General characteristics and clinical presentation of injuries
The level of maxillofacial trauma is steadily rising due to labor intensification and transport development. Facial bone fractures are classified as severe accidents. The severity of such injuries is regulated by Order of the Russian Ministry of Health No. 322 and is assessed by three criteria: the nature of injuries, the duration of health impairment, and long-term consequences.
In practice, facial injuries are rarely limited to contusions alone. During an external examination of the patient, the physician frequently detects pronounced swelling of the lips and cheeks, bruising, and occasionally soft tissue wounds in the perioral region. The mucous membrane and gingiva become hyperemic, and palpation causes acute pain. Behind this "soft-tissue" clinical picture lies the primary pathology — dental dislocations and fractures. At the same time, the maxilla (maxilla) takes the impact significantly more often than the mandible (mandibula).
Dental dislocations: etiology and classification
A dislocation occurs as a result of a direct blow, an attempt to bite hard food with a mobile tooth, bad habits (such as opening bottles with teeth), or iatrogenic factors — careless use of dental forceps and elevators. As a result of the trauma, a partial or complete rupture of the periodontal fibers and the neurovascular bundle occurs.
According to the nature of displacement, three main forms of dislocations are distinguished:
- Subluxation. Only a portion of the periodontal fibers is ruptured. The patient complains of pain that intensifies with mechanical load. The mouth is often half-open, as an attempt to close the jaws causes severe pain due to tooth displacement. The root maintains a connection with the alveolus, but the radiogram clearly shows a widening of the periodontal space.
- Luxation (complete dislocation). The tooth completely falls out of the socket with the rupture of all ligaments. In the early period, the alveolus bleeds or fills with a clot, and gingival tears are possible. An empty socket is visible on the radiogram.
- Intrusive dislocation. The mechanism of trauma is an impact on the incisal edge strictly along the vertical axis. The root is driven deep into the alveolar process, breaking the bony trabeculae of the spongy substance. The clinical crown visually shortens (it may even hide under the gingiva). The tooth becomes completely immobile due to wedging, and the periodontal space completely disappears on the radiogram.
Dental fractures
Central and lateral maxillary incisors fracture most frequently. The fracture line may be transverse, oblique, or longitudinal. If two or more root fracture lines are diagnosed, such a fracture is termed comminuted.
The clinical picture depends on the volume of damaged tissues:
- Within enamel and dentin (without pulp chamber exposure): Patients are troubled by an aesthetic defect and pain from stimuli. An important consequence of the trauma for soft tissues: the lips and tongue are chronically traumatized by the sharp edges of the fractured crown, which can lead to the formation of painful erosions and decubital ulcers.
- With pulp chamber exposure: Exposure of the pulp causes sharp pain and leads to the development of traumatic pulpitis. Bright red tissue is visualized at the fracture site.
- Root fracture: Always accompanied by dislocation of the coronal part of the tooth. Interestingly, the crown may turn pink if a pulp rupture with hemorrhage into the pulp chamber has occurred.
A specific palpation technique is used for precise diagnosis of the root fracture level: the physician slightly displaces the crown with one hand while palpating the vestibular surface of the alveolar process with the second finger of the left hand. This allows tactile detection of the fracture boundary.
Treatment principles and possible complications
Patient management tactics directly depend on the nature of the trauma:
- Treatment of subluxation. Repositioning is performed under anesthesia, the tooth is taken out of occlusion, and a splint (individual mouthguard, Sekletov ribbon splint) is applied for 5–6 weeks. EPT (electric pulp testing) must be performed to monitor pulp vitality.
- Treatment of complete luxation. Replantation is indicated. The avulsed tooth must not be cleaned of periodontal remnants — the socket is merely rinsed with saline. If less than 10 hours have passed, the pulp is preserved; if more, it is extirpated beforehand, and the canal is filled with phosphate cement with a pin to retain the tooth in case of potential root resorption.
- Treatment of intrusive dislocation. Presents the greatest difficulties. In children (or with shallow intrusion), an expectant management strategy is chosen for spontaneous eruption of the tooth. In complex cases, surgical reposition or orthodontic extrusion is resorted to.
Among the main complications are root resorption (inflammatory, leading to tooth loss, or replacement resorption) and ankylosis (fusion of the root with the bone).
Briefly: answers to topical questions
What types of splints are used for tooth fixation in subluxation?
Three main splinting options are used to fix a tooth in case of subluxation.
- Individual mouthguard splint — made of fast-curing acrylic resin, it must include at least two healthy teeth on each side of the dislocated tooth.
- G.A. Sekletov "fragment tape splint" — made of a tin strip, it covers the incisal edge and palatal surface of the tooth to prevent its displacement.
- Smooth wire splint — a less preferred method, as twisting the fixing wire ligature carries the risk of displacing the tooth out of the socket.
What long-term complications can develop after a tooth dislocation?
Complications such as root resorption, inflammatory processes, and ankylosis can develop after a tooth dislocation.
- External root resorption — occurs after subluxation, the process does not progress, and the severity depends on the root displacement during trauma.
- Acute inflammation — can develop in intrusion, requiring immediate endodontic intervention (tooth trepanation and pulp removal).
- Ankylosis — fusion of the root with the bone, which can occur in intrusion and require mechanical disruption of the junction or tooth extraction.
What are the absolute and relative contraindications to tooth replantation in complete dislocation?
The sources do not divide contraindications to replantation into absolute and relative. The following contraindications are indicated:
- Destruction of the socket walls.
- Developed inflammatory process.
- Pronounced destruction of the dislocated tooth.
To remember the types of healing after replantation, use the abbreviation PPO: Periodontal (best outcome, periodontium preserved on the root and alveolus), Periodontal-fibrous (uneven space), Osteoid (periodontium destroyed, space absent on the radiograph, high risk of rapid resorption).
Class and exam questions
Why is the pulp not removed immediately in case of subluxation?
The absence of electrical excitability (according to pulp testing) in the first weeks does not always mean irreversible pulp death. The tooth is monitored dynamically, as recovery of values may take several months.
Why is a post with phosphate cement placed in the canal during replantation (after 10 hours)?
Resorption of the root often begins after replantation. In this case, it is the post that will serve as a framework keeping the tooth in the jaw and preventing it from falling out.
Should the tooth socket be curetted before replanting an avulsed tooth?
It is strictly forbidden. The socket walls are only washed with saline to preserve viable periodontal fragments — this is critically important for successful tooth engraftment.
Why is an intruded tooth completely immobile?
During a vertical impact, the wide part of the root penetrates into the narrower part of the alveolus. Mechanical wedging occurs in the bone tissue with complete destruction of the periodontal space.
What else to study on this topic
- Orthodontic appliances for extrusion of an intruded tooth
- Clinical features and prevention of inflammatory root resorption
- Surgical treatment of fractures of the alveolar process of the jaws
- Dynamic control of pulp vitality using electric pulp testing (EPT)
- Management tactics for patients with post-traumatic ankylosis
Master the entire topic in the course "Surgical Dentistry"
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- Complete guideline on "Non-ballistic soft tissue injuries of the face" and 866 more pages of the subject
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Other topics in the section "Chapter 11. Non-ballistic and ballistic facial injuries. Thermal and radiation lesions of the maxillofacial region (V.V. Afanasyev)"
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