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REVIEW

Clinical practice

Dental trauma

Katarzyna Emerich & Jacek Wyszkowski

Received: 30 November 2009 /Accepted: 8 December 2009 /Published online: 8 January 2010# Springer-Verlag 2009

Abstract Approximately 50% of children under the age of 15

are victims of various kinds of injuries in the orofacial region.

Post-traumatic complications may occur, including crowndiscolouration, cervical root fracture, ankylosis, root resorp-

tion and tooth loss. The most severe complication after dental

injury in primary dentition can affect the developing perma-

nent tooth germ, and various consequences may be seen

several years later when the permanent tooth erupts. In the

permanent dentition, the most severe dental injury affects the

surrounding alveolar bone structure and will lead to loss of

the tooth. Current literature emphasises that awareness of

appropriate triage procedures following dental trauma is

unsatisfactory and that delay in treatment is the single most

influential factor affecting prognosis. What should a paedia-

trician know, and more importantly, how should he/she advise

parents and caretakers? In an emergency situation such as

tooth avulsion, reimplantation within 30 min is the best

treatment option at the site of the accident. If reimplantation of

the tooth is impossible, milk, saline or even saliva are the

preferred transport media. The prognosis for an avulsed tooth

depends upon prompt care, which is a determinant factor for

successful treatment of the traumatised tooth. In all other

dental trauma cases, it is important to refer the child to a

paediatric dentist, to follow up the healing process and reduce

late post-traumatic complications. With timely interventions

and appropriate treatment, the prognosis for healing

following most dental injuries is good. In conclusion, it

is important that paediatricians are able to inform parents

and caretakers about all possible and long-lasting con-sequences of different dental injuries.

Keywords Dental injury . First-aid

Introduction

The paediatrician, more than any other child health profes-

sional, should have the knowledge required to provide parents

with professional advice in all aspects concerning a childs

health. This should include basic knowledge about the most

common orofacial injuries. From the day the child starts

walking, different dental injuries can occur. Older children

participating in different activities, e.g. sports, are also prone

to various injuries. Dental trauma can have serious con-

sequences that are not only physical, but also economic, social

and psychological. The paediatrician, being the doctor of first

choice for most parents and caretakers, has a responsibility to

advise them competently in cases of dental injury affecting the

teeth and jaws. The paediatrician should know how to

competently direct the procedure to be followed for a victim

of an accident. As timing is frequently a decisive factor

for the success of long-term treatment, it is important

that paediatricians have a clear path to follow when they

are unexpectedly faced with such stressful situations.

Epidemiology

The largest group receiving dental injuries are children and

adolescents. Very often, due to lack of experience, they are

not aware of the consequences of different activities and

thus cannot predict the possibility of an accident. Research

K. Emerich (*)

Department of Paediatric Dentistry,

Medical University of Gdansk,

ul. Orzeszkowej 18,

80-208 Gdansk, Poland

e-mail: [email protected]

J. Wyszkowski

Private Dental Clinic,

Gdynia, Poland

Eur J Pediatr (2010) 169:10451050

DOI 10.1007/s00431-009-1130-x


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indicates that approximately 50% of children under the age

of 15 receive various kinds of injuries to the orofacial

region [8, 15]. Dental injuries are the commonest type of

orofacial injury [12].

The consequences of dental trauma can vary from simple

tooth fractures to complicated tooth avulsion. In the

literature, however, the most frequently described conse-

quences are crown fractures, representing up to 79% of alldental injuries [11]. The most complex injury is the

complete dislocation of the tooth from its alveolus. Tooth

avulsion, a real emergency in dentistry, represents up to

21% of all dental injuries [7, 11, 19].

Aetiology

Age predilection is as follows:

Toddlers especially 12-year-oldfalls, child abuse

Kindergarten children especially 5-year-olds

hyper-activity, running, jumping

Schoolchildren especially boys 811-year-olds

playground accidents, cycling

Adolescentssports activities, assault, motor vehicle

and motorcycle collisions

Local predisposing factors are as follows:

Anterior overbite >4 mm, increased overjet, protrusion

of upper incisors

Incompetent or short upper lip, mouth breathing

Definition

One of the most remarkable and relevant problems regarding

dental traumatology is the wide range of existing diagnostic

classification systems. Over 50 distinct classification systems

have been identified in the literature [9]. One of the simplest

is the WHO classification, which forms the basis for several

other, more detailed, classifications [21]. The WHO classi-

fication divides dental trauma into ten categories:

1. Fracture of enamelthe tooth is usually non-tender

and without visible colour change but has rough edges

(Fig. 1d).

2. Crown fracture without pulp involvementthe frac-

ture involves the enamel and the dentin layer (Fig. 1a).

The tooth is typically tender to the touch and to air

exposure.

3. Crown fracture with pulp involvementthe fracture

involves the enamel, dentin and pulp. The tooth is tender

and has a visible area of pink, red or even blood at the

centre of the fractured tooth crown (Fig. 1b).

4. Root fracturethe fracture can be seen only on X-ray.

The treatment and the prognosis depend on the

fracture run and location.

5. Crown and root fracturethis is a very complicated

case, and most such fractures need tooth extraction.

6. Fracture of tooth unspecified.

7. Luxation of toothincreased mobility of a tooth

following trauma.8. Intrusion or extrusion of toothintruded tooth is forced

into the socket in an axial (apical) direction, at times to

the point of being buried and not visible. Tooth presents

decreased mobility and resembles ankylosis (Fig. 1c).

Extruded tooth is partially displaced from the socket

along the long axis. Such teeth have greatly increased

mobility, and radiographs show displacement.

9. Avulsion of toothcomplete extraction of the tooth

(crown and root).

10. Other injuries including laceration of oral soft tissues

(Fig. 1d).

Complications

These depend on whether the injury affects the primary or

permanent dentition. In the primary dentition, fractures are

less common than avulsion and different types of luxation

including intrusion and extrusion.

Primary teeth injury outcomes are as follows:

& Failure to continue eruption due to abnormal root

development

& Colour changes in the crown (grey if the pulp becomes

necrotic, yellowish if the pulp chamber becomes

obliterated, pink if internal resorption develops)

& Infection of the necrotic pulp leading to periapical infection

& Abscess as a result of pulp necrosis andperiapical infection

& Loss of space in the dental arch due to tooth loss in the

early years of life

& Ankylosis, leading to prolonged retention of the

primary teeth, mostly as a result of intrusion injury

& Damage to the permanent tooth germ as a result of

intrusion injury at the time when the primary root is

fully developed and the tooth germ is situated near to

the primary tooth root apex (usually injuries between 2

and 4 years of age)

& Abnormal exfoliation due to pathological root resorption

& Delayed eruption of permanent tooth due to scar tissue

development after primary tooth loss or pathological

development of permanent tooth germ.

The most severe complications after dental injury in the

primary dentition can affect the developing permanent tooth

germ, which will become apparent several years later when

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the permanent teeth erupt. Depending on the stage of tooth

germ development, injury in the primary dentition can affect

the crown, the root or the whole permanent tooth (Fig. 2).

Permanent teeth injury outcomes are as follows:

& Colour changes in the crown (grey if the pulp becomes

necrotic, yellowish if the pulp chamber becomes

obliterated, pink if internal resorption develops)

& Infection of the pulp leading to periapical infection and

different abscesses

& Loss of space in the dental arch especially in children

with dental crowding

& Ankylosis mostly as a result of intrusion injury or late

reimplantation after avulsion

& Resorption of the root structure (especially replacement

resorption) due to periodontal ligament damage

(Fig. 3b)

& Reinclusion of the tooth as a result of root replacement

resorption and ankylosis (Fig. 3a, b)

& Abnormal root development due to injury to erupting

tooth without a fully developed root.

The most severe complications after dental injury in

permanent dentition can affect the surrounding bone structure,

which will lead to loss of the tooth and alveolar bone.

It is important that paediatricians are able to inform

parents and caretakers about all possible and long-lasting

consequences of different dental injuries.

Traumatic dental injuries are time-consuming and costly

to treat [14]. They can impair the quality of life, affecting

various aspects of life, including function, appearance and

interpersonal relationships [13]. With timely interventions

and appropriate treatment, the prognosis for healingfollowing most dental injuries is good.

Treatment indications

Primary dentition injuries

The majority of primary dentition injuries, involving

different kinds of luxation, only require observation, good

Fig. 1 a Crown fracture within

enamel and dentin. b Crown

fracture with pulp involvement.

c Intruded central incisor on the

left hand side. d Enamel fracture

on the left hand side central

incisor and soft tissue laceration

Fig. 2 Different developmental

anomalies in permanent denti-tion due to primary tooth injury:

a abnormal root development,

b enamel hypoplasia,

c abnormal crown and

root development

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oral hygiene and a soft diet for 12 weeks. In crown

fractures, which are observed quite rarely, extraction is

usually the treatment of choice. If the child is cooperative,

root canal treatment followed by crown restoration is

possible. It is very important to monitor primary teeth at

least annually after dental trauma until the permanent

successors erupt because different complications such as

pulp necrosis or periapical inflammation may occur several

weeks, months or years after the injury. X-ray examination

may be required to assess the signs of pulpal or periodontal

complications. Soft tissue injuries should be monitoredweekly until they are healed.

The parents should be informed that the risk of damage

to permanent successors in primary tooth trauma is high.

Permanent dentition injuries

It is known that the prognosis for traumatic dental injuries

depends on the time between the accident and initiation of

treatment [1, 18]. Paradoxically, the literature highlights the

tendency to delay presentation for dental treatment [11, 20].

All crown fractures may be easily restored, but if the

pulpal tissue is involved, treatment should be performedwithin several hours from the injury to save the vitality of

the tooth. In crown fractures, it is essential to find the piece

of the tooth because it can be reattached (Fig. 4). In root

fractures and crown/root fractures, the prognosis depends

on the fracture run and location.

Different injuries to the periodontal tissues (luxation and

extrusion) may loosen the tooth or even lead to tooth

avulsion. The severity of the periodontal ligament damage

will determine the healing outcome. The general outcome is

dependent upon stage of root formation and type of injury.

Thus, pulpal and periodontal ligament healing complica-

tions are the most frequent in cases with completed root

formation vs. incomplete root formation [3]. If the tooth is

loose, it should be splinted [16].

Tooth avulsion, being a complex injury affecting

multiple tissues, should be considered a real emergency

requiring prompt and appropriate management to signifi-

cantly improve the prognosis [6]. Immediate reimplantationwithin 30 min after injury or maintenance of the avulsed

tooth in storage media compatible for the survival of

periodontal ligament cells before reimplantation is funda-

mental for successful healing [2, 4, 6]. The longer the time

elapsed between tooth avulsion and reimplantation, the

greater the risk of replacement resorption or inflammatory

root resorption [4, 5]. If the root surface is contaminated, it

should be gently cleaned with a stream of saline or even

cold tap water before reimplantation. To avoid periodontal

ligament damage, the tooth should be held by the crown [5,

17]. A temporary splint comprised of aluminium foil,

available in every kitchen or from any chocolate bar, can be used until dental intervention [10] (Fig. 3c). Alterna-

tively, if immediate reimplantation is impossible, an

avulsed tooth should be placed in physiological saline,

milk or even saliva (between the cheek and the lower

molars). Providing one of the procedures indicated above is

applied, the patient should be seen by the dentist at his/her

earliest convenience.

Fig. 3 a Reinclusion of right

central incisor caused by root

ankylosis and replacement

resorption 2 years after

reimplantation; b X-ray of case

A; c temporary splinting with

aluminium foil

Fig. 4 Crown fracture without pulpal involvement: a clinical status after dental trauma; b fractured pieces of both incisors; c clinical status after

crown restoration

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Guidelines

Conflict of interest The authors received no extra funding forpreparation of this manuscript and believe that there is no relationship

that can lead to any conflict of interests relevant to the content of this

article.

References

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within 15 min: a long-term clinical follow-up study. Endod Dent

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3. Andreasen FM, Andreasen JO (1993) Luxation injuries. In:Andreasen JO, Andreasen FM (eds) Textbook and color atlas of

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Type of injury Recommendationshow to proceed

Primary dentition injuries

Different fractures Refer to paediatric dentist as soon as possible

Luxation, intrusion and extrusion

Avulsion Monitor the healing process and inform the parents about the need for dental consultation

Soft tissue lacerationPermanent dentition injuries

Crown fracture within enamel or

enamel/dentin

Instruct the parents to find the tooth piece. Refer to a dentist. In most cases a delayed treatment approach

(i.e. even after more than 24 h) is realistic

Crown fracture with pulp

involvement

Instruct the parents to find the tooth piece. Refer to a dentist. In most cases a subacute treatment

approach (i.e. within 24 h) should be recommended

Other fractures Refer to a dentist as soon as possible

Luxation and intrusion Refer to a dentist. In most cases a subacute treatment approach should be recommended

Extrusion and lateral luxation Refer to a dentist. In most cases an acute treatment approach (i.e. within a few hours) should be

recommended

Avulsion First-aid procedureinstruct the parents how to act

1. Find the tooth as quickly as possible

2. Hold the tooth only by the crown and rinse it with cold tap water3. Immediately reimplant the tooth in its socket

4. Immobilise the tooth (e.g. with aluminium foil)

5. If the tooth cannot be reimplanted, keep it wet at all times. Place the tooth in milk, saline or even

salivaplace the tooth between the cheek and the gums

6. See a dentist as soon as possible

If the tooth is not reimplanted at the time of injury an acute approach is recommended; otherwise

subacute

Soft tissue laceration Monitor the healing process and inform the parents about the need for dental consultation

Eur J Pediatr (2010) 169:10451050 1049


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17. International Association of Dental Traumatology. http://www.iadt-

dentaltrauma.org/web/index.php?option=com_content&task=

view&id=28&Itemid=43 Accessed Oct 10, 2009

18. Kumomoto DP, Winters JE (2000) Private practice and

community activities in sports dentistry. Dent Clin North Am

44:209220

19. Marcenes W, Alessi ON, Traebert J (2000) Causes and

prevalence of traumatic injuries to the permanent incisors of

school children aged 12 years in Jaragua do Sul, Brazil. Int

Dent J 50:8792

20. Rajab LD (2003) Traumatic dental injuries In children presenting

for treatment at the Department of Pediatric Dentistry, University

of Jordan, 19972000. Dent Traumatol 19:611

21. World Health Organization (1978) Application of the International

Classification of Diseases to Dentistry and Stomatology (ICD-DA).

WHO, Geneva, pp 8889

1050 Eur J Pediatr (2010) 169:10451050
http://www.iadt-dentaltrauma.org/web/index.php?option=com_content&task=view&id=28&Itemid=43http://www.iadt-dentaltrauma.org/web/index.php?option=com_content&task=view&id=28&Itemid=43http://www.iadt-dentaltrauma.org/web/index.php?option=com_content&task=view&id=28&Itemid=43http://www.iadt-dentaltrauma.org/web/index.php?option=com_content&task=view&id=28&Itemid=43http://www.iadt-dentaltrauma.org/web/index.php?option=com_content&task=view&id=28&Itemid=43http://www.iadt-dentaltrauma.org/web/index.php?option=com_content&task=view&id=28&Itemid=43


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