Management of Dental Injuries and Reimplantation of an Avulsed Tooth

CHAPTER 81 Management of Dental Injuries and Reimplantation of an Avulsed Tooth

Dental trauma, ranging from a slight chip of the enamel to avulsion of a tooth, causes some of the most common injuries to the face. An occlusive misadventure (e.g., biting a hard object or a seizure) or a blow to the face can cause dental trauma. Up to 10% of emergency department visits are due to dental trauma. Injuries to the maxillary central incisors account for 70% of dental injuries, subluxations account for about 50% of injuries to the teeth, and up to 5 million avulsions occur annually in the United States. It is estimated that 50% of children will experience dental trauma. Management depends on the age of the patient and the nature of the injury. Often, the primary care clinician is the first to evaluate such an injury. Occasionally, the clinician will receive a phone call from a patient requesting guidance after a fracture, subluxation, luxation, or avulsion has occurred. Proper management of dental trauma may minimize pain and disfigurement. For example, knowledge of proper storage and treatment of an avulsed tooth is crucial to optimize the chances of successful reimplantation.

NOTE: If a tooth or portion of a tooth is missing and it cannot be unequivocally located by history or physical examination, attempts should be made to locate it with radiographs. Facial films may find it in a maxillary sinus (which may necessitate surgery), a chest radiograph may document that it has been aspirated (requiring bronchoscopic retrieval), or abdominal films may document that it has been swallowed. Also, with a luxation or avulsion, care should be taken to determine whether a tooth is primary (i.e., deciduous, milk, temporary) or permanent in children because it may change the management (Fig. 81-1). This determination may be tricky in children between the ages of 6 and 12 years who may have “mixed” dentition. In addition, patients (parents) should be aware that it may not always be possible to detect the presence or extent of a dental fracture with the initial examination and radiographs. Root fractures (although rare), which may require extensive dental care, are notorious for avoiding detection by radiography; they may be diagnosed only later by radiography, as they are healing.

Figure 81-1 The normal eruptive patterns of primary and permanent teeth. Extra or fewer teeth are common in both types of teeth.

(Redrawn from Upadhye S, Ross DJ: Fractures tooth management. In Reichman EF, Simon RR [eds]: Emergency Medicine Procedures. New York, McGraw-Hill, 2004, pp 1397–1402.)

Management of a dental fracture is based on the extent of the fracture (Fig. 81-2) and the age of the patient. Ellis I fractures involve only the enamel of the tooth. They may be a mere “chip” off of the tooth. Management is necessary only if a resultant sharp edge is disturbing the adjacent soft tissues. In that case, a nail file (emery board) can be used to file down the edge. Referral can be made to a general dentist for cosmetic restoration. Patients or parents may appreciate being reassured that the tooth can usually be restored to its natural appearance with the use of enamel-bonding plastic materials.

Figure 81-2 Ellis classification for fractures of anterior teeth.

(From James DM: Immediate management of tooth fracture and avulsion. In James DM [ed]: Field Guide to Urgent and Ambulatory Care Procedures. Philadelphia, Lippincott Williams & Wilkins, 2001, pp 36–39.)

Ellis II fractures, which account for 70% of tooth fractures, not only involve the enamel but also expose the dentin layer, which has a creamy- or ivory-yellow color compared with the white enamel. Beneath the dentin lies the pulp, which continually lays down dentin for the life of the tooth, and the goal of emergency management is to maintain the vitality of this pulp. Patients usually complain of sensitivity to hot, cold, or even air passing over the exposed surface when breathing. They should be warned that any trauma to a tooth may lead to pulpal necrosis or tooth resorption, regardless of management, and that dental referral is required within 24 hours. Patients younger than 12 years of age have less dentin, so there is usually less discomfort. However, because dentin is a microtubular structure that can allow bacteria to penetrate the pulp, tooth fractures in children and adolescents involving the dentin are more serious because the pulp is more likely to be contaminated. Fortunately, this age group also has much greater pulpal regenerative ability. Early treatment may prevent contamination of the pulp and the need for subsequent root canal, so a pediatric or general dentist should be notified right away. For patients older than 12 years of age, because they have more dentin and less pulp, referral can be made for the next working day. Regardless of age, warming the sterile saline before flushing may decrease temperature sensitivity. A thin layer of a protective dressing that is also a sedative to the pulp (e.g., calcium hydroxide paste or zinc oxide with eugenol; see Suppliers section), or even toothpaste, should be applied with a small applicator. The exposed dentin should be covered and then the paste covered with a dry gauze. To maintain a dry field while working, cotton gauze or rolls can be placed on either side of the tooth. Patients older than 12 years of age should then be advised to avoid extremes of intraoral temperatures. A piece of dental foil or aluminum foil placed over the paste-covering gauze may provide additional protection from discomfort associated with temperature extremes until the dentist can see the patient. If available, instead of gauze, three to four coats of dental varnish (see Suppliers section) or clear nail polish can be painted over the paste. Allow time to dry between coats; this may help protect against temperature extremes.

Ellis III fractures expose the pulp of the tooth. Again, because there is more pulp relative to dentin in children, fractures involving the pulp are more common in children. Pulp can easily be distinguished from dentin because exposed pulp produces a red blush or a drop of blood when brushed with sterile gauze. These fractures are a dental emergency, and the usual treatment is removal of the pulp (pulpotomy). Significant delay in care can lead to long-term pain and abscess formation. The clinician should not attempt to probe the pulp or remove any material; instead, the affected area should be covered with aluminum foil, adequate analgesia should be provided, and oral antibiotics effective for mouth flora should be prescribed. Such a fracture can cause considerable pain, so a dental anesthetic nerve block may be appreciated. The patient should then consult a dentist immediately because definitive treatment for all but the smallest pulpal exposures is endodontic or root canal therapy. If a dentist will not be available, bleeding can be stopped by dripping dilute epinephrine (or lidocaine with epinephrine) over the site. Injection of lidocaine with epinephrine around the tooth also often provides hemostasis. If unsuccessful, pressure can be applied with a saline-moistened, sterile cotton-tipped applicator. It may take 3 to 5 minutes for hemostasis. A thick coat of calcium hydroxide or zinc oxide with eugenol paste can then be applied to the tooth and an adjacent tooth (for stability), making sure that it is not so thick as to interfere with occlusion. If a dentist is not available, a minimal Ellis III fracture (<1 to 2 mm pulp exposure) can be treated as an Ellis II fracture and followed up by a dentist in 24 hours, although this alternative is less than ideal.

Teeth are held in place by surrounding periodontal membrane fibers and ligaments, a fragile cell layer lining the root known as the cementum, and alveolar bone (Fig. 81-3). These structures combined are known as the attachment apparatus. The crown is the hard enamel portion of the tooth located above the gum line. With trauma, periodontal fibers and the attachment apparatus may be concussed (Fig. 81-4), a tooth may be subluxed (ligaments damaged) or luxated (dislocated) extrusively, intrusively, or laterally, or an entire tooth may be avulsed (Fig. 81-5). Concussion is defined as injury to the tooth, and although the tooth will be tender to palpation, there will be no increased mobility. The radiograph will be negative. If examination of the surrounding gingiva reveals blood, there has also usually been ligamentous damage, which is confirmed if the tooth can be wiggled. Ligamentous damage can be caused by subluxation or luxation, with subluxation resulting in a loose tooth that may or may not be sensitive to touch. Extrusive luxation results in a misaligned, loose tooth that is often elevated above those bordering it. The patient frequently complains of malocclusion because this tooth contacts the opposing teeth early when chewing. Intrusive luxation is a more severe form of luxation in which the tooth is driven into the alveolar bone. With primary teeth, this process can cause damage to the permanent tooth bud. Depending on the force involved, the tooth can even be driven into the maxillary sinus and appear avulsed. If intrusive luxation is suspected and the tooth is not visible, a radiograph may be needed to locate the tooth. Although an extrusive luxation is the result of a partial avulsion or dislodgment of the tooth, there is no fracture, so the radiograph will be negative. Lateral luxation is the result of an alveolar bone fracture with lateral displacement of the tooth in the mesial, distal, buccal, or lingual direction. A radiograph should confirm the fracture.