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

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 premorbidanatomy.

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 involvementA) 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 SUBLUXATIONInjury 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