CC
A 22-year-old male presents to the oral and maxillofacial surgery office complaining of anterior facial pain, swelling, oral bleeding, and mobile teeth.
HPI
The patient reports that he was riding his mountain bike when an abrupt bump resulted in his striking his lower face against the handlebars. He dismounted the bicycle without other injuries and drove himself to an outside emergency department (ED). He denies loss of consciousness, nausea, vomiting, visual disturbances, or headache (indicative of head trauma with intracranial injury). He further denies stridor, dyspnea, or increased work of breathing (suggestive of foreign body aspiration resulting from dislodged teeth, dental restorations, or orthodontic appliances). He notes several dental fractures, profound mobility of the lower teeth, and gingival bleeding. He undergoes primary and secondary surveys, according to the Advanced Trauma Life Support (ATLS) protocol, and the results are found to be negative. A computed tomography (CT) scan is obtained, and the patient is given instructions to report by private car to your office for evaluation.
PMHX/PDHX/medications/allergies/SH/FH
The patient denies any significant cardiac, pulmonary, renal, hepatic, or neurologic diseases.
Examination
General. The patient is a well-developed, well-nourished adult male in mild distress secondary to pain and oral bleeding. He is neurologically intact.
Maxillofacial. There are no lacerations, contusions, or abrasions of the scalp, midface, or chin. The pupils are equal at 4 mm, round, and reactive to light and accommodation. The nasal dorsum is midline and stable. There is no rhinorrhea (a concern for violation of the cribriform plate with cerebrospinal fluid [CSF] leakage) and no septal hematoma on speculum examination. The ears are symmetric and without injury to the pinnae. Examination of the external auditory meatus reveals no otorrhea (also a concern for CSF leakage) or disruption of the tympanic membrane. There is no mastoid ecchymosis noted (Battle’s sign, significant for occult skull base fracture). The orbits, midface, and mandible are without step deformity or crepitus on palpation. Cranial nerves II through XII are intact.
Intraoral. There is a 1-cm abrasion of the upper lip skin without significant laceration. Intraorally, there is profound ecchymosis of the upper lip mucosa with a laceration extending into the sublabial vestibule ( Fig. 48.1 ). Teeth #7 and #8 are mobile as a single unit with displacement of the buccal cortical plate on manipulation. Tooth #9 is grossly mobile and subluxed several millimeters. It also demonstrates an oblique coronal fracture with pinpoint pulp exposure (Ellis class III). In addition, tooth #9 is sensitive to mechanical stimulation with a cotton-tipped applicator and tender to percussion. There is occlusal prematurity with interference of the maxillary anterior teeth on attempted intercuspation.
Imaging
A maxillofacial CT scan demonstrates an alveolar segment fracture involving teeth #7 and #8, with subluxation of tooth #9 and fracture of the alveolar plate ( Fig. 48.2 ). There are otherwise no injuries to the maxillofacial skeleton, cervical spine, brain, or cranium. The minimum radiographic study necessary for diagnosis of dentoalveolar fractures is a periapical radiograph, although the diagnosis can often be made with a physical examination alone. Based on availability, other radiographic studies may include:
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Computed tomography
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Cone-beam CT (CBCT)
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Periapical radiograph with a horizontally and laterally directed central beam to evaluate traumatized roots for fractures
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Occlusal view
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Panoramic radiograph
Labs
No routine laboratory tests are indicated for the work-up and diagnosis of dentoalveolar injuries in a healthy individual. If coagulopathy is suspected based on the medical history and physical examination, a coagulation profile, including the prothrombin time or partial thromboplastin time, international normalized ratio, and platelet count, may be obtained.
Assessment
Anterior maxillary alveolar segment fractures involving teeth #7 through #9, with lateral luxation and an Ellis class III fracture of tooth #9, and an intraoral laceration of the upper lip.
Treatment
Initial stabilization includes reduction of the teeth and splinting ( Fig. 48.3 ). With the current patient, bonded flexible wire splinting was not available, so the teeth were splinted with an arch bar. The occlusion was checked, and the teeth were not in occlusion during maximum intercuspation. The patient’s tetanus status was up to date. He was given a prescription for amoxicillin and chlorhexidine and discharged home. The teeth were splinted for 8 weeks because of the alveolar segment fracture. Root canal therapy was initiated on day 10 with calcium hydroxide therapy.
Complications
In the past, only about 25% to 40% of replanted, avulsed teeth show periodontal ligament (PDL) healing. This has been attributed to poor handling of the tooth. Three different types of posttraumatic external root resorption have been distinguished in the literature: surface resorption (repair-related root resorption), inflammatory resorption (infection-related root resorption), and replacement resorption (ankylosis-related root resorption). Surface resorption has no significant clinical consequences and can be observed. However, the other types of resorption can ultimately result in tooth loss. In the avulsed tooth, if the PDL that is still attached to the tooth does not dry out, the cells can remain viable for an extended period, depending on the storage medium. After the tooth has been reimplanted and stabilized, the viable PDL cells reattach to the PDL within the socket. When the injury to the cementum of the root is localized, there is minimal destructive inflammation, allowing for new cementum to be laid down after the inflammation resolves. When there is poor handling of the avulsed tooth (e.g., drying or storage in nonphysiologic solutions), damage and necrosis of the PDL occur. Subsequently, there is a large area of inflammation to remove the damaged PDL and cementum. This must be replaced by new tissue. The slower moving cementoblasts compete with the osteoblasts in the replacement process, resulting in some areas of the root surface being replaced by bone. Over time, through osseous remodeling, this can result in osseous or replacement resorption. Internal root resorption can occur through persistent inflammation or metaplastic replacement of normal pulp tissue. This can result in late tooth fractures. Root surface treatments and root canal therapy are directed toward prevention of this complication. Ideal management of dentoalveolar trauma may have to be delayed because of life-threatening injuries that must be managed first ( Fig. 48.4 ). This may result in resorptive complications.
Discussion
Appropriate diagnosis is critical in identifying and treating patients with dentoalveolar injuries, which are known to affect one-fourth of all children and one-third of all adults. Depending on the mechanism of injury, a number of maxillofacial injuries may present with concomitant intracranial or cervical spine injuries despite normal neurologic findings on physical examination. After a thorough physical examination that follows the ATLS protocol, attention is directed to the head and neck. Contaminated facial wounds should be irrigated with normal saline if available, although tap water has been shown to be as effective as saline. Patients with grossly contaminated wounds or facial injuries caused by dog or human bites should be considered for tetanus immunization based on their vaccination history. If an adult has an ambiguous immunization history or has received fewer than three prior doses of tetanus toxoid, they should receive tetanus immune globulin and the tetanus–diphtheria or tetanus–diphtheria–acellular pertussis (Tdap) vaccine. Prior tetanus disease is inadequate at providing immunity because a small amount of the highly potent toxin is sufficient to cause clinical neuromuscular weakness and airway compromise. Antibiotic coverage must be based on the mechanism and extent of injury. It is indicated in contaminated wounds with significant soft tissue injury, luxated teeth, avulsed teeth, pulp exposures, root fractures, and alveolar fractures. Amoxicillin is usually chosen unless the patient is allergic to penicillin; in such cases, clindamycin can be substituted. Chlorhexidine oral rinse is an excellent choice for most oral injuries to help prevent infection.
The cause of dentoalveolar trauma varies among different demographics, but it generally results from falls, playground accidents, domestic violence, bicycle accidents, motor vehicle accidents, assaults, altercations, and sports injuries. Gassner and colleagues reported an incidence of 48.25% in all facial injuries, 57.8% in play and household accidents, 50.1% in sports accidents, 38.6% in accidents at work, 35.8% in acts of violence, 34.2% in traffic accidents, and 31% in unspecified accidents. Falling is the primary cause of dentoalveolar trauma in early childhood. Andreasen reported a bimodal trend in the peak incidence of dentoalveolar trauma in children aged 2 to 4 and 8 to 10 years.
Dentoalveolar injuries have been classified by the International Association of Dental Traumatology, which regularly reviews and updates guidelines. These guidelines and are published online at https://dentaltraumaguide.org . Broadly, the discrete categories of dentoalveolar injury include:
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Injuries to the periodontium
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Injuries to the dental crown and root
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Injuries to the supporting alveolar bone
Injuries to the periodontium and the recommended treatment
Injuries to the periodontium resulting from forces directed through the tooth and to the surrounding bone and periodontal attachment are the most common types of dental trauma in the primary dentition.
Concussion
With concussion, there is no visible trauma to tooth or alveolar structures, but there is pain on percussion. Treatment is conservative, with no chew diet only and surveillance of pulpal vitality for at least a year but preferably longer.
Subluxation
Subluxation is increased mobility of the tooth without dislocation. Treatment is conservative, though a flexible splint may be applied for patient comfort up to 2 weeks. The pulp condition should be monitored for at least 1 year but preferably longer.
Extrusion
Extrusion is coronal dislocation of the tooth caused by separation of the PDL without alveolar bone disruption. Clinically, the tooth appears elongated and demonstrates mobility. Treatment involves repositioning the tooth into the socket; stabilizing the tooth for 2 weeks with a nonrigid, flexible splint; and performing root canal therapy in teeth with closed apices. If the marginal alveolar bone demonstrates radiographic signs of breakdown at follow-up, prolonged splinting is recommended, up to 6 weeks after the injury. If the pulp becomes necrotic and infected, endodontic treatment appropriate to root development is indicated.
Lateral luxation
Lateral luxation is tooth displacement with fracture of the alveolar process. Treatment involves repositioning to its original position and flexible splinting for 4 weeks. If the marginal alveolar bone demonstrates radiographic signs of breakdown at follow-up, prolonged splinting is recommended, up to 6 weeks after the injury.
For teeth with incomplete root formation, spontaneous pulp revascularization may occur. When there are signs of pulpal necrosis or infection or inflammatory external resorption, root canal treatment should be started. Endodontic procedures suitable for immature teeth should be used. Teeth with complete root formation will likely develop pulpal necrosis and must undergo root canal therapy 2 weeks after injury. Root canal therapy should initially be performed using a corticosteroid–antibiotic or calcium hydroxide as an intracanal medication.
Intrusion
This is apical dislocation of the tooth, with crushing injury of supporting alveolar bone. The tooth is clinically immobile, and may resemble ankylosis on percussion.
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Repositioning: For teeth with incomplete root formation, allow several weeks for passive eruption. If no spontaneous movement may be appreciated, orthodontic repositioning should be started after 4 weeks of conservative treatment. For teeth with complete apical development, the clinician should allow for re-eruption without intervention if the tooth is intruded less than 3 mm. If no eruption within 8 weeks, the tooth must be repositioned surgically and splinted for 4 weeks with a passive and flexible splint. Alternatively, the tooth could be repositioned orthodontically before ankylosis develops. If the tooth is intruded 3 to 7 mm, the tooth should preferably be repositioned surgically. Alternatively, the tooth could be repositioned orthodontically. If the tooth is intruded beyond 7 mm, the tooth should be repositioned surgically.
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Endodontic treatment: For teeth with incomplete root formation, spontaneous pulp revascularization may occur. When there are signs of pulpal necrosis or infection or inflammatory external resorption, root canal treatment should be started. Endodontic procedures suitable for immature teeth should be used. Teeth with complete root formation that are intruded will likely develop pulpal necrosis and must undergo root canal therapy 2 weeks after injury or as soon as the position of the tooth allows. Root canal therapy should initially be performed using a corticosteroid-antibiotic or calcium hydroxide as an intracanal medication.
Avulsion or exarticulation
This is the complete loss of tooth from alveolar supporting bone.
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Replantation: Successful long-term tooth retention and function depend greatly on the steps performed in the first critical minutes after injury. The most commonly avulsed tooth is the maxillary central incisor, and it most often affects children 7 to 10 years of age. In most cases, replantation of avulsed permanent teeth should be attempted. If it is a primary tooth, reimplantation should not be attempted. It is important to take a complete medical history before treatment. Contraindications to replantation include immunosuppressed patients after transplant surgery and patients with cardiac valve replacement. When possible, the teeth should be positioned back into the socket immediately and stabilized. If this is not possible, the prognosis of the avulsed tooth is dependent on how it was handled. The prognosis is improved if there is no dry time, the tooth is stored in physiologic solution, milk, Hanks Balanced Salt Solution (HBSS) or saliva, and replantation is within 1 hour.
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Teeth reimplanted at the scene of the accident: If the tooth can be found at the time of the accident, it can be reimplanted at the scene. If the tooth is dirty, rinse it gently in milk or saline or in the patient’s saliva and replant or return it to its original position in the jaw. It can be held into position with light pressure. The patient should go immediately to the urgent care facility or to the dental office depending on the type of accident and other injuries. The tooth can be realigned or repositioned, if in the wrong location, for up to 48 hours after the injury. The tooth must be stabilized with a flexible splint, wire, and composite for 2 weeks. In cases of associated alveolar segment fracture or maxillary or mandibular fracture, a more rigid splint is indicated and should be left in place for about 4 weeks. The patient is prescribed antibiotics and chlorhexidine, and tetanus vaccination status is assessed and treated accordingly. The pulp is monitored for possible root canal therapy depending whether the tooth apes is closed or the tooth is still developing.
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For a tooth stored in physiologic solution or nonphysiologic solution with less than 1 hour extraoral dry time:
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Closed apex: The socket is irrigated to remove any coagulum or debris. Any socket fractures are reduced. The tooth is gently reimplanted. The tooth is stabilized with flexible wire and composite, for 2 weeks. In cases of associated alveolar segment fracture or maxillary or mandibular fracture, a more rigid splint is indicated and should be left in place for about 4 weeks. Endodontic treatment should be initiated within 2 weeks after replantation. Calcium hydroxide is recommended as an intracanal medicament for up to 1 month followed by root canal filling. (When corticosteroid or an corticosteroid–antibiotic mixture is used as an antiinflammatory and antiresorptive intracanal medication, it should be placed immediately or shortly after replantation and left in place for at least 6 weeks. Calcium hydroxide is an effective antimicrobial agent that decreases resorption and promotes healing. The more alkaline environment in the dentin slows the resorptive cells and promote hard tissue formation. It is recommended that the calcium hydroxide not be changed frequently because it can also injure cells needed for root repair. The root canal can now be obturated with the final filling material, such as gutta percha.
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Open apex: For teeth with an open apex, the goal is to encourage revascularization, continued root formation, and apex closure. The tooth is stabilized with a flexible wire and composite for 2 weeks. The tooth is monitored for signs of pulpal necrosis. If spontaneous revascularization does not occur, apexification, pulp revitalization or revascularization, or root canal treatment should be initiated as soon as pulp necrosis and infection is identified. Apexification therapy should be performed with calcium hydroxide therapy.
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For an extraoral dry time longer than 60 minutes:
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Closed apex: Teeth that have been out of the mouth for longer than 1 hour and not in a storage medium will have a necrotic PDL and a poorer prognosis, with a greater risk of root resorption. The socket is irrigated to remove any coagulum or debris. Any socket fractures are reduced. The tooth is gently reimplanted. The tooth is stabilized with flexible wire and composite for 2 weeks. In cases of associated alveolar segment fracture or maxillary or mandibular fracture, a more rigid splint is indicated and should be left in place for about 4 weeks. Endodontic treatment should be initiated within 2 weeks post replantation. A study using Emdogain (Straumann) has shown some beneficial effects for teeth with extended dry times. Emdogain is an enamel matrix protein that has been shown to make the root more resistant to resorption and stimulate new PDL formation from the socket.
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Open apex: For teeth with an open apex, the goal is to encourage revascularization, continued root formation and apex closure. The tooth is stabilized with a flexible wire and composite for 2 weeks. The tooth is monitored for signs of pulpal necrosis. If spontaneous revascularization does not occur, apexification, pulp revitalization/revascularization or root canal treatment should be initiated as soon as pulp necrosis and infection is identified. Apexification therapy should be performed with calcium hydroxide therapy.
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Pediatric considerations: Prominent maxillary central incisors that protrude beyond the confines of the upper lip are associated with a higher incidence of dental trauma in these children. Children are more challenging to examine and treat and require cooperation from parents. Intrusion of the primary dentition results in crown deformation of enamel hypoplasia of the underlying permanent teeth. For these reasons, primary teeth, if avulsed, should not be replanted for fear of injury to the underlying permanent teeth.
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Storage media and other solutions: Avulsed teeth should be placed back into the socket directly when in the field, preferably within the first 15 to 20 minutes. However, this can result in aspiration in pediatric patients or patients with other injuries. This is the most physiologic for the tooth. Transport media is not always readily available. HBSS can help to maintain the PDL. Organ transport solution can also be used but may be more difficult to obtain. When these solutions are not available, consider the use of other physiologic solutions such as the patient’s own saliva or cow’s milk. Organ transport solution allows the PDL cells to survive for 1 week, and HBSS allows cells to survive for 24 hours, but milk only allows 6 hours of survival. Water is a poor storage media for teeth because it is a hypotonic solution. It results in rapid lysis of the PDL cells. Tetracycline has antiresorptive and antimicrobial properties. Tetracycline has a direct inhibitory effect on collagenase activity and osteoclasts. Its antimicrobial effects help to eliminate bacteria that have contaminated the alveolus, PDL, and pulpal tissues. Although animal studies have been promising, human studies have failed to demonstrate improved pulp revascularization when teeth are soaked in topical antibiotics. Thus, its routine use is not currently recommended.
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Splinting ( Box 48.1 ): Splinting after injuries to the periodontium, root injuries, and alveolar segment fractures immobilizes the tooth or segment after it has been reduced into proper position and allows for PDL healing; bony segment healing; and in some situations, revascularization of the tooth. Several techniques have been described for various injuries. These splinting techniques have their advantages and disadvantages and thus must be tailored to the fixation needs. The bonded composite with flexible wire is the treatment of choice for injuries to the periodontium and root fractures. This technique allows flexible stabilization that allows some movement of the tooth in relation to the alveolus. This in turn allows for healing of the PDL and reduces the risk of ankylosis or resorption. The recommended fixation time for an injury to the periodontium is 2 weeks.
