Iraqi University/ College of Dentistry

Oral Surgery / Stage V

Dr. Haydar Munir Salih Alnamer
B.D.S., Ph.D. (Board Certified) LEC: 3

MAXILLOFACIAL TRAUMA – CHAPTER THREE -

Dentoalveolar Injuries

The term 'dentoalveolar injury' describes trauma that is localized to the teeth and
the supporting structures of the alveolus. These injuries can occur in isolation, or as
part of a more serious maxillofacial injury.

Dentoalveolar injuries occur in all age groups but they are more common in children.
Each age group has specific etiologies; in children the most common cause is fall,
whereas in adolescents, contact sports and playground activities are the main cause,
adult injuries are caused by RTAs, contact sports, altercations or assaults and
industrial accidents. Males are more frequently involved in such injuries than
females.

Factors affecting dentoalveolar injuries

• Dentoalveolar injuries can result from direct or indirect trauma.

With direct trauma maxillary incisors are the most frequently traumatized teeth,
especially if they are associated with a Class II Division malocclusion.
Indirect trauma to the dentition usually results from the forceful impact of the
mandible with the maxilla, following a blow to the chin region or from forceful
whiplash to the head and neck. These traumas will often result in injury to the
posterior teeth, anterior soft tissue or both.

• The extent of injury also depends on the energy of impact:

Low-velocity blow usually causes damage to the supporting dentoalveolar

structures.
High-velocity impact usually results in crown fractures.
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• It also depends on the objects:

Sharp objects favor crown fractures.

Blunt objects usually result in luxations or root fracture.

• Direction of the impacting force:

Classification

• Injuries to the hard dental tissue and pulp.

• Injuries to the periodontal tissue.
• Injuries to the supporting bone.
• Injuries to the gingiva and oral mucosa.
• Combination.

Injuries to the hard-dental tissue and pulp

Crown infraction; it is incomplete fracture or crack of enamel without loss of tooth

substance.
Uncomplicated crown fracture; which is confined to the enamel or involving the
enamel and dentin without pulp exposure.
Complicated crown fracture; involves enamel and dentin with pulp exposure.
Uncomplicated crown-root fracture; involving enamel, dentin and cementum
without pulp exposure.
Complicated crown-root fracture; involving enamel, dentin and cementum with
pulp exposure.
Root fracture; involving dentin, cementum and pulp.

Injuries to the periodontal tissue

Concussion; is an injury to the tooth-supporting structures without abnormal

loosening or displacement of the tooth but with marked reaction to percussion.
Subluxation; (loosening) is an injury to the tooth-supporting structures with
abnormal loosening but without displacement of the tooth .
Intrusive luxation; (central dislocation) is displacement of the tooth into the

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alveolar bone with comminution or fracture of the alveolar socket.

Extrusive luxation; (peripheral dislocation or partial avulsion) is partial
displacement of the tooth out of the alveolar socket.
Lateral_ luxation; is displacement of the tooth in a direction other than axially,
accompanied by a comminution or fracture of the alveolar socket.
Avulsion; is a complete displacement of a tooth out of the alveolar socket.
injuries to the supporting alveolar bone
Comminution of alveolar socket; it can occur with intrusive and lateral luxation
Fracture of a single alveolar socket wall; confined to facial or lingual wall.
Fracture of both walls of socket or alveolus.
Fracture of maxilla or mandible;
involving the alveolar bone with or without the socket.
Injuries to the gingiva or oral mucosa
Contusion of Gingiva or Mucosa;
a bruise is usually produced by impact from a blunt object and results in submucosal
hemorrhage without a break in the mucosa.
Abrasion of Gingiva or Oral Mucosa;
a superficial wound produced by rubbing or scraping of the mucosa, leaving a raw,
bleeding surface.
Laceration of Gingiva or Oral Mucosa;
a shallow or deep wound in the mucosa results from a tear and is usually produced
by a sharp object.

Examination and clinical manifestations

A complete history of the mechanism and events of the injury should be obtained
and a thorough clinical and radiographic examination performed quickly to ensure
proper diagnosis and treatment.
Clinical examination should include an inspection of soft tissue for embedded
fragments of tooth or debris. Lacerations, abrasions, and contusions should be
examined and evaluated for damage to vital structures, such as the parotid duct,
submandibular duct, nerves, and blood vessels. The teeth should be examined for

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abnormal mobility horizontally and axially, all teeth should be accounted for at the
time of examination. Missing teeth or pieces of teeth that have not been left at the
scene of the accident must be considered to have been aspirated, swallowed, or
displaced into soft tissue of the lip, cheek, floor of the mouth, neck, nasal cavity, or
maxillary sinus.
dentoalveolar fractures are commonly associated with significant damage to the lips.
There is often substantial bruising and swelling and there may be portions of tooth
or foreign bodies embedded in the soft tissues. The direction of tooth displacement
should be noted. In the primary dentition, the dislocation of the apex of the displaced
primary tooth can possibly damage the permanent successor.

The involved teeth should be tapped or percussed with the handle of a mouth mirror;
pain elicited with percussion is suggestive of injury to the periodontal ligament. The
sound elicited by percussion is also of diagnostic value; a sound resembling a hard
metallic ring is elicited with teeth that are locked into bone, whereas a dull sound
indicates a subluxated tooth. Pulp testing during the acute phase of injury is of
questionable value.

Radiographic evaluation

A single radiograph may not be sufficient to demonstrate dentoalveolar injuries,

most commonly a combination of occlusal and periapical radiographs is used, it
should provide the following information:

Presence of root fractures Degree of extrusion or intrusion Extent of root

development Size of the pulp chamber and root canal, tooth fragments and foreign
bodies lodged in soft tissue.

A radiographic examination of the head and neck, chest, and abdomen must be
performed to rule out the presence of teeth or teeth fragments within these tissues or
organs. Radiographic evaluations for foreign bodies within the soft tissues of the
lips or cheeks are taken with the radiographic film placed inside the soft tissues to
be examined, labial to the alveolus with a reduced radiographic exposure time is
used (approximately one third of normal). Foreign bodies in the floor of the mouth
are viewed with cross-sectioned occlusal radiographs and with reduced radiographic
exposure time.

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Treatment

Several factors need to be considered:

~ Age of patient and degree of cooperation. If the injury involves primary or

permanent teeth and the degree of root development and if the apical foramen is
wide or narrow.

~ Location and extent of injury.

~ Residual bone support.

~ Periodontal health of the remaining teeth.

~ Vitality of the teeth.

~ Injury to the soft tissues.

~ Concomitant injuries.

~ Time between trauma and treatment.

Crown infraction Evaluation is by direct trans-illumination (directing a light beam

perpendicular to the long axis of the tooth from the incisal edge). No treatment is
required for cracks, vitality test should be performed at the time of diagnosis with
periodic follow up.

Crown fracture

• Limited to enamel- smoothening of the sharp edges and restoration with

composite.
• Enamel and dentin- it requires covering the exposed dentin with calcium
hydroxide or glass ionomer cement as a liner and restoration with composite.
Reattachment of the fractured fragment using dentin- bonding agents can be
performed.
• Crown fracture with pulp exposure- the primary aim is to preserve vitality of
the pulp. Treatment is by pulp capping with calcium hydroxide liner or MTA,
pulpotomy or endodontic treatment. Pulp- capping procedure should be

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carried out only in teeth with small exposures and those that appear within 24
hours after injury.
• Crown-root fracture- treatment goals are to preserve the remaining root
fragment to support a post and crown prosthesis if possible. Primary teeth with
any type of crown-root fracture should be extracted. In uncomplicated crown-
root fracture; if the fracture line is above or slightly below the cervical margin,
the tooth can be restored, as with a crown fracture. If the fracture continues
too apically to allow adequate restoration, extraction of the tooth may be
indicated.
• Complicated crown-root fracture- the level of the root fracture determines the
treatment. Extraction is usually indicated if the coronal segment includes more
than one third of the clinical root or in cases of vertical root fractures;
otherwise, the tooth may be treated endodontically and restored.

Root fracture

Root fractures in primary teeth without mobility- can be preserved and should
exfoliate normally. If there is mobility or dislocation of the coronal segment, the
tooth should be removed without attempts to remove the apical fragments, which
could possibly damage the permanent tooth. Normal physiologic resorption of the
apical fragment can be expected. Mobile coronal fragments should be removed.

Root fractures of permanent teeth- the prognosis depends to a large extent on the
level of fracture. A calcified or fibrous bridge occasionally results in 'healing' of the
root, particularly if the fracture is in the apical third, but fractures that occur near the
gingival level have a poorer prognosis. If the fracture is above or close to the gingival
crevice, the tooth should be removed or the coronal fragment should be removed and
endodontic treatment performed on the root. The root can then be restored with a
post and core restoration. Fractures in the middle to apical one third of the root have
a good prognosis for survival of the pulp and healing of the root fragments to one
another. These fractures should be treated with repositioning (if any mobility is
detectable) and firm immobilization for 2 to 3 months. During this time, bridging of
the fracture with calcified tissue usually occurs, and the tooth remains vital. Other
treatment options include replacement with endosseous implants. Vertical root
fractures should be extracted.

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Injuries to the periodontal tissue

• Concussion- Usually no treatment is indicated other than palliative therapy,

in some cases relieving the tooth from occlusal forces by grinding of the
opposing tooth may be required. Periodic follow up evaluation of the pulp is
necessary.
• Subluxation- Treatment includes soft diet or occlusal adjustment to remove
the tooth from the traumatic effect of occlusion. Splinting for 7-10 days is
necessary. Periodic follow-up evaluations.
• Intrusive luxation- in the primary dentition, the permanent successor develops
lingual to the primary incisor. If the intruded tooth impinges on the permanent
tooth, the primary tooth should be extracted immediately and as a
traumatically as possible to prevent injury to the permanent tooth bud.
For permanent teeth, the recommended treatment includes:

1. The tooth can be allowed to erupt if the tooth is immature.

2. Immediate surgical repositioning of the tooth into its proper place in the arch can
be carried out. It has been shown that there is a greater incidence of external root
resorption, increased risk of sequestration, and marginal bone loss with this
technique because of additional trauma to the periodontal structures.

3. Splinting to the adjacent teeth.

4. Low-force orthodontic repositioning of immature and mature teeth can be carried

out over a period of 3 to 4 weeks to allow remodeling of the bone and periodontal
fibers.

Extrusive luxation- Treatment should be as soon as possible within the first few
hours after injury. The tooth that is partially displaced out of the alveolar socket
should be manipulated digitally into proper position and should be splinted with a
non-rigid material for 1 to 2 weeks to allow some physiologic movement of the
involved tooth so that ankylosis may be prevented. Extruded primary teeth should
be removed to prevent damage to permanent teeth.

Lateral luxation- is usually accompanied by comminution or fracture of the alveolar

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socket. The tooth and alveolar bone can typically be manipulated digitally (usually
with force) into proper position and splinted to adjacent stable teeth for 2-8 weeks.
If treatment is delayed more than 48 hours, it is difficult to reposition the tooth
manually, orthodontic intervention maybe necessary.

Avulsion (exarticulation) - is an urgent situation requiring immediate action.

Factors that influence success are:

1. The stage of root development; survival of the pulp is possible in teeth with
incomplete root formation

2. The length of time the tooth is allowed to dry; if the tooth is re-implanted within
30 minutes of avulsion, there is a good chance of successful re-implantation. For
extra-alveolar periods longer than 2 hours, complications associated with notable
root resorption increase greatly.

3. The length of storage outside the mouth.

4. The medium used and correct handling and splinting; storage media include:
saliva, saline, milk, which is considered the best medium because of its availability,
pH compatibility to vital cells, freedom from bacteria, and function of maintaining
the vitality of the periodontal ligament cells 3 hours in the postavulsion period, and
Hank's balanced salt solution (HBSS), which is considered to have excellent
storage potential. Water is the least desirable storage medium because of its
hypotonic environment, which can cause cell lysis. Immediate replacement is still
the ideal treatment. The involved tooth should be splinted with a semi-rigid splint
for 7 to 10 days. Rigid splinting of re-implanted teeth increases the extent of root
resorption; thus, a minimum of 1 week is sufficient. If there has been a notable
concomitant alveolar fracture, a rigid splint should be used for 3 to 4 weeks.
Replanted teeth should be followed up regularly.

Injuries to the supporting alveolar wall

Comminution of alveolar bone: is usually associated with lateral or intrusive

luxation injuries. The fractures are generally reduced with digital manipulation and

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the luxation injury is treated. Follow-up for evidence of root resorption of the
involved teeth is indicated.

Fractures of alveolar socket wall or alveolar process: closed reduction of the fracture
by digital manipulation, the occlusion should be checked and the involved teeth
removed from the forces of traumatic occlusion. Soft tissue lacerations should be
sutured and the involved teeth should be in a rigid splint for 4 weeks to allow osseous
healing. Alveolar process fractures with primary teeth that are not notably displaced
or easily manipulated back into proper position may not require splinting because
the bone heals quickly in children. However, splinting of the involved segment may
be difficult in children because of the lack of sufficient tooth support. The child
should maintain a soft diet for 2 weeks, with periodic follow-up examinations
required to monitor pulp health. Open reduction is rarely performed in alveolar
fractures unless access is required as part of the treatment of an underlying jaw
fracture.

Injuries to gingiva

A copious irrigation for gingival wound is necessary, suturing may be difficult due
to the friability of tissue. A suitable antiseptic mouthwash should be prescribed in
the postoperative period.

Splinting techniques

Splinting provides stabilization of traumatized teeth and prevents further damage to

the pulp and periodontal tissue during the healing period, allowing the attachment
apparatus time to regenerate.

In most cases splints should be maintained for 10-14 days, longer periods are
required for alveolar bone fractures (6 weeks) and for root fractures 2-4 months may
be required. The requirements for an acceptable splint are as follows:

1. It is easy to fabricate directly in the mouth, without lengthy laboratory

procedures.
2. It can be placed passively without force to the teeth.
3. It does not contact the gingival tissue and thus cause gingival irritation.
4. It does not interfere with normal occlusion.

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5. It is easily cleaned and allows proper oral hygiene.

6. It does not traumatize the teeth or gingiva during application.
7. It allows an approach for endodontic therapy.
8. It is easily removed.
9. It provides good esthetic results.
10. It does not injure the pulp of the traumatized teeth or adjacent teeth.
11. It does not interfere with intraoral radiographic techniques.
12. It allows placement of a rubber dam in all types of dentition.
13. It does not promote root resorption.
14. It allows slight mobility so that the position of the tooth after re-
implantation exerts minimal pressure between the root surface and the
alveolar bone.
15. It is economical and requires minimal specialized equipment.

Enamel bonded composite resin splints

It is a relatively easy, versatile method for stabilization of teeth with effective,

esthetic composite resin materials. This method provides excellent stabilization and
allows the patient to keep the teeth and gingiva clear

Because the splint is away from the periodontal tissue. The procedure is simple and
efficient, may not require anesthesia, is hygienic, and serves as definitive treatment.
One disadvantage of the method is that the material may fracture because the acrylic
is brittle when exposed to occlusal masticatory forces.

Etch wire composite splint

The wire should be of proper stiffness. It is used with all types of dentoalveolar
trauma, luxation injuries, root fractures, auto-transplantation, and alveolar fractures
in which good stabilization can be obtained. This technique is esthetic, hygienic, and
quick to construct, it is useful with missing teeth or in a mixed dentition in which
teeth are not fully erupted and the edentulous area has to be spanned. The only teeth
that might not be suitable for this type of splint are those with artificial crowns or
large fillings because they cannot be etched and composite material bonded to the
surface.

Cap-splints

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They include metal (like Silver alloy), heat or cold-curing acrylic splints. This
technique requires reduction into correct position and then accurate impression of
teeth and both jaws. It provides excellent immobilization and protection of
traumatized teeth.

Vacuum-formed plastic splints

Simple splints for subluxed teeth or minor alveolar fractures can also be constructed
from vacuum-formed plastic. An impression is taken following repositioning of the
tooth or alveolar fragment. A thin plastic veneer splint is then vacuum-formed in the
laboratory. The splint can be self-retaining but is usually fixed with a zinc oxide
based cement or cold- cure acrylic resin, although individually chipped or fractured
teeth should be covered with calcium hydroxide. This type of splints may
compromise oral hygiene leading to gingival inflammation and interference with
healing of the traumatized tissues.

Orthodontic appliance

Edgewise brackets and arch wire can be used to provide support for traumatized
teeth but they must be passive.

Arch bars

They are used for stabilization of alveolar process fractures if the teeth within the
segment are stable and can also use for supporting subluxed teeth, but they are not
recommended for tooth fixation because the tied wire tends to loosen with time and
rest on the marginal gingiva, causing mechanical irritation and a site for bacterial
deposition. If the teeth are mobile, the supporting wires, if positioned apically to the
cervical prominence, may have a tendency to elevate the tooth slowly.

Interdental wiring techniques

They can be used but are technically difficult and troublesome. The patient may have
difficulty in cleaning around the wires and the wires may slip apically below the
cervical prominence of the tooth and elevate the tooth or damage the cementum
surface.

>- Figure-of-eight wiring - using soft stainless steel wires around the abutment teeth
and the subluxed tooth in a figure of eight manner. They can be used a temporary

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form of immobilization.

>- Loop wiring- it provides slightly better immobilization for the subluxed teeth. A
length of wire is passed as a single loop around the cervical margins of the subluxed
and adjacent teeth, this loop is loosely tightened, then individual wires passing
interdentally above and below the loop wire are tightened, finally the original loop
wire is twisted tightly.

Complications

Traumatized teeth may develop pulpitis or become devitalized and with time this
frequently leads to the development of apical infection. Such teeth can be treated
endodontically.

Discoloration of traumatized teeth which is mostly internal, it results either from

canal obliteration caused by laying down of tertiary dentine leading to yellow
discoloration or pulp necrosis which is caused by penetration of the dentine tubules
by noxious by-products leading to grey discoloration, it usually worsens with time.

Local gingivitis is inevitable when fixation involves interdental wires or arch bars.
Applying too much interdental force to individual teeth from eyelet wires or arch
bars can lead to periodontal problems, the lower incisors are most vulnerable and
may be partially extruded or even lost. The complication can be avoided by
spreading the load more widely and evenly and by avoiding the application of wires
to suspect teeth.

Untreated alveolar fractures either unite in an incorrect position or become infected

often with sequestration of detached fragments of bone.

Tooth fragments or foreign bodies embedded in the lip usually heal over and remain
as hard lumps that may become infected.

Root resorption which can be external or internal; external root resorption occurs on
the outer surface of the root usually as a result of an inflammatory stimulus. Internal
resorption takes place within the root canal system and is less common than external
root resorption.

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Ankylosis is a common consequence of severe dental trauma. The tooth substance

at the area of damaged periodontal ligament and cementum is progressively replaced
by bone. Avulsed and re- implanted teeth with extended extra-alveolar dry time and
closed apices are particularly susceptible to ankylosis. Rigid stabilization of teeth
may predispose to ankylosis and external root resorption. Physiologic movements of
the tooth are thought by some to promote fibrous (desired) attachment instead of
osseous attachment of the root to alveolar bone (ankylosis).

Soft tissue injuries

Soft tissues include all the non-bony structures: skin, fat, muscle, nerves and blood
vessels. The general health and quality of the soft tissues are key elements in gaining
a satisfactory outcome.

Soft tissue facial injuries can be in the form of: abrasions, contusions, lacerations or
a combination.

Abrasion

It is a superficial wound that usually denudes the epithelium, and occasionally

involves deeper layers, it is caused by friction between an object and the surface of
the soft tissue, and it can be caused iatrogenically when the shank of a rotating bur
touches the oral mucosa. Abrasions are painful because they involve the terminal
endings of many nerve fibers. Bleeding is usually minor because it is from capillaries
and responds well to application of gentle pressure.

If the abrasion is not deep, re-epithelialization occurs without scarring. When the
abrasion extends into the deeper layers of the dermis, healing of the deeper tissues
occurs with the formation of scar tissue, and some permanent deformity can be
expected.

Management of abrasions consists of thorough cleansing to remove foreign material.

All particles of foreign matter must be removed. If these particles are allowed to
remain within the tissue, a permanent "tattoo" that is difficult to treat results. Deep
contaminated abrasions may require anesthesia and a surgical scrub brush to remove
the debris completely. Once the wound is free of debris, topical application of an
antibiotic ointment is adequate treatment. A loose bandage can be applied if the

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abrasion is deep but is unnecessary in superficial abrasions. Systemic antibiotics are

not usually indicated.

Re-epithelialization occurs under the eschar, which is a crust of dried blood and
serum that develops after an injury to soft tissue (e.g., a scab), the eschar will then
drop off.

Contusion

Also called bruise results from subcutaneous or submucosal hemorrhage without a

break in the soft tissue surface, it indicates that tissue Disruption has occurred within
the tissues usually caused by blunt trauma.

Contusions usually require no treatment. Within several days the body resorbs the
hemorrhage formed within a contusion and areas of ecchymosis caused by
extravasation of blood into the skin or mucosa will change in color from purplish
discoloration to blue, green, and yellow before fading.

Laceration

It is a tear in the epithelial and sub-epithelial tissues caused most commonly by a

sharp object such as a knife or a piece of glass. If the object is not sharp, the
lacerations created may be jagged. The depth of laceration may involve the external
surface only, but others may extend deep into tissue, disrupting nerves, blood
vessels, muscle, and other major structures.

Management involves five major steps:

1. Cleansing of the wound; to remove debris by copious irrigation with normal

saline, a brush may be needed.

2. Debridement of the wound; refers to the removal of contused and devitalized

tissue from a wound and the removal of jagged pieces of surface tissue to enable
linear closure. In the maxillofacial region, which has a rich blood supply, the amount
of debridement should be kept to a minimum.

3. Hemostasis; it may necessitate ligation or cauterization

4. Closure of the wound; the goal is proper positioning of all tissue layers from inside

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out. Resorbable sutures should be used to close the muscle layer or layers, after
which the mucosa and/or skin is sutured. The wound edges should be well aligned
to prevent unsightly scar.

5. Systemic antibiotics (e.g., penicillin) should be considered in deep and full

thickness lacerations; otherwise the dermal surface should then be covered with an
antibiotic ointment. Facial skin sutures should be removed 4 to 6 days
postoperatively; adhesive strips can be placed at the time of suture removal to give
external support to the healing wound.

Facial wounds of special significance

• Any wound with tissue loss such as missile injuries are rarely suitable for
primary repair because of tissue necrosis and contamination.
• Animal and human bites. The bacterial and saliva contamination of these
injuries interferes with healing and repair may need to be modified.

• Shelved wounds such as those produced by glass fragments.

• Lacerations of the eyelids particularly those involving the lacrimal canaliculi.

• Lip lacerations involving the red margin, where accurate realignment of both
the muscle layer and the vermilion is critical.
• Cheek lacerations transecting major branches of the facial nerve or parotid
duct.

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