Dental fractures aka “broken teeth” require different management based on the extent of the injury. The Ellis classification, which subdivides dental fractures into three classes of injury, is useful for ED providers because it determines emergent care of the dental fracture :
- Ellis I fractures involve only the enamel. They typically require no emergency treatment. If sharp edges are present, those can be smoothed for patient comfort. Dentist follow up can be at the patient’s convenience.
- Ellis II fractures involve the dentin but not the pulp and can be identified on exam by the creamy yellow color of dentin compared to the whiter, harder enamel. These fractures require more urgent care. Because dentin is a microtubular structure, Ellis II fractures threaten the integrity of the pulp and can lead to contamination of the pulp by oral flora . After recognizing an Ellis II fracture, the ED provider should anesthetize, clean and dry the tooth (Peridex can be used to sterilize the tooth) and seal the exposed dentin, which can be done with dental cement . Urgent dental follow up in the next 24 hours is recommended. Patients will require frequent visits and radiographs.
- Ellis III fractures are full thickness and expose the pulp. They can be identified by visualization of the pink-red pulp as well as bleeding from the pulp on cleaning of the tooth. Like Ellis II injuries, the pulp is at risk with these injuries but at a greater extent given the direct exposure of pulp to the oral environment. Ellis class III injuries require a two step sealing procedure. After anesthetizing, cleaning and drying the tooth, bleeding should be controlled with careful direct pressure. The first sealant layer is a calcium hydroxide base. On top of this base, the same dental cement coverage is applied. Like Ellis II injuries, Ellis III injuries require urgent dental follow up preferably within 24 hours.