Fractures of the Teeth & Jaws Joseph L Fractures of the Teeth & Jaws Joseph L. McQuirter, DDS Oral and Maxillofacial Surgery

Fractures of the Teeth & Jaws (Orofacial Fractures) Dentoalveolar (teeth and surrounding bone) Mandibular (lower jaw) Maxillary (upper jaw)

Learning Objectives List the treatment options and surgical intervention for orofacial fractures Understand the approach to treatment for specific orofacial fractures List common early and late complications of orofacial injuries List the types of orofacial injuries List anatomic structures commonly affected by orofacial injuries Describe functional impairments resulting from orfacial fractures Explain the mechanism of injury for orofacial fractures Become familiar with the diagnostic work up for patients presenting orofacial injury

Fractures of the Teeth and Jaws Dentoalveolar Mandibular Maxillary

When facial bones break How effective are our attempts to repair?

Mechanism of Injury Accidental Intentional Assault Domestic Workplace Associated with Crime Interpersonal Conflicts Self Inflicted Vehicular Injury Sports Falls

Mechanism of Injury High Impact Low Impact Penetrating

deceleration type-injury High Impact Facial Fractures Vehicular high speed deceleration type-injury

Sports Related Injuries (low impact)

Fall Injury (unrestrained)

Assault Domestic Workplace Associated with Crime Rihanna Lucy Newman Assault Domestic Workplace Associated with Crime Interpersonal Conflicts

Fist blow to face

Sports Safety Equipment

there are still unexplained injuries In spite of our best efforts and millions being spent to protect and ensure safety there are still unexplained injuries

Fractures of the Teeth and Jaws Dentoalveolar Mandibular Maxillary

Dento alveolar Fractures (Dental / Tooth) (Alveolar Bone) Dental Alveolar Bone

Dentoalveolar Fractures Fracture of teeth and adjacent alveolar bone

Classification of Tooth Injuries Fracture of tooth crown without pulp involvement Fracture of tooth crown with pulp involvement Crown root fractures Root fractures Concussion injuries Luxation injuries Tooth avulsion (Exarticulation) 4 3 2 1

Alveolar Bone Fractures

Diagnosis – Dentoalveolar injuries 1 Diagnosis – Dentoalveolar injuries 1. Clasic signs of inflammation from injury (Pain, swelling, redness) 2. Mobility 3. Malocclusion (malaligned/displaced teeth)

Etiology of Dentoalveolar Injuries Altercations Falls Seizure disorders Sporting activity Vehicular injuries Endoscopic procedures (anesthesia intubation) Abusive behavior Mental health disorders

Treatment Objective 1. RESTORE FORM 2. RESTORE FUNCTION

RESTORE FORM ~ Place displaced teeth of tooth/bone segment back to their natural position ~ Stabilize repositioned teeth/bone segment

RESTORE FUNCTION ~ Normal bite - Non injured teeth should come together without interference from the displaced/fractured segments. ~ Preserve vitality of dislodged teeth or dentoalveolar segment

Prognosis is Dependent on Viability of Pulp and Periodontal Tissues

Injuries to the tooth Root Canal Treatment Likely Fracture of tooth crown without pulp involvement Fracture of tooth crown with pulp involvement Crown root fractures Root fractures Concussion injuries Luxation injuries Tooth avulsion (Exarticulation) Root Canal Treatment Likely 4 3 2 1

Injuries to the tooth Luxation injuries Fracture of tooth crown without pulp involvement Fracture of tooth crown with pulp involvement Crown root fractures Root fractures Concussion injuries Luxation injuries Tooth avulsion (Exarticulation) Requires reduction and stabilization Requires reimplantation and stabilization

Intruded Tooth Avulsed Tooth Extruded Tooth

Tooth avulsion Out of mouth for less than 2 hours Reimplant immediately if possible Transport in Hank’s solution, milk, saline or saliva (mouth) Provide local anesthesia Saline irrigation and gentle evacuation of blood from socket Reimplant tooth and stabilize

Transport media for the avulsed tooth In the tooth socket Saliva (in the mouth) Milk Hank’s balanced salt solution ViaSpan cold storage solution

Preserving The avulsed tooth Hank’s balanced salt solution, commercially available as : Save-A-Tooth (Phoenix Lazarus, Inc.) (Save-A-Tooth is a mainstay in many athletic first aid kits) ViaSpan, cold storage solution is currently available as an organ transport solution

Reduce Dentoalveolar Fractures

Simple, non-traumatic stabilization for mobile teeth and dentoalveolar fractures

Complications of Dental Injuries Missing teeth, tooth fragments, broken fillings, appliances must be accounted for ~ Aspirated ~ Ingested ~ Witnessed expelled tooth at the injury location Traumatic occlusion Infection Loss of Teeth and Bone Associated injuries ~ Blunt head trauma ~ Soft tissue injuries ~ Bleeding ~ Infection risk (Tetanus prophylaxis /risk)

Ingested Tooth Aspirated Tooth Tooth Fragment in Lip Tongue Bite - Look for Tooth Fragment Ingested Tooth Tooth Fragment in Lip Aspirated Tooth

Lead Poisoning from Retained and Swallowed Shotgun Pellets in Maxillofacial Gunshot Injury McQuirter JL, et al. Elevated Blood Lead Resulting from Maxillofacial Gunshot Injuries: Three Case Reports of Ingested Lead Particles after Gunshot Injury to the Face. J Oral Maxillofac Surg 61(5):593-603, 2003.

Molar tooth dislodged to mid-tongue area from gunshot injury

Late Complications Infection Ankylosis of Teeth Devitalization/Discoloration of Teeth Loss of Teeth/Dentoalveloar Segment

Dentoalveolar segment loss due to periodontal disease compromising interdental blood supply

Fractures of the Teeth and Jaws Dentoalveolar Mandibular Maxillary

Mandibular Fractures

Diagnosis Clinical/Physical Findings Diagnostic Studies

Clinical Findings Altered Form Altered Function

Altered Form Swelling Displacement of Anatomical parts Decreased Muscle Tone

Swelling and bleeding

Step / Gap defect in dental arch

The Opposing Jaw Displaced anatomy in both jaws

Superimposition of other anatomical parts sometimes makes radiographic diagnosis difficult

Clinical confirmation of suspected fracture Ecchymosis In The Floor of the Mouth Clinical confirmation of suspected fracture

Altered Function Occlusal Abnormalities Decrease Range of Motion Deviation of Jaw with Opening Altered mental nerve function Structural Integrity of the Bone Compromised of Host Defense Soft Tissue Compromise Speech Swallowing Respiration Bleeding

Bimanual palpation of the mandible in a cephalad position allows excellent evaluation and comparison of the anatomic structures

The application of gentle bimanual pressure over the angle regions can unmask a minimally displaced fracture in the anterior region of the mandible.

Treatment Objective 1. RESTORE FORM 2. RESTORE FUNCTION