Dento Alveolar Fractures

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  • 1. Maxillofacial Trauma Dento-alveolar fractures dr shabeel p n www.hi-dentfinishingschool.blogspot.com
  • 2. 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)
  • 3. Etiology
    • RTA (minor accidents)
    • Collisions and falls
    • Cycling accidents
    • Epileptic seizures
    • Iatrogenic damage during:
        • Extraction of teeth
        • Endoscopy procedure
        • Endotreacheal intubation
  • 4. Classification of dento-alveolar injuries ( Andreasen & Andreasen 1994)
    • Dental hard tissue injury
    • Crown infracture and fracture with or without root fracture
    • Periodontal injury
    • Concussion, subluxation, intrusion, extrusion, lateral luxation, avulsion
    • Alveolar bone injury
    • Intrusion of teeth with fracture of socket, alveolus or jaws
    • Gingival injury
    • contusion, abrasion, laceration, degloving
    • Combination of the above
  • 5. 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
  • 6. Treatment objectives
    • Preservation of damaged teeth depends on:
        • Complexity of maxillofacial injury
        • Age of the patient
        • General dental condition
        • Site of injury
        • Wishes of the patient
    • Prognosis is influenced by:
        • Open root apices
        • Intact gingival tissue
        • Absence of root fracture
        • periodontal-bone support
  • 7. Injuries to the primary dentition
      • 70% 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
  • 8. Management of injuries to permanent dentition
    • Crown 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 extraction
      • Saving the tooth by:
            • Rigid splinting for a minimum of 8 weeks
            • Devitlaiztion (RCT) with eventful apico surgery
            • Orthodontic extrusion or crown lengthening
  • 9. Injuries to periodontal tissues
    • Force distributed over several teeth or impact cushioned by overlying soft tissue may result into:
        • Concussion
        • Subluxation
        • Intrusion
        • Displacement and avulsion
        • Fracture 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
  • 10. 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 composite
        • Arch bar
        • Orthodontic wire
        • Soft 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 development
        • length of exposure
        • medium storage
        • handling and splinting
  • 11. Alveolar fracture
    • Alveolar 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
  • 12. 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
  • 13. Management of tuberosity fracture
    • Removal 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
  • 14. Injuries to the gingival and soft tissues
    • Damage 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
  • 15. Management of soft tissue injuries
    • Inspection of a full thickness perforating wound
    • Debridment and copious lavage
    • with cholohexidine solution
    • Removal of denuded piece of bone
    • Repair of soft tissue injury
    • Application of external support strapping to help in tissue adaptation
    • Antibiotic prescription