maxillofacial and dento-alveolar trauma

lecture given 9/29/2026

oral region comprises only 1% of the human body area, but accounts for ______% of all bodily injuries

among facial injuries, dental injuries are the ______

5

most common

studies by bell suggests the redundant nature of _________ allows most dentoalveolar bony injuries to heal well, despite mucosal lacerations and extensive communication

vascular supply

what is the etiology of dental injuries?

slips and falls, sports, interpersonal violence (#2 cause), motor vehicle accidents (#1 cause), industrial mishaps, domestic abuse and violence, substance abuse, medial and physical disorders

stats on dental trauma

children with primary dentition: 11-20%

children with perm dentition: 5-20%

boys 2x more likely than girls

peak incidence in primary dentition at 2-4 yr

another peak ar 8-12 yr

which teeth are most commonly involved in dental trauma?

maxillary central incisors

maxillary lateral incisors

mandibular anteriors

what history needs to be collected when someone comes in for dental trauma?

treatment provided since injury

unconsciousness, nausea/vomiting, amnesia, headache, visual disturbances, confusion

general health

tooth or pieces of tooth noted at site of incident

malocclusion

unaccounted for avulsed teeth, free tooth fragments, or dislodged restorations raise suspicion of _____

aspiration

auscultation of the chest to rule out wheezing or labored breathing is essential

what physical exam needs to happen for a pt with dental trauma?

soft tissue

jaw and alveolar bone

occlusion

teeth

infection

fracture

displacement

mobility

pulp testing

percussion

what radiographic exam needs to happen for a pt with dental trauma?

presence of root fracture

degree of extrusion or intrusion

presence of pre exisiting periapical disease

extent of root development

size of the pulp chamber and root canal

presence of jaw fractures

tooth fragment and foreign bodies lodged in soft tissues

periapical, occlusion, pano, CBCT, medical CT

ellis and davey I

fracture within enamel

ellis and davey II

fracture of enamel and dentin

ellis and davey III

fracture involving pulp

ellis and davey IV

fractures involving the roots

andreasen classification

adopted by WHO using international classification of disease codes

simple and comprehensive

applies to both permanent and primary dentition

descriptions of injuries to teeth, supporting structures, and gingival/oral mucosa

what is the treatment for a crown fracture only in enamel?

smooth, relieve occlusion

follow up in 6 wks to 1 yr

soft diet

no antibiotics

what is the treatment for a crown fracture in enamel/dentin?

restore, relieve occlusion

follow up in 6 wks to 1 yr

soft diet

no antibiotics

what is the treatment for a crown fracture in enamel/dentin/pulp (immature teeth)?

calcium hydroxide pulp cap or pulpotomy

follow up in 6 wks to 1 yr

soft diet

no antibiotics

what is the treatment for a crown fracture in enamel/dentin/pulp (mature teeth)?

endodontic treatment

follow up in 6 wks to 1 yr

soft diet

no antibiotics

pulp capping

if there is a small exposure

the pt is seen shortly after injury

the pt has no root fracture

the tooth is not displaced

no large or deep restorations exist that might indicate chronic inflammation of the pulp

what is the treatment for a crown/root fracture with pulp involvement?

expose fracture site- gingivectomy, ortho extrusion, endodontic

follow up after 6 weeks to 1 yr

soft diet

no antibiotics

what is the treatment for a crown/root fracture without pulp involvement?

expose fracture site- gingivectomy, ortho extrusion

follow up after 6 weeks to 1 yr

soft diet

no antibiotics

what is the treatment for a vertical root fracture?

extraction

no follow up

no soft diet

no antibiotics

what is the treatment for a horizontal root fracture in the apical or middle?

reposition and stabilize

follow up in 4 to 8 wks, 6 mo to 1 yr, every 5 yrs

soft diet

no antibiotics

what is the treatment for a horizontal root fracture in the apical 1/3?

extraction

no follow up

soft diet

no antibiotics

what are pulpal responses to trauma?

hyperemia

pulpal hemorrhage

pulpal necrosis

calcific metamorphosis

internal resorption

what is the tooth reaction to trauma?

surface resorption

inflammatory resorption

replacement resorption

concussion

tooth receives trauma but no evidence of mobility, no displacement, no fracture, tenderness to percussion

no treatment- watch monitoring

subluxation

loosening force is absorbed by the tooth without apparent loss of tooth structure

occlusal adjustment, watchful monitoring, and vitality testing

intrusive luxation

displacement of the tooth into the alveolus

immature apex (incomplete root development)

mature apex (complete root development)

intrusive luxation with incomplete root development

allow the tooth to erupt (6-12 mo)

watchful monitoring for signs of pulpal necrosis

if pulpal necrosis develops, then endo with calcium hydroxide

intrusive luxation with complete root development

reposition to original position and splint

ortho extrusion (96% chance pulpal necrosis)

calcium hydroxide endodontic treatment (6-12 mo)

52% incidence of inflammatory or replacement resorption

extrusive luxation

the tooth is displaced coronally

the tooth should be repositioned and splinted for 2 wks

64% incidence of pulpal necrosis

74% incidence of external resorption

lateral luxation

can occur in buccal, lingual, mesial, or distal direction

can result in fracture of alveolar bone

tooth should be manually repositioned and non-rigidly splinted for 4-8 weeks

watchful monitoring for the need for endo

if the tooth is displaced more than 5mm, endo is indicated

avulsed teeth

most common in 7-10 yrs

maxillary central incisor is most common

what is the most important factor for long term prognosis of an avulsed tooth?

the amount of vital periodontal fibers remaining at the root tooth surface prior to reimplantation

what factors should be considered prior to reimplanting an avulsed tooth?

tooth should be free of perio disease

alveolar socket should be reasonably intact

no ortho contraindication

extra alveolar period should be considered

the stage of root development

periodontal ligament cells

necrotic with teeth that have been extra oral for 120 min or more

hanks balanced salt solution can maintain the PD, osmolality, pH, and cell metabolism

healing takes 3-4 weeks

hanks solution

ph 7.2m osmolality 320 mosm

group of salts rich in bicarbonate ions

used as a buffer system in cell culture media and aid in maintaining the optimum physiological pH for cellular growth

whole milk

avulsed tooth short term storage for up to 6 hrs

better than saliva

does not prevent cell death

what is the treatment for an avulsed tooth with an open apex within 2 hrs?

reimplant as soon as possible

do not remove the PDL

transport in hanks or whole milk

place in doxycycline solution for 5 min (higher rate of pulpal revascularization)

do not remove the blood clot from the alveolar socket

watchful monitoring for endo treatment need

semi- rigid splint fixation for 10-14 days

take tooth out of occlusion

tetanus prophy consideration

post op instructions- antibiotics for 7-10 days, soft diet, chlorhexadine mouth rinse 2x a day, OHI

what is the treatment for an avulsed tooth with an open or closed apex more than 2 hrs?

remove necrotic PDL

scrap PDL from root

soak in sodium hypochlorite for 30 min

endo treatment in hand (clean and shape canal)

citric acid solution for 3 min- open dental tubules allows for fibrous attachment

soak in 1% stannous fluoride for 5 min- more resistant to root resorption

place in doxycycline solution for 5 min- more resistant to root resorption

semi-rigid splint for 10-14 days

take tooth out of occlusion

what are risks of reimplanting avulsed teeth?

ankylosis increases with prolonged splinting

external resorption increases with rigid splints

how long should…

mobile teeth

displaced tooth

root fracture

avulsed (mature)

avulsed (immature)

be splinted for?

7-10 days

2-3 weeks

2-4 mo

7-10 days

3-4 weeks

dentoalveolar fracture

fracture of the alveolar bone involving 1 or more teeth

treatment- reduce the alveolar segment, stabilization with splint for 4-6 wks, closure of mucobuccal laceration, check occlusion / antibiotic treatment for 7-10 days, chlorhexadine 2x daily for 1 week, splinting for 4-6 weeks, soft diet, follow up

how should luxation or extrusion of a primary tooth be handled?

re-position or remove

how should intrusion of a primary tooth be handled?

remove if contacting perm tooth or if re-eruption has not started after 4-8 weeks

remove if signs of infection

allow to erupt if not contacting perm tooth

how should root fracture of a primary tooth be handled?

apical 1/3- observation

middle or cervical 1/3- removal of primary tooth without damaging permanent tooth

glasgow coma scale

assesses a pts level of consciousness following brain injury by scoring eye opening, verbal response, and motor response

scores range from 3 (deepest coma) to 15 (fully awake)

it helps to guide treatment decisions and tract pt progress over time

8 or less= severe brain injury

9-12= suggests a moderate injury

13-15= mild brain injury

soft tissue injury

examine location and associated structures

irrigation, layered closure

antibiotics

what are the types of mandibular fractures in order of most to least common?

condyle

angle

symphysis

body

alveolar

ramus

coronoid

simple/closed mandibular fracture

does not produce an open wound to the external environment (skin, mucosa, or PDL)

compound/open mandibular fracture

an external wound, involving the skin, mucosa, or PDL communicates with the fracture site

comminuted mandibular fracture

bone is splintered or crushed

greenstick mandibular fracture

one cortext of the bone is broken, the other cortext is bent

pathological mandibular fracture

due to a pre-existing pathological weakness of the bone (cyst, tumor, ect)

what are the other classifications of mandibular fracture?

displaced or not displaced

horizontal or vertical

favorable or unfavorable

what are the general principles of fracture treatment?

reduction

stabilization

fixation

rehabilitation

what are the objectives of treating fractures?

re-establish

occlusion

occlusion

occlusion

form

function

what are the treatment options for mandibular fractures?

no treatment / liquid diet

closed reduction

open reduction

what are indicatons for a closed reduction treatment for a mandibular fracture?

non-displaced favorable

grossly comminuted fractures

deficient or lack of overlying soft tissues

fractures in children with developing dentition

coronoid process fractures

majority of condylar fractures

what are methods of a closed reduction treatment for a mandibular fracture

ivy loops

arch bars

splints- gunning splints/dentures/cap splints

external pin fixation

what are methods of an open reduction treatment for a mandibular fracture?

non-rigid fixation- wire

semi-rigid- monocortical screws/plates (champy)

rigid fixation- compression plates, reconstruction plates

symptoms of le fort type 1 fractures

swelling of upper lip

buccal surface brusing

malocclusion

loosening of teeth

symptoms of le fort type 2 fractures

deformity and swelling of midface

widening of intercanthal space

mobility of upper jaw and nose

malocclusion

periorbital edema and ecchymosis

epistaxis

bruising and vestibule plate bruising

cerebrospinal fluid rhinorrhea

symptoms of le fort type 3 fractures

similar to type 2

lengthening and flattening of face

orbital hooding

enophthalmos

mastoid region bruising

ear drainage

hemotympanum

what are most common signs and symptoms of ZMC fractures?

pain, edema, swelling, bruising of the cheeks and eyelids

malar flattening

step defect palated along infraorbital rim

step defect palated at frontozygomatic suture

trismus

infraorbital nerve paresthesia or anesthesia

enophthalmos

diplopia

decreased mobility of extra-ocular eye muscles, reduced upward gaze