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DENTOALVEOLAR TRAUMA

DENTOALVEOLAR TRAUMA. AO ASIF PRINCIPLES OF OPERATIVE TREATMENT OF CRANIOMAXILLOFACIAL TRAUMA AND RECONSTRUCTION AUGUST 11& 12, 2007 Lecture Date: 3/31/2011. TO BE OR NOT TO BE. INVOLVED OR FRACTURED IS THE QUESTION. Hard and Soft Tissue Manifestations.

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DENTOALVEOLAR TRAUMA

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  1. DENTOALVEOLAR TRAUMA AO ASIF PRINCIPLES OF OPERATIVE TREATMENT OF CRANIOMAXILLOFACIAL TRAUMA AND RECONSTRUCTION AUGUST 11& 12, 2007 Lecture Date: 3/31/2011

  2. TO BE OR NOT TO BE INVOLVED OR FRACTURED IS THE QUESTION

  3. Hard and Soft Tissue Manifestations • When dealing with trauma we have to deal with both hard tissue and soft tissue trauma. If the soft tissue is contused most likely you have an underlying osseous defect that needs to be dealt with.

  4. CLINICAL EVALUATION • Soft tissues • Nerves • Skeleton • Dentition

  5. Note on the Previous Slide • “Saturday Night Special” – this guy didn’t have a good night • A boot to the mouth can cause some problems. His alcohol level was >300. • When you look at his face you see two black eyes (“coon eyes”) this typically implies a vaso or skull fracture and a midface fracture • It looks like his eyes are far apart. Anytime you have a fracture called traumatic canthus so he has an ethmoid fracture. • He also has a nasal fracture. • All four of these need to be taken into account on someone who has be involved in a traumatic event

  6. DENTOALVEOLAR TRAUMA • When dealing with this you need to take into account what is going on with the soft tissue and direct your treatment appropriately • Injuries involving the teeth, the alveolar portion of the maxilla/mandible and the adjacent soft tissues

  7. Reasonable step defect indicating a problem with the mandible

  8. NATIONAL HEALTH AND NUTRITION EXAMINATON SURVEY • Subjects from 6-50 years of age • Enamel fracture identified as most common sequela of trauma- 45.8% • 25% of US pop. with dental trauma • Upper centrals most commonly traumatized tooth • Upper centrals = buckybeavers • M:F 1.5:1

  9. EPIDEMIOLOGY CON’T • Prevalence in hospital emergency departments: 4.6% to 10.5% of trauma admissions have dental trauma 42% age less than 6 y.o., 21% age 6-10 and 11% age 11-15, however 79% involved permanent teeth. 45% of patients have concomittant soft tissue injuries • It is interesting that almost 1 out of 2 patients who have dental trauma will also have soft tissue trauma

  10. ASSOCIATION OF OTHER OROFACIAL INJURIES • 1/3 of all mand. condyle fractures involve injury to 3.7 teeth • If the MOA was a MVA to produce the condyle fx, then related injury to teeth was 47% • Bilateral condyle fx resulted in 64% of pts with dental injury • Unilateral condyles: 25% with dental injury • Endoscopy/intubation= .06% dental injury

  11. HistoryDirection of Force • Contracue – when you have a force directed on a piece of the bone you need to worry about where the forces translate • Parasymphysis fracture – force is to the contralateralcondyle • Blow to the central symphysis of the mandible – possible to have bilateral condyle fracture

  12. FACIAL AND MANDIBULAR INJURIES SINGLE MOST COMMON ANTECEDENT OF TMJ INTERNAL DERANGEMENT

  13. EVALUATION OF DENTOALVEOLAR TRAUMA

  14. EXAMINATION • Usually associated with trauma or violence therefore trauma survey mandated for elucidation of other injury patterns • Look at other body parts, make sure no neurologic problems (concussion), make sure there are no ocular process going on (making sure the eye ball moves and does so in all 6 extraocular movements), check the nose and the midline, then check the whole face (cheek bones, orbital rims, zygomatic arches, maxilla for mobility, then the mandible)

  15. ASSESSMENT • Debridement and removal of intraoral and extraoral blood • Record location and size of all lacerations, abrasions, contusions, hematomas • A hematoma is a collection of blood (blood clot) • What is in blood? • Glucose – so hematomas get infected • If the patient has a big hematoma he suggests you evacuate it with a needle and put a dressing over the top • Radiography to include periapicals, panoramic and if head and neck trauma then a standard radiographic survey • Typically with head and neck trauma they typically get a CAT scan • TMJ assessment

  16. Missing Teeth • In the mouth • In the body • In the Street

  17. MECHANISM OF INJURY • Very important • More likely this is a concussive injury. • There may be entrance into the pulp chamber. The tooth may be pushed in one direction. • These teeth will be very sensitive. • Not uncommon to have some soft tissue involvement

  18. Hockey • Often gives avulsion of teeth and fractures

  19. Horse Hooves • Commonly happens when the rodeo comes to town

  20. Unrestrained in Motor Vehicle Accident (MVA) • You usually hit your chin on the dash board and pop your condyle • If you ever get thrown out of a car your injury pattern is unpredictable

  21. WHAT IF NO APPARENT ACCIDENTAL CAUSE HIGH INDEX OF SUSPENSION FOR CHILD AND ELDER ABUSE

  22. 50 % OF DIAGNOSED CHILD ABUSE CASES WITH OROFACIAL TRAUMA • You have a specific duty to report child abuse • If you suspect it, you have to report it • When you do this social services may come in and take the child • Same thing is required when you are dealing with spousal abuse

  23. Need to take pictures if you suspect the trauma is from abuse

  24. CLASSIFICATION: BASED ON DESCRIPTION OF INJURY

  25. Diagnosis • Crown fracture • Root fracture • Concussion/subluxation • Extrusion/lateral luxation • Intrusion • Avulsion • Alveolar fracture

  26. Teeth can be fractured • C = into nerve • A = craze • B = portion of incisal edge

  27. Once it goes beneath the alveolus you then have the potential that this is not salvageable • F = root fracture, these almost always require removal

  28. Can have slight intrusive injuries • Or when patient has a blow to the tip of the incisor, you have a fracture at the tip of the alveolus

  29. Avulsion • Intrusion • Frank alveolar fracture

  30. NONDISPLACEMENT VS DISPLACEMENT INJURIES • Nondisplacement: Concussive i.e. tooth has sustained an injury but not displaced, not mobile but very sensitive to percussion • Displacement: Luxation i.e. displacement or dislocation from socket. • Worst injuries, almost always have a process involving the apex Types: 1)Extrusive; 2) Intrusive 3) Lateral luxation 4) Avulsion/Exarticulation • Primary teeth are typically not replaced if they are avulsed • What do you put an avulsed tooth in? • Spit • Milk • Hanks Balanced Salt Solution – best material to put it in • He doesn’t recommend putting it in the buccal vestibule or under the tongue because the kid then swallows it • Tell the parent not to wash it off. If you scrub the apex you take off all the Purkinje fibers and then the tooth will become ankylosed when place back in

  31. CROWN FRACTURES • Crown fxs comprise 26-76% of injuries to permanent dentition • enamel vs dentin vs pulp vscementum • ROOT FRACTURES VS CROWN FXS AND NEED TO RESTORE AND/OR EXTIRPATE PULP • The deeper the fracture the greater the chance that the tooth is nonsalvagable and you may end up having to extirpate the pulp. • Equipment Needs • Composite resins can be utilized for splints • Ortho wire or nylon fishing line to secure the parts

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