by imaging characteristics alone, although the borders of an LCH lesion

typically are better defined. Multiple lesions in a younger age group (usually
the first three decades) are more likely to be LCH than squamous cell
carcinoma, which typically appears as a single lesion in middle-aged or elderly
patients.
The differential interpretation of solitary intraosseous lesions includes
metastatic disease and malignant neoplasms extending into bone from
adjacent soft tissues. However, the well-defined borders and the
periosteal reaction seen in LCH help in the differential interpretation.

Management
Patients suspected to have LCH should be referred to an oral and
maxillofacial radiologist for a complete work-up, which may include nuclear
medicine to detect other possible bone lesions. If confirmed, the lesion
should undergo biospy. Because the histopathologic appearance of
histiocytosis may be hidden by changes caused by secondary infection from
the oral cavity in alveolar lesions, it is important to correlate the radiologic
and histopathologic findings from the biopsy.
Management of localized lesions usually consists of surgical curettage
or limited radiation therapy. Surgical management of jaw lesions usually is
preferable because these lesions have a low recurrence rate. The earlier
LCH lesions of the mandible are diagnosed and controlled, and fewer
teeth are lost to bone destruction. Disseminated disease is treated with
chemotherapy.

Oral and Maxillofacial Imaging for Cancer

Survivors
Patients who have survived cancer treatment require dental treatment just
like any other patient. For a cancer survivor, an oral and maxillofacial
radiologic examination may be more important than for a healthy patient
to receive a recall examination. Some patients who have received a full
course of radiation therapy are concerned about the additional radiation
dose from an oral and maxillofacial radiologic examination. However, this
is not a valid concern because the relatively minuscule dose associated
with oral and maxillofacial radiologic imaging examinations is negligible
compared with the dose received from radiation therapy for a malignancy.
A patient treated for head and neck malignancy with radiation therapy
— even with today's advanced radiotherapeutic methods—is prone to
develop postradiation dental caries and radiation-induced bone
necrosis. Careful clinical examination and a thorough oral and
maxillofacial radiologic examination may be periodically required to
ensure that the remaining
dentition and periodontal apparatus is in good shape. Radiation caries occurs
in many patients and appears clinically different from typical dental caries. If
untreated, these carious teeth can develop nonvital pulps, and there may be
extension of the inflammatory response to the jaw more widely. If such a
patient requires tooth extraction, healing can be expected to be slow, and
occasionally osteoradionecrosis may result. Also, bisphosphonates and other
related therapies are now used extensively with some chemotherapy
regimens, as in multiple myeloma. Changes seen with either radiation therapy
or medication may mimic odontogenic inflammatory disease and should be
differentiated to avoid unnecessary treatment and secondary osteonecrosis
(see Chapter 22).
The role of oral and maxillofacial radiology in these patients should not
be restricted to examination only of the teeth and supporting structures.
Equally important is monitoring of the outcome of treatment and specifically
the examination of oral and maxillofacial images for evidence of neoplasm
recurrence, and the development of metastases and osteonecrosis.

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27

Trauma
Sanjay M. Mallya

Abstract
Radiologic examination is an integral component in the diagnostic
evaluation of the patient with trauma to the teeth and jaws. It provides
essential information on the presence, location, and orientation of
fracture planes and fragments, the involvement of adjacent vital
anatomic structures, and the presence of foreign objects that may
have become embedded within the soft tissues. Posttherapeutic
radiographs allow monitoring of healing and the detection of long-term
changes resulting from the trauma.

Keywords
maxillofacial trauma; mandibular fracture; dentoalveolar fracture; dental
fractures; condylar fractures; root fractures
Radiologic examination is an integral component of the diagnostic
evaluation of the patient with trauma to the teeth and jaws. It provides
essential information about the presence, location, and orientation of
fracture planes and fragments; the involvement of adjacent vital anatomic
structures; and the presence of foreign objects that have may have
become embedded within the soft tissues. Posttherapeutic images allow
for the monitoring of healing and detection of long-term changes resulting
from the trauma.

Applied Radiology
The initial assessment of a patient with craniofacial trauma is directed
toward developing a prioritized treatment plan based on the severity of the
trauma and to determine the presence of any life-threatening injuries.
Diagnostic
imaging is an important component guiding this management. Depending
on the extent of the injuries and the clinical context, the imaging
examination may encompass the brain, facial bones, dentoalveolar arches,
and cervical spine. In acute trauma settings, this is typically accomplished
with multidetector computed tomography (MDCT) and magnetic resonance
imaging (MRI), depending on the clinical presentation, and may be
supplemented with conventional oral and maxillofacial images. However,
the choice of the imaging examination may be limited by the extent of the
patient's injuries and the availability of imaging modalities.

Dentoalveolar Fractures
Patients with trauma to the teeth and supporting alveolar processes of the
jaws must be evaluated with imaging. Such examinations are necessary
prior to definitive management, especially in pediatric patients where
manipulation of a traumatized deciduous tooth root could potentially
damage the underlying permanent tooth bud. Intraoral images are the first
choice and provide the best image resolution with regard to the detection
of coronal and root fractures and the potential displacement of the tooth
within its socket. To effectively identify root fractures, at least two
periapical images should be made at different horizontal angulations of the
x-ray beam. Furthermore, the examination must include intraoral images of
teeth in the opposing arch. When mouth opening is limited because of
trauma, cross-sectional occlusal images (see Chapter 7) may be used
instead of periapical images. In pediatric patients, an American National
Standards Institute (ANSI) size 2 receptor may be used to obtain such
occlusal images.
Panoramic imaging is a convenient approach to examine a broad
anatomic region in order to localize dentoalveolar injuries and detect
mandibular fractures. However, the image resolution is often inadequate to
critically evaluate traumatic injuries to the teeth and supporting bone,
especially in the anterior regions of the jaws. Small or limited field-of-view
(FOV) cone beam computed tomography (CBCT) provides high-resolution
multiplanar imaging and may facilitate the identification of fractures
involving the teeth and alveolar processes.
If a tooth or a large fragment of a tooth is missing, a chest or abdominal
image can provide information on accidental aspiration or ingestion. If there
are lacerations in the lips or cheek, the soft tissues must be evaluated for
potential embedded foreign bodies or tooth fragments. This can be
accomplished relatively simply by exposing an intraoral receptor placed
adjacent to the traumatized soft tissue. If the laceration is in the tongue, an
imaging examination can be accomplished with a mandibular occlusal
projection image. Alternatively, the tongue can be protruded and then imaged
with a receptor placed adjacent to the laceration site.

Mandibular Fractures
Panoramic imaging is often the initial examination performed to evaluate
suspected or clinically evident mandibular fractures in a conscious patient.
Where involvement of the mandibular body or alveolar process is
suspected, cross-sectional mandibular occlusal images can provide
additional information about the orientation of the fracture plane and
potential displacement of the fractured segments. Likewise, panoramic
imaging is often supplemented by an open-mouth Towne view to evaluate
the mandibular condylar head and neck, especially in cases of
nondisplaced greenstick fractures of the condylar neck.
Patients with suspected multiple or complex fractures of the mandible are
best imaged with CBCT or preferably MDCT. Where soft tissue injuries to
the temporomandibular joint capsule and disk are present or suspected,
MRI is the modality of choice.

Maxillofacial Fractures
Computed tomography (CT) is the method of choice for imaging fractures
of the maxillofacial skeleton, particularly when they involve multiple bones.
Because of its superior soft tissue detail, MDCT is preferred to CBCT.

Radiologic Signs of Fracture

Fractures are often erroneously referred to as “lines,” despite their three-
dimensional nature. Fractures represent planes of cleavage through a tooth or
bone, and these planes can extend deep into the tissues. A fracture may be
missed if the plane of the fracture is not aligned with the direction of the
incident x-ray beam on a single planar image.
The following are general signs that may indicate the presence of a fracture
of a tooth or bone:

1. The presence of one or two usually sharply defined radiolucent

lines within the anatomic boundaries of a structure.
Radiolucent line(s) that extend beyond the boundaries of the
mandible most likely represent an superimposed structure. If a line
extends beyond the boundaries of a tooth root, it may represent a
superimposed neurovascular canal.
2. A change in the normal anatomic outline or shape of the
structure. Noticeable asymmetry or a change in the contour of the
occlusal plane may indicate the presence and location of a fracture.
3. A loss of continuity of an outer border. This may appear as a gap in
 the continuity of the otherwise smooth tooth or cortical border. Such
a gap may also produce a “step-type” defect, where the two
fragments have become displaced relative to one another.
4. An increase in the radiopacity of a structure. When two fragments
of tooth or bone overlap, that region may appear “doubly”
radiopaque. The region adjacent to this radiopaque zone must be
scrutinized for discontinuity of borders or step deformities as
described earlier.

Dentoalveolar Trauma
Dentoalveolar injuries can affect all age groups and are caused by falls,
contact sports and playground activities, and child abuse. Injuries may
also occur as part of more extensive facial trauma caused by motor
vehicle accidents.
Trauma to the teeth may be iatrogenic; indeed, dental trauma is the most
frequent general anesthesia–related claim in litigation. Andreasen's
classification system of dentoalveolar injuries is widely used to facilitate
communication and treatment planning of injuries to the primary and
permanent dentition. The system categorizes the hard tissue injuries into
three groups: tooth fractures, periodontal tissue injury, and injuries to the
supporting bone (Box 27.1).

Box 27.1
Classification of Dentoalveolar Injuries
Dental Fractures

Crown infraction
Crown fracture,
uncomplicated Crown
fracture, complicated
Fracture of enamel, dentin, and cementum, uncomplicated
Fracture of enamel, dentin, and cementum, complicated
Root fracture

Periodontal Tissue Injury

Concussion
Subluxation
Luxation

Injuries to Supporting Bone

 Comminution of alveolar bone
Single-wall alveolar fracture
Fracture of the alveolar process
Fracture of the maxilla or
mandible

Dental Fractures
Dental Crown Fractures
Definition
Fractures of the dental crown account for approximately 25% of traumatic
injuries to the permanent teeth and 40% of injuries to the deciduous teeth.
The most common event responsible for the fracture of permanent teeth is
a fall, followed by accidents involving vehicles (e.g., bicycles, motorcycles,
and automobiles), and impacts from foreign objects striking the teeth.
Fractures involving only the crown are divided into three categories:

1. Crown infraction: Fractures and cracks confined to enamel without

the loss of enamel substance (Fig. 27.1A).

FIG. 27.1 Classification of dental fractures. (A) Crown infraction. (B)

Uncomplicated crown fracture. (C) Complicated crown fracture. (D)
Uncomplicated crown-root fracture. (E) Complicated crown-root
fracture.
 (F) Horizontal root fracture.

2. Uncomplicated crown fractures: Fractures confined to enamel

or enamel and dentin with no pulp exposure (see Fig. 27.1B).
3. Complicated crown fractures: Fractures that involve enamel,
dentin, and pulp (see Fig. 27.1C).

Clinical Features
Fractures of the dental crowns most frequently involve anterior
teeth. Infractions and cracks in the enamel are best detected by
indirect light or transillumination. Histologic studies have shown that
such cracks extend through the enamel but do not involve dentin.
Uncomplicated crown fractures that involve dentin can be recognized by
the contrast in color between dentin and the peripheral layer of enamel.
The exposed dentin is usually sensitive to chemical, thermal, or mechanical
stimulation. In the permanent dentition, uncomplicated crown fractures are
more common than complicated ones. In contrast, complicated and
uncomplicated fractures occur with nearly equal frequencies in the
deciduous teeth. When the fracture extends deeper into the tooth, the pink
blush of the pulp may be evident through the thin remaining dentin wall.
Complicated crown fractures are distinguishable by bleeding from the
exposed pulp or by droplets of blood forming from pinpoint exposures. The
pulp is visible and may extrude from the open pulp chamber if the fracture
is not recent. The exposed pulp is sensitive to most forms of stimulation.

Imaging Features
The objectives of imaging are to identify the location and extent of the
fracture, and its relationship to the pulp chamber (Fig. 27.2). Imaging also
provides a baseline record for comparison with future images made to
monitor the development of the pathologic consequences of dental trauma,
such as periapical inflammation, disruption of root development, and root
resorption. The initial assessment of tooth trauma is usually made with
intraoral imaging. Imaging of the adjacent soft tissues may be needed to
locate embedded tooth fragments or foreign objects (Fig. 27.3).
FIG. 27.2 Incisal-edge fracture involving the right maxillary lateral
incisor (arrow) and subluxation of both the central and the lateral
incisors. Note the increases to the widths of the apical periodontal
ligament spaces.

FIG. 27.3 Image of the tongue to locate fractured tooth fragments

embedded in the soft tissue. The image is underexposed to
highlight contrast between the small radiopaque fragments and the
soft tissue of the tongue. (Courtesy Dr. A. Tadinada, University of
Connecticut School of Dental Medicine, Farmington, CT.)
Management
Crown infractions typically do not require management beyond smoothing
of rough edges or restoration of form and function to the traumatized tooth.
The vitality of the tooth should be determined at the initial visit and after
approximately 6 to 8 weeks following pulpal recovery and secondary dentin
formation. The prognosis for teeth with fractures limited to the enamel is
good, and pulpal necrosis develops in less than 2% of such cases. If a
fracture involves both dentin and enamel, the frequency of pulpal necrosis
is approximately 3%. Oblique fractures have a worse prognosis than
horizontal fractures because potentially a greater amount of dentin is
exposed.
Concomitant concussion and luxation disturb the blood supply and
increase the frequency of subsequent pulpal necrosis.
When complicated crown fractures occur in immature, developing
permanent teeth, attempts should be made to maintain pulp vitality to
allow for subsequent root development. If development of the root apex is
completed, endodontic therapy is typically the treatment of choice,
although pulp capping and partial pulpectomy may be acceptable
depending on the size of the pulp exposure and the amount of elapsed
time since the trauma. In the primary dentition, complicated crown
fractures are managed by pulp capping and pulpectomy to attempt to
retain pulp vitality. Depending on the child's maturity and cooperation,
extraction may, however, be an acceptable option.

Dental Crown and Root Fractures

Definition
Fractures involving both the crown and roots (i.e., crown-root fractures) are
most often complicated by pulp exposure. The permanent teeth are
affected about twice as frequently as the deciduous teeth. Most crown and
root fractures of the anterior teeth are the result of direct trauma. Many
posterior teeth are predisposed to such fractures by large restorations or
extensive caries.

Clinical Features
The fracture plane of a typical crown-root fracture of an anterior tooth
extends obliquely from the labial surface near the gingival third of the crown
to a position apical to the gingival attachment on the palatal or lingual
surface. The involved teeth are tender to percussion, and the patient may
experience pain with separation of the fractured tooth fragments when the
tooth is loaded (e.g., during mastication). Displacement of the fragments is
usually minimal, and the coronal fragment may be mobile. Crown-root
fractures occasionally
manifest with bleeding from the pulp.

Imaging Features
Manifestation of a fracture on conventional two-dimensional imaging
depends on the relative angulation of the incident x-ray beam to the
fracture plane and the degree of separation of the fragments. If the x-ray
beam is aligned along the fracture plane, the root fracture is depicted as a
single well-defined radiolucent line confined to the anatomic limits of the
root. However, if the x- ray beam traverses the fracture plane in a more
oblique manner, the root fracture appears as a poorly defined single line or
as two discrete lines that converge at the mesial and distal surfaces of the
root.
The identification of crown-root fractures can be challenging. Periapical
and cross-sectional occlusal images are used for the initial assessment,
with multiple images made at different horizontal and vertical angulations
to maximize detection of the fracture plane.

Management
Emergency management involves temporary stabilization of the involved
teeth. Management options include fragment removal and restoration, often
after endodontic therapy. If the pulp is not exposed and the fracture does
not extend more than 3 to 4 mm below the epithelial attachment, restorative
treatment is likely to be successful. Orthodontic extrusion and crown
lengthening may be necessary. In partially developed teeth, pulp capping
should be considered to retain pulp vitality until the completion of root
development. If only a small amount of root is lost with the coronal fragment
but the pulp has been compromised, it is likely that the tooth can be
restored after endodontic treatment. Fractures that extend deeper into the
root, especially in the vertical direction, have a poor prognosis and are
managed by extraction, with subsequent implant-supported or conventional
prosthetic rehabilitation.

Dental Root Fractures

Definition
Root fractures are categorized as horizontal or vertical, depending on the
orientation of the fracture plane, and they all involve the pulp. For horizontal
fractures, the plane of cleavage can vary in angulation from one that is more
oblique to one that is more horizontal through the thickness of the root. In
contrast, the fracture planes in vertical root fractures run lengthwise from the
crown toward the apex of the tooth, usually through the facial and lingual root
surfaces.
Clinical Features
Horizontal root fractures occur more commonly in maxillary central incisors
and are usually the result of a direct application of traumatic force to the
face, alveolar processes, or teeth. In contrast, vertical fractures most
commonly occur in endodontically treated premolar and molar teeth. They
may also be iatrogenic, following the insertion of retention screws or pins
into teeth, or result from high occlusal forces, particularly in teeth with large
restorations.
The mobility of the fractured tooth crown relates to the level of the
fracture.
When the fracture plane is located toward the apex, the tooth is relatively
more stable. The mobility of a traumatized tooth is tested by placing a
finger firmly over the alveolar process; if movement of only the crown is
detected, a root fracture is likely. Fractures of the root may occur with
fractures of the alveolar process and are often not detected. This situation
is most commonly observed in the anterior region of the mandible, where
root fractures are infrequent. Although root fracture is usually associated
with temporary loss of sensitivity (by all usual criteria), the sensitivity of
most teeth returns to normal within about 6 months.

Imaging Features
As described earlier, manifestation of a root fracture on conventional two-
dimensional imaging depends on the relative angulation of the incident x-
ray beam to the fracture plane and on the degree of separation of the
fragments. A root fracture may manifest as a single well-defined
radiolucent line, a poorly defined single line, or as two discrete lines that
converge at the mesial and distal surfaces of the root. Horizontal root
fractures may occur at any level and involve one (Fig. 27.4) or more roots
of multiroot teeth. Most of the fractures occur in the apical and middle
thirds of the root. The fracture plane is often diagonal through the root.
Comminuted root fractures may also be less well defined.
 FIG. 27.4 (A) Recent horizontal fracture of the right maxillary
central incisor and apical rarefying osteitis involving the adjacent
left central incisor. (B) Healed fracture with slight displacement of
the fragments. (C) Healed fracture with root resorption and
separation of the fractured segments.

The imaging appearance of nondisplaced root fractures is usually subtle

and may necessitate multiple image exposures made at different
angulations.
These fractures may, however, not be evident on periapical images,
particularly immediately following the traumatic episode. Subsequent
inflammation of the adjacent periodontal ligament and resorption may
increase the visible separation between the fragments and facilitate
image detection. In some instances when the fracture plane is not
visible, the only evidence of a fracture may be a localized increase in
the width of the periodontal ligament space adjacent to the fracture site
(Fig. 27.5A). With longer-standing fractures, the width of the fracture
plane tends to increase with resorption of the fractured surfaces (see
Fig. 27.5B). Over time, calcification and obliteration of the pulp
chamber and canal may be seen.
 FIG. 27.5 (A) Subtle evidence of a root fracture involving the root
of the maxillary right central incisor. Although a fracture plane is
not apparent on the mesial aspect of the root because of
malalignment of the x-ray beam, there is widening of the
periodontal membrane space on the mesial surface (arrow) at the
site of the fracture. (B) Later dislocation of the root fragments.

In vertical root fractures, the fracture plane is along the vertical axis of
the root (Fig. 27.6). Nondisplaced fractures, and fractures in the
mesiodistal plane are often undetectable on periapical images and pose a
diagnostic challenge. More recently, high-resolution, small FOV CBCT
imaging has been used to evaluate teeth with root fractures (Fig. 27.7).
CBCT imaging offers multiplanar views of the tooth and thus overcomes
the limitation of x-ray beam orientation (Fig. 27.8). Additionally, CBCT also
provides better depictions of the adjacent periradicular bone and the
supporting alveolar process (see Figs. 27.7 and 27.8). Guidelines from the
American Academy of Oral and Maxillofacial Radiology and the American
Association of Endodontics recommend that small-FOV CBCT be
considered the imaging modality of choice when clinical examination and
two-dimensional intraoral images are inconclusive in the detection of a
vertical root fracture. However, vertical root fractures are more frequent in
teeth that have been endodontically treated and potentially in those with
metal post-core restorations. Artifacts from highly attenuating materials
(e.g., gutta percha and metal) can degrade image quality, making fracture
identification difficult and often impossible (Fig. 27.9). The presence of a
vertical root fracture may, however, be identified indirectly by the presence
of focal widening of the periodontal ligament space adjacent to the
fracture site (Fig. 27.10).

FIG. 27.6 (A) Vertical fracture through the root of a mandibular first
premolar that has been endodontically treated. The fracture plane
extends through the root canal, and there is more displacement
between the root fragments at the apex of the root. (B) Vertical root
fracture through the root of a mandibular canine with significant
displacement of the fragments.

FIG. 27.7 (A) Cone beam computed tomography (CBCT) section

shows a vertical fracture through the root of a maxillary incisor that
has been endodontically treated and restored with a postcore
restoration. The fracture plane begins at the base of the metal
post. (B) CBCT section shows a fractured root of a maxillary incisor
with exposure of the pulp.

FIG. 27.8 (A) Periapical image of the maxillary central incisors with
no evidence of a root fracture. (B) In the same patient, cone beam
computed tomography (CBCT) section through the maxillary left
central incisor shows an angular fracture through the root.
Resorption of the fractured edges has caused separation of the
fragments. Resorption of the pulp canal in the distal fragment is
evident. (C) Axial CBCT section through the apical third of the
roots shows a fracture of the maxillary left central incisor root.

FIG. 27.9 Panoramic-type reconstruction from a small field-of-view

cone beam computed tomography volume shows a dark line
running parallel to the root canal filling material in the mesial root of
 the mandibular molar. This “cupping” or “beam hardening” artifact
could be misinterpreted as a vertical root fracture.

FIG. 27.10 Vertical fracture through the root of a maxillary second

premolar that has been endodontically treated. The fracture is
barely perceptible and extends to the middle third of the root.
Localized widening of the periodontal ligament space (arrow) is
present as a consequence of the inflammation caused by the root
fracture.

Differential Interpretation
Superimposition of the image of a fracture of the alveolar process, or
small neurovascular canals, or soft tissue structures such as the lip, ala
of the nose, or nasolabial fold over the image of a root may mimic a root
fracture.

Management
Horizontal fractures in the coronal third of the root have a poor prognosis
and are typically managed by extraction unless the residual root fragment
can be orthodontically extruded and restored. Horizontal fractures in the
middle or apical thirds of the roots of permanent teeth are manually
repositioned and immobilized with a splint. The prognosis is generally
favorable because of the relatively low incidence of pulpal necrosis.
Fractures located closer to the apex have a better prognosis. Fractured
deciduous tooth roots may be retained with the expectation that they will
be normally resorbed, as attempts at removal may result in damage to the
developing succedaneous tooth.
It is important to determine pulp vitality on follow-up visits. Notably,
false-
negative responses may persist for as long as 3 months. Endodontic
therapy is performed when there is evidence of pulpal necrosis. It is also
common for bone resorption to occur at the site of the fracture rather than
at the apex.
The prognosis of teeth with vertical root fractures is poor. Single-rooted
teeth with vertical root fractures must be extracted. Multirooted teeth may
be hemisected and the intact fragment of the tooth may be restored with
endodontic therapy and a crown.

Periodontal Tissue Injury

Patients with dentoalveolar trauma must be examined clinically and
radiologically to assess the nature and extent of injury to the
periodontal tissues.

Concussion
Definition
The term concussion refers to a crush injury to the vascular structures
at the tooth root apex and the periodontal ligament, resulting in
inflammatory edema. The affected tooth is minimally loosened with no
displacement. The injury may result in mild extrusion of the tooth from
its socket, causing its occlusal surface to make premature contact with
an opposing tooth during mandibular closing.

Clinical Features
The patient usually complains that the traumatized tooth is tender to
touch, and this can be confirmed by gentle horizontal or vertical
percussion of the tooth. The tooth may also be sensitive to biting forces,
although patients usually try to modify their occlusion to avoid contacting
the traumatized tooth.

Imaging Features
The imaging appearance of a dental concussion may be subtle. No changes
may be visible, or there may be localized widening of the apical periodontal
ligament space (Fig. 27.11). Changes to the size of the pulp chamber and root
canals may develop in the months and years after traumatic injury to the teeth,
and this may be particularly evident in teeth that are still developing. Should
pulpal necrosis occur after trauma, there may be no further deposition of
(secondary) dentin as the odontoblasts and the pulpal and pulpal stem cell
populations die.
 FIG. 27.11 Widening of the periodontal ligament spaces of the
incisors after dental concussion.

Teeth that have undergone trauma before apical closure may develop a
morphologically abnormal apex called an osteodentin cap. As the process
of pulpal necrosis begins coronally and progresses apically, vital
odontoblasts may remain at the developing root apex and tertiary dentin
(osteodentin) may be deposited ahead of the advancing front of pulpal
necrosis. This disorganized and irregularly mineralized matrix may
resemble bone in structure and morphologically “caps” the end of the root.
The osteodentin cap in some instances may appear on an image to be
continuous with the developing root apex or appear separate from it. In
contrast to the pattern of internal resorption, where the root canal is focally
widened (Fig. 27.12), the root canal seen in association with a tooth that
has developed an osteodentin cap appears uniformly widened from the
pulp chamber to the apex (Fig.
27.13). The development of the canal and deposition of dentin in a tooth
that has developed an osteodentin cap appears “frozen in time” at the
developmental stage at which pulpal necrosis occurred. When the image
of the cap is covered or “hidden” from view, the apex of the root resembles
that of a developing tooth (see Fig. 27.13C).
FIG. 27.12 Consequences of dental trauma. An incisal fracture of
the maxillary left central incisor is present. Note obliteration of the
pulp chamber but not the root canal and internal root resorption.
Also note the periapical radiolucency involving the maxillary right
central incisor and the widened pulp chamber and canal.
 FIG. 27.13 Panoramic (A) and periapical (B) images showing an
osteodentin cap associated with the maxillary right central incisor.
There is a large area of rarefying osteitis extending from the
maxillary midline to the mesial surface of the maxillary right canine.
Note the uniformly wide root canal of the incisor. When the
osteodentin cap is “obscured,” the apex of the root is reminiscent
of a developing root apex (C).

Management
Because significant displacement of the tooth or teeth does not occur, the
appropriate treatment is conservative and may include occlusal adjustment
of the opposing tooth or teeth (if necessary) or the application of a flexible
splint. Periodic monitoring in the first year with repeated vitality testing and
images are indicated. Should rarefying osteitis develop, endodontic
treatment is appropriate.

Subluxation
Definition
The term subluxation refers to periodontal tissue injury that causes
abnormal loosening more than with concussion but with no
displacement.

Clinical Features
The traumatized tooth is tender to horizontal or vertical percussion and is
sensitive to biting forces. Bleeding at the gingival crevice is indicative of the
damage to the periodontal tissues.

Imaging Features
As with dental concussion, the imaging manifestations are subtle, with no
visible changes or with localized widening of the apical periodontal ligament
space.

Management
Treatment is conservative, with occlusal adjustments of the opposing
dentition and a splint as needed. Periodic monitoring in the first year—with
repeated vitality testing and images—is indicated. Approximately 26% of
teeth with subluxations will require endodontic treatment due to the
development of pulpal necrosis.

Luxation
Definition
Luxation is a dislocation of the tooth from its socket after severing of the
periodontal attachment. Such teeth are abnormally mobile and displaced.
Depending on their magnitude and direction, traumatic forces can cause
intrusive luxation (displacement of a tooth into the alveolar process),
extrusive luxation (partial displacement of a tooth out of its socket), or
lateral luxation (movement of a tooth in a direction other than intrusive or
extrusive displacement). In intrusive and lateral luxation, comminution or
crushing of the alveolar process may accompany tooth dislocation.
The movement of the apex and disruption of the circulation to the
traumatized tooth that accompanies luxation can produce either
temporary or permanent changes to the dental pulp, and these changes
may result in pulpal necrosis. If the pulp survives the traumatic incident,
the rate of dentin formation may accelerate and continue until it
obliterates the pulp chamber and root canal. This process may occur in
both permanent and deciduous teeth.

Clinical Features
Clinical history is helpful in identifying luxation and ordering the appropriate
images. The clinical crowns of intruded teeth may appear reduced in
height.
Maxillary incisors may be intruded so deeply into the alveolar process
that they appear to be completely avulsed or lost. The displaced tooth
may cause some damage to adjacent teeth, and particularly to
underlying developing permanent teeth.
Depending on the orientation and magnitude of the force and the shape of
the root, the tooth may be displaced through the buccal or, less commonly, the
lingual cortex of the alveolar process, where it may be seen and palpated. On
repeated vitality testing, the sensitivity of a luxated tooth may be temporarily
decreased or undetectable, especially shortly after the injury. Vitality may
return weeks or several months later.
Usually two or more teeth are involved in luxation injuries, and the
teeth most frequently affected are the deciduous and permanent
maxillary incisors. The mandibular teeth are seldom affected. The type of
luxation appears to vary with age; this may reflect changes to the nature
of maturing bone. Both intrusions and extrusions occur in the deciduous
dentition. In the permanent dentition, the intrusive type of luxation is less
frequent.

Imaging Features
Imaging examinations of luxated teeth demonstrate the extent of injury to
the root, periodontal ligament, and alveolar process. An image made at
the time of injury can serve as a valuable reference point for comparison
with subsequent images. Luxation injuries are often accompanied by
damage to the bony socket and alveolus.
The depressed position of the crown of an intruded tooth is often
apparent on an image (Fig. 27.14), although a minimally intruded tooth
may be difficult to demonstrate. Intrusion may result in partial or total
obliteration of the apical periodontal ligament space. Multiple radiologic
projections, including occlusal views, may be necessary to show the
direction of tooth displacement and the relationship of the displaced tooth
to adjacent teeth and the outer cortex of bone.
 FIG. 27.14 Intruded maxillary central incisor after trauma. Note the
fractured incisal edges of both central incisors.

A tooth that has been extruded may demonstrate varying degrees of apical
widening of the periodontal ligament space, depending on the magnitude of
the extrusive force (Fig. 27.15). A laterally luxated tooth with some degree of
extrusion may show a widened periodontal ligament space with greater width
on the side of impact.

FIG. 27.15 Extruded maxillary lateral incisor after trauma. Note the
localized increase to the width of the apical periodontal ligament
 space.

Management
Management of intrusive luxation is dictated by root development. Teeth
with partially developed roots can be allowed to reerupt, with orthodontic
extrusion as needed. Teeth with completely developed roots may be
repositioned and stabilized, followed by initiation of endodontic treatment.
Teeth with extrusive luxation may be gently repositioned and splinted.
Pulp necrosis is a common sequela, occurring in approximately 65% of
teeth with such injuries. Thus periodic vitality testing and follow-up imaging
are essential.
Lateral luxation is managed by digital manipulation to reposition the
displaced teeth to reestablish occlusion, with splinting as needed. Follow-
up imaging and vitality testing of the traumatized tooth and adjacent teeth
are continued for several months.

Avulsion
Definition
The term avulsion refers to complete displacement of a tooth from the
alveolar process. Teeth may be avulsed when a force is applied directly to
the tooth or by indirect trauma, such as a force applied as a result of
sudden jaw closure.
Avulsion occurs in approximately 15% of traumatic injuries to the teeth, with
fights being responsible for the avulsion of most permanent teeth and
accidental falls accounting for the traumatic loss of most deciduous teeth.

Clinical Features
Maxillary central incisors are the most commonly avulsed teeth from both
dentitions. Most often only a single tooth is lost. This injury typically occurs
in a relatively young age group when the permanent central incisors are
just erupting. Fractures of the alveolar process and lip lacerations may
also be seen with an avulsed tooth.

Imaging Features
In a recent avulsion, the lamina dura of the empty socket is apparent and
usually persists for several months. The missing tooth may be displaced
into the adjacent soft tissue and its image may project over the image of the
alveolar process, giving the false impression that it lies within the bone. To
differentiate between an intruded tooth and an avulsed tooth lying within the
adjacent soft tissues, a soft tissue image of the lacerated lip or tongue
should
be made. In some instances, new bone within the healing socket may be very
dense and resemble a retained root tip (Fig. 27.16).

FIG. 27.16 Bone formation during healing of a first premolar tooth

socket. Note how the bone is developing from the lateral walls of
the socket. The central radiolucent line (arrow) may have a similar
appearance to that of a root canal, falsely giving the impression of
a retained tooth fragment.

Management
If the avulsed tooth cannot be found by clinical or radiologic examination, a
chest or abdominal image may be considered to localize it within the airway
or gastrointestinal tract. Avulsed teeth can be reimplanted into the
dentoalveolar socket. The success of reimplantation is determined by the
viability of the periodontal tissues that remain attached to the tooth surface,
the condition of the tooth, and the length of time it is out of its socket.
Optimally, teeth must be reimplanted within 2 hours of avulsion.
Commercially available solutions, such as Hanks solution, provide a
compatible osmolarity and pH to store teeth for as long as 24 hours. Milk
has often been used as a medium to store avulsed teeth but is effective for
only approximately 6 hours.
Endodontic therapy may be necessary after reimplantation, and external
root resorption is a common complication. Avulsed deciduous teeth are not
reimplanted, as the procedure can damage the underlying developing
permanent tooth.

Alveolar Process Injury

Definition
Simple fractures of the alveolar process may involve the buccal or lingual
cortical plates of the maxillae or mandible. These fractures are commonly
associated with luxation injuries with or without dislocation. Several teeth
are usually affected, and the fracture plane is most often horizontal in
orientation. The fracture may involve a single cortical plate or extend
through the entire alveolar process; the fracture plane may also be located
apical to the teeth or involve the tooth socket. Alveolar process injuries are
commonly associated with luxation injuries, often with tooth fractures.

Clinical Features
Alveolar fractures are more common in the anterior and premolar regions
and are relatively rare in the posterior segments of the arches. In the
posterior region, fracture of the buccal plate usually occurs during removal
of a maxillary posterior tooth.
A characteristic feature of an alveolar process fracture is marked
malocclusion with displacement and mobility of the fragment, with
several teeth moving as a block. The teeth in the fragment have a
recognizable dull sound when percussed, and the attached gingiva may
have lacerations. The detached bone may include the floor of the
maxillary sinus, in which case bleeding from the nose on the involved
side may occur as well as ecchymosis of the buccal vestibule.
Misalignment or displacement of the fractured segments may result in
altered occlusion.

Imaging Features
Patients with limited dentoalveolar trauma are often imaged with periapical
and occlusal images. These images may show radiolucent fracture lines
located at any level between the crest of the alveolar process and the
periapical region. Fractures of a single cortical plate are difficult to detect,
especially when the fractured segments are nondisplaced. However, a
fracture of the anterior labial cortical plate may be apparent on an occlusal
image if bone displacement has occurred and the x-ray beam is oriented at
nearly right angles to the direction of bone displacement. Fractures of both
cortical plates of the alveolar process are usually apparent (Fig. 27.17).
 FIG. 27.17 (A and B) Two images demonstrating an alveolar
process fracture extending from the distal aspect of the mandibular
right cuspid in an anterior direction (arrows) and through the tooth
socket of the right central incisor.

Small-FOV CBCT imaging provides better depiction of the location,

extent, and displacement of the fractured bone plates (Fig. 27.18). The
AAOMR-AAE imaging guidelines recommend that in the absence of other
maxillofacial or soft tissue injuries that may require other advanced
imaging modalities, small- FOV CBCT should be considered the imaging
modality of choice for the diagnosis of limited dentoalveolar trauma.

FIG. 27.18 (A and B) Cone beam computed tomography (CBCT)

sections through the long axes of the maxillary central incisors
showing fractures of the buccal cortical plate (white arrow) and
asymmetric widening of the periodontal ligament spaces, indicating
luxation injuries and alveolar fractures. (C) Coronal CBCT section
through the maxillary anterior region shows an alveolar fracture,
manifested as a horizontal radiolucent line (black arrows).
 The closer the proximity of the fracture is to the alveolar crest, the
greater the possibility that a root fracture is also present. On conventional
imaging, it may be difficult to differentiate a root fracture from an
overlapping fracture line of the alveolar process. Multiple images made at
different projection angles may help with this differentiation; if the fracture
plane is truly associated with the tooth, the radiolucent line should not shift
relative to the tooth. Fractures of the posterior alveolar process may
involve the floor of the maxillary sinus and result in abnormal thickening of
the sinus mucosa or the accumulation of blood and sinus secretions, in
which case an air-fluid level may be apparent.
The location of the fracture line relative to the apices is an indicator of
risk of subsequent complication. When the fracture plane is in contact with
the root apices, the risk for internal or external resorption is high.

Management
Treatment of limited injury to the alveolar process is directed toward
fracture reduction and stabilization. Closed reduction by digital
manipulation and rigid splints are often adequate. Fracture segments
that are markedly displaced may need open reduction.

Traumatic Injuries to the Facial Bones

Facial fractures most frequently affect the mandible and midface and, to
a lesser extent, the maxillae. Radiologic examinations play a crucial role
in the diagnosis and management of traumatic injuries to these and the
other facial bones. Superficial signs of injury, such as soft tissue
swelling, hemorrhage, or hematoma formation from a laceration or
abrasion, may focus the radiologic examination. Localized injuries may
be investigated with plain imaging.
Imaging of a maxillofacial fracture is conducted primarily using MDCT.

Mandibular Fractures
The mandible is the most commonly fractured facial bone. Eighty percent of
mandibular fractures occur in males. Assaults, motor vehicle accidents, and
falls are the three most frequent causes of injury. Most mandibular fractures
occur in the 18- to 54-year age group. Fractures of the symphysis, body, and
angle are most frequent, followed by the condyle, condylar neck, and ramus.
Fractures of the alveolar and coronoid processes are less frequent. Fractures
are more likely to occur on weekend days than on other days of the week.
Trauma to the mandible is often associated with other injuries, most
commonly concussion (loss of consciousness) and other fractures, usually of