Residency · Residency · Oral Maxillofacial Surgery

Dentoalveolar Trauma

Overview

Dentoalveolar trauma includes injuries to the teeth, supporting structures (periodontal ligament, alveolar bone), and adjacent soft tissues. It is common in children and young adults from falls, sports, violence, and motor vehicle collisions. Prompt and appropriate management preserves tooth vitality, prevents resorption, and maintains alveolar bone. The OMFS surgeon must be proficient in emergency management, splinting, and follow-up protocols.

Classification of Dental Injuries

Ellis Classification (Crown Fractures)

Ellis Class I involves enamel only and requires no treatment other than smoothing sharp edges. Ellis Class II involves enamel and dentin exposure (yellowish dentin visible), causing sensitivity to air and cold, and is treated with a calcium hydroxide liner and composite restoration. Ellis Class III involves enamel, dentin, and pulp exposure (a bleeding point is visible) and requires emergent management to preserve pulp vitality. In teeth with an immature apex (open root), direct pulp capping with MTA or calcium hydroxide, or partial pulpotomy (Cvek pulpotomy), preserves vitality and allows root maturation. In teeth with a mature apex, direct pulp capping is performed if the patient is seen within hours, and root canal therapy is initiated if treatment is delayed or necrosis develops.

Root Fractures

Horizontal root fractures are classified by location. Apical third fractures have the best prognosis and are repositioned and splinted for 4 weeks. Middle third fractures are repositioned and splinted for 4-8 weeks with vitality monitoring. Cervical third fractures have the worst prognosis and may require extraction. Vertical root fractures are generally untreatable and require extraction. Crown-root fractures involve enamel, dentin, and root with or without pulp involvement. Subgingival extension may require crown lengthening, orthodontic extrusion, or extraction.

Luxation Injuries

Concussion produces a tooth that is tender to touch and percussion but not displaced or mobile, reflecting PDL inflammation without structural damage. Treatment is a soft diet with monitoring. Subluxation produces a mobile but undisplaced tooth with PDL damage and possible bleeding from the gingival sulcus. Treatment is a soft diet with monitoring, and splinting for 2 weeks if the tooth is very mobile. Extrusive luxation displaces the tooth partially out of the socket, giving it an elongated appearance. Treatment involves digital repositioning into the socket under local anesthesia and a flexible splint for 2 weeks. Lateral luxation displaces the tooth laterally (usually palatally or lingually), often with alveolar bone fracture. Treatment involves disengaging with forceps, repositioning, and a flexible splint for 4 weeks; alveolar bone fracture requires longer splinting of 4-6 weeks. Intrusive luxation drives the tooth into the alveolar bone, making it appear shortened. In teeth with an immature root (open apex), spontaneous re-eruption is allowed with monitoring for 2-4 weeks, and orthodontic extrusion is used if no movement occurs. In teeth with a mature root (closed apex), surgical or orthodontic repositioning is performed, though there is high risk of ankylosis and root resorption. Intrusion is the most severe luxation injury with the worst prognosis for pulp survival.

<image>Illustrations demonstrating the spectrum of dental luxation injuries: concussion, subluxation, extrusive luxation, lateral luxation with alveolar plate fracture, and intrusive luxation, with cross-sectional views showing the periodontal ligament status, tooth position relative to the socket, and the associated alveolar bone involvement for each injury type</image>

Avulsion

Epidemiology

Avulsion most commonly involves the maxillary central incisors, with peak incidence at 7-10 years of age. Time is the critical factor, as extraoral dry time directly impacts prognosis.

Emergency Management

At the Scene

The tooth should be found and handled by the crown only without touching the root. If contaminated, the tooth is gently rinsed with saline or milk without scrubbing the root surface. Immediate replantation provides the best outcome. If replantation is not possible, the tooth should be stored in an appropriate medium: Hank's Balanced Salt Solution (HBSS) is best and maintains PDL cell viability for hours; cold milk is good and maintains osmolality and pH for 1-2 hours; saliva (patient's buccal vestibule) and saline are acceptable; water is unacceptable because it is hypotonic and lyses PDL cells, and dry storage is also unacceptable.

In the Clinic

When extraoral dry time is less than 60 minutes and PDL cells are likely viable, the root surface is gently rinsed with saline without scrubbing or curetting. The socket is irrigated with saline, and the tooth is replanted with gentle digital pressure. Position is verified clinically and radiographically. A flexible splint is applied for 2 weeks. Antibiotics (doxycycline or penicillin) and tetanus prophylaxis are prescribed, and follow-up for endodontic evaluation is arranged.

When extraoral dry time exceeds 60 minutes and PDL cells are not viable, replantation is still performed but ankylosis and replacement resorption are expected. The tooth is soaked in 2% sodium fluoride solution for 20 minutes to slow resorption, then replanted and splinted for 4 weeks. Root canal therapy is initiated within 2 weeks. In growing children, the tooth serves as a space maintainer until definitive replacement is possible.

Primary (deciduous) teeth should not be replanted due to the risk of damage to the developing permanent tooth bud.

Endodontic Management After Avulsion

For mature teeth (closed apex), root canal therapy is initiated 7-14 days after replantation, with a calcium hydroxide intracanal dressing initially and definitive obturation later. For immature teeth (open apex), revascularization is monitored (positive response to vitality testing). If pulp necrosis develops, apexification with MTA or calcium hydroxide is performed, followed by root canal. Revascularization procedures (regenerative endodontics) may allow continued root development.

Prognosis After Avulsion

PDL healing (the best outcome) produces normal attachment without resorption and requires viable PDL cells. Inflammatory resorption is infection-mediated and may respond to root canal therapy. Replacement resorption (ankylosis) involves the root being replaced by bone with progressive loss of root structure and eventual tooth loss. Extraoral dry time is the single most important prognostic factor.

Alveolar Fractures

Alveolar process fractures involve a fracture of the alveolar bone with or without tooth involvement, usually affecting a segment of bone with multiple teeth. Clinical findings include a mobile segment of teeth and bone, gingival tears, occlusal derangement, and step deformity. Treatment involves reducing the displaced segment under local or general anesthesia, stabilizing with an arch bar or rigid splint for 4-6 weeks, monitoring involved teeth for vitality (pulp testing at intervals), and prescribing antibiotics (penicillin or amoxicillin).

Splinting

Principles

Flexible (physiologic) splinting is preferred for most dental injuries because it allows functional tooth movement and promotes PDL healing. Rigid splinting is reserved for alveolar fractures and root fractures. The splint should not impinge on the gingiva or impede oral hygiene and should be passive (not actively moving teeth).

Methods

The titanium trauma splint (TTS) is a thin, flexible wire bonded with composite and is ideal for luxation injuries. Composite and wire uses 0.4 mm stainless steel wire or orthodontic wire bonded to tooth surfaces with composite resin. Arch bars are used for alveolar fractures and when multiple teeth are involved. Orthodontic brackets and wire are used if already in place or if needed for longer-term stabilization.

Duration

Subluxation requires 2 weeks of flexible splinting. Extrusive luxation requires 2 weeks of flexible splinting. Lateral luxation requires 4 weeks of flexible splinting. Intrusion requires 4 weeks of flexible splinting if repositioned. Avulsion requires 2 weeks of flexible splinting if PDL is viable and 4 weeks if PDL is non-viable. Mid-root fractures require 4-8 weeks of flexible splinting. Cervical root fractures require up to 4 months. Alveolar fractures require 4-6 weeks of rigid splinting.

<image>Clinical photographs showing the splinting technique for dentoalveolar trauma: a flexible titanium trauma splint bonded with composite resin to the labial surfaces of a replanted avulsed maxillary central incisor and the adjacent teeth, alongside a rigid arch bar splint stabilizing a four-tooth alveolar segment fracture with the reduced bone fragment in anatomic position</image>

Pediatric Considerations

Primary tooth avulsion should not be replanted due to risk to the permanent tooth bud. Primary tooth intrusion that displaces toward the permanent tooth bud (usually labially) requires extraction, while displacement away from the bud (usually lingually or palatally) allows spontaneous re-eruption or extraction. Primary tooth luxation requires extraction if interfering with occlusion or if there is risk to the permanent successor. Developing permanent teeth with an open apex have a better prognosis due to revascularization potential. Long-term monitoring assesses for disturbance to permanent tooth development after primary tooth trauma.

Follow-Up Protocol

At 1-2 weeks, splints are removed for subluxation and extrusive luxation, and clinical and radiographic checks are performed. At 4 weeks, splints are removed for lateral luxation, avulsion, and root fractures, and vitality testing is performed. At 6-8 weeks, endodontic evaluation and radiographic check for resorption are performed. At 3 months, vitality testing and radiograph are obtained. At 6 months, vitality testing and radiograph assess for resorption and ankylosis. At 1 year and annually for 5 years, long-term monitoring for late complications (resorption, ankylosis, periapical pathology) is performed.

Clinical Pearls

Time is teeth -- in avulsion injuries, every minute of extraoral dry time worsens the prognosis, and patients, parents, coaches, and teachers should be educated on immediate replantation. The vermillion border alignment in associated lip lacerations takes priority and should be marked before injecting local anesthetic. Primary teeth should never be replanted because the risk to the developing permanent tooth bud outweighs any benefit. Flexible splinting is the standard for most dental injuries, with rigid fixation reserved for alveolar fractures. Intrusive luxation in a mature tooth has the worst prognosis, with ankylosis and resorption expected, and early root canal should be considered. Associated injuries should always be checked for because dentoalveolar trauma rarely occurs in isolation -- fractures, soft tissue injuries, and adjacent tooth involvement should all be examined. Tetanus prophylaxis and antibiotics are standard for avulsion and contaminated wounds. Long-term follow-up is essential because root resorption and pulp necrosis can develop months to years after the initial injury. In children with open-apex teeth, time should be allowed for potential revascularization before committing to endodontic treatment.

References

• Andersson L, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries. Dent Traumatol. 2012.
• DiAngelis AJ, et al. International Association of Dental Traumatology guidelines for the management of luxation injuries. Dent Traumatol. 2012.
• Cvek M. A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture. J Endod. 1978.
• Andreasen JO, Andreasen FM, Andersson L. Textbook and Color Atlas of Traumatic Injuries to the Teeth. Wiley-Blackwell. 2019.
• Hinckfuss SE, Messer LB. An evidence-based assessment of the clinical guidelines for replanted avulsed teeth. Part I: timing of pulp extirpation. Dent Traumatol. 2009.
• Trope M. Avulsion of permanent teeth: theory to practice. Dent Traumatol. 2011.

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