Chapter 182. Fractured Tooth Management

Traumatic dental injuries are common and can have significant lasting consequences for the patient. Recent estimates indicate over three quarters of a million annual Emergency Department visits in the United States for dental-related complaints.1 Nearly 12% of these are related to some form of trauma.1 It has been estimated that approximately 50% of children will sustain traumatic dental injuries, and the majority of these are to the permanent dentition.2–4 Violence of a suspicious nature, such as domestic or child abuse, must always be considered when evaluating dental injuries. The goals of the emergent treatment of dental trauma are to maintain patient comfort and tooth vitality, while ensuring prompt dental follow-up for definitive care.

Tooth Anatomy

There are significant differences in the adult and pediatric dentitions that impact their treatment in the Emergency Department (Figure 182-1). The pediatric dentition is known as the primary or deciduous dentition and consists of 20 teeth, which includes 8 incisors, 4 canines, and 8 molars. The adult dentition consists of 32 teeth and is composed of 8 incisors, 4 canines, 8 premolars, and 12 molars. The variable absence of a tooth or the addition of an extra tooth is common in either dentition. The teeth in both the pediatric and adult dentitions erupt in a predictable sequence, albeit with considerable individual variation (Figure 182-1). Treatment strategies differ for permanent versus deciduous (primary) teeth as well as by the age of the adult tooth. Exercise great care when evaluating patients with a “mixed” dentition, roughly between the ages of 6 and 12 years.

The anatomy of a tooth is rather simple (Figure 182-2). The tooth itself consists of a neurovascular pulp surrounded by supportive dentin, which is surrounded by a hard thick crown of enamel. The crown portion lies above the gum line or gingiva. The root portion lies embedded within the alveolar bone of the jaw, anchored by a thin layer of cementum and the periodontal ligament. The alveolar bone, periodontal ligament fibers, and fragile cementum cell layer taken together are considered a functional unit known as the attachment apparatus. A complete attachment apparatus requires a fully formed root apex. Immature adult teeth do not have a fully formed apex and necessitate special attention to maintain pulpal viability.2,4,5

Tooth Injury

Mechanisms of tooth injury include direct trauma (i.e., a blow) or occlusive trauma (i.e., biting on a hard object or a seizure). These mechanisms can result in a spectrum of injury patterns that vary from simple ...