Broken teeth in children

Are traumas to the mouth and fractured/broken teeth common in children?

Yes, they are very common! Minor traumas to the mouth are certainly common, but statistics show that about half of the children will also suffer a trauma to their teeth during their school years. Most traumas occur because of falls, in adolescents they may occur during sport activities.

What are the different types of teeth and how can they break?

Before we start discussing injuries to the mouth and their management, let’s get to know how our teeth are organized in our mouths, and the specific structure of each tooth. Before reading this section, I suggest you read the post about baby teeth on this website.

Let us start by talking about the structure of each tooth. Our teeth are made up of 3 different parts:
Crown – this is the part that we can see and it is visible above the gums
Neck – this is the part that attaches the crown of the tooth to the root
Root – this is the part of the tooth that we cannot see, it is found inside the jaw bone. Our teeth are attached to our jawbone with the help of connective tissue (called periodontal ligament).

When it comes to the actual tooth – our teeth are composed of layers. If we were to look at the tooth from the inside out, we would first see the innermost part, which contains vessels and nerves. Next, we have a layer called dentin. The outermost layer is the enamel which is the hard material containing phosphorous, calcium, hydrogen and fluoride that covers our teeth.

When it comes to the type of teeth that we have in our mouth – there is a slight difference between our baby teeth and our adult teeth:
Baby teeth – by the time a child is 3 years old, they will usually have about 20 baby teeth. We have teeth in our upper jaw and teeth in our lower jaw and the two types of teeth are quite similar. Starting with the teeth in the back and working our way towards the front, we have molars, canines and then finally the incisors, in the front of our mouth.
Adult teeth – the structure of our permanent teeth is similar to that of our baby teeth. The only difference is the presence of premolar teeth between our molars and canines and the development of wisdom teeth. The most commonly injured teeth are the front incisors. Makes sense.

What types of tooth injuries do we have in children?

Generally speaking, it is important to learn how to distinguish between two types of injuries: dislodgement, which is when a tooth is pushed out of place, and fractures or chips, which can vary in size and thickness.
Dislodged tooth – several different types of injuries can lead to the displacement of a tooth out of its place. What these injuries have in common is trauma to the area where the root of the tooth lies or trauma to the structures that support the tooth – the connective tissue that attaches the tooth to the bone (that same periodontal ligament we mentioned earlier).
These types of injuries may present as a painful tooth without any external signs (concussion), a loose tooth that is easily moved (the child will usually complain of pain during eating, the tooth is loose and there is some bleeding between the tooth and the gums), a tooth pushed inwards into the jaw, a tooth pushed outwards away from the jaw, a tooth that dislodged sideways or a tooth that was completely knocked out.
Fractured tooth – there are different types of fractures, too. These will have a crack or a fracture in one or more of the different layers and structures of the tooth. These types of injuries will have anything from a chip in the enamel to a fracture in one of the structures, including a possible fracture in the jaw bone, exposing the pulp.

Are injuries to baby teeth significant? Baby teeth fall out eventually, so why do we even need to bother with their injuries?

Firstly, children use their baby teeth for several years, so the dislodgements and fracture of baby teeth can have a functional, aesthetic and psychological effect on the child. Furthermore, since some of our permanent teeth’s roots are present already at birth or may develop during childhood, any injury to a baby tooth that occurs near the location of the adult tooth roots may harm the permanent tooth. The younger the child is, the higher the chance of the injury affecting the permanent tooth as the mouth is smaller, and the different structures are closer to each other. Therefore, proper and professional management of these cases is very important.

What are the complications of tooth injuries in children?

There are many different potential complications. The complication may vary depending on age of the child and whether the injury occurred in the baby or adult teeth.

Change in colour
This occurs as a result of ischemia to the pulp of the tooth (the area that contains the blood vessels and nerves) and may manifest both in the baby teeth and the adult teeth if the permanent tooth found beneath the baby tooth is injured. The colour of the tooth can turn pink, yellow, brown, grey or black. In addition to the aesthetic implications of this, these teeth are also prone to infection and may lead to resorption of bone surrounding the root of the tooth and this may affect the stability of the tooth. By contrast, many cases of discoloration of baby teeth will be reversible without any intervention, but these cases will still need close follow-up and observation.

Sensitivity to cold or hot food/beverages
Exposure of the inner layers of the tooth can lead to sensitivity when eating or drinking cold and hot foods and beverages.

Difficulty chewing
If a fracture or dislodgement affects the child’s ability to open or close their mouth, this could influence their ability to chew food.

Infections
Continuous injury to the deeper inner layers of the tooth can lead to the penetration of bacteria and development of infections.

Instability of the tooth
Injury to the area of the periodontal ligament and eventually to the root of the tooth can lead to loss of tooth stability.

Injury to a permanent tooth secondary to injury to an adjacent baby tooth
Injury to a permanent tooth that has not erupted yet following an injury to an adjacent baby tooth can affect the colour of the tooth, impair the development of the external enamel layer (if the injury occurs at the time when the tooth is undergoing calcification), impair its eruption and disrupt the structure of the crown or root of the tooth.

So how are these different tooth injuries managed?

Since most injuries are a result of falls, it is important, just like every other injury in children, to make sure that these do not happen again. When a tooth is fractured and the fractured piece is not found, keep in mind that the child may have either swallowed or aspirated the broken piece, and assess the need for a chest and abdominal x-ray. Sometimes, there could be injury to the soft tissue in the lips or in other areas in the oral cavity that may require stitches. Of-course it would be difficult for us to go into all the details of management of all these different types of injuries here, but let us try to go over the main ideas and concepts:

Fractures in the crown
Generally, one could say that there is a difference between a chip, a shallow fracture and a deep or more complex fracture. Sometimes it is enough to just shave and smoothen the area, and often there will be a need for a revision or reduction (placing the broken piece back in place). In complex cases there may be a need for further intervention, depending on the severity of the injury (root canal treatment, extractions, etc.).

Fractures in the root of the tooth
Management of these fractures varies depending on the specific location in the root. Sometimes, only observation and follow-up are needed and other times a partial or full extraction may be required.

Dislodged tooth
See below.

What does first aid treatment for a dislodged tooth entail?

Management of dislodgment injuries depends on whether the tooth affected is a baby tooth or an adult tooth.
For example, when a tooth is completely knocked out, management is very different if it is a baby tooth we’re talking about or a permanent tooth.
For a knocked out permanent tooth, we have to try and restore the tooth as quickly as possible – place the tooth back into place, place a pad in the child’s mouth and ask them to bite on it in order to prevent the tooth from falling off again. And rush to the dentist as quickly as you possibly can.
For a baby tooth that has been knocked out, it is better not to place the tooth back in its place to avoid injury to the permanent tooth beneath/above it.
If you are unable to see a dentist right away or if you are unsure whether the tooth affected is a baby tooth or an adult tooth, you can place it in a glass of cold milk. If you do not have access to milk, then place the tooth in a container with the child’s saliva. Both of these fluids will help preserve the cells in the area of the periodontal ligament and will increase the chances of a successful treatment at the dentist. Do not place the tooth in tap water as this will destroy the cells.
For dislodgement injuries that result in shifting or loosening of the tooth, a soft food diet is advised while the tooth is still painful and a prompt dental assessment.
For dislodgement injuries that result in inward pushing of the tooth, it is important to see a pediatric dentist immediately to assess the extent of the damage to the permanent tooth below the affected tooth.
For injuries where a tooth is pushed outwards it is important to keep in mind that the tooth may fall out and there is a chance that the child will aspirate it. So, if it is hanging very loose and there is a concern for aspiration, sometimes it is better to pull it out, place it in a glass of milk and rush to the dentist.
Other management methods for dislodgement injuries range from simple observation to fixation, root canal treatment and extraction.

Discoloration as a result of tooth injury

The causes of a grey or black tooth following an injury that the parents may or may not remember are:
1. A hematoma within the tooth – here the discoloration will appear shortly after the injury. This change in colour is reversible and tends to resolve spontaneously, just like a blow to the leg would cause a change in colour of our skin from red to purple, and eventually back to the original colour.
2. Ischemia/death of the tooth – the trauma to the tooth can injure the blood vessels to the pulp of the tooth and lead to its death. When the trauma results in a fracture, there is less of a chance for discoloration, when the crown is affected rather than the root.

What happens if a child needs a crown?

There are many situations when a fractured tooth results in the need for a full or partial crown placement.
The dentist will carry out an x-ray and will have to determine whether the pulp of the tooth is exposed and whether it requires further intervention.
If the parents managed to save the fractured tooth piece and it fits the fracture line, the dentist may try to glue the fractured piece back in place. Another option would be to build a new crown using a material called composite.

What happens if a child needs a tooth extraction?

It depends on the case. If a permanent tooth needs to be extracted, then an acrylic artificial tooth can be placed until the child is old enough for an implant.

How do you know if a tooth injury is serious and requires a visit to the dentist? How do you know if it is urgent?

It is important to see a pediatric dentist for any tooth injury, even when it seems minor and insignificant to the parents. To minimize the potential harm that may be caused, allow the professional to determine the severity of the injury, carry out x-rays, and advise you on when to return for follow-up.

In summary, tooth injuries are common and important in pediatrics. Since these injuries could potentially cause both short and long-term effects, always see your pediatric dentist for assessment following any type of injury. See your dentist even if the injury feels minor, so that they can suggest the best intervention and management for you.

Take care my friends.