1 s2.0 S106474062100078X
1 s2.0 S106474062100078X
1 s2.0 S106474062100078X
A l v e o l a r Fr a c t u re s
Jungsuk Cho, DMD, MDa, Alex Sachs, DMDb, Larry L. Cunningham Jr, DDS, MDb,*
KEYWORDS
Dentoalveolar fracture Avulsion Dental trauma Alveolar fracture Luxation
Maxillomandibular fixation Risdon cable wire Erich arch bars
KEY POINTS
Dentoalveolar fracture can be classified into the following 4 groups: (1) crown/root fractures, (2)
luxation/displacement of teeth, (3) avulsion, and (4) alveolar fractures.
Crown/Root fractures require thorough examination and evaluation of the viability of the tooth.
Avulsion and luxation of teeth are managed through repositioning to the original position and
require nonrigid fixation (splinting) for 2 weeks.
Alveolar fracture requires rigid fixation (Erich arch bars, Risdon cable wires) for 4 weeks.
Special considerations must be made for the pediatric population because of primary and mixed
dentition phases.
tients do not present to a dentist after cavity; however, the most important aspect for a
a
Temple University School of Dentistry, 3223 North Broad Street, Philadelphia, PA 19140, USA; b University of
Pittsburgh Department of Oral and Maxillofacial Surgery, School of Dental Medicine, 3501 Terrace Street, G-32
Salk Hall, Pittsburgh, PA 15261, USA
* Corresponding author.
E-mail address: [email protected]
clinician is consistency. The examination should for the comprehensive diagnosis of dentoalveolar
be methodical to ensure facial lacerations, gross and maxillofacial fractures.
skeletal step-offs, involvement of cranial nerves,
oropharynx, and dental examinations are appro-
Imaging
priately documented.
It is often easiest to begin with a soft tissue ex- There are numerous different imaging options
amination of the oral cavity. Oral soft tissues are available for the diagnosis of dentoalveolar
highly vascularized and bleed easily, thus identi- trauma, and the choice of imaging is largely based
fying the source of bleeding is essential to help on the modalities available and the extent of injury.
with the remainder of the examination. The soft tis- In this hospital setting, trauma patients with clinical
sues of the gingiva, palate, lips, pharynx, and floor signs of facial injury will often undergo maxillofa-
of mouth should be evaluated for lacerations or in- cial computed tomography (CT) scans, which
juries.5 This is followed by a hard tissue examina- can be used to diagnose dentoalveolar trauma5
tion, counting all the teeth in the mouth to ensure (Fig. 2). Maxillofacial CT allows for complete visu-
none was lost during the injury. In general, an adult alization of skeletal and soft tissue structures,
can have up to 32 permanent teeth and children which is useful to visualize airway patency, soft tis-
have 20 primary teeth. However, this can be sue infection, and differentiate between isolated
complicated in children ages 6 to 12 years who dentoalveolar injury and more extensive facial
are in the mixed dentition stage as the permanent fractures such as maxillary and/or mandibular
dentition remains unerupted in the alveolus6 fractures. However, if clinical suspicion for com-
(Fig. 1). If an avulsed tooth is not accounted for, plex facial injury is low and there are concerns
a thorough review of head, neck, chest, and for radiation exposure, dental radiographs allow
abdomen imaging is required to rule out aspira- excellent visualization and have less radiation.
tion, swallowing, or other displacement of the This is particularly useful in the pediatric popula-
tooth.5 tion where the panoramic x-ray allows visualiza-
Once the teeth are accounted for, each tooth tion of unerupted teeth (see Fig. 1).
should be visually inspected for signs of trauma, Periapical and bitewing imaging is useful in the
including fractured enamel, missing restorations, diagnosis of isolated dental injury or periodontal
or gross displacement.7 After visual inspection, injury.8 They provide accurate evaluation of dental
palpation of the dental arches should be anatomy and integrity, which can facilitate dental
completed specifically looking for the mobility of restoring and rehabilitating. Panoramic imaging
individual teeth or alveolar segments, which helps can also be useful as a screening tool for evalua-
differentiate between dentoalveolar injury and tion of the entire dentition in one clear image.
more extensive trauma like mandibular fracture.5 Although both these images are clinically most ac-
Furthermore, radiographic imaging is warranted curate at a low cost and low radiation exposure,
Fig. 1. Panoramic x-ray indicating mixed dentition phase with permanent dentition tooth buds in the maxillary
and mandibular alveolus.
Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en agosto 01, 2022. Para
uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.
Dental Trauma and Alveolar Fractures 119
Fig. 2. Maxillofacial computed tomography (CT) indicating an intrusion of anterior maxillary teeth with alveolar
fragments in sagittal, coronal, and axial views. 3D reconstruction was made using combined CT images.
they are only available in outpatient dental clinics stable occlusion remains the goal of facial
and not the emergency room. It is important to reconstruction.3
refer these patients to dentists after discharge for Although the prevalence of dental trauma asso-
further evaluation and treatment. ciated with maxillofacial fracture varies depending
Lastly, photographic documentation can be on the literature (19%,12 41.8%,13 and 47.5%3), it
very useful in cases of facial and dentoalveolar is safe to say that dentoalveolar and maxillofacial
trauma. Photos allow for monitoring of soft tissue fractures occur concomitantly frequently enough
healing as well as changes in tooth coloration, that the practitioner managing facial fractures
which may indicate pulp necrosis and affect needs a working knowledge of dentoalveolar in-
long-term treatment planning.9 juries. In one study, the most common cause of
The classification of dentoalveolar trauma can dental trauma was due to falls in 40% of cases, fol-
be classified within the following 2 broad lowed by road traffic crashes (33.12%), violence
categories: (21.25%), and occupational accidents in 5.63%.10
Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en agosto 01, 2022. Para
uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.
120 Cho et al
Fig. 3. Classification of dentoalveolar injury correlating to Table 1. (From Reynolds JS, Reynolds MT, Powers MP.
Diagnosis and Management of Dentoalveolar Injuries. Fourth Edi. Elsevier Inc.; 2013. doi:10.1016/b978-1-4557-
0554-2.00013-7)
Fig. 4. Classification of subluxation/displacement (periodontal) injury correlating to Table 2. (From Reynolds JS,
Reynolds MT, Powers MP. Diagnosis and Management of Dentoalveolar Injuries. Fourth Edi. Elsevier Inc.; 2013.
doi:10.1016/b978-1-4557-0554-2.00013-7)
Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en agosto 01, 2022. Para
uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.
Dental Trauma and Alveolar Fractures 121
Table 1
Dental injuries and their definition
bone grafting in anticipation of placement of a fracture requires rigid fixation with Erich arch bars
dental implant requiring between 3 and 9 months for 3 to 4 weeks. An exception to digital manipula-
for the bone graft healing alone. Ultimately, this tion is intrusion of the traumatized tooth, which is
route of restoration of oral cavity function and es- treated most conservatively through close observa-
thetics requires extensive follow-up and remains tion to allow for spontaneous re-eruption.14 In the
a financial burden that may not be feasible for all literature, spontaneous re-eruption occurs with
patients. minimal intrusion less than 3 mm; however, when
there is severe displacement greater than 7 mm,
Luxation/Displacement of Teeth surgical repositioning is recommended followed
The second most common dentoalveolar injuries by flexible splint for 4 to 8 weeks5 (Fig. 5). If the
are luxations or displacement of teeth-lateral luxa- injury is severe and there is complete loss of alve-
tion (12.50%) and subluxation (10%).10 The luxation olus integrity as depicted in Fig. 2, removal of these
of the teeth is further categorized into subluxation, teeth is sometimes necessary.
extrusion, and intrusion. In general, subluxation
Avulsion
and extrusion are repositioned to their original posi-
tion using digital manipulation and require some The treatment of avulsion depends on whether the
modality of semirigid fixation (splinting) for 2 weeks, patient has deciduous or permanent dentition. The
whereas the involvement of a multitooth segmental most common dental avulsion occurs in the
Table 2
Subluxation/Displacement injuries (concussion/subluxation) and their definition
Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en agosto 01, 2022. Para
uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.
122 Cho et al
Fig. 5. Nonrigid splinting with 26 gauge wires and composite resin for luxation/avulsion fixation.
anterior maxillary and mandible teeth (49.8%). A can be reduced using the closed reduction with
primary tooth should not be replaced as this could rigid fixation for 4 weeks. There are many wiring
lead to problems with the permanent dentition.15 A techniques for closed reduction depending on
permanent tooth, on the contrary, requires imme- the patient’s age, dentition (primary, mixed, per-
diate reimplantation and should be splinted for manent dentition), or lack of dentition. When pa-
7–10 days.5 Permanent dentition reimplantation tients have permanent dentition, Erich arch bars
success depends on the following: the stage of can be used (Fig. 6). Open reduction and internal
root development, the length of dry, extra alveolar fixation of alveolar fractures is indicated when an
storage, immediate replantation, and the wet stor- extensive alveolar fracture is associated with a uni-
age period.7 Although appropriate irrigation and lateral Le Fort I maxillary fracture, when the den-
removal of any foreign body material is required toalveolar fracture cannot be reduced using
for appropriate diagnosis, minimal debridement closed methods, and/or postoperative maxillo-
is recommended around the alveolus socket mandibular fixation is undesirable.16
because of the small tissue pedicle that provides
blood supply to the traumatized area.5 Considerations in the pediatric patient
Pediatric patients have unique challenges in maxil-
lofacial and dentoalveolar fractures because of
Alveolar Fracture
concerns for growth, tooth buds, and dental varia-
Many maxillofacial traumas have concomitant tions, which makes the placement of fixation
dentoalveolar fractures with an incidence ranging plates difficult.17 Fig. 1 (panorex with mixed denti-
from 19% to 47.5%.3,12,13 If there are alveolar frac- tion) illustrates these challenges as one can see
tures associated with luxation and/or avulsion, that the primary dentition does not provide the sta-
proper protocols for avulsion and luxation should bility to withstand the forces of Erich arch bars.
be followed in conjunction with anatomic reduc- Furthermore, the tooth buds prevent the place-
tion and repositioning of the alveolar fracture using ment of plates, IMF screws, or hybrid arch bars
closed or open techniques. Most alveolar fractures as they may damage the permanent dentition.
Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en agosto 01, 2022. Para
uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.
Dental Trauma and Alveolar Fractures 123
Fig. 6. Rigid fixation with Erich arch bars is indicated for alveolar fractures involved with dentoalveolar trauma.
26 gauge wires were used to secure the arch bars.
Fig. 7. Rigid fixation with Risdon Cable wire (maxilla) is indicated for alveolar fractures involving mixed denti-
tion. The cable wire should be fixated to the permanent first molars to alleviate unnecessary tension on primary
dentition.
Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en agosto 01, 2022. Para
uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.
124 Cho et al
Although nonsurgical and conservative ap- Implications for prevention. Oral Surg Oral Med
proaches are typically recommended because of Oral Pathol Oral Radiol Endod 1999;87(1):27–33.
the high osteogenic growth potential and remodel- 4. Galvagno SM, Nahmias JT, Young DA. Advanced
ing found in pediatric patients, mandible fractures Trauma Life SupportÒ Update 2019: Management
with dentoalveolar fractures necessitate open and Applications for Adults and Special Popula-
reduction and internal fixation.17 Thus, the use of tions. Anesthesiol Clin 2019;37(1):13–32.
Risdon cable wires (Fig. 7—Risdon wire) can be 5. Reynolds JS, Reynolds MT, Powers MP. Diagnosis
used because it can be easily adapted to primary and Management of Dentoalveolar Injuries. Oral
teeth with fixation on the permanent molars as Maxillofac Trauma 2013;248–92.
long as patient is older than 6 years. This allows 6. Olynik CR, Gray A, Sinada GG. Dentoalveolar
the placement of guiding elastics or wires.17 Ulti- Trauma. Otolaryngol Clin North Am 2013;46(5):
mately, there are many techniques and variations 807–23.
in open reduction; however, the choice of tech- 7. Jones LC. Dental Trauma. Oral Maxillofacial Surg
nique depends on surgeon’s experience, comfort, Clin N Am 2020;32(4):631–8.
and availability of resources. 8. Alimohammadi R. Imaging of Dentoalveolar and Jaw
Trauma. Radiol Clin North Am 2018;56(1):105–24.
CLINICS CARE POINTS 9. Bourguignon C, Cohenca N, Lauridsen E, et al. Inter-
national Association of Dental Traumatology guide-
lines for the management of traumatic dental
injuries: 1. Fractures and luxations. Dent Traumatol
Dentoalveolar fracture can be classified into 2020;36(4):314–30.
the following 4 groups: (1) crown/root frac-
10. Kallel I, Douki N, Amaidi S, et al. The Incidence of
tures, (2) luxation/displacement of teeth, (3)
avulsion, and (4) alveolar fractures Complications of Dental Trauma and Associated
Factors: A Retrospective Study. Int J Dent 2020;
Thorough examination and radiographic im- 2020.
aging are indicated for an accurate diagnosis
11. Lieger O, Zix J, Kruse A, et al. Dental Injuries in As-
to guide treatment
sociation With Facial Fractures. J Oral Maxillofac
Nonrigid fixation (splinting with wires and Surg 2009;67(8):1680–4.
composite) is used for subluxation or avulsion
12. Hamdan MA, Rock WP. A study comparing the prev-
of tooth for 2 weeks
alence and distribution of traumatic dental injuries
Rigid fixation (Erich arch bars, Risdon cable among 10–12-year-old children in an urban and in
wires) is used for dentoalveolar trauma a rural area of Jordan. Int J Paediatr Dent 1995;
involving the alveolus requiring immobiliza-
5(4):237–41.
tion for 4 weeks
13. Zhou HH, Ongodia D, Liu Q, et al. Dental trauma in
Special considerations must be made for pri- patients with maxillofacial fractures. Dent Traumatol
mary teeth and mixed dentition to avoid 2013;29(4):285–90.
injuring tooth buds and arising permanent
14. Reynolds JS, Reynolds MT, Powers MP. Diagnosis
dentition
and Management of Dentoalveolar Injuries. In:
Fonseca R, editor. Oral and Maxillofacial Surgery.
3rd edition, volume 2. St. Louis, MO: Saunders;
2017. p. 248–92.
DISCLOSURE 15. Flores MT, Malmgren B, Andersson L, et al. Guide-
lines for the management of traumatic dental in-
The authors have nothing to disclose.
juries. III. Primary teeth. Dent Traumatol 2007;
REFERENCES 23(4):196–202.
16. Andreasen JO, Lauridsen E. Alveolar process frac-
1. Corso P, Finkelstein E, Miller T, et al. Incidence and tures in the permanent dentition. Part 1. Etiology
lifetime costs of injuries in the United States. Inj and clinical characteristics. A retrospective analysis
Prev 2015;21(6):434–40. of 299 cases involving 815 teeth. Dent Traumatol
2. Lam R. Epidemiology and outcomes of traumatic 2015;31(6):442–7.
dental injuries: A review of the literature. Aust Dent 17. Madsen M, Tiwana PS, Alpert B. The Use of Risdon
J 2016;61:4–20. Cables in Pediatric Maxillofacial Trauma: A Tech-
3. Gassner R, Bösch R, Tuli T, et al. Prevalence of nique Revisited. Craniomaxillofac Trauma Reconstr
dental trauma in 6000 patients with facial injuries 2012;5(2):107–9.
Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en agosto 01, 2022. Para
uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.