Mastering Minor Care: Dental Fractures
/Background:
Dental fractures are injuries that emergency medicine clinicians will encounter. Appropriate care in the emergency department and timely follow up are important to avoiding adverse outcomes. We will review the basic management of trauma in a healthy tooth.
Fig 1. Basic Tooth Anatomy
Evaluation:
When evaluating dental trauma, the mouth and face should be thoroughly inspected so that other traumatic injuries are not missed. Percussion testing should be performed. Mobility of the teeth and the bite alignment should also be assessed. Examine all intraoral lacerations for tooth fragments. If teeth are missing, get a chest x-ray to rule out pulmonary aspiration or consider CT maxillofacial to rule out intrusion into the alveolar ridge.
Ellis Classification:
Dental fractures can be classified by the Ellis system which takes in to account the depth and layer of the injury.
Enamel Fracture (Ellis Class I)
Ellis Class I is a complete fracture of the enamel with no visible exposed dentin. There will be no color change of the tooth and the tooth should not be painful. If there is tenderness, evaluate the tooth for a possible root fracture or luxation. This fracture pattern requires routine follow-up with a dentist and is for cosmetic purposes only. If there is a sharp edge, consider filing it down with emery board for comfort.
Enamel-Dentin Fracture (Ellis class II)
Ellis Class II involves a fracture that exposes the dentin which is yellow. The dentin is sensitive, can become infected, and should be covered up. The tooth will be tender to palpation and when exposed to air. With Ellis class II fractures, the pulp is vulnerable to contamination by oral flora since the dentin is a porous layer and ineffective as a protective seal for the pulp. The clinician needs to seal the fracture to protect that patient from puplitis which puts the patient at risk for loss of the tooth. To accomplish this, anesthetize the tooth, clean and dry the tooth, and then apply calcium hydroxide. Dermabond can also be used. The patient should be advised to avoid hot and cold foods. They should follow up with a dentist in 24 hours. Consider antibiotic coverage with penicillin or clindamycin, although evidence is limited.
Enamel-Dentin-Pulp Fracture (Ellis Class III)
Ellis III fractures are full-thickness fractures that expose the pulp. Pulp has a reddish-pink color. When the tooth is wiped clean, it may bleed. The pulp needs to be covered because of the risk for infection. The tooth should be sealed with calcium hydroxide layer as above. Direct pressure may need to be applied to the pulp to control bleeding. These patients will also need urgent dental follow up (24 hours) and strong consideration for antibiotics.
| Ellis Fracture Class | Presentation | ED Management |
|---|---|---|
| I : Enamel only | Tooth edge is missing | Elective dental follow-up |
| II: Enamel and dentin | Yellow dentin exposed, tooth sensitivity | Apply sealant, consider antibiotics, dental follow up in 24 hours |
| III: Enamel, dentin, and pulp | Pulp is visible, may bleed, tooth sensitivity | Apply sealant, prescribe antibiotics, dental follow up in 24 hours |
References:
Andreasen JO, Storgard J, et al., The role of antibiotics in preventing healing complications after traumatic dental injuries: a literature review. Endodontic Topics 2006; 14 (1), 80-92.
Diangelis AJ, Andreasen JO, Ebeleseder KA, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol. 2012 Feb. 28(1):2-12.
Douglass AB, Douglass JM. Common dental emergencies. Am Fam Physician. 2003 Feb. 1;67(3):511-517.
Flores M.T., Andersson L., Andreasen J.O., et al: Guidelines for the management of traumatic dental injuries. Dent Traumatol. 2007; 23: 66-71.
Harwood-Nuss A, Linden C, Luten R, eds. Dental injuries. The Clinical Practice of Emergency Medicine. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 1996. 418-421.
Hile LM, Linklater DR. Use of 2-octyl cyanoacrylate for the repair of a fractured molar tooth. Ann Emerg Med. 2006 May. 47(5):424-6.
AUTHORED BY EILEEN HALL, MD
Dr. Hall is a PGY-3 in Emergency Medicine at the University of Cincinnati
POST AND PEER EDITING BY JAMES LI, MD
Dr. Li is a PGY-3 in Emergency Medicine at the University of Cincinnati
FACULTY EDITING BY EDMOND HOOKER, MD, DRPH
Dr. Hooker is an Assistant Professor of Emergency Medicine at the University of Cincinnati and Faculty Editor of the ‘Minor Care Series’
