Original Article 607

Dental Injuries and Management

Likith V. Reddy, MD DDS FACS1 Ritesh Bhattacharjee, BDS, MPH2 Emily Misch, MD, MPH3
Mofiyinfolu Sokoya, MD4 Yadranko Ducic, MD, FRCS(C), FACS4

1 Department of Oral and Maxillofacial Surgery, Texas A&M College of Address for correspondence Ritesh Bhattacharjee, BDS, MPH,
Dentistry—Baylor, University Medical Center, Dallas, Texas Department of Oral and Maxillofacial Surgery, Biomedical Sciences,
2 Department of Oral and Maxillofacial Surgery, Biomedical Sciences, Texas A&M College of Dentistry, 3302 Gaston Avenue, Dallas,
Texas A&M College of Dentistry, Dallas, Texas TX 75246 (e-mail: [email protected]).
3 Department of Otolaryngology, University of Colorado, Anschutz
Medical Campus, Aurora, Colorado
4 Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas

Facial Plast Surg 2019;35:607–613.

Abstract Traumatic dental injuries affect 1 to 3% of the population, and disproportionately affect
children and adolescents. The management of these injuries incorporates the age of
patients, as children between 6 and 13 years of age have a mixed dentition. This helps to

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preserve the vitality of teeth that may be salvaged after a traumatic event. The clinical
examination of these cases involves a thorough examination of the maxilla and mandible for
associated fractures and any lodged debris and dislodged teeth or tooth fragments. The
objective is to rule out any accidental aspiration or displacement into the nose, sinuses, or
soft tissue. After ruling out any complications, the focus is on determining the type of injury
to the tooth or teeth involved. These include clinical examination for any color change in the
teeth, mobility testing, and testing for pulp vitality. Radiographic evaluation using
periapical, occlusal, panoramic radiographs, and cone beam computed tomography is
performed to view the effect of trauma on the tooth, root, periodontal ligament, and
adjoining bone. The most commonly used classification system for dental trauma is
Andreasen’s classification and is applied to both deciduous and permanent teeth. Managing
dental trauma is based on the type of injury, such as hard tissue and pulp injuries, injuries to
periodontal tissue, injuries of the supporting bone, and injuries of the gingiva and oral
mucosa. Hard-tissue injuries without the involvement of the pulp typically require restora-
tion only. Any pulp involvement may require endodontic treatment. Fractures involving the
Keywords alveolar bone or luxation of the tooth require stabilization which is typically achieved with
► trauma flexible splints. The most common procedures employed in managing dental injuries include
► tooth root canal/endodontics, surgical tooth repositioning, and flexible splinting. Recognition and
► luxation treatment of these injuries are necessary to facilitate proper healing and salvage of a
► fracture patient’s natural dentition, reducing future complications to patients.

The incidence rate of traumatic dental injuries (TDIs) is Evidence of incisal dentoalveolar trauma has been reported
approximately 1 to 3%, with the highest incidence among among one in four adults in the United States.3
12-year-old children.1 Children and adolescents report a Age is a large factor in determining an appropriate approach
disproportionally higher number of traumatic dental inju- to treatment. Most of these children will have primary teeth or
ries, approximately 18 to 20%.2 Boys tend to be at higher risk a mixed dentition of primary and permanent teeth.4 It is
of injuries compared with girls, and children who are higher important to consider the age and corresponding eruption
risk takers tend to have repeated dentoalveolar trauma. status of affected teeth.

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608 Management of Dental Injuries Reddy et al.

Fig. 1 General tooth anatomy (Dental Anatomy Section, p. 35).

Dental Anatomy Fig. 2 Panoramic radiograph demonstrating mixed dentition in an

adolescent patient (Mixed Dentition Section, p. 55 ).
Teeth are primarily composed of four dental tissues (►Fig. 1).

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Enamel, dentin, and cementum are hard or calcified tissues, ynx, oropharynx, piriform sinuses, supraglottis, glottis, and
the pulp or tooth core are composed of blood vessels, subglottis. Aspiration of teeth may require urgent rigid
connective tissue, and nerve, that is, soft or uncalcified bronchoscopy with removal of the foreign body.
tissues. Once the ABCs have been stabilized, a thorough examina-
Enamel: it is a calcified tissue covering crown of the tooth. tion should be conducted to rule out the presence of associ-
It is not composed of any living cells and requires restoration ated fractures of the maxilla and mandible. An intraoral soft
for repair. tissue examination should include assessment for the pres-
Anatomical crown: visible part of the tooth and is covered ence of mucosal laceration of the lips, tongue, palate, floor of
by enamel. mouth, and buccal mucosa and vestibule. Before any exami-
Pulp chamber: space occupied by blood vessels, connec- nation, it is advisable to thoroughly remove any debris and
tive tissue, and innervation at the center of teeth. foreign substances. Active bleeding should also be controlled.
Neck: area where the crown connects to the root. Gingival lacerations are usually associated with displaced
Dentin: calcified tissue which lies below enamel and teeth. Bleeding along the gingival crevice and marginal
cementum. Composed of microscopic tubules which are gingiva are indicative of damage to the periodontium,
thought to conduct sensations of from the tooth surface to periodontal ligament, or an underlying fracture of the man-
the pulp. dible. All teeth should be accounted for and any missing tooth
Cementum: connective tissue covering tooth and root and fragments which are not seen on clinical examination should
provides attachment to the periodontal ligament. be considered aspirated or displaced into the nasal cavity,
Periodontal ligament: connective tissue fibers connecting maxillary sinus, or adjoining soft tissues. Radiographic eval-
root surface to the tooth socket. uation of head, neck, chest, and abdomen are conducted to
eliminate the suspicion of tooth fragments displaced to these
areas.
Mixed Dentition Stage
Fractures involving the alveolar process which protrude
Mixed dentition or transitional dentition stage (►Fig. 2) is through overlying mucosa are usually self-evident. Crepita-
the time period in the dental development of children when tion and mobility of alveolar fragments on palpation can
deciduous and secondary teeth erupt into the oral cavity. indicate an underlying fracture. Fractures are also evident in
This stage typically lasts between 6 and 13 years of age.5 It the case of a previously unknown step deformity, gross
can be difficult to evaluate malocclusion in mixed dentition malocclusion, or pain on palpation of alveolar segment.
as teeth are in various stages of eruption. Developing teeth After removing debris and blood from tooth surface, a
may react unfavorably to a traumatic disturbance; prema- thorough examination of tooth structure is conducted. All
ture loss of developing teeth may lead to subsequent mis- infarctions, fractures, or cracks on the tooth surface are
alignment of permanent teeth. noted. These infarction lines can be detected using a light
beam shined parallel to the long axis of the tooth. Further
investigation into the extent of the fracture should be
Clinical Examination
undertaken, that is, whether fracture extends dentin, pulp,
Any evaluation of a trauma patient should first involve etc. A change in tooth color or translucency indicates pulp
assessing the ABCs (airway, breathing, and circulation) of exposure. Indirect fractures of the crown root in one quad-
trauma. If necessary, airway evaluation should involve a rant are usually accompanied by similar fractures in the
flexible laryngoscopy to evaluate the nasal airway, nasophar- ipsilateral jaw.

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 Management of Dental Injuries Reddy et al. 609

Displaced Teeth Types of Traumatic Dental Injuries and

While displaced teeth are usually self-evident, dental occlu- Classification
sion examination provides clues to minor degrees of tooth
movement. The most common direction of dislocation is The purpose of these classifications is to provide a universal
buccolingual.6 Lateral luxation and intrusion have fewer and comprehensive overview of dentoalveolar fractures for
clinical signs as the teeth get locked in position. Apical and communication and treatment planning. The various systems
lingual displacement of the apex of a primary tooth can of classification take into consideration multiple factors, such as
interfere with a permanent successor. etiology, anatomy, pathology, and treatment. The three most
common systems are Ellis and Davey classification (primarily
Mobility Testing developed to classify anterior teeth injuries), Sander and Andrea-
Testing for mobility should be conducted horizontally and sen’s, or the World Health Organization (WHO). Andreasen’s
axially using manual palpation or a tongue blade. If a tooth classification (►Table 1) was originally adopted by the WHO and
appears very mobile but is not displaced, a root fracture is is the most widely used in literature.8,10,11 This classification can
suspected. When multiple teeth on an alveolar segment be applied to both the deciduous and permanent dentition.
appear mobile, a dentoalveolar fracture is suspected.

Management of Traumatic Dental Injuries,

Pulp Testing
Based on Injury Type and Location
Vitality tests evaluate conduction of stimuli to sensory recep-
tors in the dental pulp. These tests can be difficult to perform Fractures involving the crown to the depth of dentin require

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and, in many cases, are unreliable in an acute trauma setting. mostly bonding. If the pulp is involved, root canal treatment is
Especially in children, the lack of reliability and false-negative typically required. Fractures to the gingival margin are
results make it an unreliable choice. The laser Doppler Flow- extracted. Injuries to the periodontium and the supporting
metry has recently been used to assess pulpal flow and alveolar structures require stabilization in younger patients.
vitality.7 Pulp testing fares better when testing several weeks Avulsion of teeth occurs due to the soft and flexible nature of
after the traumatic event 8. Others tools such as heated gutta the bone; however, the loss of teeth/avulsion in adults may also
percha tips, ice, or cold air flow can also be used.7,8 be due to alveolar fracture or poor periodontal status. Patients
with alveolar fracture are stabilized with splinting, arch bar
placement or open reduction and, internal fixation. The chal-
Radiology
lenge is inadequate space for the placement of arch bars
The objective of radiology is to evaluate the effect of injuries without damaging the teeth. In patients with poor periodontal
on the tooth, root, periodontal ligament, and status of status, no attempt is made to salvage the tooth. Dental
adjacent bone. In children they provide a further perspective implants have higher predictability in these cases. The priority
on underlying developing teeth. Viewing fractured teeth in stabilization of the tooth is primarily to salvage and main-
from multiple radiographic angles is recommended. Guide- tain the bone that would help in the placement of dental
lines suggest the following radiographic views: implants at a later time (typically 6 months).
Guidelines for managing traumatic dental injuries are
• Periapical radiograph with 90-degree angulation central
appended below:
beam for the tooth of interest.
• Periapical radiograph lateral angulations of the mesial
• Enamel infraction: an incomplete crack or fracture of the
and distal aspects of the tooth.
tooth crown with no associated symptoms or tenderness
• Occlusal view.
(►Fig. 3A). Any associated symptoms or sensitivity would
Periapical radiographs provide the most detailed view on root require further radiologic evaluation for luxation. The
fracture and teeth dislocation. Occlusal radiographs help to surface of the crack or fracture is bonded with resin to
evaluate root fractures and lateral luxation with lingual dis- prevent stains or discoloration. No follow-up is required
placement of the crown. They are also more comfortable for unless an infarction is associated with a luxation or other
patients, as they apply less pressure on the traumatized area. fracture. The tooth should continue to display root devel-
Suspected jaw fractures or alveolar ridge fractures require the opment if it is immature.
use of extraoral radiographs, such as panoramic radiograph. • Enamel fracture: it involves complete fracture of enamel
These radiographs are best suited to screen fractures of the without visible dentin exposure (►Fig. 3B). There are no
condyle, subcondylar region, and mandibular angle or body signs of tenderness or sensitivity. If present, this may be
fractures. Access to routine dental X-rays can be limited in a associated with luxation injury. Radiographs of the teeth
hospital setting and a computed tomography (CT) scan may be should also include lip and cheek to identify enamel frag-
the only means of radiographic evaluation in an acute-trauma ments. If the tooth fragment is available, it can be bonded to
setting. the fracture surface. If unavailable, restoration and contour-
Radiographic findings: displaced teeth usually appear as a ing with composite resin is recommended. Clinical and
widening of the periodontal ligament or displaced lamina dura.9 radiographic examination should occur at 6 to 8 weeks and
Extruded teeth show the appearance of a periapical radiolucen- 1 year after treatment. The fractured tooth should show
cy compatible with the shape of the apical portion of the root.9 continuous root development if it is immature.

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610 Management of Dental Injuries Reddy et al.

• Enamel–dentin fracture: the fracture is limited to dentine

the mandible
and enamel, with associated structural tooth loss; how-

Fracture of
ever, there is no pulp exposure (►Fig. 3C). On percussion,
any sign of tenderness would require evaluation for
possible luxation or root fracture injury. Pulp testing
usually provides positive results. The loss of dentin and
Root fracture

the maxillae
enamel is evident radiographically. Periapical, occlusal,
Fracture of eccentric, lip, and cheek radiographs should be taken to
identify any root fractures, tooth displacement, or tooth
fragments that are not evident on clinical examination.
Any available tooth fragment may be bonded to the tooth.
alveolar process
Fracture of the

Lack of natural tooth fragments would require restoring

Complicated
crown–root

mandibular

exposed dentin with glass ionomer cement, composite

Avulsion

resin, or any other dental restorative material. A fracture

fracture

with proximity to pulp of 0.5 mm would require placing a

calcium hydroxide base over the fractured area before
Table 1 World Health Organization Andreasen’s classification (1994): based on anatomic, therapeutic and prognostic considerations

restoring it with a dental material. Follow up at 6 to

crown–root fracture

8 weeks and 1 year is recommended to observe continued

Intrusive luxation

alveolar process

root development in children and positive response to

Uncomplicated

Fracture of the

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pulp testing. No root development and growth in decid-
maxillary

uous teeth may need endodontic treatment.

• Enamel–dentin–pulp fracture: this fracture results in
enamel–dentin loss with exposure of pulp (►Fig. 3D).
Percussion will yield tenderness, indicating underlying
Complicated-crown

luxation or root fracture. Exposure of pulp causes sensi-

Lateral luxation

tivity. Loss of dentin and enamel will be evident radio-

Fracture of the

alveolar socket

graphically. Periapical, occlusal, eccentric, lip, and cheek

mandibular

radiographs should be taken to identify any root fractures,

fracture

tooth displacements, or tooth fragments that are not

evident on clinical examination. In young patients, it is
important to preserve pulp vitality by pulp capping or
Abrasion of gingiva

partial pulpotomy. Mature teeth require endodontic

Extrusive luxation

intervention, that is, root canal treatment, pulpotomy,

Enamel–dentin

or oral mucosa
Fracture of the

alveolar socket

or pulp capping, depending on the extent of pulp expo-

maxillary

sure. Fractured crowns can be restored with dental resto-

fracture

rations or available tooth fragments can be bonded to the

fractured area. Six to 8 weeks and 1 year of follow-up is
recommended for pulp-vitality testing and observance of
Comminution of
Enamel fracture

the mandibular

continued development in deciduous teeth.

alveolar socket

gingiva or oral
Contusion of

• Crown-root fracture without pulp exposure: this fracture of

Subluxation

the tooth involves enamel, dentin, and cementum without

mucosa

pulp exposure (►Fig. 3E). The fracture can extend below

to the gingival margin. The tooth is tender on percussion;
coronal tooth fragments may be mobile. The extent of the
Comminution of

fracture to root apex may not be visible. Periapical,

alveolar socket
Laceration of
the maxillary

occlusal, and eccentric radiographs are recommended to

oral mucosa
Concussion
infraction

gingiva or

determine root fracture lines. Temporarily stabilizing

Enamel

loose segments to adjacent tooth or teeth is recom-

mended until a treatment plan is confirmed.
Injuries to dental hard

In the long term, there are multiple ways to manage

Injuries to gingiva or

crown-root fractures. The fractured fragment can be

periodontal tissue

supporting bone

removed and the apical segment can be restored until

tissue and pulp

the gingival margin. Alternatively, an osteotomy, osteoplasty,

oral mucosa
Injuries to

Injuries to

or gingivectomy can be performed to remove the fractured

fragment, followed by endodontic treatment and post and
core restoration. The tooth can be repositioned to a coronal
position and remove the fractured fragment or completely

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 Management of Dental Injuries Reddy et al. 611

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Fig. 3 Types of dental trauma. A: Enamel infarction; B: Enamel fracture; C: Enamel-dentin fracture; D: Enamel-dentin-pulp fracture; E: Crown-
root fracture; F: Root fracture; G: Alveolar fracture; H: Intrusive luxation (arrow indicates direction of axial displacement); I: Lateral luxation
(arrows indicate displacement in lingual/palatal or labial direction); J: Extrusive luxation (arrow indicates tooth mobility) (Management of
Traumatic Dental Injuries based on injury type and location Section, p. 105 ).

extract the tooth and fractured fragments and follow this injury follows the same guidelines as crown-root fracture
with implant restoration. The implant should be monitored without pulp exposure.
for stability and retention with favorable healing. If neces- • Root fracture: in root fractures, the coronal aspect of the
sary, a complete extraction followed by a bridge restoration tooth can be mobile or displaced. Tenderness on percussion
can also provide aesthetic and limited functional relief. may be present and the gingival sulcus will show bleeding.
Follow-up should be conducted in 6 to 8 weeks and up to Tooth sensation may be lost due to nerve damage and the
1 year. Ideally, the retained tooth should be asymptomatic. crown may show transient discoloration (red or gray). The
The deciduous teeth should show continued development. fracture line will be either horizontal or oblique (►Fig. 3F).
Complications following this fracture include sensitivity, Fractures of the cervical third of tooth tend to be horizontal,
nonvitality, apical periodontitis, lack of development in while fractures of the apical third are usually oblique. The
deciduous tooth, and implant failure. displaced tooth fragment should be repositioned as soon as
possible, and the repositioning should be checked radio-
• Crown–root fracture with pulp exposure: it is a fracture graphically. The tooth should be stabilized to an adjacent
involving, enamel, dentin, cementum, and exposure of tooth using a flexible splint for 4 weeks. If the fracture is
pulp chamber. The tooth is tender on percussion and more cervical, stabilization is recommended for longer (3–4
coronal segment is mobile with the extent of tooth to months). It is important to monitor healing and pulp vitality
apex not being visible. Periapical and occlusal radiographs for 1 year. Any sign of necrosis requires endodontic treat-
are recommended. The loose segment should be tempo- ment of the coronal aspect of the tooth to the fracture line.
rarily stabilized to adjacent tooth or teeth, until a treat- The tooth should show signs of repair between fractured
ment plan is confirmed. In case of open apex, pulp segments. Follow-up should occur at 4 weeks for radio-
preservation can be attempted with pulpotomy. This is graphs and splint removal, 6 to 8 weeks for clinical and
especially indicated in young patients with newly erupted radiographic evaluation, and 1 to 5 years for clinical and
permanent teeth. Long-term treatment for this type of radiographic evaluation.

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612 Management of Dental Injuries Reddy et al.

• Alveolar fracture: the fracture can extend to the alveolar • Lateral luxation: this injury is categorized by displacement
bone and adjacent bone (►Fig. 3G). Several teeth, includ- of tooth in the lingual/palatal or labial direction (►Fig. 3H).
ing the segment, will display mobility. Occlusion change The tooth is immobile on percussion and is accompanied by
may be noted due to misalignment of the fractured an ankylotic (high metallic) sound. The alveolar process is
segment. The fracture lines can be located at any level fractured and bleeding in the gingival crevice may be
compared with the marginal bone. Panoramic radio- present. A widened periodontal ligament space is present
graphs are recommended, in addition to occlusal views and best appreciated on an occlusal or eccentric radiograph.
and periapical radiographs at three angles. Cone beam CT The tooth can be repositioned using forceps or digits.
imaging is also indicated. One should reposition the Radiographs should be used to confirm disengagement
displaced segment and check for proper occlusion before from bony lock. The tooth should be splinted to the adjacent
splinting. Any gingival lacerations should be splinted. tooth with a flexible splint for up to 4 weeks. The splint is
The splinted segment should be kept stable for 4 weeks. removed at 4 weeks with clinical and radiographic exami-
After 4 weeks, splints can be removed and radiographs nation recommended at 4 weeks, 8 weeks, 6 months, and
taken. Clinical and radiographic follow-up should contin- 1 year, followed by yearly follow-up for 5 years. Any signs of
ue for 4 months, 6 months, 1 year, and 5 years. Teeth pulp necrosis would indicate endodontic treatment.
should show response to sensory testing. • Extrusive luxation: here, the tooth is significantly mobile
• Concussion: tapping or percussion of tooth results in and appears elongated (►Fig. 3J). Bleeding in the gingival
tenderness; however, there are no signs of mobility or crevice may be present. An apical radiograph shows an
displacement. These injuries do not usually require treat- increase in periodontal ligament space in the apex. The

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ment, though observing pulp condition requires follow- tooth should be gently repositioned in the tooth socket
up for 1 year. Radiographic and clinical examination and radiographically confirm repositioning. A flexible
should occur at 4 weeks, 8 weeks, and 1 year. splint should be attached to adjacent teeth for 2 weeks.
• Subluxation: tenderness on tapping or percussion will be Any pulpal necrosis in permanent teeth will require
noted. There will be increased mobility but no displace- endodontic treatment. The splint should be removed at
ment. This is typically accompanied with bleeding from 2 weeks and clinical and radiographic examination should
gingival crevice. Transient pulpal damage can also be occur at 2 weeks, 4 weeks, 8 weeks, 6 months, and 1 year,
present. Usually, no radiographic findings are visible. followed by yearly follow-up for 5 years. Radiographs
The injury may not require treatment; however signifi- should show healed periodontium. The marginal bone
cant mobility requires splinting to an adjacent tooth for 1 height should correspond to height after repositioning.
to 2 weeks. If a splint is placed, it may be removed after
Procedures in Traumatic Dental Injury
2 weeks. Clinical and radiographic examination should
Management
occur at 2, 4, 8 weeks, 6 months, and 1 year.
• Intrusive luxation: the tooth is displaced into the alveolar Endodontic treatment/root canal: endodontic treatment is
bone axially (►Fig. 3H). The tooth will be immobile and necessary for inflamed or infected teeth to prevent future
produces an ankylotic sound (high metallic) upon percus- complications. Traumatic injuries to the tooth pulp may be
sion. Bleeding may be present on the gingival crevice, and unnoticed clinically, but are associated with acute pain, and
the tooth may appear more apically placed or sunken can develop into an abscess. Root canals and associated pulp
compared with adjacent teeth. The periodontal ligament chambers are hollow structures within teeth and house
space may be absent along all or part of the root. The dental innervation and blood supply. Endodontic treatment
cementoenamel junction is located more apically to adja- removes these structures to shape, clean, and decontami-
cent teeth and at some angles to the marginal bone. In nate these hollow areas using files, irrigating solutions, and
younger patients with deciduous teeth, a tooth with in- obturating fillings.
complete root formation should be allowed to erupt with- Surgical tooth repositioning: in surgical tooth reposition-
out intervention. If no natural movement is seen, ing, the following two basic techniques are employed: tip-
orthodontic repositioning is indicated. In cases of intrusion ping and bodily movement relative to the alveolar process.
greater than 7 mm, the tooth should be surgically reposi- The objectives are to move the tooth into a more desirable
tioned. For permanent teeth, less than 3 mm of intrusion position and maintain pulp vitality. Movement of the tooth
should be allowed to erupt naturally. If no movement is apex should be very limited. Newly erupted teeth with a wide
observed for 2 to 4 weeks, one should surgically or ortho- apical foramen tolerate repositioning most favorably.12 The
dontically reposition teeth before ankyloses develops. In- application of the following criteria increase the likelihood of
trusion at or beyond 7 mm should be surgically success with surgical repositioning:
repositioned, followed by flexible splinting to an adjacent
tooth for an additional 4 to 8 weeks. Most teeth will require • Root length: greater success has been achieved when a
endodontic therapy as pulpal necrosis is highly likely. Splint root length of half or more has grown before surgical
removal is indicated at 4, 6, or 8 weeks, accompanied by repositioning. If an adequate root length is not present,
clinical and radiographic examination for up to 1 year. the root grows in length only to a certain extent.
Yearly follow-up for 5 years are recommended, monitoring • Root parallelism: moving the apical portion of the tooth
that a tooth retains its corrected position. too distal increases the likelihood of pulpal death and

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 Management of Dental Injuries Reddy et al. 613

ankylosis. Panoramic radiographs provide the best guides Funding

to achieve parallelism. Authors have no financial interests to disclose.
• Occlusion: maintaining occlusal contact between reposi-
tioned tooth and opposing teeth provides better results Conflicts of Interest
and reduces the likelihood of ankylosis. Any delay in Authors have no conflicts of interest to disclose.
eruption of the repositioned tooth may cause the oppos-
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