Tooth Fracture

Tooth fracture is a break in the crown, root or both from trauma, biting hard objects, decay weakened structure, large restorations or bruxism. The treatment depends on the depth of the fracture, whether the pulp is exposed, the position of the fracture line and the maturity of the tooth.

• Classification of crown fractures:
  • Enamel infraction (crack) or enamel fracture only.
  • Enamel and dentine fracture without pulp exposure (uncomplicated).
  • Enamel, dentine and pulp fracture (complicated crown fracture).
  • Crown root fracture (extends below the gum margin).
  • Root fracture (horizontal, oblique or vertical).
• Most trauma involves upper central incisors in children and young adults (falls, sport, road traffic accidents, violence, bicycle accidents); in adults, molars and premolars with large restorations or caries fracture during chewing.
• Associated injuries must be sought: lip and gum lacerations with embedded tooth fragments, concussion, luxation or avulsion of other teeth, alveolar bone and mandibular fracture, and cervical spine injury.

• Pain on biting, temperature sensitivity or pain on air exposure; a sharp edge cutting the tongue or lip; visible chipped tooth or missing fragment; bleeding from the pulp (pink or red spot) in a complicated fracture; tooth mobility with a root fracture or crown root fracture; displaced bite.
• Dentine exposure appears yellow and is sensitive; pulp exposure is pink or red and bleeds, and is painful.
• Examination: check airway, consciousness and head injury; examine lips and gums for fragments; assess every tooth for mobility, displacement, percussion tenderness, bleeding at the gum line, and occlusion; check the jaw for step deformity and trismus.
• Red flags: lost tooth fragment not found (possible inhalation, swallowing, or embedded in lip), loss of consciousness, vomiting or confusion after injury, malocclusion, jaw pain, facial swelling, bleeding that will not stop, signs of abuse in a child.

• Clinical examination of all teeth, soft tissues and bite; transillumination and magnification.
• Pulp sensibility testing (cold, electric pulp test) at the time of injury as a baseline and repeat at 6 to 8 weeks, 3 months, 6 months and 1 year (tests may be unreliable in the first weeks).
• Percussion and mobility tests; periodontal probing to detect a vertical root or crown root fracture (narrow deep pocket).
• Imaging: periapical radiographs from different angles (with a horizontal angle change of 15 to 20 degrees for root fractures), occlusal view, panoramic radiograph for suspected jaw fracture, and cone beam computed tomography for complex root fractures.
• Soft tissue radiograph or ultrasound of the lip and cheek, and chest X-ray if a fragment may have been inhaled or swallowed and symptoms (cough, wheeze, stridor) are present.
• Differentials: enamel hypoplasia, cracked tooth, tooth wear, caries cavitation, tooth luxation or avulsion, and alveolar fracture.

Immediate care

• Manage airway, bleeding and head injury first; rinse the mouth with water or saline and control bleeding with pressure on gauze.
• Find and keep fragments: store in milk or saline (not dry); take them to the dentist as they can be bonded back.
• Cover exposed dentine with glass ionomer cement or a dentine bonding agent; place a protective covering over any sharp edge (orthodontic wax or temporary filling material).
• Analgesia: paracetamol 1 g orally every 6 hours (maximum 4 g daily) with or without ibuprofen 400 mg orally every 8 hours with food for 2 to 3 days (children: paracetamol 15 mg/kg every 6 hours, ibuprofen 10 mg/kg every 8 hours).
• Soft diet, avoid biting hard foods; chlorhexidine 0.12 to 0.2 percent mouthwash twice daily for 1 week if there is soft tissue injury.
• Tetanus: if the wound is contaminated and the patient is unvaccinated or incompletely vaccinated, give tetanus diphtheria vaccine 0.5 mL intramuscularly, plus tetanus immunoglobulin 250 IU intramuscularly for high risk wounds; if the last dose was within 10 years (5 years for dirty wounds), no dose is needed.
• Antibiotics are not routinely required; give amoxicillin 500 mg orally three times daily for 5 days (children by weight) only for infection, contaminated lacerations, or associated alveolar or jaw fractures.

Dental treatment (arrange within 24 hours for pulp exposure and within a few days for other fractures)

• Enamel fracture: smooth the edge or restore with composite.
• Enamel and dentine fracture: reattach the fragment with adhesive bonding or restore with composite resin; protect the dentine promptly.
• Complicated crown fracture: vital pulp therapy (direct pulp cap or partial pulpotomy with mineral trioxide aggregate or calcium silicate cement) in young teeth to maintain vitality; root canal treatment in mature teeth or when the pulp is necrotic; then restore.
• Crown root fracture: remove the fragment, then restore, with crown lengthening or orthodontic extrusion if the fracture is subgingival; extraction if not restorable.
• Root fracture: reposition and splint with a flexible splint for 4 weeks (mid-root) or 4 months (near the gum line); monitor pulp status; root canal treatment of the coronal segment if it necroses; extraction of the coronal fragment for fractures too close to the gum line.
• Check follow up at 2 weeks, 6 to 8 weeks, 3 months, 6 months, and 1 year, with radiographs and pulp tests; watch for discolouration, sinus tract, abscess, and root resorption.

Prevention

• Mouthguard for contact sports; avoid chewing ice, pens and hard objects; protect heavily restored teeth with cuspal coverage crowns or onlays; treat bruxism with a night guard; seat belts and helmets.

Special groups

• Children and adolescents with immature roots: preserve the vital pulp (pulp cap or partial pulpotomy, or regenerative endodontics) so the root can finish developing; apexification is used only if the pulp is lost; consider safeguarding concerns if injuries are inconsistent with the story.
• Fractures with head injury or loss of consciousness: neurological observation and referral first.