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Maxillofacial TraumaMaxillofacial Trauma

Dento-alveolar fracturesDento-alveolar fractures

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DefinitionDefinition

Are those in which avulsion, subluxation or Are those in which avulsion, subluxation or fracture of the teeth occurs in association with a fracture of the teeth occurs in association with a fracture of the alveolusfracture of the alveolus

It may occur as an isolated clinical entity or in It may occur as an isolated clinical entity or in conjunction with any other soft tissue or facial conjunction with any other soft tissue or facial bone fracturebone fracture

Isolated dento-alveolar fracture seen among Isolated dento-alveolar fracture seen among children and adolescents and boys are 3 times children and adolescents and boys are 3 times at risk than girls at risk than girls (Hunter et al 1990, Andreason & (Hunter et al 1990, Andreason & Andreason 1994)Andreason 1994)

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EtiologyEtiology

RTA (minor accidents)RTA (minor accidents)Collisions and fallsCollisions and fallsCycling accidentsCycling accidentsEpileptic seizuresEpileptic seizuresIatrogenic damage during:Iatrogenic damage during:

Extraction of teethExtraction of teethEndoscopy procedureEndoscopy procedureEndotreacheal intubationEndotreacheal intubation

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Classification of dento-alveolar injuriesClassification of dento-alveolar injuries((Andreasen & Andreasen 1994)Andreasen & Andreasen 1994)

Dental hard tissue injuryDental hard tissue injuryCrown infracture and fracture with or without root fractureCrown infracture and fracture with or without root fracture

Periodontal injuryPeriodontal injuryConcussion, subluxation, intrusion, extrusion, lateral luxation, Concussion, subluxation, intrusion, extrusion, lateral luxation,

avulsionavulsion

Alveolar bone injuryAlveolar bone injuryIntrusion of teeth with fracture of socket, alveolus or jawsIntrusion of teeth with fracture of socket, alveolus or jaws

Gingival injuryGingival injurycontusion, abrasion, laceration, deglovingcontusion, abrasion, laceration, degloving

Combination of the aboveCombination of the above

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Dental hard tissue injuryDental hard tissue injuryOccurs as a result of direct trauma or by forcible Occurs as a result of direct trauma or by forcible impaction against the opposing dentitionimpaction against the opposing dentition

Anterior teeth damaged by direct impact while Anterior teeth damaged by direct impact while posterior ones damaged by impaction between the posterior ones damaged by impaction between the two jawstwo jaws

Upper teeth intrusion are more frequent and impact Upper teeth intrusion are more frequent and impact against lower teeth may lead to vertical splittingagainst lower teeth may lead to vertical splitting

Meticulous clinical and radiographical examination Meticulous clinical and radiographical examination are very essential to determine the degree of dental are very essential to determine the degree of dental damage and chest x-ray when missing or knocked damage and chest x-ray when missing or knocked out tooth is suspectedout tooth is suspected

Early treatment is imperative to relieve pain and Early treatment is imperative to relieve pain and preserve toothpreserve tooth

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TreatmentTreatment objectivesobjectives

Preservation of damaged teeth depends on:Preservation of damaged teeth depends on:Complexity of maxillofacial injuryComplexity of maxillofacial injuryAge of the patientAge of the patientGeneral dental conditionGeneral dental conditionSite of injurySite of injuryWishes of the patientWishes of the patient

Prognosis is influenced by:Prognosis is influenced by: Open root apicesOpen root apices Intact gingival tissueIntact gingival tissue Absence of root fracture Absence of root fracture periodontal-bone supportperiodontal-bone support

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Injuries to the primary dentitionInjuries to the primary dentition

– 70% involve maxillary central incisors70% involve maxillary central incisors

– Intrusion, lateral luxation and avulsion are the commonestIntrusion, lateral luxation and avulsion are the commonest

– Intruded teeth are likely to normally erupt spontaneouslyIntruded teeth are likely to normally erupt spontaneously

– Damage to developing permanent teeth by displaced tooth Damage to developing permanent teeth by displaced tooth are recognizable problemare recognizable problem

Management:Management:

Fractured, extruded or grossly displaced teeth are to be Fractured, extruded or grossly displaced teeth are to be extractedextracted

Less displaced with no occlusal interference should be Less displaced with no occlusal interference should be monitored since extraction carries risk to permanent onemonitored since extraction carries risk to permanent one

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Management of injuries to permanent dentitionManagement of injuries to permanent dentition

Crown fractureCrown fracture Dressing of exposed dentin, minimal pulpotomy or Dressing of exposed dentin, minimal pulpotomy or

pulp extirpation and restoration of damaged part of pulp extirpation and restoration of damaged part of the tooththe tooth

Root fractureRoot fracture (Oblique, vertical or transverse)(Oblique, vertical or transverse)

– Inevitable extractionInevitable extraction– Saving the tooth by:Saving the tooth by:

Rigid splinting for a minimum of 8 weeksRigid splinting for a minimum of 8 weeksDevitlaiztion (RCT) with eventful apico surgeryDevitlaiztion (RCT) with eventful apico surgeryOrthodontic extrusion or crown lengtheningOrthodontic extrusion or crown lengthening

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Injuries to periodontal tissuesInjuries to periodontal tissuesForce distributed over several teeth or impact Force distributed over several teeth or impact cushioned by overlying soft tissue may result cushioned by overlying soft tissue may result into:into:

Concussion Concussion Subluxation Subluxation IntrusionIntrusionDisplacement and avulsionDisplacement and avulsionFracture of teeth structureFracture of teeth structure

Looseness and displacement of teeth carries a Looseness and displacement of teeth carries a high risk of subsequent pulp necrosishigh risk of subsequent pulp necrosis

As with root fracture, late complications can be As with root fracture, late complications can be resorption, canal obliteration, ankylosis and loss resorption, canal obliteration, ankylosis and loss of alveolar boneof alveolar bone

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Management of injuries to the periodontal tissuesManagement of injuries to the periodontal tissues Loosened, laterally luxated and extruded teeth should Loosened, laterally luxated and extruded teeth should be repositioned and splinted for 1-3 weeks be repositioned and splinted for 1-3 weeks respectively by semi rigid splint:respectively by semi rigid splint:

Acid-etch compositeAcid-etch compositeArch barArch barOrthodontic wireOrthodontic wireSoft stainless-steel wire-loop, Soft stainless-steel wire-loop, Vacum formed splintVacum formed splint

Avulsed teeth necessities immediate replantation and Avulsed teeth necessities immediate replantation and semi-rigid splinting for 1-2 weeks and prognosis is semi-rigid splinting for 1-2 weeks and prognosis is influenced by:influenced by:

stage of root developmentstage of root developmentlength of exposurelength of exposuremedium storagemedium storagehandling and splintinghandling and splinting

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Alveolar fractureAlveolar fractureAlveolar injury in mandible is associated with complete fracture Alveolar injury in mandible is associated with complete fracture of tooth-bearing area and in maxilla is often isolated injuryof tooth-bearing area and in maxilla is often isolated injury

Teeth damage might be no existed but the potential Teeth damage might be no existed but the potential devitilzation should be expecteddevitilzation should be expected

Alveolar fractures are often seen as two distinct fragment Alveolar fractures are often seen as two distinct fragment containing teeth but comminuted fracture is possiblecontaining teeth but comminuted fracture is possible

Alveolar fracture in mandible my go along with mandible Alveolar fracture in mandible my go along with mandible fracture and impacted fracture into the maxilla may appear to fracture and impacted fracture into the maxilla may appear to be immobilebe immobile

Midline split of palate with unilateral Le Fort I lead to large Midline split of palate with unilateral Le Fort I lead to large dento-alveolar fracturedento-alveolar fracture

Fracture of tuberosity and fracture of antral floor is a Fracture of tuberosity and fracture of antral floor is a recognized complication of upper molars extractionrecognized complication of upper molars extraction

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Management of injuries to the alveolar boneManagement of injuries to the alveolar bone(Block or plate fracture)(Block or plate fracture)

Finger manipulationFinger manipulation

Reduction (closed ) and fixationReduction (closed ) and fixation

Rigid wire and composite splintRigid wire and composite splint

Elimination of premature contact and Elimination of premature contact and occlusal traumaocclusal trauma

Short inter-maxillary fixationShort inter-maxillary fixation

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Management of tuberosity fractureManagement of tuberosity fracture

Removal of comminuted fracture of loss Removal of comminuted fracture of loss alveolar bone and teeth and repair of soft alveolar bone and teeth and repair of soft tissuetissue

Delay of extraction of teeth in case of Delay of extraction of teeth in case of tuberosity fracture for (6-8 weeks)tuberosity fracture for (6-8 weeks)

Mandatory extraction of a tooth from a block Mandatory extraction of a tooth from a block fracture should be carried out surgicallyfracture should be carried out surgically

Splinting of a tooth of fractured tuberodity in Splinting of a tooth of fractured tuberodity in to other standing teeth for one monthto other standing teeth for one month

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Injuries to the gingival and soft tissuesInjuries to the gingival and soft tissues

Damage to the lip observed more with Damage to the lip observed more with anterior dento-alveolar fractureanterior dento-alveolar fracture

Embedded of portion of a tooth or foreign Embedded of portion of a tooth or foreign bodies in soft tissues is very substantialbodies in soft tissues is very substantial

Laceration of the gingiva is associated with Laceration of the gingiva is associated with dento-alveolar fracturedento-alveolar fracture

Degloving of the mental region is a common Degloving of the mental region is a common injury to the lower anterior teethinjury to the lower anterior teeth

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Management of soft tissue injuriesManagement of soft tissue injuries

Inspection of a full thickness perforating woundInspection of a full thickness perforating wound

Debridment and copious lavageDebridment and copious lavage with cholohexidine solutionwith cholohexidine solution

Removal of denuded piece of boneRemoval of denuded piece of boneRepair of soft tissue injuryRepair of soft tissue injury

Application of external support strapping to help in Application of external support strapping to help in tissue adaptationtissue adaptation

Antibiotic prescriptionAntibiotic prescription

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