Orofacial Trauma: Diagnosis and Management Options

1. TRAUMA TO TEETH ANDORO FACIAL SKELETON Dr. Sravani Kota

2. Trauma to the orofacial region • Trauma to soft tissues • Fracture of teeth • Fracture of maxillofacial structures • Mid face fracture • Mandibular fracture

3. Diagnostic steps following dental trauma • Details of injury • When? How? Did you loose consciousness? • Bleeding from the tooth? • Bleeding from the nose? • Paraesthesia, anaesthesia over any area? • Medical history?

4. Examination of patient Extra oral examination Lacerations, swelling, oedemaecchymosis? Haemmorhage sub conjuctival?

5. Intra oral examination Hematoma Ecchymosis Check for teeth present/ absent/mobility Alveolar segmental

6. TRAUMATIC INJURY OF THE TEETH Factors affecting trauma to teeth Energy of Impact- Low velocity- greater damage- damage to supporting structures Type of object- Soft object- lesser crown fractures- supporting structures affected Shape- Sharp- clean crown fracture- no damage to supporting structures Direction- Enamel weakest parallel to enamel rods Dentin perpendicular to dentinal tubules

7. Trauma to the tooth can cause: Concussion- Mild Traumatic event leads to damage to the periodontium without loosening or displacement of tooth “ Crushing  Vascular / PDL  Inflammation Tender on percussion R/f Widening of PDLLater reduction of pulp Canal size

8. Rx Relieve occlusion Observe periodically for a year – vitality tests and radiographs Soft diet – 2 weeks LUXATION Dislocation of tooth within its socket ,leading to loosening and some degree of displacement “

9. Subluxation – Abnormal loosening without frank dislocation Extrusive luxation- Partial displacement out of socket Lateral luxation –Lateral displacement Intrusive luxation- Into the alveolar bone

10. Features Bleeding from sulcus- Indicating periodontal damage Mobile Sensitive to masticatory force R/f Widening of PDL space Pulp chamber obliteration- in cases of intrusion

11. Management: Subluxation- A splint can be placed to stabilize the involved teeth which can be removed in 7-10 days

12. Extrusive luxation: Clinician first repositions tooth into the socket then splinting is done same is the case of lateral luxation Splinting can be removed after 14 days Intrusive luxation; best to wait and watch to re erupt on its own accord or ortodontic treatment

13. Avulsion Complete displacement of tooth from its socket

16. In some cases root resorption begins within a week in some cases after years If permanent tooth with fully formed root present place after RCT done

17. Ellis classification of tooth # Class I  ENAMEL Class II  DENTINE Class III  PULP Class IV  NON-VITAL Class V  AVULSED Class VI  ROOT # Class VII  DISPLACED Class VIII  CROWN # Class IX  ANY DECIDUOUS TEETH #

18. Bennet’s classification Class I - Traumatized tooth without coronal or root fracture. A- Tooth firm in alveolus B- Tooth subluxated in the alveolus Class II- Coronal fracture A- Involving enamel B- Involving enamel and dentin Class III- Coronal fracture with pulp exposure Class IV- Root fracture A- Without coronal fracture B- With coronal fracture Class V- Avulsion of the tooth

19. INVESTIGATIONS iopa occlusal opg- mandibular # extra oral radiogrpahs tmj radiographs ct ,mri, cbct Radiographic signs of fracture Radiolucent line Change in normal outline Deviation in smooth outline Step defect Increase in bone density

20. Fractures of maxillofacial skeleton Mid face fractures Horizontal # Le Forte I Pyramidal # Le Forte II Craniofacial Dysjunction #Le Forte III Zygomatic #

21. Horizontal # Le-Forte I # line above the teeth  Below the zygomatic process  Through the Max sinus & Tuberosities  Inferior portion of pterygoid process.

22. Clinical features Swelling around upper lip Pain  Nose & Face Flattening of middle face Epistaxis, Double vision Varying degree of parasthesia, Mobile Maxilla Impact / Force directed towards max region

24. Pyramidal # Le-Forte II Nasal bone + frontal proccess of maxilla + lacrimal bone + floor of orbit + zygomatico maxillary suture + Base of Zygomatic process of maxilla + Lateral wall of maxilla + Pterygomaxillaryfossa through pterygoid plates

25. Clinical features: Edema & swelling middle 3rd of face Bilateral circum orbital ecchymosis Subconjunctival hemorrhage Infraorbital step deformity Parasthesia/ palatal hematoma Cracked pot sound Nasal bleeding Difficulty in mouth opening

26. Craniofacial dysjunction Le-Forte III Nasofrontal & frontomaxillary suture +medial wall of orbit through nasolacrimal groove & ethmoid bones + floor of the orbit along inferior orbital fissure + lateral orbital wall + zygomatico frontal junction & zygomatic arch + through the interface of pterygoid plates to the base of the spenoid

27. Clinical features • Gross edema of soft tissue • Tender frontozygomaticsuture&Arch • Dish faced deformity • Lowering of occular level • Tilting of occlusal plane • Cerebrospinal fluid rhinorrhoea

28. MANDIBULAR #

29. Condylar neck- Most common site Clinical features Swelling over the temporomandibular joint area Bleeding from the ear Ecchymosis of the skin under mastoid process Battles sign Deviation of mandible towards side of fracture Limitation of protrusion or lateral movement

30. Angle of the mandible Swelling over suspected site Anaesthesia or paresthesia Of lower lip Step deformity on palpation Lingual/ buccal vestibular hematoma Mandibular movements painful

31. To summarize…