Anatomically, each tooth has a crown and root portion. Externally, the crown is covered with white enamel and the root portion with cementum. The cementoenamel junction (cervical line) is where the crown and root meet. The yellow-to-tan dentin is the 2nd innermost layer and comprises the bulk of the tooth. The red-to-pink pulp tissue is located in the center of the tooth and includes the tooth’s neurovascular supply. The Ellis classification system is commonly used to describe tooth fractures above the cervical line in anterior teeth:
Ellis class I: Involves only the enamel.
Ellis class II: Involves the enamel plus exposure of the dentin. The patient may complain of temperature sensitivity.
Ellis class III: Fracture extends into the pulp. A pink or bloody discoloration on the fracture surface is diagnostic. The patient may have severe pain but may also have no pain due to loss of tooth nerve function.
Tooth Numbering System. The standard tooth numbering system should be used to descriptively identify which tooth or teeth are fractured or otherwise pathologically affected. (Source: Hay WW, Levin MJ, Deterding RR, Abzug MJ. Current Diagnosis & Treatment: Pediatrics. 24th ed. New York, NY: McGraw Hill; 2018. Copyright McGraw Hill Education.)
Tooth Fractures. Enamel, dentin, and pulp are the anatomic landmarks used in the Ellis classification of tooth fractures.
Ellis Class I Tooth Fracture. Note the fracture of the left upper central incisor. The sole involvement of the enamel is consistent with an Ellis class I fracture. (Photo contributor: James F. Steiner, DDS.)
Tooth fractures of the dental root may also occur below the cementoenamel junction and are commonly missed on initial evaluation. Bleeding may be observed at the gingival crevice with associated tooth tenderness on percussion. Radiographic evaluation may aid in differentiating these conditions.
Management and Disposition
Ellis class I: Pain control and referral for rough tooth edge and cosmetic management are indicated.
Ellis class II: Patients under 12 years of age have less dentin than older patients and are at risk for pulp infection. They should have a calcium hydroxide dressing placed, covered with gauze or aluminum foil, and be seen by a dentist within 24 hours. Older patients should see a dentist within 24 to 48 hours.
Ellis class III: This is considered a dental emergency, and dental consultation within 24 to 48 hours is indicated. Delay in treatment may result in abscess formation.
Root fractures: Early reduction, immobilization/splinting, and dental referral within 24 to 48 hours is indicated. Most teeth sustaining root fractures maintain pulp viability.