Oral and maxillofacial injuries

Oral and maxillofacial injuries
in children
Department of Pedodontia and preventive
dentistry
Submitted to : submitted by :
Nadia dhiman
BDS final year

Contents
 Introduction
 Prevalence
 Etiology
 Predisposing conditions
 History taking and examination
 Treatment of soft tissue injury
 Treatment of facial fracture
 Traumatic injuries to teeth
 Management of traumatic injuries to teeth
 Trauma prevention

Introduction
 Maxillofacial trauma or facial trauma is any
physical trauma to the face .
 The Merriam Webster Dictionary defines trauma
as an injury (as a wound) to living tissue caused
by an extrinsic agent.
 Amongst all facial injuries, dental injuries are the
most common of which crown fractures and
luxation occur most frequently.

Prevalence
a)Soft tissue injury b) Hard tissue injury
Head injury Facial fracture Injury to
the anterior teeth

Soft tissue injury
 Chin is the most frequently involved anatomical
site followed by lip.
 Scar on the chin give an indication of an injury

 Laceration is the most frequently encountered
injury that causes a discontinuity in the skin or
mucosal surface.
 Laceration can of following types
 A)simple c) jagged
 B)stellate d) beveled or flap like .

Hard tissue injury
 A) head injury -40% of all automobile accidents involve a
head injury in children between 12-14 years of age .
 B)facial fractures- depend on following factors
-Age - 1.5%-8% in age 1-14 years
-Sex – boys : girls is 2:1
-anatomical site – mandible fracture.
 C) Injury to anterior teeth-
age -1-2.5 years
sex- equal male to female predilection

 teeth involved
37%-upper central incisor
18%-lower central incisor
6% - lower lateral incisor
3% - upper lateral incisor

Etiology
• FALL: - Frequent during first year of life - peak
incidence just before school age
• BATTERED CHILD SYNDROME: - abused or
neglected child who have suffered serious
physical abuse

ACCIDENTS: - bicycle accidents, automobile
accidents, play ground accidents
• SPORTS: - sports like football, baseball,
basketball, wrestling, kabbadi.

• Cerebral palsy: due to
– abnormal muscle tone and function in oral area
producing protrusion of maxillary anterior teeth
– Poor skeletal and muscle co-ordination
• Dentinogenesis imperfecta

Severity of Injury
• Energy of impact
• Resiliency of the impacting object
• Shape of the impacting object
• Angle of direction of the impacting force

Mechanism of dental trauma
(Andreasen and Bennett)
 Direct trauma: occurs when the tooth
itself is hit.
 Indirect trauma: inflicted when lower
dental arch is forcefully closed against
the upper.

According to Forsberg and
Tedestam
 Following are factors one which increases
suseptibility to dental injury
A) post normal occlusion B) overjet more then 4mm
C) short upper lip D) incompetent lips
E) mouth breathing

History taking and Examination
 Personal data – name
age
sex
address
telephone number.
 History of traumatic injury
when ,where , how, treatment
given elsewhere or source of referral , history of
previous injury .

Medical history
 Brief medical history about number of
disorders
a)allergic reaction to medication
b)epilepsy
c)cardiac disorders
d)bleeding disorders

Clinical Examination
• A careful, methodical approach to the
clinical examination will reduce the
possibility of overlooking or missing
important details.

Examination of Soft tissues
• All areas of soft tissue injury should
be noted, and the lips, cheeks,
and tongue adjacent to any
fractured teeth should be carefully
examined and palpated.
• It is not unusual for tooth
fragments to be buried in the lips.
• The radiographic examination
should include specific exposures
of the lips and cheeks if
lacerations and fractured teeth
are present

Examination of facial bones
• The maxilla, mandible, and temperomandibular joint should be
examined visually and by palpation
• Look for distortions, malalignment, or indications of fractures.
• Indications of possible fractures should be followed up
radiographically.
 • Also note possible tooth dislocation, gross occlusal
interference, and development of apical pathosis.

Examination of teeth
• The teeth must be examined for fractures, mobility,
displacement, injury to periodontal ligament and
alveolus, and pulpal trauma.
• Remember to examine the teeth in the opposite
arch also. They too may have been involved to
some degree.

 Examination must include recording
various signs and symptoms such as –
1) Pain
2) Crepitation
3) Limited mandibular opening /excursion
4) Step defect in bone contour
5) Anesthesia /paraesthesia

clinical tests
1)Radiographic evaluation
2)For injuries to teeth the commonly used radiographs are
a) intraoral-intraoral periapical view(IOPA),occlusal.
b) extraoral- orthopantomogram(OPG).
3) special test
a)CT-scan
b)MRI
4)Vitality test –heat test with gutta percha
- ice
- electric pulp tester

Oral and maxillofacial injuries

Treatment of soft tissue injury
 Debridement
 Hemostasis
 Contamination
 Primary closure
 Surgical drains
 Postoperative wound care
 Burns

Debridement
-Procedure include removal of dead tissue and
foreign body.
-Mechanical cleansing is performed by using scrub
brush.
Hemostasis
-measures like legation of vessels or
electrocautery of visible bleeding vessel
should be done cautiously.

Contamination
 Tetanus prophylaxis is mandatory in all wound with
antibiotic prophylaxis.
PRIMARY CLOSURE
main aim of a clinician whos treat case of soft tissue
injury is to restore the tissues to their premorbid
anatomy.
surgical drains
surgical drains should be placed only if there is a
significant oozing at the end of sugical procedure from
the bed below the skin flap

Postoperative wound care
 Soft tissue wounds in the maxillofacial region should be kept
moist by application of a thin film of antiboitic ointment or
vaseline.

Burns
 American burn association injury severity grading
system has classified burns in children as :
-minor = cover less than 10% of body surface.
-moderate = cover more than 10% to 20%
-major = covering more then 20%

Treatment of facial fracture
 Treatment of facial fracture follows the general orthopedic principles as
follows:
a)reduction
b)fixation
a) Reduction – involves restoring the premorbid anatomical continuity of the
fractured fragments . Following type of methods are employed
1) open reduction 2) closed reduction
involves exposure of the involves approximation of the
fractured fractured fragments without
fragments,direct visualization, direct exposure.
and reduction.

Fixation
 Fixation of the reduced fractured fragments to ensure immobilization
for a period of 4-6 weeks in children and 6-8 weeks in adults is crucial
in fracture healing.
 Various modalities of immobilization exist for fixation of facial fracture
which include :
a. Ivy loops
b. arch bar
c. gunning splints
d. lag screws
e. compression screws
f. bone plates (titanium and resorbable)
g. interdental fixation by wires

Ivy Loop construction on
model in posterior teeth
Ivy loop placement in
anterior teeth

Arch bar fixation to be used
for smaller period in children
Compression screws

use of bone plates in permanent dentition

OPG showing use of bone plates in mixed dentition period

Management of traumatic injury to
teeth Most widely accepted classification is
Ellis and Davey’s classification(1960)
class 1-simple fracture of crown involving enamel.
class 2-extensive fracture of the crown with considerable
amount of dentin involved without pulp exposure.
class 3-extensive fracture of crown with considerable amount of
dentin involved with pulp exposure.
class 4-traumatized tooth becomes nonvital(with or without loss
of crown structure)
class 5-tooth lost due to trauma
class 6-fracture of root with or without loss of crown structure
class 7-displacement of the tooth wihout crown or root fracture
class 8-fracture of crown en mass
class 9-fracture of decidous teeth

WHO Classification
 873.60 enamel fracture
 873.61crown fracture without pulp involvement
 873.62 crown fracture with pulp involvement
 873.63 root fracture
 873.64 crown root fracture
 873.66 tooth Luxation
 873.67 intrusion or extrusion
 873.68 avulsion
 873.69 other injuries
 802.20;802.40 fracture or continution of the alveolar process
this may or may not involve the tooth
 802.21;802.41-fracture of the body of the mandible and maxilla

Andreasen- WHO 1992
 A. Injuries to hard dental tissues and pulp
 B. Injuries to periodontal tissues
 C. Injuries to supporting bone
 D. Injuries to gingiva or oral mucosa

Treatment of traumatic injuries in primary
dentition and young permanent teeth
A) Crown fracture
enamel enamel and dentin pulp
fracture fracture involvement
B) root fracture
C) displacement injuries

a) Crown fracture
1- enamel fracture –
o in cases where just a part of enamel is chipped off it may be treated by
smoothening any rough edges .
o second choice acid etch composites may be utilized followed by periodic check
ups at 6months interval are necessary.
o sometimes at a later date tooth may undergo internal resorption which
necessitate extraction.

2-Enamel and Dentin fracture
 Radiographs are mandatory to determine the full extent of the
injury
 Layer of calcium hydroxide or glass ionomer lining cement may
be applied as soon as possible then covered by composite
restoration to maintain integrity of the protective coating.
 At the scheduled 6 monthly visits if the pulp become necrotic
,endodontic treatment may be required.

3-fracture with pulp involvement
A) IN DECIDOUS DENTITION
 Treatment of tooth with pulp involvememt is challenging for it depends on
cooperation of the young patient
 Pulp capping procedures are not recommended
 Pulpectomy using zinc oxide eugenol or vitapex can be considered
 In case of a risk of damage to the developing permanent teeth from periapical
pathology and lack of cooperation in young patient extraction of the traumatized
primary tooth is recommended.
 PULPECTOMY – this is the complete removal of the pulp indicated in following
procedure :
a) pulp is degenerated and of questionable
vitality.
b) pulp exposure greater than 72hours.

B) IN YOUNG PERMANENT TEETH
Treatment of fracture with involvement of pulp
depend on following factors
a) size of exposure
b) pulp contamination
c) vitality of pulp
d) state of development of root
Following procedures are undertaken
1. direct pulp capping
2. pulpotomy (apexogenesis)
3. pulpectomy
4. apexification
5. extraction

1-Pulp capping
Recommended only for small exposures that can be treated
immediately after the injury .
2- Pulpotomy (Apexogenesis)
involves the removal of the damaged and infllamed pulp tissue
to the level of clinicaly healthy pulp followed by calcium
hydroxide dressing .
APEXOGENESIS(in vital tooth)-defined as
“physiological root end development and formation”
example –an incisor with an open apex and incomplete root
formation is a good candidate for this procedure

3-Apexification
 Done in non vital tooth
 Defined as a method of apical closure by formation of
osteocementum or a similar hard tissue .
 Procedure-anesthetize and isolate the tooth
- extirpate the necrotic pulp
- incorporate MTA
- fill the canal with calcium hydroxide
dressing 0.5mm short of the radiographic apex and
seal the canal with zinc oxide eugenol .

3-Root fracture
 Root fractures occur in apical, middle and coronal third of the
root .
 In case of coronal third root fracture ,the proximity of gingival
margin to the fracture site makes the pulp suseptible to
bacterial invasion leading to infection and necrosis.
 After a radiographic and clinical
assessment these teeth are subjected to
digital reduction under a local
anesthetic and stablized by splinting.

Functions of splint
a)immobilize the loose tooth
b) hold repositioned teeth in alignment
c) protect the damaged tissue from
occlusal forces .

Different types of splints
 A) Fixed splint
1. acid etch composite splint
2. orthodontic brackets and wire splint
3. Interdental wiring
4. arch bar
5. arch wire and acid etch resin composite splint
6. full arch vacuum molded acrylic splint
B) removable splint
- removable appliance fabricated in acrylic

c)-displacement injuries
 Terminology;1.concussion -an injury to the tooth-
supporting structure without abnormal loosening or
displacement but with marked reaction to percussion.
 2.subluxation- injury to the supporting structure with
abnormal loosening but without clinically or
radiographically demonstrable displacement of teeth.
 3.intrusive luxation -displacement of the tooth deeper
into the alveolar bone. the injury is accompanied by
communication or fracture of the alveolar socket .
 4.extrusive luxation partial displacement of the tooth
out of its socket .
 5.lateral luxation -displacement of the tooth in a
direction other than axially .this is accompanied by
comminution or fracture of the alveolar socket.

MECHANISM OF CONCUSSION
INJURY
 frontal impact leads to
hemorrhage
and edema in the PDL.

MECHANISM OF SUBLUXATION
Injury if the impact has greater force,
fibers may be torn,
resulting in loosening
of the injured tooth.

Mechanism of extrusive luxation
 Oblique forces displaces the tooth out of socket.
only the gingival fibers palatally prevents the tooth
from being avulsed.

Mechanism of lateral luxation
 Horizontal forces displace the crown palatally and
the apex labially . apart from severance
of the PDL and the
neurovascular supply to the pulp,
compression of the PDL is
found on the palatal aspect
of the root

Mechanism of intrusive luxation
 Axial impact leads to extensive injury
to the pulp and peridontium.

Treatment Concussion
 Adjusting the occlusion
 Pulp test is repeated at 1,3,6,12 month.

Subluxation
 Adjusting the occlusion Teeth repositioning and
splinting Half of this will undergo pulpal necrosis
and requires RCT.
 Splinting
Objective of splinting
Stabilization of the injured tooth and prevention of
further damage to the pulp and periodontal
structure during healing period. In luxation injuries,
the value and influence of splinting upon
periodontal and pulpal healing has not been
classified.

Lateral luxation
 Repositioning and stabilization
 Rct if pulp exposure

 Laterally luxated
teeth
 Percussion test

 Mobility and senstivity
test
 Radiographic
examination

 Anesthesia
 Repositioning the
teeth

 Splinting
 After etching

 Splinting material
 3 weeks after
splinting

 Splinting removed
 6months after injury

Intrusive luxation
 Immature teeth will re-erupt within 3-4
weeks
 Spontaneous eruption of intruded teeth

Mature teeth
 Orthodontic
reposition and
stabilization 3-4
weeks gingivectomy
and RCT
 Dentin protection

Avulsion
 An avulsed tooth is completely displaced
out of its socket and may be referred as
exarticulation or complete avulsion.
Incidence: 1-16% of all traumatic injuries
of permanent teeth. 7-13% of primary
dentition male: female ratio 3:1 age
group 7-11 yrs maxillary central
 incisors are commonly avulsed

Complication following luxation
injuries:
These include
 pulp necrosis,
 pulp canal obliteration,
 root resorption ( external or internal)
 Pulp canal obliteration:
1) Partial obliteration
2) Total canal obliteration

Follow-up Evaluation
 • Trauma patients should be evaluated often
enough, and over a long enough period of time,
– To determine that complete recovery has taken
place or
– To detect as early as possible pulpal
deterioration and root resorption.
 • If pulpal recovery (eg, revascularization) is to
be monitored, frequent initial re-evaluations
(every 3 to 4 weeks for the first 6 months) and
then yearly are recommended.

Trauma Prevention
 • Living and growing carry a high risk of trauma.
 • A child will not learn to walk without falling, and
few children reach 4 years of age without having
received a blow to the mouth.
 • We cannot totally prevent trauma.
 • Moreover, the results of treatment of trauma are
often less predictable than those of other types of
dental treatment.

 On the brighter side, there are preventive
measures that have been proved to reduce the
prevalence of traumatic episodes in certain
environmental situations.
 • For example, because the prevalence of
fractured incisors is higher among those with
protrusive anterior teeth, many dentists are
recommending early reduction of excessive
protrusion to reduce the susceptibility of such
teeth to injury.

The use of car safety
seats and restraining
belts has prevented
many injuries to infants
and young children.

The protective mouth guard has
prevented or reduced the severity
of countless injuries to the teeth
of youngsters participating in
organized athletic activities;
active youngsters should be
encouraged to wear their mouth
guards during high- risk
unsupervised athletic activities.

 When we have the opportunity to save a
child from pain and suffering, an ounce of
prevention is worth a pound of cure.

Reference
 Textbook of Pedodontics by Shobha tandon -2nd
edition
 Textbook of Pediatric dentistry by S.G.damle -3rd
edition
 Grossman’s endodontic practise by Suresh
chandra and Gopi krishnan -12th edition

Oral and maxillofacial injuries

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