Patient evaluation

Dentoalveolar injuries should be considered an emergency situation because successful management of the injury requires proper diagnosis and treatment within a limited time to achieve more favorable outcomes. The initial evaluation must include a general assessment of the patient’s overall condition—not only past medical history but also time, place, and mechanism of trauma and associated injuries. Immediate pain relief and reduction of dental and alveolar injuries allow for better assessment of the dentition.

History

The history obtained from patients with dentoalveolar injury should include the following information:

• 1.

  Biographic and demographic data, including name, age, gender, and race.

• 2.

  The time interval between the injury and presentation to the clinic or emergency department. The success of managing luxated teeth, crown fractures, and alveolar bone fractures may be influenced by delayed treatment.

• 3.

  The site of the accident, which may provide clues to the degree of bacterial contamination and possible need for tetanus prophylaxis.

• 4.

  The nature of the accident, which can provide insight into the type of injury to be suspected. For example, a fall often causes injury to the maxillary anterior dentition, but a blow to the chin frequently causes crown-root fractures of the premolars or molars along with symphyseal or condylar fractures of the mandible. In children and women, if the history of the injury does not correspond to the type of injury expected, abuse should be considered. The clinician should carefully document the findings and discussion with the patient. The nature of the injury also may provide information regarding other associated occult injuries. For example, an occult injury to the neck should be ruled out during the examination of the patient who has been thrown forward against the dashboard as an unrestrained passenger or against the guardrail from a bicycle accident.

• 5.

  Information related to the events surrounding the accident, including whether teeth or pieces of teeth were noted at the accident site. Unless all crowns and teeth are accounted for, radiographic examination of the periapical tissues, chest, abdominal region, and the perioral soft tissue should be performed to ascertain whether the missing fragments of teeth are in these tissues or body cavities. The clinician should determine whether the patient or parent replanted any partially or completely avulsed teeth and how a tooth was stored before presentation to the dentist or the emergency room. Finally, information should be obtained about whether the patient had loss of consciousness, confusion, nausea, vomiting, or visual disturbances after the accident. If any of these symptoms occurred, intracranial injury should be suspected and the patient should be referred for immediate neurologic evaluation. Treatment of the dentoalveolar injury can be delayed until such evaluation is completed.

• 6.

  Changes in the occlusion as a result of the injury, which could indicate tooth displacement or dentoalveolar and/or jaw fractures.

• 7.

  Medical and dental history, which may delay or modify treatments, including the presence of major systemic illness such as bleeding disorders or epilepsy.

History

The history obtained from patients with dentoalveolar injury should include the following information:

• 1.

  Biographic and demographic data, including name, age, gender, and race.

• 2.

  The time interval between the injury and presentation to the clinic or emergency department. The success of managing luxated teeth, crown fractures, and alveolar bone fractures may be influenced by delayed treatment.

• 3.

  The site of the accident, which may provide clues to the degree of bacterial contamination and possible need for tetanus prophylaxis.

• 4.

  The nature of the accident, which can provide insight into the type of injury to be suspected. For example, a fall often causes injury to the maxillary anterior dentition, but a blow to the chin frequently causes crown-root fractures of the premolars or molars along with symphyseal or condylar fractures of the mandible. In children and women, if the history of the injury does not correspond to the type of injury expected, abuse should be considered. The clinician should carefully document the findings and discussion with the patient. The nature of the injury also may provide information regarding other associated occult injuries. For example, an occult injury to the neck should be ruled out during the examination of the patient who has been thrown forward against the dashboard as an unrestrained passenger or against the guardrail from a bicycle accident.

• 5.

  Information related to the events surrounding the accident, including whether teeth or pieces of teeth were noted at the accident site. Unless all crowns and teeth are accounted for, radiographic examination of the periapical tissues, chest, abdominal region, and the perioral soft tissue should be performed to ascertain whether the missing fragments of teeth are in these tissues or body cavities. The clinician should determine whether the patient or parent replanted any partially or completely avulsed teeth and how a tooth was stored before presentation to the dentist or the emergency room. Finally, information should be obtained about whether the patient had loss of consciousness, confusion, nausea, vomiting, or visual disturbances after the accident. If any of these symptoms occurred, intracranial injury should be suspected and the patient should be referred for immediate neurologic evaluation. Treatment of the dentoalveolar injury can be delayed until such evaluation is completed.

• 6.

  Changes in the occlusion as a result of the injury, which could indicate tooth displacement or dentoalveolar and/or jaw fractures.

• 7.

  Medical and dental history, which may delay or modify treatments, including the presence of major systemic illness such as bleeding disorders or epilepsy.

Clinical examination

An important aspect of the physical examination is the overall evaluation of the physical status of the patient. Guided by the findings of the history, the patient should be examined for the presence of concomitant injury, including measurement of vital signs such as pulse rate, blood pressure, and respiration. Significant changes may indicate intracranial injury, cervical spine injury, chest or abdominal injury, or even aspiration of an avulsed tooth. The patient’s mental status also should be assessed by asking specific questions and observing the patient’s reaction and behavior during the history and examinations. Once a general examination is completed and any concomitant injury is ruled out, the oral and maxillofacial examination is performed.

• 1.

  Extraoral soft tissue examinations include inspection of the soft tissue for lacerations, abrasions, and contusions of the skin of the face, chin, forehead, and scalp. The depth, location, and proximity to vital structures of any lacerations should be noted, recorded, and considered when the lacerations are repaired. Location of laceration may suggest the site of dental injury. The temporomandibular joint is palpated and range of jaw motion determined to rule out condylar fracture.

• 2.

  Intraoral soft tissue examination includes assessment for injuries of the oral mucosa and gingiva and laceration of the lips, tongue, floor of the mouth, and cheek. Such injuries require thorough evaluation for the presence of foreign bodies, debris, and teeth or teeth fragments embedded within the tissue. It may be necessary to clean the laceration and the oral cavity to remove any clots and stop active bleeding to conduct an adequate examination. Gingival lacerations are often indications of tooth displacement, and bleeding from nonlacerated marginal gingival frequently is indicative of periodontal ligament damage or mandibular fracture. It is important to account for all teeth; missing teeth or pieces of teeth that have not been left at the scene of the accident should be considered to have been aspirated, swallowed, or displaced into the soft tissues, nasal cavity, or maxillary sinus until proven otherwise. These areas should be examined radiographically to rule out the presence of teeth or fragments.

• 3.

  Examination of the jaws and alveolar bone. Fractures of the alveolar process are readily detected by visual inspection and often manifested as gingival laceration. In the absence of such laceration, manual palpation of fractured segments of the alveolar process usually reveals mobility and crepitation of the fragments. Fractures of the underlying bone can be detected by the presence of gross malocclusion, pain, and mobility of the fractured segment to palpation. Bleeding from the gingival crevice of a tooth, vertical laceration of the attached mucosa, and submucosal ecchymosis of the floor of the mouth are other signs of jaw fracture.

• 4.

  Before examining the teeth for fractures, they should be cleansed of blood and debris. Any infraction (cracks through the enamel) or fractures of the crowns should be noted. Infraction lines can be detected by directing a light beam parallel to the long axis of the tooth. Crown fractures should be evaluated to determine extension into the dentin and the pulp. The size and location of pulp exposures, if present, should be recorded. Crown-root fractures in all quadrants also should be evaluated. Changes in the color of traumatized teeth and translucency may indicate exposed pulp. It is important to remember that indirect trauma leading to crown-root fractures in one quadrant is often accompanied by similar fractures of the same side of the opposing jaw. Displacement of teeth from dentoalveolar trauma usually can be detected by visual examination. Examination of the occlusion may help to detect minor degrees of tooth movements. Although teeth may be displaced in any direction, the most common displacement is buccolingually. The direction and extent of displacement should be recorded. Lateral luxation and intrusion of teeth may cause minimal clinical symptoms because the teeth remain located in this displaced position. Lingual displacement of the apex of primary teeth can interfere with permanent successors. All teeth should be tested for horizontal and axial mobility. If a tooth does not appear to be displaced but is mobile, a root fracture should be suspected. In such instances, the location of the fracture usually determines the degree of mobility. Movement of the tooth being tested, together with the adjacent tooth, suggests dentoalveolar fracture. The purpose of vitality testing is to register the conduction of stimuli to the sensory receptors of the dental pulp. This test can be performed using mechanical stimulation with cotton soaked in saline or by thermal test using treated guttapercha, ice, ethyl chloride, carbon dioxide snow, dichloro-difluormethane, or electric vitalometers. The test may be difficult to perform or be relatively unreliable in the acute setting after traumatic injury, however. Results also can be unreliable in uncooperative children. Results may be more accurate when pulp testing is performed several weeks later; such tests should be performed before endodontic therapy.

Radiographic evaluation

Indications for radiographic examinations are as follows:

• 1.

  Presence of root fractures

• 2.

  Degree of extrusion or intrusion

• 3.

  Presence of pre-existing periodontal disease

• 4.

  Extent of root development

• 5.

  Size of the pulp chamber

• 6.

  Presence of jaw fractures

• 7.

  Tooth fragments and foreign bodies lodged in soft tissues

Radiographic examination is essential to determine whether any underlying structures are damaged and should include periapical, occlusal, and panoramic radiographs. The periapical radiograph provides the most detailed information about root fractures and the dislocation of teeth. After treatment, periapical films can confirm the proper positioning of an avulsed or luxated tooth into the alveolus. Occlusal radiographs, however, provide a larger field of view, and the detail is almost as sharp as a periapical radiograph.

When occlusal radiographs or periapical films are used to examine soft tissues for the presence of foreign bodies, reduce the radiographic exposure time. The panoramic radiograph is a useful screening view and can demonstrate fractures of the mandible and maxilla and fractures of the alveolar ridges and teeth. In the hospital setting, dental radiographs may not be available. Although not ideal, plain films, such as the mandibular series and the Caldwell views, may reveal tooth and alveolar injuries. In the trauma patient whose tooth has not been accounted for at the accident scene, arrange for chest films to rule out the possibility of aspiration. Abdominal radiographic films can determine whether displaced teeth or prosthetic appliances have been ingested.

Classification