Dental Injuries in Association With Facial Fractures

Transcription

1 J Oral Maxillofac Surg 67: , 2009 Dental Injuries in Association With Facial Fractures Olivier Lieger, MD, DMD,* Jürgen Zix, MD, DMD, Astrid Kruse, MD, DMD, and Tateyuki Iizuka, MD, DDS, PhD Purpose: The aim of the study was to investigate the association between dental injuries and facial fractures. Materials and Methods: We performed a prospective study of 273 patients examined at a level 1 trauma center in Switzerland from September 2005 until August 2006 who had facial fractures. Medical history and clinical and radiologic examination findings were recorded to evaluate demographics, etiology, presentation, and type of facial fracture, as well as its relationship to dental injury site and type. Results: In 273 patients with dentition, we recorded 339 different facial fractures. Of these patients, 130 (47.5%) sustained a fracture in the non tooth-bearing region, 44 (16%) had a fractured maxilla, and 65 (24%) had a fractured mandible. Among 224 patients with dentition who had a facial fracture in only 1 compartment, 140 injured teeth were found in 50 patients. Of 122 patients with an injury limited to the non tooth-bearing facial skeleton, 12 sustained dental trauma (10%). In patients with fractures limited to the maxilla (n 41), 6 patients had dental injuries (14.5%). In patients with fractures to the mandible (n 61), 24 sustained dental injuries (39%). When we compared the type of tooth lesion and the location, simple crown fractures prevailed in both jaws. Patients with a fracture of the mandible were most likely to have a dental injury (39.3%). The highest incidence of dental lesions was found in the maxilla in combination with fractures of the lower jaw (39%). This incidence was even higher than the incidence of dental lesions in the lower jaw in combination with fractures of the mandible (24%). Conclusions: Knowledge of the association of dental injuries and maxillofacial fractures is a basic tool for their prevention. Our study showed that in cases of trauma with mandibular fracture, the teeth in the upper jaw might be at higher risk than the teeth in the lower jaw. Further larger-scale studies on this topic could clarify this finding and may provide suggestions for the amelioration of safety devices (such as modified bicycle helmets) American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 67: , 2009 *Oral and Maxillofacial Surgeon, Department of Cranio-Maxillofacial Surgery, Canton Hospital Lucerne, Lucerne, Switzerland. Oral and Maxillofacial Surgeon, Department of Cranio-Maxillofacial Surgery, University of Berne, Berne, Switzerland. Resident, Department of Cranio-Maxillofacial Surgery, University of Zurich, Zurich, Switzerland. Professor and Head of Department, Department of Cranio-Maxillofacial Surgery, University of Berne, Berne, Switzerland. Address correspondence and reprint requests to Dr Lieger: Department of Cranio-Maxillofacial Surgery, Canton Hospital Lucerne, CH-6000 Lucerne 16, Switzerland; olivier.lieger@ksl.ch 2009 American Association of Oral and Maxillofacial Surgeons /09/ $36.00/0 doi: /j.joms Dental injuries in association with facial fractures are common in maxillofacial emergencies. 1-5 Good occlusion remains the main goal in fracture treatment. Dental injuries may complicate the treatment of facial fractures and usually require postoperative dental treatment adding cost and inconvenience for the patient. Earlier investigations concerning dental injuries have mainly been registered in association with fractures of the lower jaw. 1,2 Up to now, only 1 article has been published describing the type and frequency of dental lesions in facial trauma. 5 Of the patients analyzed in that article, only 7 had sustained a facial fracture. To our knowledge, a comprehensive study of dental injuries in relation to facial fractures has not been done. The aim of this study was therefore to analyze the correlation between facial fractures and dental injuries in patients treated at a level 1 trauma center in Switzerland from September 2005 until August Materials and Methods During a 1-year period ( ), 273 patients treated for facial fractures were evaluated in a prospective manner at the Department of Cranio-Maxillofacial Surgery, University Hospital Berne (Berne, Switzerland). Information collected from these cases 1680

2 LIEGER ET AL 1681 included age and gender of the patient, mechanism of injury, type of facial fracture, dental status, and type of dental injury. One maxillofacial surgeon was responsible for primary examination, treatment, and follow-up. The mechanism of injury was subdivided into assaults, road traffic accidents, falls, sports injuries, occupational injuries, and others. All fractures were recorded and assigned to 1 of the following groups: mandible, maxilla, or other (ie, non tooth-bearing bone). The type of fracture was classified and analyzed by use of computed tomography scans and panoramic or occipitomental radiographs. Comparison of facial fractures and dental lesions was performed, using only the data of patients with fractures in just 1 compartment (non tooth-bearing area, maxilla, or mandible). Dental injuries were classified according to the system described by Andreasen and Andreasen. 6 The dentition was also divided into 4 groups to simplify analysis (upper buccal segment, lower buccal segment, upper anterior segment, and lower anterior segment). The buccal segment groups included premolars and molars, and the anterior segment groups included canines and incisors. A 21% B 15% Mechanism of injury (n=273) 5% 20% 30% 9% Falls Occupational RTA Sports Assault Others Mechanisms of injury in cases with facial trauma and dental lesions (n=50) 24% 16% 2% 20% 8% Falls Occupational RTA Sports Assault Others Results 30% FIGURE 1. A, Distribution of mechanisms of injury in all cases recorded (n 273). B, Distribution of mechanisms of injury in cases with facial trauma and dental lesions (n 50). RTA, road traffic accident. In this study 357 facial fractures were registered in 273 patients (185 male and 88 female patients; ratio, 2.1:1) during the period of the study. Of these patients, 17 were edentulous (6%). Of the 256 patients with dentition, a total of 224 sustained a facial fracture in only one third of the face. The age of the patients (n 273) at the time of trauma ranged from 1 to 93 years (mean, 40.5 years; median, 37 years). In the majority of patients, trauma was the result of a fall (30% [n 79]); in 21% (n 58) it was related to sports and in 20% (n 54) it was associated with a road traffic accident, whereas violence was the cause of trauma in 15% (n 42) (Fig 1A). When we examined patients with facial fractures in combination with dental lesions, we found that the largest fraction were patients who had a traffic accident (30% [n 15]) (Fig 1B). In second place were those with sports injuries, at 24% (n 12). In those who had traffic accidents, bicycle riders were the largest patient group sustaining facial fractures with or without dental injuries (Fig 2). Of the 29 bicycle riders, 12 (41%) were wearing helmets at the time of injury. With regard to gender, sports injuries and falls were the most frequently recorded mechanisms of facial trauma in male patients (24% [n 44] and 22% [n 40], respectively) whereas falls were the most frequently recorded mechanism in female patients (44% [n 39]). INCIDENCE AND LOCATION OF FACIAL FRACTURES AND DENTAL INJURIES AND THEIR CORRELATION Among 273 patients with dentition, 339 different facial bone fractures were recorded (Fig 3). Of these patients, 130 (47.5%) sustained a fracture in the non tooth-bearing region, 44 (16%) had a fractured maxilla, and 65 (24%) had a fractured mandible. In 34 cases (12.5%) more than 1 facial compartment was involved. These cases and the edentulous cases were excluded from further analysis. In the 224 patients with dentition who sustained a facial fracture in only 1 compartment, 50 patients presented with 140 injured teeth. Of the 122 patients with an injury limited to the non tooth-bearing facial skeleton, 12 had dental trauma (10%). In patients with fractures limited to the maxilla (n 41), 6 patients had dental injuries (14.5%). In patients with fractures to the mandible (n 61), 24 sustained dental injuries (39%).

3 1682 DENTAL INJURIES AND FACIAL FRACTURES A Road users in all traffic accidents (n=54/273) 54% B 9% 4% 15% 11% Road users in traffic accidents in cases with facial fractures and dental lesions (n=14/50) 51% 14% 0% 21% pedestrian car driver car passenger motorcycle scooter bicycle pedestrian car driver car passenger motorcycle scooter bicycle The percentage of male patients and female patients sustaining dental injuries was 18% for each gender (n 34 and n 16, respectively). Most injuries occurred in the maxillary anterior region (n 50 [49.5%] and n 18 [36%], respectively). Regarding age, most dental injuries were seen during the second decade of life (n 14 [33.3%]), followed by the third decade (n 12 [26.6%]). Discussion To date, only few articles have been published describing the type and frequency of dental injuries associated with facial trauma. 1-5 These articles either concentrated on the incidence of dental lesions in fractures of the lower jaw or examined epidemiologic aspects of facial fractures or dental lesions. In the article of Da Silva et al 5 the association of facial trauma and dental lesions was analyzed. However, only 7 patients in this study had a facial fracture. Most of the patients in their study sustained soft tissue injuries in association with dental trauma. FIGURE 2. A, Distribution of patients involved in road traffic accidents (n 54). B, Distribution of patients involved in road traffic accidents who had facial fractures and dental lesions (n 14). The correlations between the numbers/types of dental injuries and the locations of the facial fractures are shown in Table 1. Regarding specific types of facial fractures, we found that most dental injuries were found in patients with symphyseal fractures of the mandible (7 of all symphyseal mandible fractures [7 of 9]), followed by condylar fractures (42.5% [14 of 33]). Because only a small fraction of patients (3 of 10) had injuries to their primary teeth, no differentiation between permanent and primary dentition was made. When comparing the type of tooth lesion and the location, we found that simple crown fractures prevailed in both jaws (Table 2), closely followed by avulsions in the maxilla as the second most common tooth lesion. In addition, when comparing the anterior segments versus buccal segments, we found crown fractures in similar numbers (n 29 vs n 28). The same applied for avulsions (n 11 vs n 12). All other types of dental injuries, however, were mainly found in the anterior segments of the jaws. FIGURE 3. A and B, Distribution of facial fractures in all patients (n 273).

4 LIEGER ET AL 1683 Table 1. CORRELATION OF FRACTURE SITE AND LOCATION OF DENTAL LESION FOR 140 DENTAL INJURIES IN 50 PATIENTS Location of Dental Lesion Location of Facial Fracture (No. of lesions) Non Tooth-Bearing Region Maxilla Mandible Maxilla Front 16 (11%) 9 (6%) 33 (24%) Side 4 (3%) 6 (4%) 21 (15%) Total 20 (14%) 15 (10%) 54 (39%) Mandible Front 6 (4%) 3 (2%) 28 (20%) Side 1 (1%) 8 (6%) 5 (4%) Total 7 (5%) 11 (8%) 33 (24%) Total (n 140) 27 (19%) 26 (18%) 87 (63%) Some studies show that in cases of facial trauma the most common location for fractures is the mandible. 7,8 In a large epidemiologic study, Gassner et al, 9 however, found a similar distribution among the mandible, maxilla, and non-tooth-bearing regions in 3,578 patients. Andreasen 10 described in detail how the association between facial and dentoalveolar injuries depends on the collision energy, direction, and resistance of the tissue protecting the involved teeth. It is, however, clear that the exact mechanisms of dental injuries often remain unknown. In our study, patients with a fracture of the mandible were most likely to have a dental injury (39.3%). This finding is similar to findings from other studies. 2,3 In dentate patients 19.5% had dental injuries in connection with facial bone fractures. Injury to a single tooth is rare. Several teeth are damaged in most cases. In most of the cases (68%) the incisors and the canines were affected. It was, however, astonishing that in only 14.6% of patients (6 of 41) with fractures limited to the maxilla, dental injuries were recorded. One could assume that a blow to the maxilla, causing a bone fracture, should be hard enough to cause dental injuries, especially given that the front teeth of the upper jaw are often involved in trauma because of their position in the sagittal plane. 10,11 On the other hand, the highest incidence of dental lesions in the maxilla was found in combination with fractures of the lower jaw (39%). This incidence was even higher than the incidence of dental lesions in the lower jaw in combination with fractures of the lower jaw (24%). This could be because of the impaction of the lower jaw against the upper teeth. In these patients the chin area most likely hit the ground first, causing forceful closure of the jaws, leading to dental injuries of both jaws. A reason why, during such injuries, more teeth are injured in the maxilla than in the mandible could be the fact that the teeth of the lower jaw have better bony anchorage and act like wedges in the case of forceful occlusion. Examining the association of type and location of dental lesions, we found that in the anterior and buccal regions, the most common lesions were simple crown fractures. This finding is in accordance with reports from different authors who found high frequencies of crown fractures in falls and collisions Avulsions were mostly observed in the maxilla, as found in other studies Lateral dislocations were found in the anterior segments of both jaws. This is in contrast to other studies, where lateral tooth dislocations primarily involved the maxillary front region. 15,18-20 Avulsions and dislocations are typically observed in the front teeth, where the direct impact generates forces that tend to displace the coronal portion orally, causing displacement of the root in the other direction or, ultimately, even avulsion of the tooth. 6 Falls were the most common cause of facial fractures in this study. In the patient group with facial fractures and dental injuries, traffic accidents and sports injuries were more prevalent. This is in agree- Table 2. CORRELATION OF TYPE AND LOCATION OF DENTAL LESION FOR 140 DENTAL INJURIES IN 50 PATIENTS Front (No. of lesions) Side (No. of lesions) Upper Jaw Lower Jaw Total Upper Jaw Lower Jaw Total Total (No. of lesions) Avulsion (16.5%) Intrusion (2%) Extrusion (3%) Lateral dislocation (15%) Concussion (6.5%) Simple crown fracture (41%) Complicated crown fracture () Crown/root fracture () Root fracture (2%) Total (68%) (32%) 140 (100%)

5 1684 DENTAL INJURIES AND FACIAL FRACTURES ment with other studies This difference in mechanisms between the entire study group and the patients with dental injuries can be explained by the fact that a large portion of patients with dental injuries seen in the emergency department sustained bicycle accidents (Fig 3B). This is in accordance with other studies. 4,27 An explanation for this phenomenon could be the high-velocity force acting on the unprotected face of the bicycle rider. In this study 12 of 29 bicycle riders (41%) were wearing helmets at the time of injury. Whether a helmet also has a protective effect on the face is unclear. To our knowledge, there are no studies on this topic in the Englishlanguage literature. The results of this study showed that between the ages of 31 and 40 years, the incidence of facial trauma was highest. It is also striking that the highest risk for male patients in our study is during the fourth decade, and for female patients, it is during the sixth decade in life. With regard to age, most falls happened in the first decade and after the age of 60 years. Rehman and Edmondson 28 examined the causes of maxillofacial injuries in elderly patients and found that in 86% (n 36), the reason was a fall. Our study shows a higher incidence of trauma in patients ranging in age from 11 to 40 years, probably because of the trend of individuals in this age group having more intense social activity. The gender ratio was in agreement with other studies (male-female ratio, 2.1:1.0). 5,29 Knowledge of the association of dental injuries and maxillofacial fractures is a basic tool for their prevention. Our study showed that in cases of trauma with mandibular fracture, the teeth in the upper jaw might be at higher risk than the teeth in the lower jaw. Further larger-scale studies on this topic could clarify this finding and may provide suggestions for the amelioration of safety devices (such as modified bicycle helmets). References 1. Silvennoinen U, Lindqvist C, Oikarinen K: Dental injuries in association with mandibular condyle fractures. Endod Dent Traumatol 9:254, Ignatius ET, Oikarinen KS, Silvennoinen U: Frequency and type of dental traumas in mandibular body and condyle fractures. Endod Dent Traumatol 8:235, Lamberg MA, Tasanen A, Kotilainen R: Injuries concomitant with fractures of the facial skeleton. Proc Finn Dent Soc 72: 170, Lindqvist C, Sorsa S, Hyrkas T, et al: Maxillofacial fractures sustained in bicycle accidents. Int J Oral Maxillofac Surg 15:12, Da Silva AC, Passeri LA, Mazzonetto R, et al: Incidence of dental trauma associated with facial trauma in Brazil: A 1-year evaluation. Dent Traumatol 20:6, Andreasen JO, Andreasen FM: Classification, epidemiology and etiology, in Textbook and Color Atlas of Traumatic Injuries to the Teeth (ed 4). Copenhagen, Munksgaard, 2007, pp Erol B, Tanrikulu R, Gorgun B: Maxillofacial fractures. Analysis of demographic distribution and treatment in 2901 patients (25-year experience). J Craniomaxillofac Surg 32:308, Motamedi MH: An assessment of maxillofacial fractures: A 5-year study of 237 patients. J Oral Maxillofac Surg 61:61, Gassner R, Tuli T, Hachl O, et al: Cranio-maxillofacial trauma: A 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg 31:51, Andreasen JO: Etiology and pathogenesis of traumatic dental injuries. Scand J Dent Res 78:329, Oikarinen K: Pathogenesis and mechanism of traumatic injuries to teeth. Endod Dent Traumatol 3:220, Hedegård B, Stålhane I: A study of traumatized permanent teeth in children 7-15 years. I. 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Int J Oral Surg 11:152, Rehman K, Edmondson H: The causes and consequences of maxillofacial injuries in elderly people. Gerodontology 19:60, Al Ahmed HE, Jaber MA, Abu Fanas SH, et al: The pattern of maxillofacial fractures in Sharjah, United Arab Emirates: A review of 230 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:166, 2004