. Soft
tissue closure was performed to reapproximate the mucosal
tissues for optimal healing conditions and to again minimize the
risk of infection.

Fig 3a - m5 This patient has a mouth full of carious lesions

and failing composite restorations.

Fig 3b - m6 Once again, optimal treatment requires tooth

preparation - a traumatic procedure where the insult is outweighed
by its benefits. The odontoblasts and pulp tissue within these teeth
won't have much clue as to whether the teeth were prepared with
the dentist's bur or punched by an assailant's fist.

Fig3c - h With composite laminate veneers in place, the

patient and her odontoblasts are happy.

Fig 4 - n3 This patient doesn't present with unusual

dental trauma - but she leaves with it. This infraorbital
ecchymosis resulted from a routine intraoral, infraorbital nerve
block. Vessel and nerve injuries including hemotomas and
parasthesias are occasional complications when these tissues
occupy an area requiring injection.

While trauma is generally considered to be accidentally sustained

tissue or psychological injury, trauma actually encompasses much more. In
fact, from a wound healing perspective, there is little difference between
tooth avulsion and tooth extraction (Fig 5). The greatest difference may be
intent. Granted that extractions are performed by qualified individuals using
sterile instruments and purposeful maneuvers in controlled environments,
but for many traumatic avulsions the healing response is very similar. The
pulpal response to a dentin and enamel crown fracture is the same as it is
for a class II preparation. The pulp doesn’t know the difference: both events
are traumatic and elicit similar wound healing events. In light of the
biological similarity between the healing
response associated with common dental procedures and accidental dental
trauma, it is difficult to believe that dentists cannot manage dentoalveolar
injuries.
To be technically correct, trauma may be of three different general
classifications: mechanical, thermal, and chemical. While accidental
mechanical trauma is the focus of this course, it is important to understand
other ways in which teeth may be injured. Thermal injury can be sustained
during high speed cavity preparation without air-water spray, overzealous
light-curing of a composite, or pulp testing with cold spray. The most
common chemical insult to teeth: dental caries! Bacteria convert food by-
 products to acid and the acid chemically demineralizes tooth enamel and
dentin.

Fig 5 - Sometimes accidental trauma is more benign than

actual treatment. This avulsion was sustained after biting a donut.

Fig 6 – Replace this with Fig 25 – this was due to a

shotgun
Drinking and driving produces much of the dentofacial
trauma seen in large metropolitan area emergency rooms. The
obvious step defects and gross malocclusion suggest multiple
maxillary and mandibular fractures - time for a visit with the oral
surgeon.

Etiology of Dental Trauma

Dental trauma is twice as prevalent in males as compared to
females. The peak incidences are between 2 and 4 years of age, as toddlers
begin to walk, and between 8-10, when children begin organized team
sports. Elderly patients are also prone to dentofacial trauma, often due to
visual impairment, disorientation, and syncope. Patients with seizure
disorders are at increased risk for dental trauma. In fact of individuals who
had at least one seizure in the past year, 10% sustained dental trauma.
Severity of seizures is the key predictor in epileptic patients.
Falls are responsible for most dental trauma. Because of their
accessibility, the maxillary central incisors are the most frequently injured
teeth. The type of injury depends on the mechanism of trauma, state of root
development, and health of the dentition and periodontium.
Individual sports that have a high prevalence of dental trauma
include gymnastics, cycling, skate-boarding, roller-blading, and horseback
riding. In addition to contact sports, team sports in which dental trauma is
prevalent include baseball and basketball (in which mouthguards are rarely
worn), and ice hockey.4 Most sports related dental trauma is sustained in
contact sports, and the most severe dental trauma is sustained in sports
where high speed collisions may occur, such as cycling and ice hockey.5
 Motor vehicle collisions and interpersonal violence also account for
a large percentage of all dental injuries. Drugs and alcohol are often
predisposing factors to both of these mechanisms of injury. Interpersonal
violence may include assault, domestic violence, and child abuse. Most
childhood injuries should raise the clinician’s suspicion of child abuse even
though dental injuries are inherently common among children.
The dental conditions that most commonly predispose a patient to
dental injury include protrusive maxillary incisors and lip incompetence.
One recent study has shown five predisposing factors related to dental
trauma: postnormal occlusion, overjet exceeding 4 mm, short upper lip, lip
incompetence, and mouth breathing.6 Clearly these factors are related to
maxillary overgrowth in either the anterior-posterior direction (resulting in
a Class II skeletal relationship) or in the vertical plane (resulting in vertical
maxillary excess, or VME). Correction of these conditions usually requires
orthodontic/orthognathic treatment. Custom-made mouthguards may
improve patient safety prior to definitive correction, but many dental
injuries occur outside of the sporting arena.

Fig 6 - By far the most common dentofacial trauma seen in the

emergency room of a large metropolitan area results from drinking
and driving. This gentleman will require the services of your friendly
oral surgeon and several of his friends.

Fig 7 - These protrusive incisors are not only at risk of

fracture - they have already been fractured and restored about 10
years before this photo was taken. Even from this photo, it is evident
that this patient would have great benefit from orthodontic and
possibly orthognathic treatment. Orthodontic care would be the first
step in reducing this patient's risk of further injury.

The Dental Trauma Evaluation

Dentoalveolar trauma must be treated as an emergency since
promptness of care is often critical to achieving a favorable outcome.
Many studies have shown that the time lapse between injury and
treatment is the most important factor in saving luxated and avulsed teeth.
Even when time is at a premium, the evaluation and emergent treatment
of an injured patient must be regarded as a priority. This immediacy does
not, however, diminish the need for a thorough history and examination.
After all, it is the history and examination results that dictate the proper
treatment plan.

The History
In addition to the normal questions pursued in medical and dental
histories, the following items should be included.
„ When and where did the injury occur? This will help assess wound
contamination, prognosis, and clues to the severity of injury and the
potential for additional injuries.
„ How long was the tooth out of the socket? The time between injury
and initial presentation will affect prognosis and may influence treatment
decisions such as whether to reimplant a tooth or suture a laceration.
„ How was the tooth preserved? Dry teeth have very poor prognoses,
whereas teeth stored in their original sockets or in isotonic solutions have
the best prognosis.
„ How did it occur? The mechanism of injury helps determine the
potential severity of injury and the likelihood of additional injuries. It is
helpful to classify injuries into categories such as blunt, lacerating,
tearing, shearing, or crushing. These classifications and others may help
anticipate the type of injuries present and may direct initial care.
„ Has the patient received prior treatment elsewhere for this condition?
„ Has the patient sustained previous dental injuries?
„ Did the trauma cause amnesia, unconsciousness, drowsiness,
vomiting, or headache? This question helps identify patients with
possible head injuries. Patients with head injuries should be referred to
facilities with qualified care providers and the necessary imaging
facilities.
„ Is there spontaneous pain from any teeth?
„ Is there thermal sensitivity of any teeth?
„ Is there tooth pain during palpation, percussion, or mastication?
„ Is there any disturbance in the bite? Occlusal discrepancies may
indicate alveolar fractures, dental fractures or luxations, bleeding into one
or both of the temporomandibular joint spaces, inflammation of one or
both temporomandibular joints, or jaw fractures.

Clinical Examination and Initial Treatment

If the airway is clear and not in jeopardy of obstruction and there
is no critical bleeding that could cause shock or vascular collapse, then an
orderly clinical examination should be performed. Record all head and
neck findings, even negative findings. If the mechanism of injury leaves
open the possibility of remote injuries, examination of the torso and limbs
should be performed as indicated.
Jaw fractures should be ruled out or identified by examining the
occlusion, the range of mandibular motion, pain upon mandibular
movement or clenching, abnormal bony steps, mobility between bone
segments, luxated or avulsed teeth, ecchymosis in the floor of the mouth,
and gingival lacerations. Even without clinical evidence of jaw fracture,
radiographic evaluation is imperative (Figs 23-25).
The temporomandibular joints should be examined by noting the
range of mandibular movements in opening, protrusion, and both lateral
excursions. Any pain or tenderness during these movements should also
be noted. Inflammation or bleeding into a temporomandibular joint may
result from forces transmitted to the joints during a direct blow anywhere
along on the mandible. Joint inflammation usually may be identified by
joint tenderness, an ipsilateral open bite, and deviation of the mandible to
the contralateral side.
Sites of avulsed teeth should be identified and examined for
evidence of associated alveolar fracture and any retained foreign bodies
or fractured tooth roots. If avulsed teeth are available, they should be
inspected for damage, lightly rinsed in cold water, debrided only of gross
debris, and replanted into the original socket as soon as possible.7-11 This
initial treatment protocol is appropriate for permanent teeth that are
believed to have viable periodontal ligament cells along the root surface.
The factors most tightly correlated to periodontal ligament healing after
dental trauma are: the stage of root development, length of dry storage
period, immediate replantation, and the wet extra-alveolar storage period.
It may be appropriate to replant primary anterior teeth depending on the
stage of root development, development of the dentition, storage time and
conditions, and the patient’s age and willingness to cooperate.8
Replantation is not indicated for many primary teeth or for
permanent teeth that have been stored dry for extended periods. There is
no unanimous agreement as to how long after avulsion a tooth should still
be replanted. If properly stored in an isotonic solution such as milk,
saline, or saliva, it is probably not unreasonable to attempt replantation
for up to 12 hours after the injury. The most effective storage site for an
avulsed tooth is its original socket. The next best storage media includes
isotonic saline solutions such as sterile saline, milk, and saliva.11-14
Obviously, the longer the tooth is out of the mouth, the fewer periodontal
ligament cells will survive, and the poorer the prognosis. The decision to
not replant a tooth, however, is an immediate failure for that tooth.
Account for all missing structures. If the patient is wearing
dentures, piece all broken pieces together to ensure that nothing has been
swallowed or aspirated. Fractured teeth should be identified and classified
as to the level of fracture. Dental fracture classifications will be discussed
below. An effort should be made to locate any missing fragments of teeth
or dental prostheses. Location of fragments may involve palpation,
exploration, and radiography of soft tissue lacerations and abrasions, as
well as chest and abdominal radiographs to identify or rule out ingestion
and aspiration. Aspirated foreign bodies may result in life threatening
lung complications. Sharp denture or tooth fragments may also cause
severe damage even resulting in death (Figs 26 & 27).
All traumatized teeth should be evaluated for mobility and
displacement. Palpation, percussion, and transillumination may help
assess pain, mobility, and otherwise unrecognized crown fractures.
All soft tissue lacerations, abrasions, contusions, and hematomas
should be documented. Any neurosensory deficits, hyperesthesias, or
motor function disturbances should also be evaluated and recorded. Any
break in soft tissue should be explored and radiographed for possible
foreign body inclusion. These wounds should be scrubbed with a
 biocompatible disinfectant and thoroughly irrigated with sterile saline to
remove contaminants and minimize the risk of infection.

Fig 23 - t2 Always rule out a mandible fracture

before treating what appears as a simple alveolar fracture.
While this patient's problem is obvious, others require more
careful investigation.

Fig 24 - r9 This patient presented to the dental

school clinic with a chief complaint of gross caries of a left
mandibular molar. Prior to extraction of the offending
tooth, clinical and radiographic examinations revealed a
right mandibular fracture through the third molar. After
further patient inquiry, the patient acknowledged right jaw
pain since an altercation 1 week prior.

Fig 25 - s Once again, gross malocclusion suggests

multiple maxillary and mandibular fractures - time for a
visit with the oral surgeon.

Fig 26 - p6 This patient presented to the emergency

room after a facial smash in a motor vehicle collision. The
patient was intubated and sedated. After noting a fractured
maxillary canine, close examination of the lateral cervical
spine radiograph revealed the incisal tooth fragment lodged
just above the epiglottis.

Fig 27 - p5 This 44-year-old male presented to the

emergency room after a dentist's screwdriver and healing
screw disappeared during stage II implant surgery. The
hardware is clearly identified on this lateral chest
radiograph. A general anesthetic and rigid brochoscopy
were required to retrieve the screw and driver.

Pulp testing traumatized teeth at initial presentation may be

useful as a baseline measure, but is really of dubious value since these
measures would be expected to be abnormal. Pulp testing is of more
value in examining the healing of traumatized teeth after initial
therapy.

Radiographic Examination
Radiographic examination is an important adjunct to the
clinical examination and history of an injury. Intraoral radiographs
may be difficult to obtain after many injuries, but may be very helpful
in evaluating dental root fractures, alveolar socket fractures, foreign
body inclusion, and possible jaw fracture. Extraoral radiographs, such
as a panoramic radiograph, should be used for evaluating possible jaw
fractures, especially those not associated with the dentition, such as
mandibular condyle, ramus, or angle fractures. (Fig 28) Soft tissue
radiographs can be made by placing the film against only the lips or
cheeks and reducing the exposure time to 25% of the normal time for
anterior teeth. Soft tissue radiographs allows visualization of many
potential foreign bodies such as gravel, glass, and tooth pieces. (Fig
29)

Fig 28a - q A drive-by shooting resulted in avulsion

of the left hemi-maxilla and all associated teeth.

Fig 28b - p9 These fragments were very difficult to

identify on plain film radiographs, emphasizing the
importance of close clinical examination in addition to
radiographic examination.

Fig 28c - p8 Cervical spine radiographs did,

however, identify the retained bullet fragments.

Fig 29 - s7 Piecing together damaged dental

prostheses ensures that all pieces are identified. Dentures are
especially problematic due to their lack of radiopacity. Still,
careful radiographic examination, especially with computed
tomography, may assist in locating missing prosthesis
fragments.

Treatment Planning
An important, yet often overlooked, component of treatment
planning for trauma patients is encouraging the involvement the patient
and the patient’s family in the recovery process. This involvement should
begin by counseling them regarding prognosis, possible complications,
treatment options, follow-up requirements, long-term care issues, cost,
and insurance issues. This is an important opportunity for the care
provider and the patient to understand what each can expect from the
other in terms of follow-up care and compliance.

Prognosis & Treatment of Luxation & Avulsion Injuries

Injuries to Tooth and Pulp (Figs 8 & 9)
5. Enamel infraction (Class I) - a crack or craze line in the
amel without any missing tooth structure
6. Enamel fracture (Class I) - some tooth structure is
displaced
7. Enamel-dentin fracture (Class II) - does not
involve the pulp
8. Complicated crown fracture (pulp exposure)
(Class III)
9. Uncomplicated crown-root fracture (Class II) -
does not involve the pulp
 10. Complicated crown-root fracture (Class III) -
involves the pulp
11. Root fracture (Class III) - does not involve the
clinical crown

Fig 8 - 1sNEW
A. Enamel infraction and enamel fracture, B. Enamel-
Dentin fracture, C. Complicated crown fracture.

Fig 9 - 2sNEW
A. Uncomplicated crown-root fracture, B. Complicated
crown-root fracture, C. Root fracture.

Injuries to Periodontium (Figs 10 & 11)

1. Concussion - tooth is traumatically sensitized, but
not loosened
2. Subluxation - tooth is loosened, but not displaced
3. Intrusive luxation - clinical crown height is
decreased as the tooth is forced further into the socket. Alveolar
socket comminution accompanies this injury.
4. Extrusive luxation - clinical crown height is
increased as the tooth is partially dislodged from the socket in the
direction of the long axis of the tooth.
5. Lateral luxation - the tooth is facially or lingually
displaced from its pretraumatic position.
 6. Avulsion - the tooth is entirely displaced from the
tooth socket.

Fig 10 - 3sNEW
A. Concussion, B. Subluxation, C. Extrusive luxation.

Fig 11 - 4sNEW
A. Lateral luxation, B. Intrusive luxation, C. Avulsion.

Injuries to Supporting Bone (Figs 12-17)

1. Comminution of socket occurs frequently with
intrusive injuries
2. Fracture of socket wall occurs frequently with
lateral luxation and avulsion
3. Fracture of alveolar process occurs more
frequently when multiple teeth receive a direct blow. Typically
involves an alveolar segment containing multiple teeth.
4. Fracture of maxilla or mandible in a general
dentist office setting, maxillary and mandibular fractures must
always be ruled out or identified prior to definitive treatment. The
most common fracture of the maxilla is a LeFort I fracture. LeFort
type fractures can be identified by mobility of all maxillary teeth
along with mobility of the entire hard palate. The nature, number,
and location of mandibular fractures varies widely as these factors
are determined by the mechanism of injury and the patient’s
dental status. Edentulous patients, for example, sustain more
mandibular body fractures. A direct, high-velocity blow to the
chin by a dashboard, for example, commonly produces bilateral
mandibular condyle fractures, sometimes with an additional
fracture in the anterior mandible. These types of injuries often
require multi-system evaluation to examine for possible head and
neck injuries or even other orthopedic injuries that a patient may
not notice on their own for several days.

Fig 12 - 5sNEW
A. Comminution of the alveolar socket is common
with intrusive luxation injuries, B. Fracture of the
socket wall, C. Fracture of the alveolar process.

Fig 13 - a5
This panoramic radiograph demonstrates a left
displaced mandibular body fracture - time to refer to
your friendly oral surgeon.
 Fig 14 - n8
This patient sustained a right mandibular
parasymphysis fracture in a motor vehicle collision.
Malocclusion is present with an associated gingival
laceration and an avulsed canine tooth.

Fig 15 - n6
This 27-year-old man fell from a 10-foot high ladder
and sustained a comminuted mandibular symphysis
fracture, several avulsed teeth, and multiple
lacerations - another patient for your oral surgeon.
Because of the mechanism of injury, this patient will
also require close examination of his head, neck,
thorax, abdomen, and other extremities.

Fig 16 - s2 This patient presented to the

emergency room with multiple mandible
fractures and a segmental fracture of the maxilla
after a motor vehicle collision.

Injuries to Soft Tissues

1. Laceration- a cut that may be of variable depth,
length, complexity, and cleanliness. Lacerations should be
evaluated for damage to adjacent structures. The clinician should
be especially aware of any associated nerve injuries. (Figs 18 &
19)
2. Contusion a bruise sustained by a crush-type
injury.
3. Abrasion a scrape-type injury. More common
extraorally. (Fig 20)
4. Avulsion soft tissue avulsion is when a segment of
tissue is totally detached or missing.
5. Hematoma an accumulation of blood beneath the
skin or mucosal surface. This may occur after a crush injury in
which the mucosa is intact, but a blood vessel is disrupted
beneath the surface. The result is bleeding into the surrounding
tissues until the local pressure tamponades the bleeding and
hemostasis is achieved. Hematoma formation may also occur as a
delayed event with lacerations that are closed superficially while
deep tissues are still bleeding.
6. Nerve injury may be classified as neuropraxia
(nerve is crushed, but no axonal disruption), axontomesis (some
axons are disrupted), and neurotemesis (complete nerve
transection). The completeness of recovery directly relates to the
magnitude of injury. Any evidence of parasthesia, anesthesia, or
dysesthesia must be documented along with the distribution of
this neurosensory disturbance.
7. Foreign body inclusion all soft tissue disruptions
should be radiographed and thoroughly cleansed to detect and
eliminate foreign bodies. (Figs 21 & 22)

Fig 18 - p
This 56-year-old woman bit and lacerated her tongue
during a motor vehicle collision.

Fig 19 - n9
Minor tongue lacerations are usually easy to manage
with local anesthetic, debridement, and thorough
irrigation. Closure should be performed with a suture
that will not be prematurely dislodged by the
vigorous activity of the tongue - silk and Vicryl are
good choices.

Fig 20 - p7
In addition to the obvious dental trauma, this patient
 sustained numerous facial abrasions, including those
above the upper lip.

Need new graphics for figs 21 and 22 Soft tissue

injuries should always be examined radiographically.
For ideal exposure and identification of many foreign
objects, decrease the normal tooth exposure time to
25% of normal. A soft tissue radiograph of this young
boy revealed fractured dentin and enamel debris.

II. Prognosis & Treatment of Crown & Root Injuries

I. Crown Fracture
Clinically examine:
12. Extent of fracture
13. Pulp exposure
14. Dislocation of tooth
15. Reaction to sensibility tests
Radiographically examine:
7. Size of pulp cavity
8. Stage of root development
9. Root fracture or luxation
A. Enamel Infraction
Treatment:
Pulp sensitivity should be controlled within 6-8 weeks with no
intervention.
Prognosis:
• Pulp necrosis: 0-3.5%
• Pulp canal obliteration: 0%
• Root resorption: 0%
B. Enamel Fracture (no dentin involvement) (Fig 30)
Treatment:
Emergently, remove sharp edges and restore, usually with
composite. Sensitivity control should be achieved within 6-8 weeks.
Definitive treatment may require a laminate veneer or crown.
Prognosis:
• Pulp necrosis: 0.2-1.0%
• Pulp canal obliteration: 0.5%
• Root resorption: 0.2%
 Fig 30a - m4
This is an enamel fracture that is not really an enamel
fracture - it’s a composite veneer fracture. This lateral
protrusive photo gives us a clue as to why the failure
occurred.

Fig 30b - m3
A composite resin repair required only enlargement and
roughening of the bonding surface and routine composite
resin obturation and finishing.

Fig 31a - c
This patient fractured the incisal corner of a porcelain
laminate veneer on tooth #8 while eating.

Fig 31b - b
Although several different treatments may serve this
patient well, the patient and dentist elected to remove
the porcelain veneers from teeth #8 and #9 and replace
them with composite veneers.

C. Enamel-Dentin Fracture Only (Figs 32-34)

Treatment:
Placement of CaOH liner if indicated. Emergently, restore with
composite or temporary crown. Check occlusion. Sensitivity should be
controlled after 6-8 weeks. Definitive treatment may involve reattachment
of crown fragment, laminate veneer, crown, or onlay, and occasionally
root canal therapy (RCT).
Prognosis:
• Pulp necrosis: 1-6%
• Pulp canal obliteration: 0%
• Root resorption: 0%

Fig 32 - m8
This fracture is clearly into dentin. There is an additional
infraction line visible just coronal to the cingulum. A full
coverage restoration will likely be needed for long term
success.
 Fig 33a - d
This young boy got into a fight at school and fractured #8
into dentin, and fractured the incisal enamel of #9.

Fig 33b - l
The incisal half of #8 was recovered from the
playground at school.

Fig 33c - k
The incisal fragment was repositioned and bonded to
the remaining crown of tooth #8. This restoration
served the patient well - until his next fight fractured it
again.

Fig 34a - f
This 7-year-old girl fractured tooth #8 by stumbling
with a glass bottle in her mouth. The fracture
extended into dentin, but did not encroach the pulp.

Fig 34b - e
A composite veneer restoration was placed. The
patient and her parents were informed that a new
veneer restoration undoubtedly would be needed
when eruption of the patient's anterior teeth are
complete.

A retrospective study of traumatized permanent teeth (15-year

follow-up):
• 488 injured teeth were examined
• 19% of the composite resin restorations had been
replaced more than 10 times.
• 25% were rated unacceptable. (Ouch!)
Robertson, Robertson, Noren: Int J Pediatr Dent 1997; 7:4, 217-
26
Note: Occlusal patchwork composite restorations WILL
FAIL. Period.
D. Pulp Exposure (Fig 35)
Treatment:
• Pulp capping (only for very small exposures)
• Pulpotomy (cervical pulpectomy may be appropriate
for primary teeth)
• Pulpectomy (for permanent teeth only)
Endodontics courses should cover follow-up treatment and
prognoses with you.
 Fig 35 - a
This young patient fractured tooth #9 into the pulp. A
root canal was performed, a temporary restoration
placed, and the patient never returned for definitive
care or follow-up.

II. Dental Fracture Involving the Tooth Root

Emergently, tooth fragments can be splinted to alleviate pain.
Definitive treatment is needed within days. The level of the fracture
determines definitive care.
A. Crown-Root Fractures Permanent Teeth
5. Extraction of the tooth - indicated for fractures
that include more than 1/3 of the root and vertical fractures that
follow the long axis of the tooth. Consider permanent
treatment, including immediate implant (immediate implant, is
not literally immediate, but after a healing period of 6-8
weeks).
6. Surgical exposure of fracture - indicated
where less than 1/3 of the root is compromised. Give local
anesthetic, remove loose fragments, perform pulpectomy and
obturation, expose root fracture with gingivectomy and
ostectomy, and restore with post-retained crown.
7. Surgical or orthodontic extrusion - indicated
in teeth with less than 1/3 of the root compromised. Perform
RCT, and attempt to reposition the coronal tooth margin at
least 1mm above the alveolar crest. Stabilize for 6 months.
Perform definitive restoration.
8. Implants - now render some of these above-
mentioned treatments more “heroic” than “1st line treatment.”
(Fig 36)

Fig 36a - m7
This 32-year-old patient initially presented with a
fracture that extended nearly halfway down the
clinical root. The remaining root was extracted
with care to preserve adjacent alveolar bone and
soft tissue contour

Fig 36b - p4
This photo depicts temporary placement at stage II
 surgery.

Fig 36c - p3
This patient was very happy with her postoperative
esthetic and functional result. As a dental assistant,
she was also glad that she didn't have to floss under
a bridge pontic.

B. Crown-Root Fractures - Primary Teeth

Extraction is usually the emergent treatment of choice.
Definitively, space maintainers are often necessary to control permanent
tooth eruption. Cervical pulpotomy is an infrequent alternative therapy.
C. Isolated Root Fracture
Clinical Exam:
• Mobility
• Dislocation
• Sensitivity
Radiographic Exam:
• Fracture site
• Dislocation
• Stage of root development
Types of Healing:
• Healing with calcified tissue
• Interposition of connective tissue
• Interposition of CT and bone
• Interposition of granulation tissue
Treatment:
• May extrude if fracture is very coronal
• Reposition
• Immobilize coronal fragment with rigid resin splint for
2-3 mos
• Follow-up for 1 year
Prognosis:
• Pulp Necrosis: 20-44%
• Pulp canal obliteration: 69%
• Root resorption: 60%
There are poorer prognoses for mature, dislocated, and non-splinted
teeth. Pulp necrosis requires RCT of coronal fragment only.
III. Luxation Injuries (Figs 37-40)
Clinical Examination:
• Pain with occlusion
• Direction of dislocation
• Tooth mobility
• Response to percussion
 • Response to vitality testing
• Bony involvement
Pathology:
The pulpal changes will depend on the status of the neurovascular
supply. The extent and duration of pulpal ischemia will determine:
• Pulpal healing and revascularization
• Partial or total pulpal necrosis
Root Resorption: (Late complications)
8. External surface resorption
9. External replacement resorption (ankylosis)
10. Inflammatory resorption
11. Internal replacement resorption (rare)
12. Internal inflammatory resorption (rare)
Treatment for Concussion and Subluxation:
1. Relieve occlusion ***
2. Possible immobilization
3. Soft diet for 14 days: no sandwiches or apples
4. Follow-up: document sensitivity testing
Minimum follow-up period: 1 year
Treatment for Extrusive and Lateral Luxation:
• Local anesthesia
• Reposition immediately. If treatment is delayed, don’t
reposition.
• Splint with resin for 3weeks.
• Splint for 6-8 weeks if adjacent bone is fractured.
Minimum follow-up period: 1 year

Fig 37 - q9
Extrusive luxation of tooth #8.

Fig 38 - q8
Lateral luxation of tooth #8.

Fig 39 - p7
This 23-year-old fell over the handlebars of his bicycle while riding
drunk at night to celebrate his birthday. Tooth #7 was fractured at
the alveolar crest and teeth #8 and #9 were extrusively luxated.
Emergently, a pulpotomy was performed on tooth #7, and teeth #8
and #9 were repositioned and splinted with composite resin.

Fig 40 - a2
In a motor vehicle collision, this patient avulsed 3 teeth
and laterally luxated the mandibular central incisors.
The avulsed teeth were never found. The incisors were
 repositioned and retained with a resin splint.

Treatment for Intrusion Injuries:

• Immediate manual repositioning
• Orthodontic repositioning over 3-4 weeks if initial tx is
delayed
• Splint for 6-8 weeks.
• Suture any gingival lacerations.
Minimum follow-up: 5 years - high incidence of late complications
Prognosis:
• Pulp necrosis: 15-59% (RCT is indicated)
• Pulp canal obliteration: 6-35% (no treatment is
indicated)
• External resorption: 1-18% (RCT is indicated)
• Internal resorption: 2% (prepare canal and fill with
CaOH. Repeat
† CaOH fill every 2-3 weeks for a couple months
to restore surface)
• Loss of supporting bone: 10%
IV. Avulsion Injuries (Fig 41)
History document the extra-alveolar period and the tooth
preservation conditions
Clinical Exam examine the condition of tooth and its alveolus
Radiographic Exam look for associated bone fracture
Indications for Reimplantation:
• No periodontal disease associated with the avulsed tooth
• The alveolar socket should be reasonably intact
• The tooth should be relatively intact
Avulsion: Replantation Technique
1. Immediate reimplantation should be encouraged:
else saline, saliva, or milk
2. Cleanse root surface of gross contaminants using a
syringe stream of saline
3. Manually reduce any alveolar fractures
4. Replant tooth and splint for 1 week
5. Perform RCT at 1 week, before splint removal
Prognosis:
Replantation tooth survival rate is 51-89%. Prognosis is related
most closely to extra-articulation time and storage media. Antibiotics have
not been shown to improve the clinical outcome. Consider immediate
implant placement. Primary teeth should not be replanted; consider a space
maintainer for primary teeth
 Fig 41a - q4
Avulsion of both maxillary central incisors.

Fig 41b -There is no radiograph evidence of

damage to the surrounding alveolar bone.

Fig41c - r6
Immediate RCT was performed with the teeth out of
the mouth.

Fig 41d - r5
The teeth were obturated out of the mouth.

Fig 41e - r7
The teeth were repositioned in their respective sockets.
They were then splinted into their proper,
pretraumatic positions.

Fig41f - r3
A very satisfactory functional and esthetic result was
obtained. This patient still requires careful long-term
follow-up.

V. Bony Injuries
Clinical Exam:
1. Palpate for mobility and fragment
dislocation
2. Check for malocclusion
3. Identify which teeth are associated
4. Rule out mandibular or maxillary fracture:
a. Malocclusion
b. Gingival laceration
c. Localized ecchymosis
d. Localized pain
e. Mobility between teeth
Treatment:
1. Reposition fragments.
2. Involved teeth generally should be
preserved.
 3. Apply rigid splint fixation for 3-6 weeks.
4. Radiographically verify reduction.
5. Consider antibiotics: Pen VK 500mg QID
for adults.
6. Minimum follow-up period: 1 year
Prognosis:
• Pulp necrosis: 75%
• Pulp canal obliteration: 15%
• Progressive root resorption: 11%
• Loss of bone support: 13%
• Infection of teeth in fracture line: 5-29%
Additional Precautions For All Dental Injuries
• Make sure all missing parts are identified
• Wiring teeth in place for a dental luxation is not
indicated
• Ensure that patients understand the importance of a
soft diet
• Do not place traumatized teeth in heavy occlusion
• Refer when necessary, some cases are
multidisciplinary

Prevention
Perhaps the most valuable service a dentist can provide in relation
to dental trauma is that of prevention. Orthodontic treatment, and
possibly surgical treatment, should be considered for prominent
maxillary central incisors. Mouthguards should be provided for all
contact sports. The dentist must emphasize the importance of wearing
mouthguards at all times during contact sports. Other protective
measures such as wearing football helmets and seat belts should be
encouraged. A prudent place to begin with increasing public awareness
and compliance is with high school and university trainers and athletic
directors.

Fig 42a - n2
This patient is a good candidate for orthodontic care
to prevent further maxillary incisor trauma.

Fig 42b - n3
This patient underwent orthodontic therapy and
subsequently had his maxillary anterior teeth
veneered.
 Mouthguard Construction
16. Customize the mouthguard for each sport, and
sometimes for each position.
17. Custom vs. boil-and-bite vs. stock
18. Patients with braces and erupting teeth
19. Laminate vs mono-layer materials
20. Make a mouthguard each season
21. Clear vs colored
22. Thickness: at least 3mm

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