Field Guide to Urgent & Ambulatory Care Procedures
1st Edition

Chapter 10
Immediate Management of Tooth Fracture and Avulsion
Dental trauma runs a gamut from a simple tooth fracture to avulsion of teeth and supporting structural fracture or dislocation. A brief synopsis of dental trauma will be presented, with techniques for the immediate management of simple tooth fractures and avulsions.
What You Need
Gauze
Adequate lighting
Calcium hydroxide paste (may substitute with toothpaste)
Cyanoacrylate glue (Dermabond or substitute with “Krazyglue”)
Small paper clips
Nail file
Tinfoil
DENTAL FRACTURES
Management of a dental fracture is based upon the extent of the fracture in relation to the tooth pulp, and the age of the patient.
Refer to Fig. 10.1 for the Ellis classification of tooth fractures.
FIG. 10.1. Ellis classification for fractures of anterior teeth.
The Ellis class I fracture involves only the enamel portion of the tooth. This appears clinically as a “chip” off the tooth. Urgent intervention is only required if there is a sharp edge that disturbs the patient’s adjacent soft tissues. In this situation, simply file down the sharp edge with a nail file until smooth. Referral to a general dentist is appropriate for cosmetic restoration.
Ellis class II fractures are more complex. They not only involve the enamel, but also expose the dentin layer of the tooth. Treatment is based on the patient’s age. As less dentin is present in the teeth of patients younger than 12 years of age, these injuries warrant dressing the exposed dentin with calcium hydroxide paste (or toothpaste), and then with a dry gauze. Referral to a dentist is required within 24 hours.
Patients older than 12 years of age will have a relatively greater dentin-to-pulp ratio. These patients should be advised to avoid extremes of intraoral temperature exposure and to obtain dental consultation by 24 hours. A gauze or piece of tinfoil over the damaged tooth may assist in protecting the damaged tooth from temperature variations. Patients should also be warned that any degree of trauma to a tooth may disrupt the neurovascular supply, with the long-term complications of pulpal necrosis or tooth resorption.
Ellis class III fractures include transection of the enamel and dentin, and expose the pulp of the damaged tooth. These fractures are differentiated from Ellis class II fractures by wiping the damaged surface with a clean gauze pad. Dentin will appear as a red blush, while a pulp exposure will yield a drop of fresh blood. These fractures are true emergencies, as delay in treatment may result in significant long-term pain and possible abscess formation. Refer these
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cases immediately to a dentist or endodontist. DO NOT attempt to probe the pulp cavity or remove any pulpal material. Cover the affected tooth with tinfoil and provide adequate analgesia (orally, or may use a dental block; see Chapter 14, “Intraoral Anesthetic Techniques and Supraperiosteal Dental Nerve Block”).
SUBLUXATED OR AVULSED TEETH
Teeth are held in place by ligaments and by the supporting gingiva. The same force that may have resulted in the fracture of a tooth may also have resulted in the actual loosening of the tooth by damage to the ligaments (subluxation). Examine the surrounding gingival crevice for blood, which is a subtle indication of ligamentous damage; also hold the tooth between your fingers and attempt to wiggle it to assess for subluxation. Minimally mobile teeth will “firm up” over a week or two as the ligaments tighten up. Advise the patient to use a soft diet, and avoid placing undue pressure on the affected tooth. Grossly mobile teeth will need stabilization, as discussed later.
A tooth that has been completely avulsed from its socket is a true dental emergency. If the patient does not know the whereabouts of the tooth, it is a good idea to obtain radiographs of the jaw to make sure the tooth was not driven below the gingiva (intrusion). If the intruded tooth is of the primary set, allow 6 to 8 weeks for reeruption from the gingiva. Intruded adult teeth must be repositioned and stabilized to prevent cosmetic deformity and possible secondary infection. The technique is described later.
The management of an avulsed tooth depends upon the age of the patient and the length of time that the tooth has been absent from the oral cavity. Primary teeth (patient age 6 months to 5 years) are not replaced, as these teeth may fuse to the supporting bone and result in facial deformity. The further management of an avulsed primary tooth is thus left to the Tooth Fairy. A permanent tooth
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should be replaced into its socket if the avulsion has been less than 3 hours. Successful reimplantation of a tooth is critically time dependent: teeth replaced at once have a much higher rate of successful reimplantation than those replaced at even 1 or 2 hours. The technique of reimplantation and stabilization is described later.
Clinical Technique
  • If the patient is on the telephone and has experienced a recent avulsion, have the patient rinse the tooth under cold water and then reimplant the tooth at once; then have the patient proceed either to you or to a dentist (if available).
  • If the patient cannot reimplant the tooth, have the patient place the tooth in a glass of milk, or wrap it in moistened gauze and instruct the patient to see either you or a dentist (if available) immediately.
    Once the Tooth Is in Your Possession:
  • Handle ONLY by the crown of the tooth. Rinse under running tapwater or saline. Alternatively, you can place the tooth in a commercial tooth protective system (i.e., Tooth Protective System). DO NOT scrub tooth.
  • If a blood clot is occupying the socket, gently swab out with gauze or have the patient rinse mouth with saline to remove the clot.
  • Reposition the tooth in its socket with anatomic alignment. (Curved side faces the tongue!)
  • Wipe off any excess blood with gauze.
  • Unfold small paper clip and mold into an arch shape to conform to the buccal side of the now reimplanted tooth, and its fellow teeth on either side (Fig. 10.2). Again, wipe buccal surfaces clean and dry with gauze. (If no paper clip is available or if this is not working for you, cut a piece of gauze into 0.25- × 2-inch strips and soak with glue. Apply this dressing to the buccal side of the reimplanted tooth to bind it to neighboring teeth.)
    FIG. 10.2. Fashioning and gluing the wire arch bar to stabilize an avulsed tooth.
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  • Once the bar has been fashioned, apply cyanoacrylate glue liberally to the wire, and position it over the reimplanted tooth and its neighbors on either side as in Fig. 10.2. Hold the arch bar with forceps to avoid getting glue on your fingers.
  • Allow glue to harden.
  • Arrange for dental follow-up within 24 hours.
Intruded Teeth:
  • Gently reposition the tooth into proper alignment with fingers, or forceps.
  • Wipe dry with gauze.
  • Fashion arch bar as earlier and glue into place as previously described.