4.14 Dental Trauma 
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(fracture, subluxation and displacement)
agk's Library of Common Simple Emergencies

Presentation
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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 bleeding.
- 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 stoma- 
   hesive 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 analges- 
   ics as needed.
- Minimally subluxed (loosened) teeth may 
   require no emergency treatment. 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, or neck.

Discussion
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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 micro- 
organisms. 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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