Orofacial Injuries

SPORTS-RELATED DENTAL EMERGENCIES

Vigorous physical activities and competitive sports offer a variety of healthful benefits. However, participating in such activities also places you and your children at risk for injury, including trauma to the teeth and mouth that needs special care in diagnosis and management. Published research papers emphasizing orofacial trauma rates in different sports have yielded an enormous increase in injury rates and consequently an enormous increase in health care costs.

(Please refer to page of literature review)

Fortunately, most of these injuries can be prevented with the use of properly fitted Custom Made Mouthguard.

(Please refer to Mouthguard page)

There are some general considerations in emergency evaluation of facial trauma as injuries with adequate force to cause facial fractures and can also result in significant associated physical injuries. So, before detailed evaluation and treatment of facial injuries the patient requires an appropriate systemic trauma evaluation. Professional sports dentist knows well and will initially conduct the ABCs evaluation of basic life-support (BLS) protocols. For example, your sports dentist knows that any injury to the face can transmit energy to the cervical spine and so, neck immobilization should be immediately considered. Moreover, he will conduct initial neurological evaluation of the conscious patient and will maintain patent airway and neck stabilization for the unconscious patient. However, maneuvering of most of the facial injuries deferred until a complete patient evaluation is accomplished.

Orofacial injuries may include soft tissue and hard tissue either bony or dental injuries or a combination of both as TMD.

SOFT TISSUE OROFACIAL INJURIES

Soft tissue orofacial injuries occur frequently during athletic competition. Such injuries range from minor abrasions to full-thickness lacerations. Most associated facial bleeding can be controlled with direct pressure. The following principles for treatment of soft tissue are applicable to any part of the orofacial region including gingiva, lip and tongue:

Skin abrasions occur when skin forcibly rubs against an object (athletic turf) or another participant, these contacts can result in superficial or deep abrasions. Your dentist will perform initial cleansing and may give you local anesthesia if vigorous scrubbing and saline irrigation is needed. Then, he/she may apply dressings that may include plain petroleum jelly, bacitracin ointment, or triple antibiotic ointment.

Hematoma, which is the accumulation of blood within the subcutaneous tissues, is usually associated with blunt trauma as by hockey stick. The resolution of ecchymosis may take 10-14 days, and the deeper firmness may require 1-2 months to soften.

Puncture wounds are relatively less common in sports. Narrow puncture wounds may not require repair, but care must be taken to ensure that no fragments remain. Antibiotic coverage is considered according to nature and depth of the wound.

Full-thickness lacerations range from simple to complex. These can vary as a result of the magnitude of force, direction of force, and object involved. In general, after control of the bleeding with direct pressure, facial lacerations are cleansed, and then closed in anatomical layers with antibiotic coverage.

Tissue avulsions with loss of tissue commonly occur in higher-velocity sporting activities. After control of local bleeding with direct pressure, referral for definitive care is necessary.

HARD TISSUE OROFACIAL INJURIES

As previously mentioned, facial fractures may take place during many sport activities and trauma assessment, including cervical spine evaluation, must be considered. Most of the time, a jaw injury is not at the location where the athlete bumped. The force is transmitted up to weaker areas. Jaw pain at a place the athlete did not bump is a strong sign of trouble. The most common areas broken are the mandibular angle (where the bone turns upward at the back of the jaw) and the temporo-mandibular joint (TMJ) area where the jaw hinges under the skull. If a jaw injury is not treated properly, the teeth might not match up correctly, or the “fit” of the jaw joint may be changed. The change can be subtle, but it can lead to chronic TMJ pain and teeth breaking down over time. Even if there is no fracture, there can be injury to the cartilage in the TMJ. Immediate care includes cold-pack application to the painful area and fast referral to the oral surgeon.

DENTOALVEOLAR INJURIES

Any tooth that receives a blow that exceeds normal physiological limits is displaced from its normal anatomic position. This force has consequences to the structure of the tooth, surrounding periodontal ligament, the vascular and nerve supply to the tooth, the surrounding bone. The degree of damage to all these structures is related to the extent of displacement from the original anatomic position, from almost no displacement to complete displacement from the bony socket (avulsion). These injuries could be classified into: pure dental trauma and combined dento-alveolar trauma that involves both the teeth and their supporting soft and hard tissue.

FRACTURE (Broken) Tooth

Uncomplicated Crown Fracture:

Fractures may appear as a crazing within the enamel or as loss of tooth substance involving only enamel or enamel and dentin, but do not involve the tooth pulp. Wherein a tooth is crazed or fractured, generally it does not constitute an emergency and can be treated by your dentist shortly after the injury. Minor fractures can be smoothed by the dentist or simply left alone. Another option is to restore the tooth with a tooth-colored restoration by composite resin. More recently, the broken portion should be saved and brought to the dental office (as described later under Avulsion). By special technique this portion will be reattached to the tooth.

Complicated Crown Fracture:

Fractures include damage to the enamel, dentin and pulp. The dentist will chose between different treatment planes according to the case. He/she may perform pulp capping, partial pulpotomy or pulpectomy (root canal filling). Then, tooth may be restored either with tooth colored restoration, full crown, or post, core and full crown.

Crown-root Fracture:

This is a fracture involving enamel, dentin and cementum, with or without pulpal involvement. The coronal fragment is attached to the gingiva and mobile. The apical segment is usually not displaced. The dentist will chose between different treatment planes according to the case. In an emergency, He/she may stabilize the coronal fragment with an acid etch/resin splint to adjacent teeth.

He/she may remove the coronal fragment and the gingiva is allowed to reattach to the exposed dentin. After some weeks, the tooth can be restored above the gingival level.
He/she may expose subgingival fracture site by: gingivectomy, orthodontic or surgical extrusion of the tooth. If root formation is complete, he will perform root canal treatment with guttapercha/sealer. Otherwise pulp capping or pulpotomy till completion of root formation.

Root Fracture: These are fractures involving dentin, cementum and the pulp. Some cases are treated using new techniques instead of jeopardizing the tooth.

Unfortunately, severe fractures often mean a traumatized tooth with a slim chance of recovery.

FIRST AID OF FRACTURE (BROKEN) TOOTH:

The portion of tooth left in mouth should be stabilized by gently biting on towel or handkerchief to control bleeding.
Should extreme pain occur, contact with other teeth, air or tongue should be limited. Pulp nerve may be exposed (due to trauma), which is extremely painful to athlete.
Immediately athlete and tooth fragments should be transported to dentist.

TOOTH DISPLACEMENT

It includes:

Luxation injuries: tooth becomes malpositioned within its socket.

Avulsion injuries: tooth becomes partially (extruded) or totally separated from its socket.

LUXATION (Tooth in socket, but wrong position)

EXTRUDED TOOTH:

(Upper tooth hangs downs and/or lower tooth raised up):

First aid includes:

Repositioning of the tooth in its socket using firm finger pressure.
Tooth should be stabilized by gently biting on towel or handkerchief.
Then, athlete would be transported immediately to dentist.

In the dental office: Unlike an avulsed tooth, which is knocked completely out of the socket, an extruded tooth is only partially dislodged. If not repositioned at the site of the injury, the dentist will gently reposition the tooth to its original occlusion and will splint the tooth. As long as the nerve and blood vessels remain intact, an extruded tooth may be saved without a root-canal treatment, depending on how displaced it is and how complete root formation is.

LATERAL DISPLACEMENT:

(Tooth pushed back or pulled forward):

First aid includes:

Using finger pressure to reposition the tooth should be tried. The displaced tooth is usually locked firmly in its new position requiring disengagement of the tooth from its bony lock. So, sometimes the athlete might suffer great deal of pain by this manipulation and he/she may require local anesthetic to reposition tooth.
If so, the tooth should be stabilized by gently biting on towel or handkerchief and athlete would be transported immediately to the dentist.

In the dental office: This trauma implies lateral eccentric displacement of the tooth in its socket; and is accompanied by comminuted fracture of bone or fracture of the alveolar bone plate(s). If not repositioned at the site of the injury, the dentist will inject regional anesthesia as repositioning may be a painful procedure. He/she will reposition the tooth using dental forceps or finger pressure. He/she will start with pressure in an incisal direction over the apex, whereby the tooth is first slightly extruded to disengage the apex and then repositioned in an apical direction. After repositioning, the dentist will check occlusion and an X-ray is taken to verify correct repositioning. Then, He/she will splint the tooth for a minimum of 3-4 weeks with a non-rigid splint (also called physiologic splint). He/she will perform regular checkups including X-rays. If there are no signs of bony breakdown, He/she will remove the splint. If unfavorable signs are present, the dentist will maintain the splint for another 3-4 weeks.

INTRUDED TOOTH:

(Tooth pushed into gum – looks short)

First aid of intruded tooth is doing nothing!! In this type of injury, the tooth is forced into the socket and locked in position in bone. Any repositioning of tooth should be avoided as this type of injury may be associated with comminuted fracture and carry high risk of inducing tooth avulsion. So, athlete should be transported immediately to the dentist.

In the dental office: At present, the value of acute repositioning of the all intruded tooth is uncertain. The dentist in these injuries will clean the area, use anesthesia, grasp the tooth with forceps, slightly try to loosen the tooth to release it from its locked position in bone and then leave it for spontaneous or guided re-eruption (orthodontic extrusion), which has been found to lead to healing in approximately half of the cases, or continue with surgical repositioning as explained later. However, spontaneous re-eruption can normally only be expected to occur in cases with incomplete root formation.

In teeth with complete root formation (closed apices), the dentist will allow eruption without intervention if the tooth is intruded less than 3 mm. However, if no movement occurred after 2-4 weeks, orthodontic extrusion or surgical repositioning would be the treatment of choice before ankylosis can develop. On the other hand, if the tooth is intruded 3-7 mm, the dentist would try to reposition of the tooth either surgically or orthodontically. But, if the tooth is intruded beyond 7 mm, reposition surgically would probably be the only choice. Once an intruded tooth has been repositioned either surgically or orthodontically, the dentist would stabilize it with a flexible splint for 4 weeks.

On either case, the dentist will perform prophylactic root canal treatment as the pulp would be most likely become necrotic. So, He / She would initiate root canal therapy using a temporary filling with calcium hydroxide 2-3 weeks after repositioning. This treatment should be followed with close and regular checkups.

In teeth with incomplete root formation (open apices), the dentist will allow eruption without intervention. However, he will revert to orthodontic repositioning, if no movement was detected within few weeks. Additionally, if the tooth is intruded more than 7 mm, reposition surgically or orthodontically would be the appropriate choice.

AVULSION

(Entire Tooth Knocked Out)

When the tooth is avulsed, attachment damage and pulp necrosis occurs. The tooth is separated from the bony socket; mainly due to the tearing of the periodontal ligament (the thin gum tissue attached to the root surface) that leaves viable periodontal ligament cells on most of the root surface. In addition, due to crushing of the tooth against its bony socket, small localized cemental damage (root surface) also occurs.

First aid: The survival of the knocked out tooth depends on rapid replacement into its socket. But, it should be mentioned that only permanent teeth should be replaced. If young athlete knocks out a baby (deciduous) tooth, it is usually best not to put it back as it may form a bridge to the bone that interferes with the development of the permanent tooth underneath.

Replantation of an avulsed tooth should preferably be done at the site of injury in order to minimize extra-alveolar time (i.e. time elapsed while the tooth is out of its socket). Every effort should be made to replant the tooth within the first 15-20 min. If the thin gum tissue (periodontal ligament) that is attached to the root(s) of the tooth dries before the tooth is replaced (extra-alveolar period >1 hour of drying), the tooth would not heal into the socket. On the other hand, if this periodontal ligament is left attached to the root surface and does not dry out (extra-alveolar period <1 hour), the consequences of tooth avulsion are usually minimal.
Additional trauma to tooth while handling should be avoided. The tooth should not be handled with fingers or instrument on the root surface, should not be brushed nor scrubbed. Additionally, tooth should not sterilized by disinfecting solutions. If debris is on tooth, gently rinse with saline loaded in disposable syringe or water for 10 seconds if saline is not available. If athlete is alert and conscious, tooth should be re-implanted without inducing additional trauma to the tooth and/or its bony socket. It should be stabilized by biting down gently on the towel or handkerchief.

If unable to re-implant, other alternatives are:

1st Best – if available, tooth is placed in specially formulated Cell culture media as Hank’s Balanced Saline Solution-HBSS “Save-a-Tooth”® in the specialized transport container or in a container filled with Viaspan®. As more than 60% of avulsion injuries occur close to the home or school, it should be beneficial to have these media available in emergency kits at these two sites.

2nd best – tooth is placed in milk.

3rd best – tooth is placed under athlete’s tongue ONLY if athlete is conscious and alert or in a container into which the athlete spits.

4th best – tooth is wrapped in saline-soaked gauze.

5th best – tooth is wrapped in plastic bag.

6th best -tooth is placed in a cup of water. Water is the least desirable storage medium because the hypotonic environment causes rapid cell lysis and increased inflammation on replantation.

Then, athlete should be transport immediately to dentist.

In the dental office: The dentist treatment goal is to stabilize the tooth until the supporting ligaments heal. So his/her treatment objective will be directed to avoid or minimize the resultant inflammation that occurs as a direct result of the two main consequences of the avulsed tooth, namely periodontal ligament damage and tooth pulp infection. The dentist will consider mainly 3 factors to apply the best line of treatment:

Length of extra-alveolar storage: A dry time of 60 mm is considered the point where survival of root periodontal ligament cells is unlikely.
Extra-alveolar storage medium: if had been used
Stage of root development: This is determined by the age of the athlete and avulsed tooth in hand. Mature tooth has closed apex where the root ends. On the other hand, the same tooth in a younger athlete has open apex (immature tooth).

So, we would be faced with one of these situations:

Closed (mature) Apex:
Tooth replanted prior to the patient’s arrival at the dental office or clinic.
Extraoral dry time less than 60 min. The tooth has been kept in physiologic storage media or osmolality balanced media (Milk, saline, saliva or Hank’s Balanced Salt Solution) and/or stored dry less than 60 minutes.
Extraoral dry time exceeding 60 min or other reasons suggesting non-viable cells.

Tooth replanted prior to the patient’s arrival at the dental office or clinic.

Treatment would be directed to:

The dentist will leave the tooth in place.
He will clean the area with water spray, saline, or chlorhexidine.
If gingival lacerations are present, he will suture them artistically to preserve esthetic and function.
He / she will verify the position of the replanted tooth both clinically and by x-ray and he / she will try to reach atraumatic normal position as much as possible.
Then, he will apply a flexible splint for up to 2 weeks.
He /she will administer systemic antibiotics, either:

Tetracycline (Doxycycline 2x / day / 7 days at appropriate dose for patient age and weight). Although disputed in some recent studies, the dentist will consider the risk of discoloration of permanent teeth before systemic administration of tetracycline in young patients (In many countries tetracycline is not recommended for patients under 12 years of age).

OR, as an alternative,

Phenoxymethyl Penicillin (Pen V) or amoxycillin, at an appropriate dose for age and weight.

Additionally, the dentist might refer the athlete to physician for tetanus evaluation, if the avulsed tooth has been in contact with soil.
Finally, he / she will initiate root canal treatment 7-10 days later and just before splint removal.

The instructions would be directed to:

Avoid participation in contact sports.
Continue on soft food diet for up to 2 weeks.
Regular teeth brushing with only soft toothbrush after each meal.
Use of chlorhexidine (0.1 %) mouth wash 2x / day / 1 week.

Follow-up

The dentist will initiate root canal treatment 7-10 days after replantation. He / she will place calcium hydroxide as an intra-canal medicament for up to 1 month followed by root canal filling with an acceptable material. Alternatively, the dentist may place an antibiotic-corticosteroid paste immediately or shortly following replantation and left for at least 2 weeks.
He / she will remove the splint and will perform clinical and radiographic control after 2 weeks.
Additionally, the dentist will perform clinical and radiographic controls after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.

Extraoral dry time less than 60 min. The tooth has been kept in physiologic storage media or osmolality balanced media (Milk, saline, saliva or Hank’s Balanced Salt Solution) and/or stored dry less than 60 minutes.

Treatment would be directed to:

The dentist will clean the root surface and apical foramen with a stream of saline and will soak the tooth in saline thereby removing contamination and dead cells from the root surface.
He / she will administer local anesthesia.
He / she will irrigate the socket with saline to clean the socket from any residues or blood clots that may hinder repositioning the tooth back to its original location.
Then, He / she will examine the alveolar socket. If there is a fracture of the socket wall, he / she will reposition it with a suitable instrument.
Carefully, the dentist will replant the tooth slowly with slight digital pressure. He will not use force.
If gingival lacerations are present, he will suture them artistically to preserve esthetic and function.
He / she will verify the position of the replanted tooth both clinically and by x-ray and he / she will try to reach atraumatic normal position as much as possible.
Then, he will apply a flexible splint for up to 2 weeks.
He /she will administer systemic antibiotics, either Tetracycline or Phenoxymethyl Penicillin (Pen V) or amoxycillin (as explained above).
Additionally, the dentist might refer the athlete to physician for tetanus evaluation, if the avulsed tooth has been in contact with soil.
Finally, he / she will initiate root canal treatment 7-10 days later and just before splint removal.

The instructions would be directed to:

Avoid participation in contact sports.
Continue on soft food diet for up to 2 weeks.
Regular teeth brushing with only soft toothbrush after each meal.
Use of chlorhexidine (0.1 %) mouth wash 2x / day / 1 week.

Follow-up

The dentist will initiate root canal treatment 7-10 days after replantation. He / she will place calcium hydroxide as an intra-canal medicament for up to 1 month followed by root canal filling with an acceptable material. Alternatively, the dentist may place an antibiotic-corticosteroid paste immediately or shortly following replantation and left for at least 2 weeks.
He / she will remove the splint and will perform clinical and radiographic control after 2 weeks.
Additionally, the dentist will perform clinical and radiographic controls after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.

Extraoral dry time exceeding 60 min or other reasons suggesting non-viable cells.

Treatment would be directed to:

The dentist in such cases will try hardly to preserve the tooth mainly by maintain alveolar bone contour to stop ankylosis and / or resorption of the root.
Unfortunately, the delayed replantation of a tooth has a poorer success rate. This is because the periodontal ligament will be dead (necrotic) and hence, it will not heal.
So, he / she will remove attached soft tissue carefully, usually with saline soaked gauze. Sometimes, the dentist may use sharp instrument (e.g. suitable curette or scalpel) or rarely soak the tooth in weak acid as Vinegar. He / she may also soak the tooth for sometimes in 2 % sodium fluoride solution (for 20 min).
He / she may either finish root canal treatment while tooth in his hands (i.e. prior to replantation), or he / she will remove only the tooth necrotic pulp and will continue 7-10 days later.
He / she will administer local anesthesia.
He / she will irrigate the socket with saline to clean the socket from any residues or blood clots that may hinder repositioning the tooth back to its original location.
Then, He / she will examine the alveolar socket. If there is a fracture of the socket wall, he / she will reposition it with a suitable instrument.
Carefully, the dentist will replant the tooth slowly with slight digital pressure. He will not use force.
If gingival lacerations are present, he will suture them artistically to preserve esthetic and function.
He / she will verify the position of the replanted tooth both clinically and by x-ray and he / she will try to reach atraumatic normal position as much as possible.

Then, he will apply a flexible splint for up to 4 weeks (not 2 weeks as before).

He /she will administer systemic antibiotics, either Tetracycline or Phenoxymethyl Penicillin (Pen V) or amoxycillin (as explained above).
Additionally, the dentist might refer the athlete to physician for tetanus evaluation, if the avulsed tooth has been in contact with soil.
Finally, he / she will initiate and / or continue root canal treatment 7-10 days later.

The instructions would be directed to:

Avoid participation in contact sports.
Continue on soft food diet for up to 2 weeks.
Regular teeth brushing with only soft toothbrush after each meal.
Use of chlorhexidine (0.1 %) mouth wash 2x / day / 1 week.

Follow-up

If root canal treatment will be initiated and / or will be continued root canal 7-10 days later, the dentist will place calcium hydroxide as an intra-canal medicament for up to 1 month followed by root canal filling with an acceptable material. Alternatively an antibiotic-corticosteroid paste may be placed immediately or shortly following replantation and left for at least 2 weeks.
He / she will remove the splint and will perform clinical and radiographic control after 4 weeks.
Additionally, the dentist will perform clinical and radiographic controls after 4 weeks, 3 months, 6 months, 1 year and then yearly thereafter.

Opened (immature) Apex:

Pulp healing (revascularization) is possible if extra-alveolar period < 1 hour. But, If extra-alveolar period >1 hour of drying, pulp death is usually evident after 2-4 weeks and presents with periapical rarefaction with or without signs of inflammatory root resorption.

UNDER RE-CONSTRUCTION …