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.

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.

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

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 .

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

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

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

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.

Proper & Accurate assessment & record keeping
is very important
to avoid unnecessary problems.
• Trauma to teeth
• Trauma to bones
Esp. Following Assaults & RTA

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

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

• 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.

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.

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.

Management of dento alveolar trauma

Management of dento alveolar trauma

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