!4.14 Dental Trauma (fracture, subluxation and displacement)
After a direct blow to the mouth the patient may have a portion of a tooth
broken off, or a tooth may be loosened to a variable degree. Ellis class I
dental fractures involve only enamel, and are problems only if they leave a
sharp edge, which can be filed down. Ellis class II fractures expose yellow
dentin, which is sensitive, can become infected, and should be covered.
Ellis class III fractures expose pulp, which bleeds and hurts. A tooth that
is either impacted inwards or partially avulsed outwards can be recognized
because its occlusal surface is out of alignment compared to adjacent teeth.
There is also usually some heorrhage at the gingival margin. If several
teeth move together, suspect a fracture of the alveolar ridge.
What to do:
* Assess the patient for any associated injuries such as facial or
mandibular fractures. Clean and irrigate the mouth to expose all
injuries. Touch injured teeth with a tongue depressor or grasp them
between gloved fingers to see if they are loose, sensitive, painful, or
* Consider where any tooth fragments are located. Broken tooth fragments
may become embedded in the soft tissue, swallowed or aspirated. A chest x
ray can disclose tooth fragments aspirated into the bronchial tree.
* For sensitive Ellis II fractures of dentin, cover the exposed surface
with a calcium hydroxide composition (Dycal), tooth varnish (copal ether
varnish), a strip of stomahesive or clear nail polish to decrease
sensitivity. Provide pain medications, instruct the patient to avoid hot
and cold food or drink and arrange for follow up with a dentist.
* Ellis III fractures into pulp should be seen by a dentist right away.
Calcium hydroxide or moist cotton covered by foil can be used as
temporary coverings. Provide for analgesics as needed.
* Minimally subluxed (loosened) teeth may require no emergency treatments .
Very loose teeth should be pressed back into their sockets and wired or
covered with a temporary periodontal splint (Coe-Pak) for stability, and
the patient should be scheduled for dental follow up and a possible root
canal procedure. These patients should be on a soft or liquid diet to
prevent further tooth motion. Antibiotic prophylaxis should be provided.
* Intruded primary teeth and permanent teeth of young patients can be left
alone and allowed to re-erupt. Intruded teeth of adolescents and older
patients are usually repositioned by an oral surgeon. An extruded primary
or permanent tooth can be readily returned to its original position by
applying firm finger pressure. both intrusive and extrusive injuries
require early dental follow up and antibiotic prophylaxis.
What not to do:
* Do not miss associated injuries of alveolar ridge, mandible, facial bone,
Exposure of dentin leads to variable sequelae depending upon the age of the
patient. Because it is composed of microtubules, dentin can serve as a
conduit for pathogenic microorganisms. In children, the exposed dentin in an
Ellis class II fracture lies nearer the neurovascular pulp and is more
likely to lead to a pulp infection. Therefore, in patients less than 12
years old, this injury requires a dressing such as Dycal. Mix a drop of
resin and catalyst over the fracture and cover with dry foil. When in doubt,
consult a dentist. In older patients with Ellis class II fractures however,
analgesics, avoidance of hot or cold foods and follow up with a dentist in
24 hours is quite adequate. If Coe-Pack or wire are not available to
stabilize loose teeth, use soft wax spread over palatal and labial surfaces
and neighboring teeth as a temporary splint.
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