Dental Trauma

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Endodontic treatment is frequently part of dental trauma management. The goal is to preserve pulpal health if possible, and avoid or treat any future pathology by selecting treatments which may optimize pulp and periodontal healing. Recommended treatment is based on the damage sustained, the perceived health of the pulp at the time of injury, the healing capacity of the pulpal tissues, and the extent of damage to the surrounding structures. 

Splinting that primarily provides dental stability is removed after 2 weeks. In the case of alveolar fractures (which is likely with lateral luxation injuries) the splint is left in place for 4 weeks before being removed. A cervical root fracture is prone to instability and a splint may be left for 4 months. In all splinting a function (non-rigid) splint is used to minimize the risk of ankylosis. Many treatment strategies focus on conservatively monitoring the pulpal response following injury. If the pulp becomes necrotic and infected, endodontic treatment appropriate to the tooth’s stage of root development is indicated.

Pulp vitality testing should be performed initially and at each follow-up appointment in order to monitor changes. The temporary loss of response to vitality testing is a frequent finding immediately after a dental injury. The lack of a response to pulp sensibility testing does not necessarily mean the pulp is necrosed.

Systemic administration of antibiotics is highly questionable for the majority of dental trauma cases. However, in the case of tooth avulsion the tooth often becomes contaminated by bacteria from the oral cavity, the storage medium, or the environment in which the avulsion occurred.  Antibiotics after avulsion and replantation have been recommended to prevent infection and to decrease the occurrence of inflammatory root resorption. A depressed immune system or concomitant injuries may also warrant antibiotic coverage. Topical antibiotics placed on the root surface prior to replantation remains controversial.

CLASSIFICATION OF DENTAL TRAUMA

Enamel-only fractures (Ellis Class I) involve the outer layer of tooth structure only. There is no visible sign of dentine exposure, and the tooth responds optimally to vitality testing. The missing fragment of enamel should be accounted for. Occasionally a piece of tooth structure may become embedded into surrounding soft tissues (e.g. lip). If this is suspected, a low (quarter) dose radiograph can be taken of the soft tissue to determine the presence a foreign body. Recommended treatment of enamel-only fractures include:

  • One parallel periapical radiograph to screen for unseen problems, and to provide a reference to compare future radiographs to. 
  • Additional radiographs are indicated if signs or symptoms of other potential injuries are present.
  • If the tooth fragment is available it could be rebonded. The fragment should be rehydrated by soaking in water or saline for 20 min before bonding. Alternatively the tooth is conservatively restored with a small direct restoration or the damaged area is adjusted (enameloplasty). 
  • No recall appointments are necessary for deciduous teeth.
  • Recall at 8 and 52 weeks if an adult tooth. A radiograph is advised at all recall appointments even if there are no clinical signs or symptoms.

Crown fractures without pulp exposure (aka uncomplicated crown fractures or enamel/dentine fracture, (Ellis Class II)) involve only enamel and dentine. There is no pulp exposure and vitality testing often indicates reversibly inflamed or healthy pulp. The missing fragment should be accounted for. Occasionally a piece of tooth structure may become embedded into surrounding soft tissue (e.g. lip). If this is suspected, a low (quarter) dose radiograph can be taken of the soft tissue to determine the presence a foreign body. Recommended treatment for uncomplicated crown fractures include:

  • One parallel periapical radiograph to screen for unseen problems, and to provide a reference to compare future radiographs to. 
  • Additional radiographs are indicated if signs or symptoms of other potential injuries are present.
  • If the tooth fragment is available it could be rebonded. The fragment should be rehydrated by soaking in water or saline for 20 min before bonding. Alternatively the tooth is conservatively restored with a direct or indirect restoration. This will seal dentine and protect the vital pulp.
  • If only a thin layer of detine is left overlying the pulp (~0.5mm), consider indirect pulp capping using a calcium hydroxide liner underneath the restoration.
  • Recall at 8 weeks if primary tooth.
  • Recall at 8 and 52 weeks if an adult tooth. A radiograph is advised at all recall appointments even if there are no clinical signs or symptoms.

Crown fractures with pulp exposure (aka complicated crown fracture (Ellis Class III)) involve enamel and dentine and has led to pulpal exposure and contamination. The missing fragment should be accounted for. Occasionally a piece of tooth structure may become embedded into surrounding soft tissue (e.g. lip). If this is suspected, a low (quarter) dose radiograph can be taken of the soft tissue to determine the presence a foreign body. Treatment depends on whether or not the pulp is vital and healthy, and also depends on the maturity of the tooth. Mature teeth have reduced blood flow through a narrower apical constriction and do not inherently possess the regenerative capacity of immature teeth. Pulp preservation and further root development is the hope for immature teeth. As long as the history and vitality testing suggests the pulp is healthy or reversibly inflamed, the recommended treatment includes:

  • One parallel periapical radiograph to screen for unseen problems, and to provide a reference to compare future radiographs to. 
  • Additional radiographs are indicated if signs or symptoms of other potential injuries are present.
  • Direct pulp capping or partial pulpotomy with MTA or calcium hydroxide, placed directly in contact with pulp.
  • If the tooth fragment is available it could be rebonded. The fragment should be rehydrated by soaking in water or saline for 20 min before bonding. Alternatively the tooth is conservatively restored with a direct or indirect restoration. This will seal dentine and protect the vital pulp.
  • Recall at 1, 8, and 52 weeks if primary tooth. 
  • Recall at 6,12, 24 and 52 weeks if an adult tooth. A radiograph is advised at all recall appointments even if there are no clinical signs or symptoms.

Uncomplicated crown-root fractures (aka crown-root fracture without pulp exposure) involve enamel, coronal dentin, root dentin and cementum. There is no pulp exposure and vitality testing indicates reversibly inflamed or healthy pulp. Often a mobile portion of the tooth is retained due to subgingival soft tissue attachment. If not present, the missing fragment should be accounted for. Occasionally a piece of tooth structure may become embedded into surrounding soft tissue (e.g. lip). If this is suspected, a low (quarter) dose radiograph can be taken of the soft tissue to determine the presence a foreign body. Diagnosis, treatment and prognosis is similar to uncomplicated crown fractures, but extensive root involvement can complicate restorative treatment. Recommended treatment for uncomplicated crown-root fractures include:

  • One parallel periapical radiograph to screen for unseen problems, and to provide a reference to compare future radiographs to. 
  • Additional radiographs of the tooth taken with different vertical and/or horizontal angulations. An occlusal radiograph may also be appropriate. 
  • CBCT may be considered for better visualization of the fracture and its relationship to bone, and could be useful to evaluate the crown-root ratio and to help determine restorative options.
  • An attempt may be made to stabilize the loose fragment. Alternatively the loose fragment is removed and the tooth restored. 
  • If only a thin layer of dentin is left overlying the pulp (~0.5mm), consider indirect pulp capping using a calcium hydroxide liner underneath the restoration.
  • Proper restoration may require additional steps, including orthodontic extrusion or crown lengthening surgery.
  • Recall at 1, 8 and 52 weeks if primary tooth. 
  • Recall at 1, 8,12, 24 and 52 weeks if an adult tooth. A radiograph is advised at all recall appointments even if there are no clinical signs or symptoms.

Complicated crown-root fractures (aka crown-root fracture with pulp exposure) involve enamel, coronal dentin, root dentin and cementum and has led to pulpal exposure and contamination. Often a mobile portion of the tooth is retained due to subgingival soft tissue attachment. If not present, the missing fragment should be accounted for. Occasionally a piece of tooth structure may become embedded into surrounding soft tissue (e.g. lip). If this is suspected, a low (quarter) dose radiograph can be taken of the soft tissue to determine the presence a foreign body. Diagnosis, treatment and prognosis is similar to complicated crown fractures, but extensive root involvement can complicate restorative treatment. Treatment depends on whether or not the pulp is vital and healthy, and also depends on the maturity of the tooth. Mature teeth have reduced blood flow through a narrower apical constriction and do not inherently possess the regenerative capacity of immature teeth. Pulp preservation and further root development is the goal for immature teeth. As long as the history and vitality testing suggests the pulp is healthy or reversibly inflamed, the recommended treatment includes:

  • One parallel periapical radiograph to screen for unseen problems, and to provide a reference to compare future radiographs to. 
  • Additional radiographs of the tooth taken with different vertical and/or horizontal angulations. An occlusal radiograph may also be appropriate. 
  • CBCT may be considered for better visualization of the fracture and its relationship to bone, and could be useful to evaluate the crown-root ratio and to help determine restorative options.
  • An attempt may be made to stabilize the loose fragment. Alternatively the loose fragment is removed and the tooth restored. 
  • Direct pulp capping or partial pulpotomy with MTA or calcium hydroxide, placed directly in contact with pulp.
  • Proper restoration may require additional steps, including orthodontic extrusion or crown lengthening surgery.
  • Recall at 1, 8 and 52 weeks if primary tooth. 
  • Recall at 1, 8,12, 24 and 52 weeks if an adult tooth. A radiograph is advised at all recall appointments even if there are no clinical signs or symptoms.

Root fractures involve dentin, cementum and pulp but the pulpal tissue has likely not been contaminated by being exposed to the outside environment. The fracture may be vertical,  horizontal, oblique, or a combination of these. The clinical findings and prognosis depend on the position, orientation and extent of the fracture. The crown of the tooth may be mobile and/or displaced, more likely if the fracture is positioned cervically. Primary teeth with root fractures may be left and monitored, but will most likely be removed if the coronal portion is displaced or mobile. Recommended treatment for root fractures include:

  • One parallel periapical radiograph to screen for unseen problems, and to provide a reference to compare future radiographs to. 
  • Additional radiographs of the tooth taken with different vertical and/or horizontal angulations. An occlusal radiograph may also be appropriate. Root fractures may be difficult to identify radiographically even after multiple images are compared. 
  • CBCT may be considered for better visualization of the fracture and its relationship to bone, and could be useful to evaluate the tooth prognosis.  
  • Reposition the mobile coronal segment, verify radiographically, and stabilize with a passive and flexible splint.
  • Cervical fractures have the potential to heal if the tooth is stabilized. No endodontic treatment should be started at the emergency visit.
  • Recall at 1, 4, 8 and 52 weeks if the primary tooth was not removed. The splint is removed at the 4 week recall appointment.
  • Recall at 4, 8,16, 24 and 52 weeks if an adult tooth. A radiograph is advised at all recall appointments even if there are no clinical signs or symptoms. If the fracture was in the apical or middle third of the tooth the splint is removed at the 4 week recall. If the fracture was in the cervical third of the tooth the splint is left for longer, only removed at the 16 week (4 month) recall.

Alveolar fractures involve the alveolar bone and possibly adjacent bones. Multiple teeth that are mobile but move together is a common sign of an alveolar fracture. The teeth may be displaced leading to occlusal misalignment. Teeth involved may not respond to vitality testing. Recommended treatment for alveolar fractures include:

  • One parallel periapical radiograph to screen for unseen problems, and to provide a reference to compare future radiographs to. 
  • Additional radiographs of the tooth taken with different vertical and/or horizontal angulations. An occlusal radiograph may also be appropriate. Alveolar fractures may be difficult to identify radiographically even after multiple images are compared. 
  • CBCT may be considered for better visualization of the location, direction and extent of the fracture.
  • Repositioning of the displaced segment and stabilization by splinting the teeth with a passive flexible splint. 
  • Suture gingival lacerations if necessary.
  • Recall at 1, 4, 8 and 52 weeks if primary tooth. The splint is removed at the 4 week recall appointment. A radiograph is advised at the 4 week recall appointment even if there are no clinical signs or symptoms.
  • Recall at 4, 8,16, 24 and 52 weeks if an adult tooth. The splint is removed at the 4 week recall appointment. A radiograph is advised at all recall appointments even if there are no clinical signs or symptoms. 

Dental concussion refers to an injury to the tooth-supporting structures without increased mobility or displacement of the tooth. The tooth is usually sensitive and tender to percussion/touch, and vitality testing indicates reversibly inflamed or healthy pulp. Recommended treatment includes:

  • One parallel periapical radiograph to screen for unseen problems, and to provide a reference to compare future radiographs to. 
  • Additional radiographs are indicated if signs or symptoms of other potential injuries are present.
  • No direct treatment is required. The tooth and pulpal condition is monitored.
  • Recall at 1 and 8 weeks if primary tooth. 
  • Recall at 4 and 52 weeks if an adult tooth. A radiograph is advised at all recall appointments even if there are no clinical signs or symptoms.

Dental subluxation refers to an injury to the tooth-supporting structures with increased mobility but without displacement of the tooth. The tooth is usually sensitive and tender to percussion/touch. Results from vitality testing may vary indicating transient pulpal damage. Bleeding from the gingival crevice may be noted. Radiographically the tooth and surrounding structures appear normal. Recommended treatment includes:

  • One parallel periapical radiograph to screen for unseen problems, and to provide a reference to compare future radiographs to. 
  • Additional radiographs of the tooth taken with different vertical and/or horizontal angulations. An occlusal radiograph may also be appropriate. 
  • No direct treatment is required. The tooth and pulpal condition is monitored.
  • A passive, flexible splint can be used to stabilize the tooth for up to 2 weeks if there is excessive mobility or tenderness when biting.
  • Recall at 1 and 8 weeks if primary tooth. 
  • Recall at 2, 12, 24, and 52 weeks if an adult tooth. A radiograph is advised at all recall appointments even if there are no clinical signs or symptoms. 
  • If there is any evidence of external inflammatory (infection-related) resorption, root canal treatment should be initiated immediately, with calcium hydroxide used as an intracanal medicament.

Extrusion (extrusive luxation) describes displacement of the tooth out of its alveolar socket in an axial direction. The tooth may appear elongated and is usually mobile, lacking a response to vitality testing. Radiographically there is periapical widening of the periodontal ligament space. There is a good chance the pulpal blood flow has been sufficiently disturbed to lead to pulpal necrosis. Recommended treatment includes:

  • One parallel periapical radiograph to screen for unseen problems, and to provide a reference to compare future radiographs to. 
  • Additional radiographs of the tooth taken with different vertical and/or horizontal angulations. An occlusal radiograph may also be appropriate. 
  • Reposition the tooth by gently pushing it back into the tooth socket under local anesthesia. Stabilize the tooth for 2 weeks using a passive and flexible splint. If breakdown/fracture of the marginal bone is suspected, splint for an additional 2 weeks (4 weeks total).
  • An extruded deciduous tooth that is mobile or displaced more than 3mm is removed.
  • Recall at 1,8 and 52 weeks if the primary tooth was retained instead of extracted. 
  • Recall at 2, 4, 8, 12, 24, and 52 weeks if an adult tooth. A radiograph is advised at all recall appointments even if there are no clinical signs or symptoms. 
  • A false negative response to vitality testing is possible for several months. Endodontic treatment should not be started solely on the basis of a negative response to pulp sensibility testing.
  • If there is any evidence of external inflammatory (infection-related) resorption, root canal treatment should be initiated immediately, with calcium hydroxide used as an intracanal medicament.

Lateral luxation describes displacement of the tooth in any non-axial direction. There is a high likelihood that lateral luxation will be accompanied by a fracture of the alveolar socket wall or facial cortical bone. The tooth is usually displaced in a palatal/lingual or labial direction and not mobile as the apex of the tooth becomes locked into place by the bony fracture. Percussion testing results in high metallic sounds similar to that of an ankylosed tooth. There is likely no response to vitality tests and there is a good chance the pulpal blood flow has been sufficiently disturbed to lead to pulpal necrosis. Radiographically there is periapical widening of the periodontal ligament space which may only be visible on radiographs taken with a horizontal angle shift or on occlusal films. Recommended treatment includes:

  • One parallel periapical radiograph to screen for unseen problems, and to provide a reference to compare future radiographs to. 
  • Additional radiographs of the tooth taken with different vertical and/or horizontal angulations. An occlusal radiograph may also be appropriate. 
  • Reposition the tooth by gently pushing It back into the tooth socket under local anesthesia and stabilize using a passive and flexible splint.
  • A deciduous tooth will likely be removed, especially if there is a risk of ingestion or aspiration. 
  • Recall at 1, 4, 8, 26, and 52 weeks if primary tooth. The splint is removed at the 4 week recall appointment.
  • Recall at 2, 4, 8, 12, 24, and 52 weeks if an adult tooth. The splint is removed at the 4 week recall appointment. A radiograph is advised at all recall appointments even if there are no clinical signs or symptoms. 
  • A false negative response to vitality testing is possible for several months. Endodontic treatment should not be started solely on the basis of a negative response to pulp sensibility testing.
  • If there is any evidence of external inflammatory (infection-related) resorption, root canal treatment should be initiated immediately, with calcium hydroxide used as an intracanal medicament.

Intrusion (intrusive luxation) describes displacement of the tooth into its alveolar socket in an axial direction. Displacement further into the bony housing means that it is likely immobile, and percussion testing results in high metallic sounds similar to that of an ankylosed tooth. There is likely no response to vitality tests and there is a good chance the pulpal blood flow has been sufficiently disturbed to lead to pulpal necrosis. The periodontal ligament space may be indiscernible and the tooth may be visually intruded on a radiograph compared to the neighbors. Recommended treatment includes:

  • One parallel periapical radiograph to screen for unseen problems, and to provide a reference to compare future radiographs to. 
  • Additional radiographs of the tooth taken with different vertical and/or horizontal angulations. An occlusal radiograph may also be appropriate. 
  • Teeth with incomplete root formation may be left to allow for spontaneous repositioning. If no movement is noted within 4 weeks, orthodontic repositioning can be initiated. 
  • Teeth with complete root formation and less than 3mm intrusion may be left to allow for spontaneous repositioning. If no movement is noted within 8 weeks, orthodontic or surgical repositioning can be initiated. 
  • An intruded deciduous tooth will likely be conservatively left and monitored. It may take 6-12 months for spontaneous repositioning. 
  • Teeth with complete root formation and 3-7mm intrusion should be orthodontically repositioned or surgically repositioned and splinted.  
  • Teeth with complete root formation +7mm intrusion should be surgically repositioned and splinted.  
  • Recall at 1, 8, 26, and 52 weeks if primary tooth. The splint is removed at the 4 week recall appointment.
  • Recall at 2, 4, 8, 12, 24, and 52 weeks if an adult tooth. The splint is removed at the 4 week recall appointment. A radiograph is advised at all recall appointments even if there are no clinical signs or symptoms. 
  • If there is any evidence of external inflammatory (infection-related) resorption, root canal treatment should be initiated immediately, with calcium hydroxide used as an intracanal medicament.

An avulsed permanent tooth is one of the few real dental emergency situations. The clinical assessment and treatment options only apply to adult teeth. Avulsed deciduous teeth are rarely replanted. Treatment is dependent on the maturity of the root (open or closed apex) and the condition of the periodontal ligament (PDL) cells. Minimizing extraoral time, using an acceptable storage medium, and getting the tooth replaced as soon as possible is of most importance when managing an avulsion injury.

PDL cell viability could be classified as:

  • Most likely viable – the tooth was replanted immediately or within 15 mins.
  • Viable but compromised – the tooth has been kept in an isotonic storage medium like saline, saliva, Hank’s balanced salt solution, or milk, and the extraoral time has been less than 60 minutes.
  • Non-viable – total extra-oral time has been in excess of 60 minutes, regardless of storage medium used. After an extra-alveolar dry time of 30 minutes most PDL cells are dead. 

If the tooth root is mature (closed apex) or immature (open apex) and the tooth has been replanted:

  • Verify the correct positioning of the tooth visually and radiographically. If not correctly repositioned, consider repositioning the tooth under local anesthetic (preferably no vasoconstrictor).
  • Stabilize the tooth using a passive flexible splint.
  • Suture gingival lacerations, if present. Consider administering systemic antibiotics and review tetanus status.
  • Recall at 2, 4, 8, 12, 24, and 52 weeks if an adult tooth. The splint is removed at the 2 week recall appointment. A radiograph is advised at all recall appointments even if there are no clinical signs or symptoms. 
  • Initiate root canal treatment within 2 weeks after replantation.

For an immature tooth, pulp revascularization and further root development is the optimistic goal. The risk of external (inflammatory) root resorption should be weighed against the odds of revascularization. Apexification, apexogenesis or orthograde root canal treatment should be initiated only when pulp necrosis and/or infection is identified. 

If the tooth root is mature (closed apex) or immature (open apex) and has been kept in a physiologic storage medium with the extraoral dry time less or more than 60 minutes:

  • Rinse away visible root contamination with a stream of saline or another isotonic solution.
  • Irrigate the socket with sterile saline under local anesthesia (preferably without a vasoconstrictor) to remove debris and coagulum.
  • A fractured alveolar wall needs to be repositioned before replantation. 
  • Replant the tooth slowly, making sure to avoid excessive pressure. Verify proper placement both clinically and radiographically. Stabilize the tooth using a passive flexible splint.
  • Suture gingival lacerations, if present. Consider administering systemic antibiotics and review tetanus status.
  • Recall at 2, 4, 8, 12, 24, and 52 weeks if an adult tooth. The splint is removed at the 2 week recall appointment. A radiograph is advised at all recall appointments even if there are no clinical signs or symptoms. 
  • Initiate root canal treatment within 2 weeks after replantation.

For an immature tooth, pulp revascularization and further root development is the optimistic goal. Delayed replantation has a poor long-term prognosis because the periodontal ligament is likely necrotic and is not expected to regenerate. The realistic outcome is ankylosis and (replacement) root resorption. Replanting these teeth temporarily maintains esthetics, function and alveolar bone contour, allowing time to plan a definitive long term strategy. The rate of ankylosis and resorption varies considerably.

For a useful resource on managing dental trauma, check out https://dentaltraumaguide.org/

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