A 12 year old male was chasing his friend through the backyard when he fell striking his face on an air conditioning unit. After cringing you learn that he did not lose consciousness and has not vomited. He also has a normal mental status. His main reason for coming to the ED to see you is related to his “two front teeth” which are his permanent teeth. On exam you see following.
Otherwise he has no pain of his mandible or TMJ. No malocclusion. no active bleeding or lacerations.
What is the diagnosis?
He has an obvious injury to his left upper central maxillary incisor. The tooth, AKA #9 (see the diagram below for more info) has a fracture. It does not appear to be misaligned in the socket. The Ellis classification of tooth fractures is as follows.
The management varies by type of fracture as you will see below.
What is the management?
The good news is that most fractured permanent teeth can be addressed several hours later. This means that you don’t have to call in the dental resident at 3 in the morning. Realistically, even teeth with pulp visible can be addressed reliably within 7 days. Obviously the sooner the better within reason in order to optimize comfort and cosmesis. If the fragment is present it can be reattached within the initial hours to day. See this or this article if you really want to learn more. As opposed to an avulsed tooth you can keep a fragment in tap water since the tooth chunk has no fibroblasts. Composite materials have excellent cosmetic and functional results if the tooth fragment is not available for bonding.
The worst complication to the permanent teeth is devitalization of the periodontal ligament. This occurs more often in avulsion or severe luxation injuries. If the tooth is untreated the prognosis is poor (obviously). One the pulp dies it becomes necrotic over a period of days to weeks. The pulp is so sensitive that even a contused tooth can lead to the neurovascular supply being disrupted. This can lead to abscess formation adjacent to the tooth as well as color change (yellow, grey or black) to the crown. Once color change occurs the tooth is at risk for root reabsorption – which is bad. Exposed pulp in fractures allow for bacterial entry as well as sensitivity to heat/cold and pain with chewing. The evidence does not suggest that antibiotics given prophylactically are likely to be beneficial.
