Traumatic Injuries of theTeeth

CONCUSSION
Definition. The term concussion indicates a crushing injury to the vascular structures at the tooth apex and to the periodontal ligament, resulting in inflammatory edema. Only minimal loosening or displacement of thetooth occurs. The injury frequently results in the elevation of the tooth out of the socket so that its occlusal surface 4/30/12 makes premature contact on

Radiographical evaluation of oral and maxillofacial trauma

Rajan mishra BDS final year

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content
Traumatic Injuries of theTeeth

CONCUSSION LUXATION AVULSION FRACTURES OF THE TEETH Dental Root Fractures Crown-Root Fractures

TRAUMATIC INJURIES TO THE 4/30/12

LUXATION

An adequate history is helpful in identifying luxation and ordering the appropriate radiographs. Subluxated teeth are in their normal location but are abnormally mobile. There may be some blood flowing from the gingival crevice, indicating periodontal ligament damage. Subluxated teeth are extremely 4/30/12

Radiographic features.

Radiographic examinations of luxated teeth may demonstrate the extent of the injury to the root, periodontal ligament, and alveolar bone. A radiograph made at the time of injury serves as a valuable reference point for comparison with subsequent radiographs. As with dental concussion, the 4/30/12

Management.

A subluxated permanent tooth may be restored to its normal position by digital pressure shortly after the accident. If swelling precludes repositioning, minimal reduction of antagonists to relieve discomfort may be necessary. Stabilize teeth by splinting to prevent further damage to the pulp and 4/30/12

AVULSION

Definition. Avulsion (or exarticulation) is the term usedto describe the complete displacement of a tooth from the alveolar process. Teeth may be avulsed by direct trauma when the force is applied directly to the tooth, or by indirect trauma (e.g., when indirect force is applied to teeth as the result of 4/30/12 the jaws striking together).

Clinical features.

Maxillary central incisors are the teeth most often avulsed from both dentitions. The appearance of the alveolar process around the missing tooth depends on the time between its loss and the clinical examination. Typically this injury occurs in a relatively young age group, when the permanent 4/30/12 central incisors are just erupting

Radiographic features.

In a recent avulsion the lamina dura of the empty socket is apparent and usually persists for several months. The replacement of the socket site with new bone requires months and, in some cases, years. As new bone forms, the opposite walls of the healing socket approach each other, reducing 4/30/12

FRACTURES OF THE TEETH

Dental Crown Fractures

Definition. Fractures of the dental crown account for about 25% of traumatic injuries to the permanent teeth and 40% of injuries to the deciduous teeth. The most common event responsible for the fracture of permanent teeth is a fall, followed by accidents involving vehicles (e.g., bicycles, automobiles) and blows from 4/30/12 foreign bodies striking the teeth.

Clinical features.

Fracture of the dental crowns most frequently involves anterior teeth. Infractions, or cracks in the enamel, are quite common but frequently are not readily detectable. Illuminating crowns with indirect light (directing the beam in the long axis of the tooth) causes cracks to appear distinctly in the 4/30/12

reference

Oral radiology principles and interpretation White and Pharoah

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Uncomplicated fractures do not involve the pulp. Uncomplicated crown fractures that do not involve the dentin usually occur at the mesial or distal corner of the maxillary central incisor. Loss of the central portion of the incisal edge is also common. Fractures that involve dentin can 4/30/12 recognized by the contrast in be

Radiographic features.

The radiograph provides information regarding the location and extent of the fracture and the relationship to the pulp chamber, as well as the stage of root development of the involved tooth (Fig.). This initial film also provides a means of comparison for follow-up studies of the involved teeth.
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Dental Root Fractures

Definition. Fractures of tooth roots are uncommon and account for 7% or fewer of traumatic injuries to permanent teeth and for about half that many in deciduous teeth. This difference probably results from the fact that the deciduous teeth are less firmly anchored in the alveolus.
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Clinical features.

Most root fractures occur in maxillary central incisors. The coronal fragments are usually displaced lingually and slightly extruded. The degree of mobility of the crown relates to the level of the fracture: the closer the fracture is to the apex, the more stable the tooth is. When testing the mobility of a traumatized 4/30/12 tooth, place a finger over the

Radiographic features.

Fractures of the dental root may occur at any level and involve one or all the roots of multirooted teeth. Most of the fractures confined to the root occur in the middle third of the root. The ability of the film to reveal the presence of aroot fracture depends on the degree of distraction of the fragments 4/30/12 and whether the x-ray beam is in

Differential diagnosis

The superimposition of soft tissue structures such as the lip, ala of the nose, and nasolabial fold over the image of a root may suggest a root fracture To avoid this diagnostic error, note that the soft tissue image of the lip line usually extends beyond the tooth margins. Fractures of the alveolar 4/30/12

Management.

Fractures in the middle or apical third of l ateral incisor also is evident. Note how the soft tissue outline the root of permanent teeth can be manually reduced to of the nose simulates a fracture of the central incisor root tip. the proper position and immobilized. Prognosis is 4/30/12

Crown-Root Fractures

Definition. Crown-root fractures involve both the crown and roots. Although uncomplicated fractures may occur, crown-root fractures usually involve the pulp. About twice as many affect the permanent as the deciduous teeth. Most crown-root fractures of the anterior teeth are the result of direct trauma. Many 4/30/12

Clinical features.

The typical crown-root fracture of an anterior tooth has a labial margin in the gingival third of the crown and courses obliquely to exit below the gingival attachment on the lingual surface. Displacement of the fragments is usually minimal. Crown-root fractures occasionally present with 4/30/12

Radiographic features.

These fractures are often not visible in the radiographic image because the x-ray beam is rarely aligned with the plane of the fracture. Also, distraction of the fragments is usually not present. The vertical fractures of crown and root that are mainly tangential 4/30/12

Management.

Removal of the coronal fragment permits the evaluation of the extent of the fracture. If the coronal fragment includes as much as 3 to 4 mm of clinical root, successful restoration of the tooth is doubtful and removal of the residual root is recommended. Also, if the crown-root fracture is vertical, 4/30/12

Vertical Root Fractures

Definition. Vertical root fractures run lengthwise from the crown toward the apex of the tooth. Usually both sides of a root are involved. The crack is usually oriented in the facial-lingual plane in both anterior and posterior teeth. These fractures usually occur in the posterior teeth in adults, especially in 4/30/12 mandibular molars. They are

Clinical features.

Patients with vertical root fractures complain of persistent dull pain (cracked tooth syndrome), often of long duration. This pain may be elicited by applying pressure to the involved tooth. Pain may be nonexistent or mild. The patient may have a periodontal lesion resembling a chronic abscess or 4/30/12

Radiographic features.

If the central ray of the x-ray beam lies in the plane of the fracture, the fracture may be visible as a radiolucent line on the radiograph. Usually, however, radiographs are not useful in identifying vertical root fractures in their early stages. Later, after the development of an inflammatory lesion, there 4/30/12

Management.

Single-rooted teeth with vertical root fractures must be extracted. Multirooted teeth may be hemisected and the intact remaining half of the tooth restored with endodontic therapy and a crown.

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TRAUMATIC INJURIES TO THE FACIAL BONES

Injury to the facial bones may occur in one or more of the bones. Facial fractures most frequently occur in the zygoma or mandible and, to a lesser extent, in the maxilla. Radiography plays a crucial role in the diagnosis and management of traumatic injuries to the facial bones. The 4/30/12 appropriate radiologic

Mandibular Fractures

The most common mandibular fracture sites are the condyle, body, and angle, followed less frequently by the parasymphyseal region, ramus, coronoid process, and alveolus. The most common cause of mandibular fractures is assault, followed by automobile accidents, falls, and 4/30/12

Mandibular Body Fractures

Definition. The mandible is the most commonly fractured facial bone. It is important to realize that a fracture of the mandibular body on one side is frequently accompanied by a fracture of the condylar process on the opposite side. Trauma to the 4/30/12 anterior mandible may result in a

Radiographic features.

The radiographic examination of a suspected fracture should include a panoramic view; however, it is important to supplement this film with right-angle views. These include occlusal and extraoral views such as the posteroanterior and submentovertex skull views. Frequently such supplemental 4/30/12

Differential diagnosis.

The superimposition of soft tissue shadows on the image of the mandible may simulate fractures. A narrow air space between the dorsal surface of the tongue and the soft palate superimposed across the angle of the mandible in a panoramic image may appear as a fracture. The air space between the dorsal 4/30/12

Management.

The management of a fracture of the mandible presents a variety of surgical problems that involve the proper reduction, fixation, and immobilization of the fractured bone. Minimally displaced fractures are managed by closed reduction and intermaxillary fixation, whereas fractures with more severely 4/30/12

Mandibular Condyle Fractures

Definition. Fractures in the region of the condyle can be divided into condylar neck fractures and condylar head fractures. Condylar neck fractures are more common and are located below the condylar head. When a condylar neck fracture occurs, the head is usually displaced 4/30/12

Clinical features.

The clinical symptoms of a fractured condylar process are not always apparent, so the preauricular area must be carefully examined and palpated. A condylar fracture may be suspected when the clinician cannot palpate the condyle in the external ear canal when the jaw is closed. Movement of the 4/30/12 jaw may cause crepitus. The

Radiographic features.

Radiographic examination of the condyles should always include lateral and anteroposterior views of each condyle. Appropriate lateral projections include panoramic (Fig. 27-12), Parma (Fig. 27-13), and lateral oblique views of the ramus and condylar regions. Frontal views include reverse-Towne's and 4/30/12

Management

The technical details of treating condylar fractures vary according to whether one or both condyles are involved, the extent of displacement, and the occurrence and severity of concomitant fractures. The treatment is directed to relieve acute symptoms, restore proper anatomic relationships, and 4/30/12

Fractures of the Alveolar Process

Definition. Simple fractures of the alveolar process may i nvolve the buccal or lingual cortical plates of the alveolar process of the maxilla or mandible. Commonly these fractures are associated with traumatic injuries to teeth that are luxated with or without dislocation. Several teeth are usually 4/30/12 affected, and the fracture line is

Clinical features.

A common location of alveolar fractures is the anterior aspect of the maxilla. Simple alveolar fractures are relatively rare in the posterior segments of the arches. In this location, fracture of the buccal plate usually occurs during removal of a maxillary posterior tooth. Fractures of the entire alveolar 4/30/12 process occur in the anterior and

Radiographic features

Intraoral radiographs often do not reveal fractures of a single cortical wall of the alveolar process, although evidence exists that the teeth have been luxated. However, a fracture of the anterior labial cortical plate may be apparent on a lateral extraoral radiograph if some bone displacement occurs and if 4/30/12 the direction of the x-ray beam

Management.

Fractures of the alveolar process are treated by repositioning the displaced teeth and associated bone fragments with digital pressure. Gingival lacerations are sutured. If the luxated permanent teeth are splinted and stable, intermaxillary fixation is not necessary. Permanent teeth are splinted for 4/30/12 about 6 weeks.

MAXILLARY FRACTURES

Midface Fractures Definition. Fractures of the midfacial region may be limited to the maxilla alone or may involve other bones, including the frontal, nasal, lacrimal, zygoma, vomer, ethmoid, and sphenoid. Such complex fractures may be quite variable but often follow

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Horizontal Fracture (Le Fort I)

Definition. The Le Fort I fracture is a relatively horizontal fracture in the body of the maxilla that results in detachment of the alveolar process of the maxilla from the middle face. It is the result of a traumatic force directed to the lower maxillary region. The fracture line 4/30/12

The radiographic examination reveals fractures of the nasal bones, both frontal processes of the maxilla (and ethmoid and frontal sinuses, if involved), and the infraorbital rims on both sides (and the floor of both orbits). Fractures in the zygoma or zygomatic process of the maxilla, separation of the 4/30/12

Management.

The treatment of this fracture is accomplished by reduction of the downward displacement of the maxilla. The maxilla is fixed in place by intermaxillary wires or arch bars. Usually treatment includes open reduction and interosseous wiring of the infraorbital rims. The accompanying

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Craniofacial Disjunction (Le Fort III)

Definition. A Le Fort III midface fracture results when the traumatic force is of sufficient magnitude to completely separate the middle third of the facial skeleton from the cranium. The fracture line usually extends through the nasal bones and the frontal processes of the maxilla or nasofrontal and maxillofrontal 4/30/12 sutures, across the floors of the

Clinical features.

Craniofacial disjunction produces a clinical appearance similar to pyramidal fracture. How- ever, this injury is considerably more extensive. The soft tissue injuries are severe, with massive edema. The nose may be blocked with blood clot, or blood, serum, or cerebrospinal 4/30/12

Radiographic features.

The radiographic projections of Le Fort III fractures usually are hazy because of extensive soft tissue swelling. The main radiographic findings are separated nasofrontal, maxillofrontal, zygomaticofrontal, and zygomaticotemporal sutures (Fig. 27-19). The nasal bones, 4/30/12

Management.

The associated severe soft tissue injury necessitates initial hemorrhage control, airway maintenance, and repair of lacerations. Surgery may be delayed until the edema has sufficiently resolved. The treatment of transverse fractures is complicated because fixation of 4/30/12

Zygomatic Fractures

Definition. Unilateral fractures involving the zygoma are of two types: zygomatic arch fractures, in which just the arch is fractured, and zygomatic complex fractures, in which the zygomatic bone is separated from its frontal, maxillary, and temporal connections. Bilateral zygomatic 4/30/12

Clinical features.

Flattening of the upper cheek with tenderness and dimpling of the skin over the zygomatic arch and zygomaticofrontal suture and a fullness of the lower cheek may occur after zygomatic complex fracture. Step defects may be palpated in the zygomaticofrontal area and along the infraorbital rim. Some 4/30/12

Radiographic features.

Because of edema obscuring the clinical features, the radiographic examination may provide the only means of determining the presence and extent of the injury. The occipitomental (Waters') radiograph provides an image of the whole zygoma and maxillary sinus. The submentovertex 4/30/12

Management.

When symptoms include minimal displacement of the zygomatic arch and no cosmetic deformity or impairment of eye movement, no treatment may be required. Otherwise, reduction is usually indicated. Fractures of the arch may be reduced through an intraoral or extraoral approach. If a 4/30/12

MONITORING THE HEALING OF FRACTURES

Radiographic examination of the facial bones after trauma is usually necessary to measure the degree of reduction from treatment and to monitor the continued immobilization of the fracture site during repair. The monitoring of fracture repair should include examination of both the alignment of the 4/30/12

Clinical features.

If the fragment is not distally impacted, it can be manipulated by holding onto the teeth. If the fracture line is at a high level, the fragment may include the pterygoid muscle attachments, which pull the fragment posteriorly and inferiorly. As a result, the posterior maxillary teeth contact 4/30/12

Radiographic features.

This fracture may be difficult to detect. The views to use are the posteroanterior, lateral skull, and Waters' projections and CT scans. Both maxillary sinuses are usually radiopaque and may show airfluid levels. The lateral view may disclose a slight posterior displacement of the fragment 4/30/12

Management.

If the fracture is not displaced and is at a relatively low level in the maxilla, it can be treated by intermaxillary fixation. Those that are high, with the fragment displaced posteriorly or with pronounced separation, require craniomaxillary fixation in addition to intermaxillary fixation. A unilateral horizontal 4/30/12 fracture is usually immobilized

Pyramidal Fracture (Le Fort II)

Definition. The Le Fort II fracture has a pyramidal appearance on the posteroanterior skull radiographhence the name. It results from a violent force applied to the central region of the middle third of the facial skeleton. This force separates the maxilla from the base of the skull by causing fractures of the 4/30/12 nasal bones and frontal

Clinical features.

In contrast to the Le Fort I (horizontal) fracture, characterized by only slight swelling about the upper lips, the Le Fort II injury results in massive edema and marked swelling of the middle third of the face. Typically, an ecchymosis around the eyes develops within minutes of the 4/30/12 injury. The edema about the eyes