Dental and dentoalveolar injuries are common in the pediatric population. Management is predicated on the type of tooth injured (primary or permanent), extent of injury, the dental and behavioral age of the patient, and ability of the patient to tolerate treatment. Although many dental injuries occur in isolation, a systematic evaluation of the patient is mandatory to confirm the absence of basal bone fractures of the maxilla or mandible, traumatic brain injury, cervical spine injury, and/or facial soft tissue injury. Long-term follow-up is paramount to achieving a functional occlusion and optimal dental health following injury.
Key points
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Growth and development of the dentition and dental arches is critical to achieving optimal masticatory function and facial proportions.
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Injuries to the developing dentition merit prompt attention to determine the best management, based on the type of tooth injured (primary or permanent), dental age and development, chronologic age, and developmental age.
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Injuries to the primary teeth are typically managed by observation.
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Injuries to the permanent teeth may require more extensive interventions, based on time elapsed between injury and evaluation, type and extent of injury, and root maturity; all factors should be considered in the context of the patient’s ability to cooperate for dental treatment.
Introduction
Traumatic dental and dentoalveolar injuries occur frequently in children and young adults. Although the oral cavity only represents 1% of the total body, injuries involving the oral cavity comprise 5% of all traumatic injuries. The oral cavity is the second most common area of injury in children 0 to 6 years of age. Approximately one-third of all adults have experienced permanent tooth trauma, most of which occurs by 19 years of age. The most commonly injured teeth are maxillary incisors, which encompass 84% of primary tooth and 87% of permanent tooth injury. Proper management of dental and dentoalveolar injuries is imperative to ensure the most favorable long-term outcome ( Fig. 1 ). The information in this review uses the evidence-based guidelines set forth by the International Association of Dental Traumatology. The International Association of Dental Traumatology has a free app, “ToothSOS,” which presents information to the public and to professionals about what to do after a dental injury.
A thorough history must be completed for any traumatic dental injury (TDI), including a basic assessment of airway, breathing, circulation, disability, and exposure, in accordance with Advanced Trauma Life Support parameters. Components include the time and place of injury, method of injury, potential for contamination of the injured structures, whether the injury was witnessed, and immediate interim management of the injury. Keep in mind that a young child is often unable to give a reliable history of the trauma event. As the clinician moves from the history to clinical evaluation, it is important to consider if the clinical findings are consistent with the history. If there is a concern for intentional injury or abuse, local protocols should immediately be followed.
Critical items to address in the clinical evaluation are: identification of injured structures, type of management indicated, patient’s ability to cooperate for the dental treatment, and recognition if a delay of hours or days before dental treatment will compromise the outcome. Comprehensive extraoral and intraoral examinations should identify all hard and soft tissue injuries, including head injuries, fractures of the facial skeleton and/or alveolar processes, fractures or absence of teeth, alterations in occlusion, and any soft tissue lesions. Examination of the soft tissue should include an assessment for any embedded tooth fragments or other debris.
Extraoral and intraoral photographs are recommended during the initial examination to establish a baseline. Radiographic imaging should also be considered as appropriate for the type of injury, ability of the patient to cooperate for imaging, and radiographic resources available. Pulp sensibility tests are not recommended in primary teeth because they are not typically diagnostic; however, such tests should be considered in the permanent dentition. Tooth position, displacement, mobility, integrity of crown, color, and tenderness to palpation and/or percussion should also be recorded.
It is difficult to meet a patient for the first time when they have suffered a dental injury. It is important to add kindness and compassion to the provision of evidence-based treatment of TDI. Research into the cause of child dental fears has found that objective dental experiences play a minor role in fear acquisition, whereas subjective dental experiences seem to play the more decisive role.
Special considerations for primary teeth
As children become more mobile, TDIs most commonly result from accidental falls, impacts, and recreational activities. , These injuries occur most often between the ages of 2 and 6 years. Oftentimes, a TDI may result in a child’s first dental visit and addressing potential anxiety of children and families is important. It may be helpful to examine uncooperative or precooperative children in a knee-to-knee position ( Fig. 2 ). These children should also be connected with a pediatric-oriented care team that offers the option of sedation or other behavior management techniques, additional treatment services if needed, and long-term follow-up.
The buds of developing permanent teeth develop in close proximity to the apex of primary tooth. Trauma to a primary tooth may result in malformed, discolored, delayed, or impacted permanent successor teeth ( Fig. 3 ). , Although the most common TDIs in the primary dentition are luxation injuries, intrusion and avulsion injuries of the primary dentition are most associated with development differences in permanent teeth. The most serious complications occur when the child is younger than 2 years at the time of injury and with intrusion injuries.
Unless there is an aspiration or ingestion risk, significant displacement of soft tissues ( Fig. 4 ), a fractured tooth with a sharp edge that will cut the tongue or lip, or an occlusal interference where the teeth do not fit together, observation is typically the most appropriate choice during an emergency situation involving primary teeth. For all primary TDI, parents/guardians should be instructed to: minimize further trauma to the area while supporting a return to normal function, provide a soft diet, and assist the child in cleaning the traumatized area with a soft toothbrush or a 0.1% to 0.2% alcohol-free chlorhexidine mouth rinse on a cotton swab two times a day for 1 week to minimize plaque accumulation and help facilitate healing.
Special considerations for permanent teeth
The most common TDIs in the permanent dentition are crown fractures ( Fig. 5 ; see Fig. 10 ). Preservation of pulp vitality in fractured immature permanent teeth allows root development to continue, improving chances of its long-term survival. Losing a permanent tooth at any age is impactful, but losing a permanent tooth at a young age creates an additional burden when alveolar growth is affected and a malocclusion is created in an esthetic zone. As such, every attempt should be made to save the tooth.
Of all TDIs, avulsion of a permanent tooth is the most devastating. Prognosis is time-dependent; viability of the periodontal ligament (PDL) cells on the surface of the avulsed tooth root and maturity of the root determine tooth survival. Patients and parents/guardians should be advised to minimize additional trauma to the area while supporting a return to normal function. Optimal home care decreases the bioburden and promotes favorable healing; the patient should be meticulous with oral hygiene and rinse with a 0.1% to 0.2% alcohol-free chlorhexidine solution or apply the solution on a cotton swab two times a day for 1 week to minimize plaque accumulation and help facilitate healing.
Fractures of the teeth
Fractures of the teeth include crown fractures, crown-root fractures, and root fractures. Determining the type and extent of a fracture through clinical and radiographic examination can help guide emergent and future treatment options.
Crown Fractures
Fractures involving the crown encompass 26.2% to 44.1% of all dental injuries. Crown fractures are categorized either as uncomplicated or complicated. Uncomplicated crown fractures are enamel fractures or enamel-dentin fractures with no exposure of the pulp; complicated crown fractures involve enamel and dentin with exposure of the dental pulp ( Fig. 6 ; see Fig. 10 ).
Crown fractures do not usually present with discomfort to palpation or percussion. In the case of tenderness, crown fractures should be assessed for luxation or root fracture injuries. For any fracture involving the crown, one must evaluate for loose or missing tooth fragments. For missing tooth fragments in the setting of soft tissue injuries, radiographs should be taken to search for the fragments or any other foreign materials (including of the lip). The exposed pulp in complicated crown fractures are sensitive to stimuli, such as cold air.
In primary teeth, a baseline radiograph is optional if the pulp is not exposed. If only the enamel is fractured, any sharp edges may be smoothed. For enamel-dentin fractures, the exposed dentin should be covered with glass ionomer or composite. Missing tooth structure is restored at the initial visit or at a follow-up appointment, if needed.
In permanent teeth, at least one periapical radiograph should be considered for any crown fractures to evaluate proximity to the nerve or to determine if any root fractures have occurred. Additional radiographs should be considered in the setting of any other clinical signs or symptoms. In some cases, recovered tooth fragments of fractured permanent teeth may be bonded back to the tooth. Tooth fragments are rehydrated in water or saline for 20 minutes before reattachment. If tooth fragments cannot be found or saved, fractured edges are smoothed and restored with composite resin. For fractures within 0.5 mm of the pulp, a pink hue in the absence of frank bleeding is often visible in the fracture area. In these cases, calcium hydroxide or mineral trioxide aggregate may be placed on the dentin as a liner and covered with a glass ionomer or a similar material.
For complicated crown fractures in primary teeth, treatment depends on the child’s ability to cooperate for dental treatment. A radiograph should be taken. Ideally, the pulp should be preserved with a partial pulpotomy, using local anesthesia and nonsetting calcium hydroxide paste covered with a glass ionomer cement then restored with composite. Alternatively, no treatment may be the most appropriate option for a precooperative child or in a clinically unstable patient, with referral for immediate treatment to a child-oriented provider.
In permanent teeth, complete root formation typically occurs approximately 4 years after eruption. Pulp vitality must be preserved in teeth with open apices or immature roots that have pulp exposures so that further root development can occur. , This is accomplished by using a partial pulpotomy or pulp capping. In mature teeth with full root formation, conservative therapy, such as a partial pulpotomy or placement of a nonsetting calcium hydroxide, mineral trioxide aggregate, or calcium silicate that does not stain, is also advised. Root canal treatment is recommended for mature teeth with full root formation that require a post and core restoration.
Crown-Root Fractures
Crown-root fractures are fractures that often continue apical to the gingival margin. These fractures are of two types: uncomplicated or complicated crown-root fractures. Uncomplicated crown-root fractures are fractures of the enamel, dentin, and cementum without pulp exposure, whereas complicated crown-root fractures involve the enamel, dentin, cementum, and dental pulp.
In primary teeth with either an uncomplicated or complicated crown-root fracture, a periapical or occlusal radiograph is recommended. No treatment may be the appropriate option in an emergency, with referral for immediate treatment to a child-oriented provider. However, if treatment is considered at the time of the trauma, local anesthesia is needed. The loose fragment should be removed, and it should be determined if the crown is restorable. If it is restorable and there is no pulp exposure, glass ionomer is placed over exposed dentin. If a pulp exposure is apparent, a pulpotomy or root canal treatment is completed. If the tooth is nonrestorable, all readily accessible loose fragments should be extracted. To minimize damage to the developing permanent successor tooth bud, aggressive excavation of nonmobile pieces should be avoided.
In permanent teeth, one periapical radiograph and two additional radiographs at varying vertical and horizontal angulations should be taken. Cone beam computed tomography (CBCT) may also be used to obtain more precise information regarding the fractured area or amount of remaining tooth structure to better inform treatment options. Any loose tooth fragments, which are usually present in crown-root fractures, should be temporarily stabilized, and missing fragments should be considered as in crown fractures.
For crown-root fractures, the overall treatment plan must take the patient’s age and behavior into consideration. Options for future treatment may involve orthodontic or surgical extrusion, root canal treatment in the setting of an infected or necrotic pulp, root submergence, reimplantation, extraction, or autotransplantation. Maintaining the tooth or a submerged root is favorable for alveolar growth and enhances the site for a future implant after skeletal maturity.
Root Fractures
Root fractures are horizontal and/or oblique fractures that involve the dentin, pulp, and cementum. The coronal fragment is often mobile and displaced, and there may be occlusal interference. In primary teeth, the fracture is typically located either midroot or in the apical third of the root. A periapical or occlusal radiograph is recommended to help localize the fracture. If there is no displacement of the coronal fragment, no treatment is necessary. If the fragment is displaced but not significantly mobile, the fragment should be left to spontaneously reposition itself, even in the presence of slight occlusal interference. If the coronal fragment is displaced, significantly mobile, or creating a significant occlusal interference, then the fragment may be extracted with local anesthesia, leaving the apical fragment to eventually resorb. Alternatively, the mobile coronal fragment may be repositioned and a passive and flexible splint placed for 4 weeks to stabilize it.
Permanent teeth with root fractures may display percussion sensitivity and bleed from the gingival sulcus. One periapical radiograph and two additional radiographs at varying vertical and horizontal angulations may help visualize the fracture. Sometimes, additional imaging, such as CBCT, may be needed to identify a root fracture that is not apparent on plain film, such as if the tooth has a nondisplaced vertical fracture.
In root fractures, displaced coronal fragments should be promptly repositioned, and accurate repositioning should be confirmed with a radiograph. A passive and flexible splint should be placed for 4 weeks to stabilize the mobile coronal segment. Stabilization for up to 4 months may be necessary for more cervically located fractures. Coronal segments should not be removed, because cervical fractures possess the capacity to heal. Endodontic treatment should not be started at the emergency visit. Both the fracture and condition of the pulp should be monitored for at least 1 year. Additional procedures may be needed in the future, depending on the maturity of the tooth and pulp status, including orthodontic or surgical extrusion of the apical segment, crown lengthening, root canal treatment in the setting of an infected or necrotic pulp, root submergence, or extraction.
Alveolar Process Fractures
Alveolar fractures, which extend from the buccal to the palatal bone in the maxilla, and the buccal to the lingual bony surface in the mandible, often present with mobility and displacement of a segment of teeth that move together. An alveolar fracture may extend into the basal bone of the maxilla or mandible. Occlusal interferences may occur because of the positioning of the fractured segment. Displaced segments are repositioned and stabilized using the teeth as anchorage.
In primary teeth, a periapical or occlusal radiograph is recommended in addition to a lateral radiograph, which may provide information regarding any labial displacement of the segment. Further imaging may also be necessary if it will impact the treatment plan. Using local anesthesia, the displaced alveolar segment should be repositioned and a passive and flexible splint should be placed for 4 weeks to stabilize as the bone heals.
In the permanent dentition, teeth within the fractured segment do not always react when the pulp is tested. One periapical radiograph and two additional radiographs, at varying vertical and horizontal angulations, which sometimes includes an occlusal radiograph, may help visualize the fracture. A panoramic radiograph and/or CBCT can also be exposed if intraoral radiographs do not provide enough information to determine treatment. After repositioning the fractured segment, a passive flexible splint should be placed for 4 weeks to stabilize ( Fig. 7 ). Any apparent gingival lacerations may be sutured. It is not recommended to start root canal treatment at the emergency visit, and pulpal status should be monitored to determine if or when endodontic treatment may be needed.
