Managing dental trauma

Feb. 12, 2014
Accidents will happen! Improving treatment outcomes in traumatic dental injuries is partially dependent on our ability to assess the situation and render the appropriate care. Dr. Stacey Simmons goes through several of her own cases and suggests protocols for each.

Accidents happen! It is inevitable that all of us will encounter and treat dental trauma. These situations can be a challenge because these patients are in pain, they are scared, nervous, and they need you — NOW! You as a provider realize the immediate demand of your time, and you are also well aware of your already full schedule and commitments.

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Improving treatment outcomes in traumatic dental injuries is partially dependent on our ability to assess the situation and render the appropriate care. Although each situation is unique, there are protocols that can be used as a guideline to help us determine the appropriate course of action.

Here are some general recommendations:

Classify the dental injury — i.e., enamel fracture, crown fracture with or without pulpal involvement, root fracture luxation (concussion, subluxation, lateral, extrusive and intrusive), avulsion, and fracture of the alveolar process.

Do a thorough assessment that includes history of the injury, TMJ evaluation, radiograph and neurological exam, and occlusal assessment.

Perform immediate treatment goals: control bleeding and pain, preserve pulp vitality (especially in immature permanent teeth), and preserve PDL cell vitality

Assess the need for splinting, which is dependent on the nature of the injury (approximations)

a.Root fracture — 3 months

b.Alveolar process fracture — 6-8 weeks

c.Luxation — 2-3 weeks. If alveolar is involved, then 6-8 weeks

d.Avulsion — 2-4 weeks

Definitive treatment protocols depend a great deal on what happens over the course of time once the initial treatment goals are completed. Depending on the nature of the injury and condition of the apex, a follow-up appointment with the patient is mandatory to allow for an assessment to determine whether or not calcium hydroxide therapy should be initiated. Long-term complication considerations include ankylosis, arrested alveolar process growth, and inflammatory root resorption. A frequent recall should be established to assess for these and other possibilities.

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Case reports

A healthy 7-year-old female presented directly from school with her father stating that she fell off the monkey bars. This was her first visit to the dentist. Initial exam revealed that tooth No. 8 was partially avulsed (Fig. 1) with only a slight attachment to the gingiva. All other teeth appeared clinically normal. Radiograph assessment revealed a large open apex on No. 8. The patient was given a local. The clot was removed and the area irrigated with a saline rinse. Next, the tooth was gently repositioned in the socket with slight compression of facial and lingual alveolar processes. A nonresilient wire splint was placed from NOs. 7 through 9. The patient was given an Rx of antibiotics for potential infection. A one-week assessment revealed a significant decrease of swelling with No. 8 appearing fairly stable. After eight weeks, tooth No. 8 had a slight delay to cold testing with all other teeth testing normal. The splint was removed. It was discussed with the father that the delayed response could be attributed to the healing of pulp or potential pathology. A two-month follow-up was recommended.

Fig. 1 A hit on the front tooth with a baseball is what brought this healthy 8-year-old male to the office. He had a lacerated maxillary lip that was bleeding and swollen; he furthermore indicated that he had severe pain on his front tooth (he pointed to No. 8). Clinical exam showed Class II mobility of No. 8 (Fig. 2) with apparent intact alveolar process. The radiograph revealed a normal, open apex and a horizontal root fracture at the junction of the coronal and middle third of the root. Local was delivered and the tooth was stabilized and splinted with a one-week recommended follow-up. At this appointment one week out, the tooth tested normal and it was advised that we continue monitoring the tooth since it had a favorable chance of healing due to the immature apices. The patient was placed on a recall regime to monitor progress.
Fig. 2 A healthy 33-year-old male presents directly from the ER. He was hit with a jackhammer and sustained an injury to tooth No. 11. The clinical exam revealed soft tissue swelling with Class II mobility to No. 11. (Fig. 3) The fulcrum for this mobility originated just below the gingiva. There was also a slight depression of the alveolar process from the buccal. The radiograph revealed a horizontal fracture on the coronal portion of tooth No. 11. Due to the location of the break, it was recommended that the patient have the tooth removed with a follow-up to assess restorative options and comprehensive care.
Fig. 3 A 38-year-old female presented with trauma to her front tooth from a skiing accident. The clinical exam revealed a swollen lower lip and with tooth No. 9 (Figs. 4 and 5) having been luxated lingually approximately 3mm. It was solid in its current position. She could not bite down and was in relatively little pain. The radiograph showed a widened PDL at the apex of the tooth. Local was delivered and the tooth was repositioned. It was splinted with a follow-up recommended in three weeks to assess for pulpal vitality and possible initiation of pulpal therapy with calcium hydroxide.
Fig.4Fig. 5
Dr. Stacey Simmons grew up in Hamilton, Mont. She did part of her undergraduate work at Purdue University and then received her bachelor’s degree in exercise physiology from the University of Utah. After applying to both medical and dental school, she decided that dentistry was her career of choice. She received her DDS degree from Marquette University School of Dentistry in Milwaukee, Wisc., in 2004. In private practice, she focuses her care on prosthodontics and cosmetic dentistry. She is a guest lecturer in the Anatomy and Physiology Department at the University of Montana. Outside the office, she trains for triathlons and spends time with her family.