Dento Alveolar Fractures

*Maxillofacial Trauma

Dento-alveolar fractures

*Definition

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

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

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

*Etiology RTA (minor accidents)Collisions and fallsCycling accidentsEpileptic seizuresIatrogenic damage during:

Extraction of teethEndoscopy procedureEndotreacheal intubation

*Classification of dento-alveolar injuries(Andreasen & Andreasen 1994)Dental hard tissue injuryCrown infracture and fracture with or without root fracture

Periodontal injuryConcussion, subluxation, intrusion, extrusion, lateral luxation, avulsion

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

Gingival injurycontusion, abrasion, laceration, degloving

Combination of the above

*Dental hard tissue injury

Occurs as a result of direct trauma or by forcible impaction against the opposing dentition

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

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

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

Early treatment is imperative to relieve pain and preserve tooth

*Treatment objectivesPreservation of damaged teeth depends on:Complexity of maxillofacial injuryAge of the patientGeneral dental conditionSite of injuryWishes of the patient

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

*Injuries to the primary dentition70% involve maxillary central incisors

Intrusion, lateral luxation and avulsion are the commonest

Intruded teeth are likely to normally erupt spontaneously

Damage to developing permanent teeth by displaced tooth are recognizable problem

Management:

Fractured, extruded or grossly displaced teeth are to be extracted

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

*Management of injuries to permanent dentitionCrown fracture Dressing of exposed dentin, minimal pulpotomy or pulp extirpation and restoration of damaged part of the tooth

Root fracture (Oblique, vertical or transverse)

Inevitable extractionSaving the tooth by:

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

*Injuries to periodontal tissuesForce distributed over several teeth or impact cushioned by overlying soft tissue may result into:Concussion Subluxation IntrusionDisplacement and avulsionFracture of teeth structure

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

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

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

Acid-etch compositeArch barOrthodontic wireSoft stainless-steel wire-loop, Vacum formed splint

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

stage of root developmentlength of exposuremedium storagehandling and splinting

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

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

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

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

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

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

*Management of injuries to the alveolar bone(Block or plate fracture)Finger manipulation

Reduction (closed ) and fixation

Rigid wire and composite splint

Elimination of premature contact and occlusal trauma

Short inter-maxillary fixation

*Management of tuberosity fractureRemoval of comminuted fracture of loss alveolar bone and teeth and repair of soft tissue Delay of extraction of teeth in case of tuberosity fracture for (6-8 weeks)

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

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

*Injuries to the gingival and soft tissuesDamage to the lip observed more with anterior dento-alveolar fracture

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

Laceration of the gingiva is associated with dento-alveolar fracture

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

*Management of soft tissue injuriesInspection of a full thickness perforating wound

Debridment and copious lavage with cholohexidine solution

Removal of denuded piece of boneRepair of soft tissue injury

Application of external support strapping to help in tissue adaptation

Antibiotic prescription

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