Traumatic dental injuries

Traumatic dental injuries (TDI) refer to injuries affecting the teeth, periodontal supporting tissues, alveolar bone, and surrounding oral soft tissues resulting from external mechanical forces.

These injuries may lead to:

• Tooth loosening

• Displacement

• Crown or root fracture

• Alveolar bone fracture

• Soft-tissue lacerations

• Complete tooth loss (avulsion)

TDI represents a true dental emergency, requiring immediate assessment and early intervention to preserve tooth vitality and prevent long-term complications.

Epidemiology

• Peak incidence: 6–12 years (children) and young adults

• Males affected more frequently

• Maxillary central incisors are most commonly injured due to anterior position

• Common causes:

  • Falls (home, school, sports)

  • Road traffic accidents

  • Physical assault

  • Occupational injuries

  • Seizures or syncope

Pathophysiology

Trauma produces injury depending on:

• Direction of force

• Magnitude of impact

• Stage of root development

• Elasticity of alveolar bone

Tissue-Level Effects

1. Tooth Structure

• Enamel cracks or fractures

• Dentin exposure

• Pulp inflammation or necrosis

2. Periodontal Ligament (PDL)

• Compression → ischemia

• Tearing → mobility or displacement

• Necrosis → ankylosis or resorption

3. Alveolar Bone

• Fracture or socket deformation

• Loss of tooth support

4. Dental Pulp

Possible outcomes:

• Reversible pulpitis

• Pulp necrosis

• Calcific metamorphosis

• Internal/external resorption

Classification and Diagnostic Criteria

1. Tooth Concussion

• Injury to supporting tissues

• No displacement or mobility

• Tender to percussion

2. Subluxation

• Increased mobility

• No displacement

• Gingival bleeding common

3. Luxation Injuries

Extrusive Luxation

• Partial displacement out of socket

Lateral Luxation

• Tooth displaced labially/palatally/lingually

• Often associated with alveolar fracture

Intrusive Luxation

• Tooth driven into alveolar bone

• Severe PDL and neurovascular damage

4. Avulsion

• Complete displacement of tooth from socket

• Periodontal ligament severed

• True dental emergency

5. Dental Fractures

• Enamel fracture

• Enamel–dentin fracture

• Complicated crown fracture (pulp exposure)

• Crown–root fracture

• Root fracture

6. Soft Tissue Injuries

Abrasion

Superficial epithelial loss caused by friction.

Contusion

Submucosal hemorrhage without surface break.

Laceration

Tear involving epithelial and connective tissues.

Signs and Symptoms

• Tooth mobility or displacement

• Pain on biting or percussion

• Bleeding from gingiva

• Missing tooth

• Facial swelling

• Occlusal disturbance

• Lip or cheek wounds

• Tooth sensitivity

• Difficulty chewing

Red Flags

• Loss of consciousness

• Vomiting or amnesia

• Jaw malocclusion

• Facial asymmetry

• Persistent bleeding

→ Requires urgent trauma referral.

Clinical Assessment

Primary Trauma Survey (ABCDE)

Always rule out:

• Head injury

• Cervical spine injury

• Facial fractures

Intra-Oral Examination

Assess:

• Tooth position

• Mobility grading

• Pulp exposure

• Occlusion

• Soft tissue wounds

• Missing fragments embedded in tissue

Investigations

Radiological Evaluation

Periapical X-ray

• Root fracture

• PDL widening

• Luxation injuries

Occlusal Radiograph

• Intrusion assessment

Orthopantomogram (OPG)

• Alveolar fracture

• Mandibular fracture

• Multiple injuries

CBCT (where available)

• Complex trauma evaluation

Treatment

Management depends on:

• Type of injury

• Tooth maturity

• Time elapsed

• Contamination level

Non-Pharmacological Management

General Measures

• Control bleeding

• Clean wound with saline

• Remove debris

• Check tetanus status

Tooth-Specific Management

Concussion / Subluxation

• Observation

• Soft diet (2 weeks)

• Oral hygiene instructions

Luxation Injuries

• Gentle repositioning

• Flexible splint (2–4 weeks)

Intrusion

• Allow spontaneous eruption (immature teeth)

• Orthodontic/surgical repositioning

Avulsion (Permanent Tooth)

Immediate reimplantation preferred (<60 minutes)

Storage media if delayed:

• Milk

• Saline

• Patient saliva

Steps:

1. Hold crown only

2. Rinse gently

3. Reimplant

4. Splint 2 weeks

5. Root canal therapy later

Do NOT reimplant primary teeth.

Primary Teeth

Extraction indicated when:

• Severe mobility

• Displacement

• Risk to permanent tooth germ

Soft Tissue Injuries

• Irrigation

• Debridement

• Suturing

• Removal of embedded fragments

Pharmacological Management

Analgesics

(According to Tanzania STG)

• Paracetamol 1 g PO 8 hourly × 3 days

OR

• Ibuprofen 400 mg PO 8 hourly × 3 days

OR

• Diclofenac 50 mg PO 8 hourly × 3 days

Antibiotics (Indicated when)

• Avulsion

• Contaminated wounds

• Bone exposure

• Extensive soft tissue injury

First line

• Amoxicillin 500 mg PO 8 hourly × 5 days

Penicillin allergy

• Metronidazole 400 mg PO 8 hourly

Tetanus Prophylaxis

• Tetanus toxoid 0.5 mL IM if not vaccinated within 10 years.

Follow-Up Schedule

• 2 weeks

• 4 weeks

• 3 months

• 6 months

• 1 year

• Annual review up to 5 years

Monitor for:

• Pulp necrosis

• Root resorption

• Ankylosis

• Infection

Complications

• Pulp necrosis

• External root resorption

• Tooth discoloration

• Ankylosis

• Chronic infection

• Tooth loss

• Facial growth disturbance (children)

Prevention

Individual Level

• Mouthguards during sports

• Helmets and seat belts

• Safe playgrounds

• Early orthodontic correction of protruding incisors

Community Level

• School injury prevention programs

• Road safety enforcement

• Public trauma education

Patient Education

Patients should be advised:

• Seek dental care immediately after injury

• Preserve avulsed tooth in milk or saliva

• Avoid biting hard food

• Maintain oral hygiene using chlorhexidine rinse

• Attend all follow-up visits

Prognosis

Best outcomes occur when:

• Treatment initiated within 30–60 minutes

• Proper splinting performed

• Infection prevented

• Long-term monitoring maintained