max fax surgery

1. Current Concepts in Management of
Dentoalveolar Trauma
Dr. Armaghan Mirza
FCPS Resident
Oral & Maxillofacial Surgery
de’Montmorency College of Dentistry

2. •Any injury to teeth or their supporting
structures is grouped under the domain
of dentoalveolar injuries.

3. Dentoalveolar Injuries
 Enamel
 Dentine
 Pulp
 Periodontal Membrane
 Alveolar bone

4. Etiology and Predisposing
Factors

5. Predisposing factors
 Male > Female
 Malocclusion - Class II division I  Proclined teeth
 Contact sports
 Interpersonal violence
 Leisure activities e.g. cycling, skateboarding
 Handicaps
 Falls / Convulsive seizures e.g. epilepsy
 Endotracheal intubation
 Non Accidental Injuries ( NAI ) Child abuse

6. Review of Literature
 Incidence of Orodental Injury 4-33%
 Peak age for Primary Dentition 1.5 - 3.5 yrs
 Peak age for Permanent Dentition 9- 10 yrs
 M : F ratio 2.5:1 to 3:1
 Most commonly affected tooth Maxillary
central Incisor
 By the age of 14 yrs, 55% have experienced trauma to
dentition.

7. Classification
 Tooth fracture
1) Uncomplicated crown fractures
a) Enamel --- including cracks
b) Enamel and Dentine --- i) Supragingival
--- ii) Subgingival
c) Enamel, dentine & freshly exposed pulp less than 2mm
2) Complicated crown fracture( involving pulp)
a) Horizontal --- i) Supragingival
--- ii) Subgingival
b) Diagonal --- i) Supragingival
--- ii) Subgingival
c) Vertical
3) Root fracture --- Apical third
--- Middle third
--- Coronal third

8. Classification
 Tooth fracture
1) Uncomplicated crown fractures
a) Enamel --- including cracks
b) Enamel and Dentine --- i) Supragingival
--- ii) Subgingival
c) Enamel, dentine & freshly exposed pulp less than 2mm
2) Complicated crown fracture( involving pulp)
a) Horizontal --- i) Supragingival
--- ii) Subgingival
b) Diagonal --- i) Supragingival
--- ii) Subgingival
c) Vertical
3) Root fracture --- Apical third
--- Middle third
--- Coronal third

9. Classification
 Tooth fracture
1) Uncomplicated crown fractures
a) Enamel --- including cracks
b) Enamel and Dentine --- i) Supragingival
--- ii) Subgingival
c) Enamel, dentine & freshly exposed pulp less than 2mm
2) Complicated crown fracture( involving pulp)
a) Horizontal --- i) Supragingival
--- ii) Subgingival
b) Diagonal --- i) Supragingival
--- ii) Subgingival
c) Vertical
3) Root fracture --- Apical third
--- Middle third
--- Coronal third

10. Classification
 Tooth fracture
1) Uncomplicated crown fractures
a) Enamel --- including cracks
b) Enamel and Dentine --- i) Supragingival
--- ii) Subgingival
c) Enamel, dentine & freshly exposed pulp less than 2mm
2) Complicated crown fracture( involving pulp)
a) Horizontal --- i) Supragingival
--- ii) Subgingival
b) Diagonal --- i) Supragingival
--- ii) Subgingival
c) Vertical
3) Root fracture --- Apical third
--- Middle third
--- Coronal third

11. Classification
 Tooth fracture
1) Uncomplicated crown fractures
a) Enamel --- including cracks
b) Enamel and Dentine --- i) Supragingival
--- ii) Subgingival
c) Enamel, dentine & freshly exposed pulp less than 2mm
2) Complicated crown fracture( involving pulp)
a) Horizontal --- i) Supragingival
--- ii) Subgingival
b) Diagonal --- i) Supragingival
--- ii) Subgingival
c) Vertical
3) Root fracture --- Apical third
--- Middle third
--- Coronal third

12.  Periodontal injuries
1) Concussion
2) Subluxation
3) Displacement
 Extrusive Displacement
 Intrusive Displacement
 Lateral Displacement
4) Avulsion
 Alveolar bone injuries
1) Crushing or compression associated
with tooth displacement
2) Fracture of alveolar wall
3) Fracture of alveolar process
4) Fracture of maxilla or mandible
 Injuries to the soft tissues
1) Contusion
2) Abrasion
3) Laceration

13.  Periodontal injuries
1) Concussion
2) Subluxation
3) Displacement
 Extrusive Displacement
 Intrusive Displacement
 Lateral Displacement
4) Avulsion
 Alveolar bone injuries
1) Crushing or compression associated
with tooth displacement
2) Fracture of alveolar wall
3) Fracture of alveolar process
4) Fracture of maxilla or mandible
 Injuries to the soft tissues
1) Contusion
2) Abrasion
3) Laceration

14.  Periodontal injuries
1) Concussion
2) Subluxation
3) Displacement
 Extrusive Displacement
 Intrusive Displacement
 Lateral Displacement
4) Avulsion
 Alveolar bone injuries
1) Crushing or compression associated
with tooth displacement
2) Fracture of alveolar wall
3) Fracture of alveolar process
4) Fracture of maxilla or mandible
 Injuries to the soft tissues
1) Contusion
2) Abrasion
3) Laceration

15.  Periodontal injuries
1) Concussion
2) Subluxation
3) Displacement
 Extrusive Displacement
 Intrusive Displacement
 Lateral Displacement
4) Avulsion
 Alveolar bone injuries
1) Crushing or compression associated
with tooth displacement
2) Fracture of alveolar wall
3) Fracture of alveolar process
4) Fracture of maxilla or mandible
 Injuries to the soft tissues
1) Contusion
2) Abrasion
3) Laceration

16.  Periodontal injuries
1) Concussion
2) Subluxation
3) Displacement
 Extrusive Displacement
 Intrusive Displacement
 Lateral Displacement
4) Avulsion
 Alveolar bone injuries
1) Crushing or compression associated
with tooth displacement
2) Fracture of alveolar wall
3) Fracture of alveolar process
4) Fracture of maxilla or mandible
 Injuries to the soft tissues
1) Contusion
2) Abrasion
3) Laceration

17. Management

18. Initial Assessment
 Confident and sympathetic approach by both doctor
and nurse to ensure that the parents feel the situation
is under control and also helps the patient to calm
down
 History taking
a) When did the accident occur?
b) Where did the accident occur?
c) How did the accident occur?
d) Has the child any other symptoms?
e) Have the lost teeth being accounted for?

19. Presenting Complaint
 Tooth sensitive to hot and cold
 Sharp tooth
 Mobile tooth / teeth
 Oral pain
 Oral bleeding
 Malocclusion

20. Investigations
 X-rays
a) Dental ---periapicals, occlusal, Lateral Ceph.
b) Jaw fractures --- Orthopantomogram, PA face
c) Lips --- Periapical, Lateral Cephalogram
( foreign bodies, tooth fragment)
d) Chest X- rays--- Aspirated tooth or tooth fragment
 Vitality test
 Transillumination

21. Enamel fracture
 With pulp vitality
Smooth fracture surface
Place protective varnish
Place fluoride gel
 Without pulp vitality:
Endodontic treatment

22. Enamel and dentin fracture
 Restoration with Composite and / or GIC

23. Enamel and Dentine fracture with
Pulpal Exposure
 < 2 mm
 Not contaminated with saliva etc.
 Presenting within 24 hours.
 Pulp caping with calcium hydroxide plus crown
restoration with composite
 > 2 mm
 Contaminated
 Presenting after 24 hours
 Pulpotomy with 2mm of pulp removed dressed with calcium
hydroxide plus restoration.
 Old exposure with pulpal necrosis
 Pulpectomy and endodontic therapy

24. Crown and root fracture
 Without pulp exposure
Remove the fracture segment
Restoration
 With pulp exposure
Remove the fractured segment
Endodontic treatment followed by
restoration

25. Root fracture
 Primary dentition
 Without mobility
Preserve and should exfoliate normally
 With mobility or cervical third fracture
Should be removed without attempt to remove apical
fragment

26. Root fracture
 Permanent dentition
 Consider level of fracture
Endodontic
Endodontic and apicectomy
Endodontic, apicectomy and
restoration (post and core, crown and
implant)

27. Alveolar bone injuries
 Reduction ---- Finger manipulation
 Fixation ---- Dental occlusal splints /
Direct wiring / Arch bar
splinting / Plating/Acid etch composite
 Immobilization --- 4 weeks
 When alveolar bone component not present
 2-3 weeks (Subluxation, displacement & avulsion)

28. Periodontal Injuries
 Subluxation
 Displacement
 Avulsion
Management
i) Reduction
ii) Immobilization --- 2-3 weeks

29. Gingival Injuries
 Cover abrasions with antiseptic pack
 Suture lacerations

30. Acute trauma of deciduous teeth
 Intrusion ----
i) wait & observe if not disturbing
the permanent tooth bud
ii) extraction if possible risk of
damaging the permanent tooth bud
 Extrusion --- Extraction
 Subluxation --- Conservative ( soft diet)
 Avulsion --- Do not attempt to reimplant

31. Immobilization period for
traumatized teeth
 Root fracture
 Middle and apical third  4 weeks
 Cervical third  2 months
 Avulsion
 Immature
 Extra alveolar time < 60 minutes;  Flexible splint 2 weeks
 Extra alveolar time > 60 minutes  very poor prognosis
 Mature
 Extra alveolar time < 60 minutes  2 weeks
 Extra alveolar time > 60 minutes  6 weeks
 Luxation
 Concussion  Splint optional (10 days)
 Subluxation  Splint optional (10 days)
 Extrusion  Splint for 3 weeks
 Lateral luxation  Splint for 3-4 weeks
 Intrusion; Immature  3 – 4 weeks
 Intrusion; Mature  2 weeks

32. Post-operative Care
 Antibiotics & Analgesics
 Liquids followed by soft diet – 4 weeks
 Nutritional supplements ( 2000 – 2200 Cal/day,
comprising proteins, fat and carbohydrates )
 Maintenance of Oral hygiene
( antimicrobial mouthwashes e.g.0.2% Chlorhexidine )
 Follow up every 3 months upto 1 year

33. Complications
 Immediate ----- Bleeding (hematoma)
Swelling
Malocclusion
 Late ---- Infection
Mal union
Non union
Root resorption (external / internal)
Root ankylosis

34. Management options for traumatic
intrusion of teeth
 Mild < 3mm ---- Passive repositioning
 Moderate 3-6mm ---- Passive repositioning
---- Active repositioning
(Immediate traction)
 Severe > 6mm ---- Immediate repositioning
( Surgical reduction)
---- Extraction / Immediate root canal
treatment
---- Extraction

35. Resorption
 Lower prevalence when the period of dryness less than or equal to 5
mins
 Prevalence of resorption with no visible contamination
57.1%
 Prevalence of resorption for contaminated tooth but washed clean
75%
 Prevalence of resorption for contaminated tooth but rubbed clean
87.5%
 Prevalence of resorption with visible contamination present
100%

36. Avulsion
 Recommended guidelines:
Extra-alveolar time: within 30 mins
Storage media:
Hanks Balanced Salt solution>saline>saliva>milk
Root treatment:
Prereplantation treatment of root surface with
fluoride resists the resorption by forming
flouroapatite.

37. Pre-replantation Treatment
 Presenting within 2 hours:
 Closed Apex: HBSS for 30 minutes
 Open Apex: HBSS for 30 minutes , 1mg/20ml
Doxycycline soltn. for 5 minutes
 Presenting after 2 hours:,
 Remove PDL by scraping or soaking in NaOCl for 30
minutes
 Endodontic debridement, cleaning and shaping of the
canal in hand
 Soak in citric acid soltn for 3minutes, 1% Stannous
Fluoride for 5 minutes and 1mg/20ml Doxycycline
soltn. for 5 minutes
 Obturate with GP

38. Avulsion
 Injured socket
Shouldn’t be debrided
Clot shouldn’t be disturbed
Gentle irrigation with saline
 Immobilization period:
Splinting for 2-3 weeks
 Endodontic treatment:
Tooth with open apex: no endodontic Rx
Tooth with closed apex: within 14 days with
calcium hydroxide upto 9-12 months
 Periodic follow up with x rays, vitality tests and
color changes upto 2 years.

39. Emergency management outside surgery
 Wash the tooth gently with water
 Avoid touching root
 Reimplant tooth immediately
 Bite on a handkerchief to hold the tooth in
place
 If unable to reimplant tooth, should put in the
saline / milk

40. Avulsion of teeth
Indicators of poor prognosis
 Extra alveolar time > 60 minutes
 Undesirable storage medium e.g. tap water
 Improper handling of root surface

41. Prevention of dentoalveolar injuries
 Educate and empower the dental team to
provide first aid care
 Encourage the use of custom mouth guards
during contact sports

42. Thank You
!for not walking out

44. Dentoalveolar Injury Duration of Immobilization
Mobile Tooth 7-10 Days
Tooth displacement 2-3 Weeks
Root fracture 2-4 Months
Replanted tooth(mature) 7-10 Days
Replanted tooth (immature) 3-4 Weeks