The clinical findings of tooth fractures vary depending upon the site of tooth fracture and the physical findings, which can be summarized using the Ellis and Davey classification given in 1970 [6]. Tooth fracture is classified and presented under nine categories, which are as follows:

• Class 1 - Simple fracture of the crown-involving little or no dentin
• Class 2 - Extensive fracture of the crown involving considerable dentin, but not the pulp
• Class 3 - Extensive fracture of the crown involving considerable dentin, and exposing the dental pulp
• Class 4 - The traumatized tooth which becomes non-vital with or without loss of crown structure
• Class 5 - Teeth lost as a trauma
• Class 6 - Fracture of the root with or without loss of crown structure
• Class 7 - Displacement of the tooth without fracture of crown or root
• Class 8 - Fracture of the crown en masse and its replacement
• Class 9 – Traumatic injuries of primary teeth

The radiographic examination of tooth fractures is required to check the site of tooth fracture and stage of tooth development. The radiographic examination is important, especially in fractures of root and the intrusive luxation injuries. The management of root fractures depends mainly on the site of root fracture, which will be decided only after the radiographic examination. The tooth fractures are usually examined using the intraoral peri-apical radiographs.[1]

The tooth fractures are often associated with swelling of the gum, lips, etc. The application of cold packs to the injured site is useful in reducing pain and swelling before the initiation of specific dental treatment for fracture restoration. Associated injuries to the oral cavity should have management as well. Prompt and proper management is necessary for tooth survival and restoring its function.

Tooth fracture involving the enamel can be treated by bonding the lost tooth fragment or by restoring with composite resin. Tooth fracture extending into dentin can be treated by covering the exposed dentinal tubules with glass ionomer cement or doing a permanent restoration using composite resins or other tooth-colored restorative materials. Treatment of tooth fractures involving the pulp of developing teeth is via doing pulp capping or partial pulpotomy procedures. Tooth fracture involving the pulp of mature teeth receive treatment via root canal treatment. In crown root fractures without involving the pulp can be treated removal of the crown root fragment and followed by restoration of the apical tooth fragment.[7] In crown root fractures involving the pulp can be treated by removal of the crown root fragment followed by endodontic treatment of the apical tooth fragment. Root fractures can be treated by splinting with a flexible splint for four weeks and followed by root canal treatment coronal fragment of the tooth.

No treatment required for management of concussion injuries, but monitoring of the pulp tissue is necessary for one year. Subluxation injuries can be treated by flexible splinting of damaged teeth for two weeks. Extrusive luxation injuries can be treated by repositioning the tooth in the socket and stabilizing with flexible splinting for two weeks. Root canal treatment is needed if pulp necrosis is anticipated. Lateral luxation injuries can be treated by disengaging from the bony lock and repositioning the tooth digitally in the socket, followed by flexible splinting for four weeks. No intervention required for intrusive luxation injuries of less than 3 mm and a spontaneous eruption is anticipated. If no such spontaneous eruption is evident, surgical repositioning is required. If intrusive luxation is more than 7 mm, surgical repositioning is required, and if there is an anticipation of pulp necrosis, root canal treatment is necessary.[1]

The differential diagnosis for tooth fractures includes dental infections, displacements, and avulsions. Though the term 'tooth fracture' is used equally for deciduous as well as permanent teeth, it merits noting that it is the permanent teeth that are mostly fractured, while the primary teeth are usually displaced. In the primary teeth, the tooth fractures require differentially diagnosed with the physiological root resorption.[8] A thorough clinical and radiological examination of permanent tooth fractures usually gives an accurate diagnosis.

The consequence of fractured tooth depends upon the type of injury, delay in treatment if any, and quality of treatment rendered. The favorable outcome of the tooth fracture is the normal healing of the pulp and periodontal tissues.[1] The initial healing process of the fractured tooth takes 1 to 2 weeks. Minor fractures restricted to the enamel usually have a better prognosis, while deeper untreated fractures may result in infection and abscess.

Tooth fractures are associated with multiple complications such as pulp necrosis, crown discolorations, peri-apical abscess, pulpal obliteration, development of fistulas, and internal or external root resorptions.[7] Pulp necrosis remains the most commonly reported complication in tooth fractures. Primary teeth with necrosis require extraction, while endodontic treatment is the recommended intervention for necrosis of permanent teeth.

The domestic or physical violence conditions in the orofacial regions usually encounter the tooth fractures. Injuries in the oral cavity, including tooth fractures, are frequently associated with child abuse. Thus the knowledge of etiology and clinical findings of tooth fractures is important for forensic medicine practitioners. The face is quite prone to injuries resulting from falls, scuffles, etc. Tooth fractures in domestic violence, child abuse, etc. mainly result from blunt trauma/ blow to the face or slapping. Tooth fractures tend to occur as a part of the facial injuries in domestic violence conditions.[9] From the forensic investigative standpoint, tooth fractures need to be considered along with the adjacent periodontal ligament and alveolar bone injuries as well. There are five different tooth and surrounding tissue injuries noted, such as concussion, subluxation, extrusive luxation, lateral luxation, and intrusive luxation injuries. The etiology of trauma to the tooth and supporting structures mainly differ in the direction of force to the tooth structures. Intrusive luxation injuries occur when the force of impact dislodges the tooth in the axial direction and into the alveolar bone. The injured tooth may get displaced through the alveolar bone, and in extensive conditions, it gets impinged on the succedaneous tooth. Radiographically, the injured tooth may appear short in length when compared to the adjacent tooth. Whereas in extrusive luxation conditions, the force of impact on the tooth is in coronal direction and causes the axial displacement from the socket. Radiographically, the tooth appears elongated, and the clinical mobility of the tooth will increase.[10] Thus, the forensic practitioners should get the appropriate data of tooth injury, a thorough clinical examination aided with additional diagnostic aids such as intraoral peri-apical radiographs and Orthopantomogram lead to an accurate diagnosis. 

The fracture of the supporting maxillary or mandibular bone is called the closed fractures or crushing injuries. The supporting bone fractures are usually associated with luxation injuries to the teeth. They typically occur when external force exerted directly on the face in case of blunt trauma on the face or slapping. Radiographically, there will be complete displacement of the tooth with marked fracture lines in the alveolar bone. The compromised periodontal conditions in diabetic patients, individuals with the habit of smoking or smokeless tobacco weaken the defensive strength of the teeth and supporting structures rendering more prone to facial injuries. Thus in people with compromised periodontal conditions, teeth fractures may occur even with a low degree of violence conditions. In the forensic practice view, the systematic health of the individuals needs to be an option before reaching the diagnosis of the violence conditions.[10]

Education of the patients and parents is crucial for preventing the tooth fractures. Parents and school teachers need training regarding the common etiological factors responsible for fractures of primary teeth.[2]

The health care team need adequate knowledge and experience to treat dental injuries. The management of tooth fractures requires knowledge regarding the normal anatomy of the tooth structure, aesthetic considerations, and economic factors of the patient as well. The inputs from dental professionals are quite crucial in finalizing the diagnosis of physical and domestic violence cases for forensic practitioners. Similarly, coordination is necessary between the conservative, prosthodontics, and pedodontics practitioners needed for the successful management of tooth fractures.