dental trauma dental trauma dental trauma refers to trauma (injury) to the teeth and/or periodontium (gums, periodontal ligament, alveolar bone), and nearby soft tissues such as the lips, tongue, etc. the study of dental trauma is called dental traumatology. dental traumaa broken upper front tooth. the layers of tissue that make up the tooth are clearly visible, with the pink pulp standing out against the paler dentine and tooth enamel.specialtyoral and maxillofacial surgery types root fracture simple mandible fracture dental injuries dental injuries include: enamel infraction enamel fracture enamel-dentine fracture enamel-dentine fracture involving pulp exposure root fracture of tooth periodontal injuries concussion (bruising) subluxation of the tooth (tooth knocked loose) luxation of the tooth (displaced) extrusive intrusive lateral avulsion of the tooth (tooth knocked out) injuries to supporting bone 3d ct of mandible fracture. this injury involves the alveolar bone and may extend beyond the alveolus. there are five different types of alveolar fractures: communicated fracture of the socket wall fracture of the socket wall dentoalveolar fracture (segmental) fracture of the maxilla : le fort fracture, zygomatic fracture, orbital blowout fracture of the mandible trauma injuries involving the alveolus can be complicated as it does not happen in isolation, very often presents along with other types of tooth tissue injuries. signs of dentoalveolar fracture: change to occlusion multiple teeth moving together as a segment and are normally displaced bruising of attached gingivae gingivae across the fracture line often lacerated investigation: require more than one radiographic view to identify the fracture line. treatment: reposition displaced teeth under local anaesthetic and stabilise the mobile segment with a splint for 4 weeks, suture any soft tissue lacerations. soft tissue laceration facial nerve branches. facial nerve should be examined for any potential damage when buccal mucosa is involved. soft tissues injuries are presented commonly in association with dental trauma. areas normally affected are lips, buccal mucosa, gingivae, frenum and tongue. the most common injuries are lips and gingivae. for lips, important to rule out presence of foreign objects in wounds and lacerations through careful examination. a radiograph can be taken to identify any potential foreign objects. gingivae lacerations that are small normally heals spontaneously and do not require any intervention. however, this can be one of the clinical presentation of an alveolar fracture. gingivae bleeding especially around the margins may suggest injury to the periodontal ligament of the tooth. the facial nerve and parotid duct should be examined for any potential damage when the buccal mucosa is involved. deep tissue wounds should be repaired in layers with sutures that are resorbable. primary teeth trauma to primary teeth occurs most commonly at the age of two to three years, during the development of motor coordination. when primary teeth are injured, the resulting treatment prioritises the safety of the adult tooth, and should avoid any risk of damaging the permanent successors. this is because the root apex of an injured primary tooth lies near the tooth germ of the adult tooth. therefore, a displaced primary tooth will be removed if it is found to have encroached upon the developing adult tooth germ. if this happens, parents should be advised of possible complications such as enamel hypoplasia, hypocalcification, crown/root dilaceration, or disruptions in tooth eruption sequence. potential sequelae can involve pulpal necrosis, pulp obliteration and root resorption. necrosis is the most common complication and an assessment is generally made based on the colour supplemented with radiograph monitoring. a change in colour may mean that the tooth is still vital but if this persists it is likely to be non-vital. dental injuries dental injury clinical findings radiographic findings treatment follow-up 1) enamel infraction a crack in enamel with no loss of tooth structure tooth is not tender no abnormalities generally no treatment needed discolouration of prominent cracks can be prevented by etching and sealing with resin no follow-up required 2) enamel fracture fracture involving enamel only tooth not tender with normal mobility and pulpal response loss of enamel may need lip or cheek x-ray to locate tooth fragments or other materials if available, tooth fragment can be bonded back onto the tooth if not available, tooth can be restored with composite resin 6–8 weeks: clinical and radiographic examination 1 year: clinical and radiographic examination 3) enamel-dentine fracture fracture involving both enamel and dentine without pulp exposure tooth not tender with normal mobility and pulpal response loss of enamel and dentine may need lip or cheek x-ray to locate tooth fragments or other materials if available, tooth fragment can be bonded back onto the tooth if not available, tooth can be restored with composite resin if dentine is within 0.5mm of the pulp, calcium hydroxide placed and covered with glass ionomer 6–8 weeks: clinical and radiographic examination 1 year: clinical and radiographic examination 4) enamel-dentine-pulp fracture fracture involving enamel and dentine with pulp exposure tooth not tender with normal mobility exposed pulp will be sensitive to stimuli loss of enamel and dentine may need lip or cheek x-ray to locate tooth fragments or other materials in developing teeth, preserve pulp vitality by pulp capping or partial pulpotomy using calcium hydroxide in mature teeth, root canal treatment is usually performed 6–8 weeks: clinical and radiographic examination 1 year: clinical and radiographic examination 5) crown-root fracture without pulp involvement fracture involving enamel, dentine and cementum without pulp exposure fracture extends below the gum margin tender tooth with mobile crown fragment fracture line extending down the root may not be visible emergency: aim is to stabilise the loose fragment by splinting it to adjacent teeth non-emergency: removal of loose fragment (following gingivectomy, surgery or via orthodontics), root canal treatment and restoration with post-retained crown in extreme cases (such as a vertical fracture), tooth may need to be extracted 6–8 weeks: clinical and radiographic examination 1 year: clinical and radiographic examination 6) crown-root fracture with pulp involvement fracture involving enamel, dentine and cementum with pulp exposure tender tooth with mobile crown fragment fracture line extending down the root may not be visible emergency: aim is to stabilise the loose fragment by splinting it to adjacent teeth in developing teeth, preserve pulp vitality by pulp capping or partial pulpotomy using calcium hydroxide in mature teeth, root canal treatment is usually performed non-emergency: removal of loose fragment (following gingivectomy, surgery or via orthodontics), root canal treatment and restoration with post-retained crown in extreme cases (such as a vertical fracture), tooth may need to be extracted 6–8 weeks: clinical and radiographic examination 1 year: clinical and radiographic examination 7) root fracture mobile or displaced crown segment tender tooth that may be bleeding from the gum tooth may be discoloured (red or grey) fracture line involving the root will be seen as well as the direction if displaced, reposition tooth and check the position with an x-ray flexible splint used to stabilise tooth for at least 4 weeks and then reassess tooth stability monitor healing for at least 1 year to assess the status of the pulp root canal treatment will be needed if pulp necrosis develops (this occurs in ~20% of root fractures²) 4 weeks: splint removal, clinical and radiographic examination 6–8 weeks: clinical and radiographic examination 4 months: splint removal in cervical third fractures, clinical and radiographic examination 6 months: clinical and radiographic examination 1 year: clinical and radiographic examination 5 years: clinical and radiographic examination periodontal injuries periodontal injury clinical findings radiographic findings treatment follow-up 1) concussion tender tooth with no displacement and normal mobility no abnormalities no treatment required 4 weeks: clinical and radiographic examination 6–8 weeks: clinical and radiographic examination 1 year: clinical and radiographic examination 2) subluxation tender tooth with no displacement but increased mobility may be bleeding from the gum no abnormalities usually no treatment required can use a flexible splint to stabilise the tooth for up to 2 weeks 2 weeks: splint removal, clinical and radiographic examination 4 weeks: clinical and radiographic examination 6–8 weeks: clinical and radiographic examination 6 months: clinical and radiographic examination 1 year: clinical and radiographic examination 3) extrusion tooth looks longer and is very mobile periodontal ligament space is increased apically tooth is repositioned gently in the socket tooth stabilised with a flexible splint for 2 weeks signs and symptoms of pulp necrosis indicates the need for root canal treatment to prevent root resorption 2 weeks: splint removal, clinical and radiographic examination 4 weeks: clinical and radiographic examination 6–8 weeks: clinical and radiographic examination 6 months: clinical and radiographic examination 1 year: clinical and radiographic examination yearly 5 years: clinical and radiographic examination 4) lateral luxation tooth is displaced, most commonly towards the roof of the mouth/tongue or the lip tooth will be immobile tapping on the tooth will give a high-pitched, metallic (ankylotic) sound alveolar process fracture periodontal ligament space is widened reposition the tooth using fingers or forceps to remove its "bony lock" and gently reposition it in the socket tooth stabilised with a flexible splint for 4 weeks signs and symptoms of pulp necrosis indicates the need for root canal treatment to prevent root resorption 2 weeks: clinical and radiographic examination 4 weeks: splint removal, clinical and radiographic examination 6–8 weeks: clinical and radiographic examination 6 months: clinical and radiographic examination 1 year: clinical and radiographic examination yearly for 5 years: clinical and radiographic examination 5) intrusion tooth is displaced into the alveolar bone tapping on the tooth will give a high-pitched, metallic (ankylotic) sound absence of periodontal ligament space from part or entirety of the root cemento-enamel junction appears more apically for the traumatised tooth if incomplete root formation: allow time for tooth to naturally erupt but if no movement after a few weeks then start orthodontic repositioning intruded >7mm: surgical or orthodontic repositioning stabilise with flexible splint for 4 weeks after repositioning if complete root formation: intruded <3mm: allow time for natural eruption but if no movement after 2–4 weeks then reposition surgically or orthodontically intruded 3-7mm: surgical or orthodontic repositioning intruded >7mm: surgical repositioning likelihood of pulpal necrosis in these teeth so root canal therapy with temporary calcium hydroxide filling in first instance and start root canal treatment 2–3 weeks after repositioning stabilise with flexible splint for 4 weeks after repositioning 2 weeks: clinical and radiographic examination 4 weeks: splint removal, clinical and radiographic examination 6–8 weeks: clinical and radiographic examination 6 months: clinical and radiographic examination 1 year: clinical and radiographic examination yearly for 5 years: clinical and radiographic examination 6) avulsion tooth completely removed from socket radiograph required to ensure that missing tooth is not intruded for information on first aid procedures for avulsed teeth, see “management” section of this page treatment will depend on whether the tooth has an open or closed apex and how long the tooth has been out of the mouth prior to dental clinic arrival (see dental trauma guide for full treatment details) 4 weeks: splint removal, clinical and radiographic examination 3 months: clinical and radiographic examination 6 months: clinical and radiographic examination 1 year: clinical and radiographic examination yearly risk factors age, especially young children primary dentition stage (2–3 years old, when children's motor function is developing and start learning how to walk/ run) mixed dentition stage (8–10 years old) permanent dentition stage (13–15 years old) male > female season (many trauma incidents occur more in summer compared to winter) sports, especially contact sports such as football, hockey, rugby, basketball and skating piercing in tongue and lips military training acute changes in the barometric pressure, i.e. dental barotrauma, which can affect scuba divers and aviators class ii malocclusion with increased overjet and class ii skeletal relationship and incompetent lips are the significant risk factors prevention prevention in general is relatively difficult as it is nearly impossible to stop accidents from happening, especially in children who are quite active. regular use of a gum shield during sports and other high-risk activities (such as military training) is the most effective prevention for dental trauma. they are mainly being fitted on the upper teeth as it has higher risk of dental trauma compared to the lower teeth. gum shields ideally have to be comfortable for users, retentive, odourless, tasteless and the materials should not be causing any harm to the body. however, studies in various high-risk populations for dental injuries have repeatedly reported low compliance of individuals for the regular using