Dentoalveolar fracture

Addis Kassahun(DMD,OMFSR-IV)

01/04/2023 AKG 1
Introduction
• Dento-alveolar injuries Involve the tooth, surrounding soft tissues,&
alveolar bone.
• Require multidisciplinary care from various dental specialties including
OMFS, restorative dentistry, prosthodontics,& orthodontics.
• Isolated dentoalveolar injuries are common among children &
adolescents.
• Those occurring concomitantly with other facial fractures are more
common among young adults.

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 Cont...
• Caused by MVA,motorcycles, bicycles, assaults, falls, sports, iatrogenic
causes from intraoral procedures,& industrial accidents.
• Among preschool children and toddlers, most often caused by falls.
• Boys have dental injury more commonly than girls.
• 71%-92% of all dental trauma sustained ,occurs before the age of 19 yrs.

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 Cont...
• Boys also are affected almost twice as often as girls.
• Peak incidence at 2 -4 years & 8-10 years.
• The most likely teeth to sustain injury in both the primary & permanent
dentition are the maxillary central incisors.

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 Cont...

• Large overjet,proclined incisors, &

short upper lip predispose to
increased incidence of dental
trauma
• Teeth protruding, as in patients
with Class II Division I
malocclusion,
• An overjet greater than 5 mm, or
• Patients with insufficient lip
closure

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• Trauma to the primary dentition most often affects the supporting
structure (luxation and exarticulation),
• Trauma to the permanent dentition mostly affects the teeth themselves
(crown fractures).

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 History and P/E
• Who, When, Where, and How.
Who is the patient?
• Name, age, address, telephone number, & other demographic data
When did the injury occur?
• This is one of the most important questions, esp in an avulsed tooth
Where did the injury occur?
• the possibility and degree of bacterial or chemical contamination.
How did the injury occur?
• Provides valuable insight into what the resultant tissue injury is likely

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What treatment has been provided since the injury (if any)?
• Elicits important information regarding the original condition of the
injured area.
• Did the patient or parent replant a partially avulsed tooth?
• How was the avulsed tooth stored before presentation to the dentist?
Did anyone note teeth or pieces of teeth at the site of the accident?
• Imperative to account for each tooth the patient had before the accident
• Rule out the presence of the missing piece within tissues or other body
cavities

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What is the general health of the patient?
• History with regard to drug allergy, heart murmur, bleeding disorder,
other systemic disease, and current medications
Did the patient have nausea, vomiting, unconsciousness, amnesia,
headache, visual disturbances, or confusion after the accident?
• May indicate intracranial injury
• Obtain medical consultation
• Immediate referral if the patient is still having any of the symptoms

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Is there a disturbance in the
bite?
• may indicate tooth
displacement or dentoalveolar
or jaw fracture

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Clinical Examination
• Vital signs such as PR, BP, and RR should be measured.
• Mental state of the patient is also assessed.
1. Extraoral soft tissue wounds.
• Lacerations, abrasions, and contusions
• Vital structures such as the parotid duct or facial nerve
2.Intraoral soft tissue wounds
• Remove blood clots, irrigate the area with NS, and cleanse the oral
cavity
• Whether any foreign bodies such as tooth crowns or teeth remain within
the substance of the lips, FOM, cheeks, or other areas

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3. Fractures of the jaws or alveolar process
• Fractures of the jaws are most readily found on palpation.
• Bleeding into the floor of the mouth or into the labial vestibule may
indicate a fracture of the jaw
• 4. Examination of the tooth crowns for the presence of # or pulp
exposure
• Depth of the fracture
• Does it extend into dentin or into the pulp?

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5. Displacement of teeth.
• Teeth can be displaced in any direction
• buccolingual direction,extruded or
intruded.
• In the most severe type of displacement,
teeth are avulsed-teeth are avulsed—
that is, totally displaced out of the
alveolar process
• Observation of the dental occlusion may
provide assistance
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6. Mobility of teeth.
• All teeth should be checked for mobility in the horizontal & vertical
directions
• A tooth that doesn’t appear to be displaced but that has considerable
mobility may have sustained a root fracture.
• If adjacent teeth move with the tooth being tested, a dentoalveolar#-
(alveolar bone and teeth are separated from the remainder of the jaw)
should be suspected

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7. Percussion of teeth
• Determines whether the periodontal ligament has undergone some
injury
• tooth doesn’t appear to be displaced but pain is felt in the region
8. Pulp testing of teeth
• Rarely used in acute injuries
• False-negative results may occur,
• Teeth should be retested several weeks later & b4 endodontic therapy

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 Radiographic Examination
• Combination of occlusal and periapical
radiographs is used.
1. Presence of root fracture
2. Degree of extrusion or intrusion
3. Presence of preexisting periapical
disease
4. Extent of root development
5. Size of the pulp chamber and root canal
6. Presence of jaw fractures
7. Tooth fragments and foreign bodies
lodged in soft tissues

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• Multiple views with differing
vertical and horizontal
angulations.

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• Displaced teeth may show a
widening of the periodontal
ligament space or displacement of
the lamina dura.
• Extruded teeth may demonstrate
a conical periapical radiolucency
• intruded teeth show an absence
of the PDL space

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• Radiographic evaluations for
foreign bodies within the soft
tissues of the lips or cheeks are
taken with the radiographic film
placed inside the soft tissues to
be examined
• Foreign bodies in the floor of the
mouth are viewed with cross-
sectioned occlusal radiographs

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Classification
• Most accepted and commonly used is Andreasen’s modification of the
WHO classification.
• Can be applied to both the permanent and primary dentition.
• Divided into 4 major categories: injuries to the
• dental tissues and pulp,
• periodontal tissues,
• supporting bone, and
• gingiva or oral mucosa.

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Injuries to Hard Dental Tissues and Pulp

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Injuries to the Periodontal Tissues

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Injuries to Supporting Bone

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Injuries to the Gingiva or Oral Mucosa

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 Ellis and Davey’s classification (1960)
• Class I: Enamel fracture
• Class II: Enamel and dentin fracture without pulp exposure
• Class III: Crown fracture with pulp exposure
• Class IV: Traumatized tooth that has become non-vital with/without loss
of tooth structure
• Class V: Teeth lost as a result of trauma (Avulsion)
• Class VI: Fracture of root with or without loss of crown structure
• Class VII: Displacement of the tooth without fracture of crown or root
• Class VIII: Fracture of the crown en masse and its replacement
• Class IX: Fracture of deciduous teeth
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Cont...

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Treatment of Dentoalveolar Injuries
• The goal is reestablishing
• normal form and function of the masticatory apparatus.

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Crown Craze or Crack

• The cracks are limited to the enamel

(i.e., enamel infraction).
• No treatment is usually indicated
• Periodic follow-up , as any force to
the tooth can result in injury to the
pulp and periodontal tissues
• Multiple cracks may be sealed with
an unfilled resin to prevent their
becoming stained.

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Crown Fracture
• Depth of tooth tissue involvement
determines the treatment.
• For # that are only through the
enamel or those with minimal
amounts of dentin involvement,
no acute treatment other than
smoothing off the sharp edges

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• If reshaping of teeth would leave a noticeable deformity,
replacement of the missing enamel by acid-etched composite
resin.

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• If a considerable amount of dentin
is exposed, the pulp must be
protected. Measures to seal the
dentinal tubules and promote
secondary dentin deposition
• Traditionally Calcium hydroxide to
exposed dentin before the
fractured part is covered with
restoration

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• Current recommendations are the placement of a dentin-
bonding agent or GIC over exposed dentin, followed by the
placement of a resin composite restoration.
• Periodic follow-up visits

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• If the pulp is exposed, the aim of treatment is to preserve it in a vital,
If 5 conditions are present:
1) The exposure is small;
2) The patient is seen soon after injury
(24 hrs after the injury)
3) The patient had no root fractures;
4) The tooth has not been displaced; and
5) No large or deep fillings exist

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• The more apically immature the tooth, the more favorable the response
the dentist can expect from pulp capping.
• Application of calcium hydroxide or MTA on the exposed pulp,
• GIC is placed over the exposed dentin and
• A watertight acid-etch composite restoration
• If the pulp exposure is large and/or if it has been present >24 hs,RCT is
favored

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 Pulpotomy
• Aseptic removal of damaged and
inflamed pulp tissue to the level of
clinically healthy pulp.
• Then calcium hydroxide is applied.
• Usually implemented in larger exposures
in which the apex is not closed.
• A temporary measure to maintain the
vitality of the radicular pulp until the
apex is closed.
• Endodontic therapy should then be
instituted
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APEXIFICATION

• Indicated for necrotic teeth

with open apices(immature
teeth)

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 Crown-Root Fracture
• Depends on the location of the fracture and local anatomic variance.
• If the coronal fragment is still in place,must be removed to assess the
depth.
• Replacement of the original fractured tooth fragment by using the acid-
etch technique, if the fracture does not descend too far apically.
• Orthodontic extrusion of the root can make it accessible for restoration.
• If the pulp is involved and the tooth is restorable, endodontic treatment.
• If, however, the tooth is not restorable, removal is indicated.
• If alveolar # , the extraction may be delayed to permit the # to heal

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 Horizontal Root Fracture
• The main factor in determining the prognosis
• If the fracture is above or close to the gingival crevice, the tooth should
be removed or
• The coronal fragment should be removed and endodontic treatment
performed on the root restored with a post and core.
• Fractures in the middle to apical third of the root have a good prognosis
• Repositioning (if any mobility is detectable) & firm immobilization for 2 to
3 months

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Treatment of Injuries to the Periodontal Tissues
Concussion
• Tooth may be sensitive to percussion ,exhibit symptoms of hyperemia
• No treatment is recommended other than palliative therapy.
• Concussed teeth may later develop a reaction to the trauma.
• The incidence of pulpal necrosis is low

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Displacements classified as
• Subluxation (loosening injury),
• Luxation (labial, lingual, or lateral),
• Intrusions, and
• Extrusions

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 Subluxation
• The tooth demonstrates tenderness to palpation with
• Slight mobility but without evidence of displacement clinically &
radiographically
• No active treatment is usually necessary.
• A flexible splint can be placed for up to 2 weeks
• Patients have masticatory discomfort, can be managed with a soft non-
chew diet and relieving the occlusion.
• Continued observation of the tooth radiographically and by vitality testing
during the follow-up period.

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 Extrusive Luxation
• The tooth is partially displaced from
the socket, & excessive mobility.
• Radiographic examination shows
increased PDL space.
• Should be repositioned in its original
position using digital pressure
• Splinted with a flexible splint for 2
weeks.
• Continued clinical and radiographic
observation is essential to identify
pulpal necrosis
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 Intrusion
• Indicates that the alveolar socket
has sustained a compression
fracture.
• On percussion, the tooth emits a
metallic sound similar to that by
an ankylosed tooth.
• May be so severe that the tooth
actually appears to be missing on
clinical examination.
• Has the worst prognosis

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The treatment of intruded teeth is controversial.
• Surgically repositioning and splinting these teeth;
• serious periodontal and pulpal consequences.
• Leaving it to reerupt.
• Orthodontic forces to assist reeruption

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• When orthodontic-assisted eruption
is used, the tooth should be extruded
slowly, over a 3- to 4-week period.
• Once the tooth is in position , it is
splinted for 2-3 months.
• Immediate application of orthodontic
force is necessary to prevent
ankylosis.
• The decision to perform endodontic
treatment is based on the follow-up
findings
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• If a deciduous tooth has been intruded to the point that it is touching the
follicle of a succedaneous tooth, it should be removed.
• If the deciduous tooth is not in direct proximity to the succedaneous
tooth, a period of observation as reeruption is common.
• If in doubt about the position of a deciduous tooth, removal is a sound
prophylactic approach.

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 Lateral Displacement
• A complex injury that includes
• Rupture or compression of PDL),
• Severance of the neurovascular bundle, and
• Fracture of the alveolar walls around the tooth
• Lingual (most common),buccal, mesial, or distal displacement of the
crown of the tooth
• Often painful, associated with large gingival laceration
• Places the tooth in a “locked” position.

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• Digitally manipulating the
tooth to release the displaced
root apex & repositioning the
tooth into the proper
alignment
• A flexible splint placement for
4 weeks
• Should be followed closely to
determine vitality.

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 Exarticulation (Complete Avulsion)
• Complete displacement of the tooth out of its
socket
• May occur by itself or in conjunction with alveolar
fractures and/or gingival lacerations.
• Usually avulsion involves a single tooth.
• The most frequently avulsed tooth is the
maxillary central incisor.
• The chances of survival of the pulp & periodontal
cells in a replanted tooth are highly dependent
on
• the extra-alveolar time and
• handling of the avulsed tooth,
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 Cont...

• Treatment must be aimed at maintaining cellular viability.

• increase the chances of successful reattachment
• decrease the chances of root resorption
• The tooth’s pH,osmolality,& cell metabolites can be physiologically
maintained by various storage media.
• The PDL is usually restored in 3-4 wks after a prompt replantation.
• After an extraoral dry time >60 minutes, the PDL cells become
nonviable

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 Cont...

• The viability of the PDL can be assessed based on

• the extraoral dry time,
• storage media, and
• time of replantation.

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5 factors to be considered before replanting avulsed teeth
1. The avulsed tooth should have no advanced periodontal disease.
2. The alveolar socket should be reasonably intact .
3. No orthodontic contraindications such as significant crowding of teeth.
4. The extraalveolar period >2 hrs are usually associated with poor results.
• Tooth replanted within the first 30 minutes, excellent prognosis .
5. The stage of root development should be evaluated.
• Survival of the pulp is possible in teeth with incomplete root formation if
replantation is accomplished within 2 hours after injury.

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 Cont...
• If replantation is not possible, the tooth should be placed in the best
transport medium available.
• The transport medium of choice is Hanks balanced salt solution
(HBSS) or Viaspan.
• Viaspan is used for transport organ storage.
• It has a pH of 7.4 with
• an osmolality of 320 mOsm,
• vital cells were present at 7 days.

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 Cont...
• Hanks solution
• Has a pH of 7.2
• Osmolality of 320 mOsm.
• Successfully preserve & reconstitute the PDL cells for at least 24hrs .
• Depleted cell metabolites can be replenished in Hanks solution.
• Commercially available as Save-A-Tooth (3M Health Care)

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Cont...

• Milk, saliva, & saline are temporary storage media readily available.
• Milk is a short-term storage medium (up to 6 hrs) provided avulsed
teeth are placed in it within 15-20 minutes
• Only prevents cell death;
• It doesn’t restore the cell’s normal morphology
• A significantly better medium than saliva or water for preserving
periodontal fibroblast viability
• Storage of avulsed teeth in water or saliva should be avoided

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 Cont...
• The tooth should be held by the crown
• If the tooth has already been replanted & seems to be in good position, it should
be radiographed and then splinted for 7 to 10 days.

• If the tooth is carried into the office and it has been out of its socket < 20
minutes, it should be immediately rinsed in saline and replanted .

• Removal of all of the blood clot from within the socket is not necessary;

• Careful suctioning & gentle irrigation with NS will remove the the clot.
• The root surface and tooth socket should never be scraped, “sterilized,
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• If the tooth has been out of the socket for more than 20 minutes,
• Should be placed into HBSS for 30 minutes and
• Then in doxycycline (1 mg/20 mL saline) for 5 minutes.
• Soaking the tooth in Hanks solution reduces the incidence of ankylosis.
• Doxycycline helps inhibit bacteria in the pulpal lumen

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• Stabilization of an avulsed tooth can be achieved using a variety of
materials such as wires, arch bars, and splints.
• Stabilizing device should be as hygienic as possible and should be
positioned away from the gingiva and tooth roots, if possible
• The stabilization applied to the tooth need not be absolutely rigid.

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An acid-etched composite system
• A wire of moderate stiffness but that still has some flexibility
• adapted to the facial surfaces of one or two teeth on each side of the
avulsed tooth.
• 7 to 10 days immobilization period
• If the apical foramen is wide open, pulp may survive and revascularize-
the tooth is usually stabilized for 3-4 wks
• Use of antibiotics (e.g., penicillin) for 7 to 10 days
• TAT
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• Teeth with immature apices have a better prognosis than do teeth with
mature apices
• Immature teeth soaked in a doxycycline solution have a higher rate of
pulpal revascularization.
• If pathology is noted, thoroughly clean and fill the canal with calcium
hydroxide (apexification procedure)
• The tooth can be obturated with gutta percha after 6-12 months of
calcium hydroxide

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• In teeth with an open or closed apex that have been extraoral for > 60
minutes, endodontic treatment can be done prior to replantation or after.
• These teeth could be soaked in a 1% stannous fluoride solution for 5
minutes and in a 1 mg/20 mL doxycycline solution for 5 minutes.
• 2 major reasons for failure of replanted teeth are
• Inflammatory & Replacement resorption (ankylosis)
• Radiographs should be taken in 2 wks, 1, 2, 3,6 months,then
semiannually

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 Alveolar Fractures
• Fractures through the alveolar process, frequently accompany injuries to
teeth.
• Injuries to the alveolar process often occur independently.
• The segment of bone contains at least one tooth but more frequently
several teeth.
• Treatment of this type of injury, as for any fracture, is first to place the
segment into its proper position and then to stabilize.
• Dento-osseous segment must be stabilized for approximately 4 wks

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Treatment

• Ligation an arch bar to the

teeth
• An acid-etched arch wire,
• A cold-cured acrylic splint can
be made

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Treatment of Injuries to the Primary Teeth
• In # involving enamel only, the sharp edges should be smoothed
For enamel and dentin (Class II) #,In severe or large fractures,
• Calcium hydroxide/MTA and/ or a light-cure glass ionomer liner/base
should be placed over the dentin
• Followed by an acid-etch resin restoration

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In primary teeth with fractures involving the pulp,
• A calcium hydroxide partial pulpotomy should be performed,
• Followed by a full-coverage restoration.
• Extraction of the involved tooth is the alternative option.
• Full coverage of all teeth that have pulpotomies or pulpectomies

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• Primary teeth that have been subluxated don’t need any acute treatment.
• soft diet and oral hygiene measures
• splinting may not be necessary
• If the root apex is displaced into the permanent tooth bud extraction is
recommended
• A tooth with a fully formed root with severe extrusion should be extracted.

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• When a primary tooth is intruded, observe the tooth for re-eruption if the
apex is displaced in a labial direction; otherwise, extracted
• If the primary tooth has not started re-erupting within 4-8 wks, it should
be extracted.
• Replantation of primary teeth is not recommended.

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 Splinting Techniques
• Splinting is a form of fixation to stabilize the injured teeth in its normal
anatomic position during the healing period.
• Requirements of an ideal splint would include:
1. Splint fabrication materials should be easily available
2. Avoids or minimizes further trauma to the injured tooth or supporting
structures,
3. Facilitates oral hygiene maintenance, avoids soft tissue irritation,
4. Stays passive ,remains in its normal position

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5. Allows physiologic movement of the tooth,
6. Does not interfere with the occlusion,
7. Allows easy access for endodontic treatment and pulp testing, and
8. Is easily removed in the dental office.

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• The splints that come closest
to fulfilling these requirements
are the
• acid-etch resin arch wire splint
& the orthodontic bracket arch
wire splint
• Titanium Trauma Splint (TTS)
with a rhomboid flat design,
• ease of adaptability to the
tooth & increased patient
comfort
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Stabilization Periods for Dentoalveolar Injuries

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Prevention of Traumatic Dental Injury
• Mouthguards,
• Stock prefabricated,Mouth-formed,Custom-made
• Patient education, and
• related to dental trauma and its first aid
• Modifying risky behavior
• increased overjet or previous history of trauma in children
• Faceguards and helmets has significantly reduced the incidence of
facial injuries in certain contact sports.

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 END
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