The phone rings late on a weekday evening at the end of summer. A 15-year-old boy has injured himself riding a skateboard. His face covered by a bloodied cloth, with others in the room looking grey and wondering if he can be fixed up. When he removes the cloth, it’s a mess of wire, teeth missing or where they shouldn’t be and blood – lots of blood. His mother is panicked and the emergency physician wonders if we need to call for “reinforcements” or book an operating room visit. Sure, it’s an emergency room in a tertiary hospital, but this could easily be the closest dental office late on a Friday or Saturday afternoon.
Faced with a mess, the clinician could be forgiven for thinking “Where do I begin to fix this?” Beyond the blood, a cool head, thorough assessment of what injuries are present, adequate diagnosis and knowledge of the short and long-term management of trauma, and awareness of when to refer, will ensure this young man can get back on his feet. This article will run through the assessment and management of complex dental trauma using a recent case. Lets call our 15-year-old “XY”.
History of the accident:
XY was playing on his friend’s skateboard when he lost control and fell onto the pavement. He fell on his face and hand approximately three hours prior to dental assessment. He was not wearing any protective equipment at the time of the injury. He was given first aid and assessed by paramedics before being transported to hospital via ambulance. One tooth was knocked out and recovered, and several other teeth were displaced. The avulsed tooth was stored dry in a facial tissue for more than an hour before emergency personnel put the tooth in milk.
Prior to any clinical assessment, an accurate, documented history should be taken from the patient and/or parent about the nature and circumstances of the incident. Details elucidated from the history will assist in the examination (e.g. a fall on the chin will lead to a high index of suspicion for mandibular fracture, fracture of posterior teeth or injury of the temporo-mandibular joints), diagnosis in determining the prognosis, potential outcomes and management.1 Traumatic injuries may be the subject of an insurance, criminal or regulatory body complaint and an accurate history will assist in responding to medico-legal requests.2
The history should be written factually and in a contemporaneous manner including details pertaining to:1,3
1) What happened during the accident: fall/collision/assault etc.
2) Timing of accident – When the accident occurred, extraoral or dry storage time for avulsed teeth.
3) Who was involved – Was the patient the only person or was someone else involved either unintentionally or intentionally.
4) Objects involved in trauma e.g. skateboard, pavement, weapon, elbow, ball, animal.
5) First aid or any management prior to presentation.
6) If teeth are fractured or “missing” were the teeth or fragments recovered?
XY was a healthy young man with all systems normal, no history of hospitalization, no known allergies and with all immunizations up-to-date. He did not lose consciousness at the time of the accident.
A thorough medical history including the status of general systems, any loss of consciousness/vomiting/blackouts/dizziness, tetanus status, allergies, and any other injuries should be undertaken.
1,2 Management of severe dental trauma in a patient with a severe hematological disorder, immunosuppression or cyanotic congenital heart defects may necessitate a referral to a tertiary hospital or other management considerations.4,5
Emergency physicians examined XY and found normal neurological signs and no signs of cervical fractures. He had swelling of the right hand and sustained a fracture of the 4th metacarpal bone. He had abrasions of his skin on his arms and upper lip. He was unable to close his mouth due to interference in occlusion but did not have any deviations on opening. There was no tenderness or swelling on palpation of the zygomas, mandible, temporo-mandibular joints or nose.
In the management of dental trauma, the patient should be assessed for other medical injuries. The dental management will be secondary to the medical management of shock, neurological injuries, respiratory distress and neck injuries. 2,6 A history of loss of consciousness, vomiting, blurred vision or headache may indicate a concussion necessitating medical assessment and management. The patient should be examined for the possibility of other injuries including fractures of limbs and aspiration.2 An extra-oral examination should include gentle palpation of facial bones and an assessment for asymmetries, swelling, bruising, lacerations or abrasions, and restriction or deviation on opening. Fracture of facial bones may require assessment by an oral and maxillofacial surgeon. The inability to close or a deviation on closing may be an indication of maxillary or mandibular fracture or injury to one or both of the temporo-mandibular joints.2
Intraoral examination of XY revealed multiple injuries to the dento-alveolar and gingival tissues. Teeth 11, 21 and 22 were extruded and the palatal alveolar process around the extruded teeth was fractured and displaced in a palatal position. At the time of injury XY was in full fixed orthodontic appliance therapy and the orthodontic wire had distorted with the extrusion of teeth 11-22. Tooth 12 was avulsed. The gingival soft tissues were torn but no degloving of tissues was observed. The socket of the avulsed tooth was patent with no collapse or communition of the supporting alveolar bone. Two of the extruded teeth had uncomplicated enamel fractures (Figs. 1&2).
FIGURE 1. Presentation of XY following a skateboarding accident. XY sustained the following injuries; avulsion of tooth 12, extrusion of teeth 11-22, soft tissue laceration of gingiva from 12-22, and palatal alveolar bone fracture around 11-22.
FIGURE 2. Recovered tooth 12 prior to treatment and replantation. The tooth was not immediately replanted at time of accident with extraoral time exceeding 90 minutes.
Clinicians managing dento-alveolar trauma should undertake a thorough and comprehensive examination of all soft and hard tissues. Lacerations should be examined for the need to repair/approximate tissues and the presence of foreign bodies including gravel, dirt, glass, and unaccounted tooth fragments/missing teeth.2,7 Degloved soft tissues may be difficult to approximate or require irrigation and debridement, which may necessitate a referral for management. The form of the alveolar ridge should be examined to look for expansion of tissues suggestive of intrusion or fracture or displacement of the apex beyond the
buccal alveolar plate.2,7 Evaluation of hard tissues should include the position of the teeth, tooth fractures, mobility, presence of any bony fractures or bony lock for lateral luxation injuries.1,4,5
Intraoral periapical radiographs were taken to assess the presence of fractures, the position of the extruded teeth, to confirm diagnosis and assess sockets. A panoramic radiograph was deemed unnecessary, as there were no suspicions of mandibular or facial fractures other than a fracture of the palatal alveolar bone of the maxilla. Radiography revealed avulsion of tooth 12 with an intact socket, extrusion and displacement of teeth 11-22. No fractures of the roots were observed (Fig. 3).
FIGURE 3. Periapical radiographs of the maxillary anterior region taken from different angles to assess for fractures, the position of the extruded teeth, to confirm diagnosis and assess sockets.
Radiography should be undertaken to assist in the diagnosis and management with respect to the ALARA principle (as low as reasonably achievable).8 Radiographs should be ordered based upon the injury observed or suspected. For patients with “missing” teeth or fractured teeth where the teeth or fragments could not be recovered the possibility of intrusion, fragments lodged in soft tissue lacerations and aspiration of avulsed teeth should also be considered and assessed. Further investigation with radiography may be warranted to locate the missing tooth/fragment or eliminate the possibility of aspiration. 4,5,7,8
XY was diagnosed with:
1) Avulsion of tooth 12 with prolonged extra-oral dry time.
2) Extrusion of teeth 11-22.
3) Soft tissue laceration of gingiva from 12-22.
4) Palatal alveolar bone fracture around 11-22.
Prognosis, management and outcomes in dental trauma are dependent upon the diagnoses. Once diagnoses are made the clinician can discuss short and long-term management, the prognosis of the injuries sustained, the need for immediate intervention or monitoring (or no intervention) and the need for endodontic therapy. A tooth that has sustained an uncomplicated crown fracture of enamel and dentin with mild subluxation will have a simpler management and improved prognosis when compared with a tooth that has been intruded completely, severely extruded or avulsed with delayed replantation.4-6,9-13
Injuries sustained in dental trauma may be singular but rarely do not involve several other tissues of soft or hard tissues of the oral cavity or face. Avulsion injuries are accompanied consistently by concomitant injuries including multiple tooth trauma, soft tissue lacerations, alveolar fractures, skeletal fractures, and head and neck trauma as was seen for this case.6
XY was treated for his other injuries by emergency staff including skin abrasions and 4th metacarpal fracture in the right hand. Due to the extent of the injury and the patient’s anxiety dental treatment was performed under IV sedation with ketamine and midazolam administered and monitored by emergency physicians and nurses. Local anesthesia was obtained with two percent lidocaine with 1:100,000 epinephrine (Lignospan Standard®, Henry Schein Dental, Cambridge, ON, Canada). The orthodontic wire and debonded brackets were removed. The decision was made to replant tooth 12 and accept that due to the delayed replantation ankylosis would be the outcome. Prior to replantation the periodontal ligament tissues were removed using pumice and gauze. The pulp was extirpated, irrigated with 5.25 percent sodium hypochlorite, dried, dressed with non-setting calcium hydroxide (Pulpdent® paste, Pulpdent, Waterman, MA, USA) and the access cavity was restored with composite resin. The socket was irrigated with saline and tooth 12 was replanted. The fractured palatal alveolar bone was reduced manually; teeth 11-22 repositioned and secured using a 0.016 round stainless steel wire utilizing the remaining brackets or flowable composite resin for retention. The gingival soft tissues were approximated and sutured with 3.0 plain gut absorbable sutures (Ethicon, Johnson & Johnson, US) (Fig. 4).
FIGURE 4. Postoperative photograph following replantation of tooth 12, repositioning of teeth 11-22, splinting of the traumatised teeth, reduction of fractured palatal bone and repair of soft tissues.
The dentist has the responsibility of diagnosing and assessing dental trauma, to inform both the patient and the parent of the prognosis and outcomes of trauma and its management including the decision to reposition, replant or replace the tooth. 14,15 Despite the financial and treatment burden of the immediate and long-term management of dental trauma the return to normalcy is paramount for both patient and parent.15
There are many resources to assist the clinician in the management of dental trauma including the International Association of Dental Traumatology guidelines, local dental and medical specialists, and the Dental Trauma Guide website (www.dentaltraumaguide.org). Where dental, medical or behavioral management of a patient with complex dental trauma is beyond the dentist’s skill, capacity or scope referral to an appropriate clinician, medical or dental is necessitated.
Minor dental trauma injuries with good, predictable outcomes such as uncomplicated crown fractures, or subluxation injuries may be deferred or delayed for a few days, particularly when the parent and patient are emotionally charged following the incident. Delay in management of severe injuries such as soft tissue trauma, foreign bodies and severe dental trauma injuries in a timely manner may result in poor aesthetic, dental and growth outcomes for the patient.3,7,11,16 Failure to address soft tissue injuries may result in recession, infection and poor aesthetics whereas delayed repositioning of a displaced tooth may be impeded by the development of a blood clot in the socket or ankylosis with delayed replantation. 6,10
In this case patient XY was assessed and treated for his medical injuries before his dental injuries. As t
he avulsed tooth 12 had an extraoral time of greater than five minutes (almost 90 minutes before dental examination) it was considered a delayed replantation. In a growing, prepubescent child with an incisor with immature root development the long-term prognosis of delayed replantation is very poor. Informed consent about the consequences of replantation and ankylosis would need to be conveyed prior to replantation. 6,10,12,14,16 As XY had already undergone most of his pubertal growth and had avulsed a tooth with mature root development the impact of replacement resorption was reduced. The pulp of tooth 12 was extirpated prior to replantation to mitigate the risks of the development of inflammatory root resorption, a sequela responsible for failed survival of delayed replantation in growing patients.6,10,12,17
Pain and behavior management
Management of luxation and extrusion injuries involves the provision of anesthesia and pain relief. This case necessitated the use of intravenous sedation in conjunction with local anesthesia due to the patient’s anxiety. The choice of method for management of behaviour and pain is dependent on the child’s temperament, developmental stage, experience, the extent of the injury and the treatment required. Extensive trauma requiring lengthy or involved treatment may be a bridge too far for even the most stoic child to endure and sedation should be considered.18
Complex dental trauma can seem intimidating for not only the patient and parent but also the unsuspecting dentist. A thorough and systematic approach to the assessment of dental trauma ensures appropriate and optimal management, and a return to ‘normalcy’ for all parties.
Dr. Kelly Oliver, is a clinical super-fellow in paediatric dentistry at the Department of Dentistry at The Hospital for Sick Children in Toronto. She trained as a paediatric dentist in Australia and has been at the frontline in emergency departments in Australia then Canada since 2008.
Oral Health welcomes this original article.
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