Management of dento alveolar trauma

Management of

Dento Alveolar Injuries

Chamara Atukorala MD

Consultant oral and Maxillofacial Surgeon

TRAUMA

The leading cause of death from 1- 44 years.

• Overall ;Fourth only to Heart disease , Cancer & Chronic Respiratory disease.

• Trauma affects 135,000,000 people a year : 103 people /Minute !

Finkelstein EA, Corso PS, Miller TR, Associates. Incidence and Economic Burden of Injuries in the United States. New York, NY: Oxford University Press; 2006.

Maxillo facial and Dentoalveolar Injuries

• Epidemiology

• Aetiology

• Prevention

• Initial Assessment

• Evaluation of the injury

• Medico-legal aspects

• Surgical Management

• Management of Post Traumatic Alveolar bone defects

Epidemiology of Maxillofacial trauma

• 5-33 %of patients with severe trauma are affected by

Maxillofacial trauma as well.

– Soft tissue injuries. (62.5%)

– Dentoalveolar, (49.9%)

– Facial bone fractures, (37.5%)

Robert Gassner, Tarkan Tuli, Oliver Hächl, Ansgar Rudisch, Hanno Ulmer,;Cranio-maxillofacial trauma: a 10 year review of 9543 cases with 21067 injuries ;Journal of Cranio-Maxillofacial Surgery, V 31, Issue 1, February 2003, Pages 51-61

0%

10%

20%

30%

40%

50%

60%

70%

soft tissue dento alveolar facial bones

Main categories of the Maxillofacial fractures

1. Craniofacial

2. Mid face

3. Lower face

4. Dento alveolar

Injuries affecting the teeth and /or their supporting tissues and can be sub divided in to

• Dental hard tissues and pulp

• Periodontal tissues

• Supporting bone

• Gingivae and oral mucosa

• Combination of above

Dentoalveolar traumatic injuries (DAI)

• Injury results from an External Force, involving teeth, alveolar portion of maxilla or mandible, & adjacent soft tissues .

• fractured, displaced, or lost anterior teeth have a significant functional, aesthetic, and psychological effects on children thus affecting quality of life

Bastone EB, Freer TJ, McNamara JR. Epidemiology of dental trauma: a review of the literature. Aust Dent J 2000;45:2–9

Dentoalveolar Injuries constitutes of • Alveolar bone Fracture 6 % • Soft tissue injury 47– 58% • Uncomplicated crown fracture 26 -76% • Complicated crown fracture 15.5% • Root fractures 7.7% • Avulsion 4–22% Caliskan MK, Turkun M. Clinical investigation of traumatic injuries of permanent incisors in Zimir.Turkey. Endod Dent Traumatol 1995;11:210–3. Majorana A, Pasini S, Bardellimi E, Keller E. Clinical and epidemiologic study of traumatic root fractures. Dent Traumatol 2002;18:77–80. Bastone EB, Freer TJ, McNamara JR. Epidemiology of dental trauma: a review of the literature. Aust Dent J 2000;45:2–9.

• Boys :girls - 2:1 in both the primary and permanent dentitions.

• Sports injuries common among teenagers ;associated with contact sports :: soccer, rugby.

• RTA and assaults are common with the late teenage years ; closely related to alcohol abuse.

• Possibility of child physical abuse must never be forgotten

• >50% of affected children have orofacial injuries.

• Improper management can lead to tooth and alveolar bone

loss leaving defective alveolus in the post traumatic state.

Iida S, Matsuya T. Paediatric maxillofacial fractures: their aetiological characters and fracture patterns. J Craniomaxillofac Surg 2002; 30:237-41. Qudah MA, Bataineh AB. A retrospective study of selected oral and maxillofacial fractures in a group of Jordanian children. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002; 94:310-4.

Maxillo facial and Dentoalveolar Injuries

• Epidemiology

• Aetiology

• Prevention

• Initial Assessment

• Evaluation of the injury

• Medico-legal aspects

• Surgical Management

• Management of Post Traumatic Alveolar bone defects

The classification OMF trauma based on aetiology

1. Assaults, (Western society )

2. RTA (Developing countries)

3. Sports Injuries,

4. Falls,

5. Industrial Injuries,

6. Others

Animal Bites,

Burns,

War Injuries.

Iatrogenic Injuries

Self-inflicted Injuries.

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Maxillo facial and Dentoalveolar Injuries

• Epidemiology

• Aetiology

• Prevention

• Initial Assessment

• Evaluation of the injury

• Medico-legal aspects

• Surgical Management

• Management of Post Traumatic Alveolar bone defects

Prevention

Cranio-Maxillo-Facial ,Dento Alveolar Trauma

Medical Prevention-

1. The use of medications to treat various abnormal physiologic conditions that may result in trauma due to falling.

• Circulatory disturbances

• Vasovagal reactions,

• TIA

• inadequate insulin

replacement in severe diabetes

2. Proper and regular dental care and maintenance ;

• preservation of alveolar bone height and strength of periodontium can prevent complete tooth avulsion in some cases .

• Splinting of loose teeth will be more likely be successful.

3. Orthodontic or orthognathic correction of severe malocclusions, particularly C 2 Div I , can help decrease the traumatic injuries

Prevention Through External Support Devices

Mouth guards and Headgears in sports

• Protection of the teeth, is achieved by a plastic interface to separate the dental arches.

• Holds the lips and cheeks away from the teeth.

• Absorb and distribute the force of the impact, decreasing the risk of mandibular angle and condylar fractures.

Seat Belts and Air Bags

• proved to be effective in reducing injuries and fatalities in motor vehicle accidents

Helmets

• Helmet use reduces the risk of head injury by 85%, • Brain injury by 88%. • The protective effect for facial injury is 65% for the upper and

mid facial regions. • Thompson DC, Rivara F, Thompson R. Helmets for preventing head and facial injuries in bicyclists. Cochrane Database of Systematic Reviews 1999, Issue 4. Art.

No.: CD001855. DOI: 10.1002/14651858.CD001855

Maxillo facial and Dentoalveolar Injuries

• Epidemiology

• Aetiology

• Prevention

• Initial Assessment

• Evaluation of the injury

• Medico-legal aspects

• Surgical Management

• Management of Post Traumatic Alveolar bone defects

In Every patient with considerable trauma

an Initial Assessment and Resuscitation

(as indicated) is carried out aiming to preserve the life.

Standard sequence of “ATLS” must be followed

Primary Survey & Resuscitation

follows a strict, sequential “ABCDE” protocol:

• A: Airway with Cervical Spine Control

• B: Breathing and Ventilation

• C: Circulation and Hemorrhage Control

• D: Disability–(Neurological status

• E: Exposure + environment

• Frequent Reassessment must be made

must follow the safest pathway, diagnosing and simultaneously treating life-threatening injuries in the order in which they would otherwise kill the patient.

Maxillofacial injuries are not addressed at the initial stage

Unless they have an impact on the Airway, Breathing, or Circulation.

e. g.

• Severe Lefort III fractures

• Bilateral para Symphyseal Mandibular fractures

• Severe bleeding from fractures obstructing the airway

Any trauma to facial region

can cause Injury to

other Cranio-Facial structures,

which may occur in isolation or in association with

Dento alveolar fractures.

These may cost patient’s life ,if not identified early.

o Head injury observation for the first 24 Hours. – GCS a useful tool in observation.

‘Head injury’ for the purposes of the guideline is defined as any trauma to the head, other than

superficial injuries to the face

Glasgow Coma Scale

The assessment and classification of patients who have sustained a head injury should be guided primarily by the adult and paediatric versions of the Glasgow Coma Scale and its derivative the Glasgow Coma Score (GCS).

Adults who have sustained a head injury should initially be assessed and their care managed according to clear principles and standard practice, as embodied in: the Advanced Trauma Life Support (ATLS)

NICE clinical guideline 56 – Head injury

Patients who have sustained a head injury and present with any of the following risk factors should have full cervical spine

immobilisation attempted unless other factors prevent this:

• GCS less than 15 on initial assessment by the healthcare professional

• neck pain or tenderness

• focal neurological deficit

• paraesthesia in the extremities

• any other clinical suspicion of cervical spine injury.

Cervical spine immobilisation should be maintained until full risk assessment including clinical assessment (and imaging if deemed necessary) indicates it is safe to remove the immobilisation device.

Comprehensive assessment & definitive management of OMF injuries carried out later

when the patient is stable

• If any teeth, crowns, or bits of denture are missing need to be recorded ;

• CXR taken to be locate them.

• Dentures, vomitus, hematoma, or other foreign bodies may block the airway .

Maxillo facial and Dentoalveolar Injuries

• Epidemiology

• Aetiology

• Prevention

• Initial Assessment

• Evaluation of the injury

• Medico-legal aspects

• Surgical Management

• Management of Post Traumatic Alveolar bone defects

HISTORY Correct diagnosis of the severity of the injury is essential : Achieved through a detailed history, clinical, & radiographic assessment Many injuries and their prognosis predicted from

• history of premorbid events, • the mechanism • energy involved in the injury itself, • its immediate sequelae.

The AMPLE history is a useful mnemonic: • A: Allergies • M: Medications current • P: Past illnesses and Pregnancy • L: Last meal • E: Events related to the injury

PHYSICAL EXAMINATION

Check for

• Symmetry

• Obvious gross deformities

Head and neck

1. Soft tissue

2. Cranial Nerves

3. Hard tissue

4. Occlusion and dentition

Soft tissues

• Scalp and forehead

• Eyes ( right & left ) – Structure

• Upper lids ,Lower lids ,Sclera ,Cornea,Pupils

– Position of the globe

• Exophthalmos, proptosis

• Enophthalmos, hypoglobus

– vision

• Ears( right and left )

• Nose

• Lips ( upper and Lower)

• Facial skin

• Tongue + ve

Soft tissue lacerations

The commonest OMF injuries : > 2/3 sustained in assaults .

These are often overlooked in trauma epidemiology and Management.

• Tetanus toxoid booster is required if there is soil contamination of a

wound and the patient has not been given a tetanus booster in 5 -10 years

Cranial nerve examination

1-12

Optic

Facial

Hard tissues

• Skull bones

• Base of skull

• Frontal bone

• Supra orbital ridges ( R & L)

• Infra orbital ridges ( R & L)

• Zygomatic arch & bone ( R & L)

• Nasal bone

• Maxillae( R & L)

• Palate

• Mandible

• Condyles ( R & L), Lower border( R & L)

• Occlusion

• Teeth

Facial fractures ; important features to look for

– Asymetry

– Pain

– swelling

– Bruising , Hematoma

– Deformity

– Mobility

– Loss of function

Sequence

Base of the skull #

– Bilateral periorbital hematomas

– Sub conjunctival hemorrhage

without post. Limit

– Haemotympanum

– CSF rhinorrhoea

– CSF otorrhoea

– Post auricular bruising

Investigations

• CT

• Plain Radiographs

Ideal is CT as indicated in the trauma patients.

With clinical examination findings , suitable plain radiographs are of great value in the diagnosis.

Projections for Upper Third of the Face The Occipitofrontal 25° ; good visualization of the orbital floor

• Caldwell’s projection in a patient with a fracture of the frontal bone (arrows).

Middle Third of the Face

• Occipitomental 30° good for the malar arches ,anterior inferior orbital margins.

• Lateral Projection; used with others to localize the fracture

OM 10° OM 30°

Lower-third

• Injuries require a posteroanterior (PA) mandible view

• & panoramic tomography (DPT) or, lateral oblique

views of both Sides

Intra oral views

The Lateral Soft Tissue view shows

foreign bodies,

nasal bones,

nasal plates of frontal processes of maxilla.

• Upper Occlusal view

occasionally to assess palate,

• Suspected orbital fractures

need CT scans

Soft tissue projections

Search Patterns & Reminders Campbell’s lines (McGrigor and Campbell )(OM 10 °projection).

Allows examination of those parts where fractures most likely to be found . Reduces the chance of missing a fracture.

Maxillo facial and Dentoalveolar Injuries

• Epidemiology

• Aetiology

• Prevention

• Initial Assessment

• Evaluation of the injury

• Medico-legal aspects

• Surgical Management

• Management of Post Traumatic Alveolar bone defects

Proper & Accurate assessment & record keeping

is very important

to avoid unnecessary problems.

• Trauma to teeth

• Trauma to bones

Esp. Following Assaults & RTA

Maxillo facial and Dentoalveolar Injuries

• Epidemiology

• Aetiology

• Prevention

• Initial Assessment

• Evaluation of the injury

• Medico-legal aspects

• Surgical Management

• Management of Post Traumatic Alveolar bone defects

Management of Soft tissue lacerations

Principles

1. Wound debridement Scrubbing

• Effective removal of debris & bacteria

Irrigation

• Irrigation effective cleansing method

2. Wound Exploration

3. Wound closure

Alveolar bone Fractures

The Classification Of Dento-alveolar Injuries Based On The World Health Organization (WHO) System.

Treatment timing guidelines by Andreasen et al.

• Acute treatment requirement (within 3 Hr) – Avulsion, Extrusion, – Root fractures – ALVEOLAR FRACTURES; – Soft tissue injuries

• Sub-acute (within 24 Hr)

– crown and crown/root fractures, – intrusion, – concussion, – subluxation and primary tooth injuries

• Delayed (after 24 Hr)

– crown fractures.

Andreasen JO, Andreasen FM, Skeie A, Hjorting-Hansen E, Schwartz O. Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries – a review article. Dent Traumatol 2002;18:116-128.

Alveolar Bone fracture Classification after William D Clark, MD

Class I fracture : fracture of the edentulous segment. Class II : dentulous segment fracture with little or no displacement.

• Class III fracture :

The fracture of dentulous segment with moderate-to-severe displacement.

• Class IV fracture :

fracture shares one or more fracture lines with other fractures of the tooth-bearing facial skeleton.

• Typical presentation : segment with two or more teeth being displaced axially or laterally.

• Cases with a tenuous blood supply to fractured segments may also require closed treatment.

Therapy Indications

• Preservation of AP anatomical integrity to prevent post-traumatic alveolar crest deformity is important.

• Have to differentiate between displaced and non-displaced alveolar process fractures.

• Clinical evidence of an alveolar process fracture • Masticatory dysfunction

• Injury of adjacent soft tissue(gingival laceration)

• Dysaesthesia

• Fracture or mobility of teeth

Treatment options

Conservative

-in undisplaced fractures

Closed repositioning:

-in displaced fractures

-if there are medical or aesthetic contraindications for an open

repositioning

Open repositioning:

-With external fixation

-With Internal fixation

Closed reduction is carried out under adequate Local anaesthesia.

– Finger Manipulation of the

fractured segment .

– Stabilisation using a splint.

for 4 – 6 weeks

Complex and multiple injuries may need general anaesthesia

Splinting methods

Closed reduction

• Dentoalveolar fracture “carrying” all lower incisors

However, severe segmental alveolar fracture require open treatment to ensure proper reduction

Open reduction : Indications

• Unstable # with severely displaced alveolar segment

• Complex injuries with associated soft tissue injuries

• If closed reduction, result in occlusal disturbance

• In case of dysaesthesia

• Exact positioning of the fracture fragments through splinting is not possible in case of missing teeth (due to trauma /in a mixed dentition)

Open Reduction and External fixation with Arch bars

Open reduction through a marginal (envelope) incision

• By open treatment, the fracture is usually exposed through a marginal (envelope) incision,

• The fragment retains its vascular supply from the lingual or palatal side. Incisions may jeopardize the vascular supply of the fractured segment, subsequently resulting in tenuous blood supply after extensive exposure.

Open reduction and Internal

Fixation of a severely displaced alveolar

fracture with a titanium mesh plate

Additional Measures

• Extraction of teeth and/ or parts of the alveolar process if the vascular supply is not guaranteed

• If indicated, antibiotic therapy and analgesic therapy

Set up of Care

• An outpatient treatment in cases with a low risk of infection and in small fractures.

• Extensive lesions should be treated in hospital

Intrusive luxation

Reduction and stabilization

immediately

Post op care

Patients are encouraged to

• Restrict to soft diet

• Avoid clenching or overload to the alveolar segment for a period of up to 4 weeks postop.

• To prevent infection after the operation, antibiotics for compound and contaminated ones.

Maxillo facial and Dentoalveolar Injuries

• Epidemiology

• Aetiology

• Prevention

• Initial Assessment

• Evaluation of the injury

• Medico-legal aspects

• Surgical Management

• Management of Post Traumatic Alveolar bone defects

Management of Post traumatic alveolar bone defects

• Localized alveolar defects are challenging from conventional prosthodontic treatment point of view.

• Alveolar bone is lost due to late complications of injury. ; if replanted tooth during growth becomes ankylosed and submerged, prevents normal growth of the alveolar crest .

To restore bone defects ,various materials & methods are used

• Augmentation with onlay bone grafts, membrane techniques, bone distraction and bone splitting.

• Bone grafting and guided bone regeneration can increase the width and, to some extent, also the height.

Bone grafting

Crestal Split Technique .

Only Lateral widening, is possible

• Alveolar widening with osteotomes produces a greenstick fracture, leaving periosteum attached to the bone.

• This periosteally pedicled buccal cortex is repositioned and a new implant bed is created without drilling.

• The resulting gap can be covered by nonresorbable membrane filled with allogenic material .

• Interpositional autogenous bone grafts have been used to improve bony healing in the gap.

Take away message

• Possibility of a head injury be excluded before Rx

begins.

• Main aim of Rx is to maintain the width and height of

the alveolus at all the time .

• Successful treatment is a challenge in DAI.Correct

diagnosis and up to date Rx is essential in proper

management of DAI.

• Improper management can lead to

aesthetic and functional abnormalities.