Dental trauma and injuries to the dentition are difficult to treat because the treatment goals serve to restore esthetics and function. The oral and maxillofacial surgeon is often called on to coordinate the efforts of rehabilitation after a dentoalveolar injury. A comprehensive understanding of the ideal treatments and use of endodontic, orthodontic, periodontal, and pediatric dental colleagues leads to the best possible results with regards to a restoration of form and function. This article provides a succinct review of the oral and maxillofacial surgeon’s treatment in dentoalveolar trauma. Epidemiology, treatment, and preventative measures are discussed in this article.
Key points
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Dentral trauma can result from a wide variety of insults to the face, and although the mechanism injury varies depending upon the demographic, the results can often be devastating and costly.
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Injuries to the dentition often do not occur in isolation, and trauma to the dentoalveolar structures can lead to significant injury to adjacent tissues, such as the gingiva, and lower third of the facial soft tissues including the chin and lips.
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Dentoalveolar injuries often require a “team” mentality including many of the dental subspecialties to attain an optimal outcome of restoration of form and function.
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The aim of this article is to describe appropriate treatment modalities to accomplish this restoration based on the stage of the dentition, age of the patient, and nature of the injury.
Epidemiology
Dental injuries are difficult to study because many injuries go unreported or are minor enough to go untreated (eg, a fracture within enamel) or may be treated in settings, such as a private clinic, where the incidence is not studied or followed. However, a 2016 review of the literature demonstrated that despite low reporting, studies found that up to 5% of the population is affected by dental trauma. The prevalence of injuries to the dentition ranges from 6% to 59% and in pediatric patients presenting with craniofacial trauma, one large study demonstrated 76% of patients had dentoalveolar injuries. , It is no surprise that male patient populations tended to have consistently higher rates of dental trauma than female cohorts; this may be attributed to involvement with contact sports with or without proper protective gear. , Additionally, there are differences in protective gear worn by males and females even within the same sport type; in softball and lacrosse, facial protection in female competitors is consistently increased over the male counterpart in baseball and lacrosse.
Developmentally speaking, an infant begins to have eruption of the anterior dentition from 6 months and continues until around age 2. During this time, they are also learning to walk/run and play. It is therefore not uncommon to sustain injuries in the anterior primary dentition from falls in the toddler patient. Once they have learned to walk, they walk to playgrounds, where an array of dental-injuring devices exist. School-aged children exhibit many injuries to primary and succedaneous dentition. Once the upper central incisors erupt into the oral cavity, they are large targets that can tend to absorb energy poorly. Then, once the permanent dentition has replaced the primary dentition (around age 12–14) involvement with sports and other activities that put the face at risk of injury (including newly licensed drivers) increases and so the mechanism of injury changes, but the patterns of teeth that are injured do not. ,
In general the anterior maxillary dentition, followed closely by the lower anteriors, are injured more frequently than the posterior dentition. This is logical. Additionally, those with malocclusions, such as a class II division I with increased protrusion to the maxillary dentition (especially those with significant overjet and lip incompetence), have increased tendency to be traumatized. And often the dental structures are not injured in isolation, and concomitant injuries to the soft tissues overlying the dentition abound. Additional injuries seen with dental trauma include facial bone fractures; nasal trauma; and head injuries, such as concussion.
All of this leads to the conclusion that the dental community (pediatric dentist, orthodontist, endodontist, oral surgeon, and periodontist) must be well versed in the proper treatment of dental trauma to be able to deliver appropriate treatment to the injured patient.
Dental injuries
Injuries to the primary dentition are treated differently from that of the permanent dentition. For this reason, this article is organized with each injury and the appropriate treatment based on the phase of dentition.
Avulsion
A tooth avulsion is a traumatic event (pun intended). Primary teeth that are avulsed should not be replaced because it could lead to problems with the developing dentition. Permanent teeth should be placed in an appropriate medium and transported with the patient for replantation.
The treatment of choice for an avulsed tooth is to have it immediately cleansed (if debris is present) and replaced in the socket. A dental professional can then be sought to help maintain this tooth. If it cannot be replaced in the socket, but the patient has full faculty and is able to transport it in their vestibule in saliva, this is also an appropriate method of transportation. Often this is not possible and the tooth is transported in liquid (to avoid desiccation). Note that in a study of 400 replanted permanent incisors, four factors weighed in greatest in relationship to periodontal ligament healing: (1) stage of root development, (2) length of the dry extra-alveolar storage period, (3) immediate replantation, and (4) length of the wet period (saliva or saline storage). The authors also noted that nonphysiologic storage in some solutions inevitably led to root resorption (homemade saline or sterilizing solutions). For this reason, particular attention should be payed to transport medium if the tooth cannot be placed into the socket immediately (because this is always the treatment of choice if the patient is able).
The transport medium should be of the appropriate pH, and provide nutrients to the periodontal cells ( Table 1 ). Hank’s Balanced Salt Solution, with its neutral pH and glucose for the periodontal cells, is the best solution for transport. It is purchased online for around $14. The shelf life of Hank’s solution is 2 years and can therefore be kept by a team doctor on the sideline of sports where dental injuries are not infrequent. The other solutions listed are less than ideal because of their acidity, tonicity, or lack of nutrients (glucose).
| Medium | pH | Osmolality | Glucose +/− |
|---|---|---|---|
| Saline | 7.0 | 295 | – |
| Tap water | 7.5 | 12 | – |
| Saliva | 6.3 | 115 | + |
| Gatorade | 3.0 | 320 | + |
| Milk | 6.75 | 275 | + |
| Hank’s Balanced Salt Solution | 7.0 | 280 | + |
The tooth should be debrided of any necrotic tissue, the socket irrigated with saline, and the tooth should then be replanted and restored to its original position within the arch form with firm digital pressure. Once an avulsed tooth has been replanted, it should be splinted to the adjacent teeth (nonrigid) for 2 to 3 weeks. Splinting times have been studied with inconclusive effects in regards to duration of splinting and its correlation with restored periodontal health. , Vitality should be monitored by an endodontist in open apex/partially developed teeth. Closed apex teeth should have a root canal performed within 7 to 10 days following replantation. Problems with replanted teeth include ankylosis (especially in cases where extraoral time of tooth exceeds 60 minutes, or storage in nonphysiologic medium is more than 20–30 minutes), external resorption, internal resorption, and infection. These teeth should be monitored radiographically and clinically following treatment until form and function are restored and then periodically for the first year following replantation. Finally, the patient should be prescribed a 7-day course of broad-spectrum antibiotics and tetanus immunization should be ensured if there is risk based on location of injury.
Patients should also be explained that although many teeth go on to heal, there is a risk of need for future extraction if the tooth does not heal properly. In the study by Andreasen and coworkers of 400 replanted permanent incisors, the need for extraction approached 30% over the period of observation (average observation was 5 years). Additionally, the risk of ankylosis increases with an increase in extraoral time, but several case reports indicate retention of the tooth, even in cases of prolonged extraoral times, such as 15 and 27 hours, is possible. , In these instances, the informed consent should include the likelihood of ankylosis and its implications, although in the growing patient, this may serve as an interim fix until skeletal maturity is reached and treatments, such as dental implants, are a desirable option.
Intrusion
The timing of addressing the intruded tooth is not as critical as in that of the avulsed tooth, but should be addressed as soon as possible. The first step in treating the intruded tooth is to note the degree to which the tooth is intruded, because this plays an important part in the overall prognosis of the tooth and the treatment. When intact, the adjacent teeth can serve as the point from which to measure as to the millimeters that the tooth appears intruded. However, because many of these injuries occur during adolescence with mixed dentition, this is difficult at times. Teeth that are intruded up to 3 mm should be initially monitored for re-eruption, but if there is no movement in the first month, the patient should be advised to have surgical extrusion or orthodontic extrusion before the possibility of replacement resorption/ankylosis that would render coronal movement of the tooth impossible. Either surgical repositioning or orthodontic extrusion is used to manage moderate cases of 3 to 7 mm, and surgical movements should be performed on all patients with severe intrusion (7 mm or greater). Primary teeth that have been intruded should have closely inspected radiographs and if the tooth remains buccal can be left in place to passively erupt and be monitored for any sign of ankylosis. If the tooth does not re-erupt in the first month it should be extracted to avoid the possibility of ankylosis and impeding the eruption of the permanent dentition. If the tooth appears to disrupt the developing follicle on radiograph, it should also be extracted to avoid undue inflammation/trauma at the follicle of the developing tooth.
Permanent teeth that are intruded less than 3 mm tend to have a better prognosis in terms of replacement resorption, and those with no concomitant coronal fractures resulting in exposed dentin have a decreased incidence of pulpal necrosis.
The vitality of the tooth should be monitored closely because these teeth have a high incidence of pulpal necrosis. These patients should be followed closely by either the general dentist or orthodontist for appropriate treatment of nonvital teeth. Finally, unless a clear portal of entry for bacteria exists with concern for infection, there is no clear indication for the administration of antibiotics in the patient with an intruded tooth.
Extrusion
Primary dentition that has experienced a minor injury (<3 mm) resulting in extrusion can be reduced provided this does not impinge on the developing dentition. Once reduced, they should be splinted for 2 weeks and monitored for infection in the 4 to 6 weeks to follow the injury ( Figs. 1–3 ). The patient’s primary dentist (pediatric or general/family dentist) should be made aware of the injury so that it, and the apical tooth buds, are appropriately monitored.
