Dental Traumatology 2014; 30: 435–441; doi: 10.1111/edt.12118
Concomitant dental injuries in maxillofacial fractures – a retrospective analysis of 1219 patients Roman K. Rahimi-Nedjat*, Keyvan Sagheb*, Christian Walter Department of Oral and Maxillofacial Surgery, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
Key words: dental injury; dental trauma; maxillofacial fractures; facial fractures Correspondence to: Roman K. Rahimi-Nedjat, Department of Oral and Maxillofacial Surgery, University Medical Center of the Johannes Gutenberg-University, Augustusplatz 2, 55131 Mainz, Rheinland-Pfalz, Germany Tel.: +(0049)6131-175086 Fax: +(0049)6131-176602 e-mail: roman.rahimi-nedjat @unimedizin-mainz.de Accepted 16 April, 2014
*Both authors contributed equally to this work.
Abstract – Background/Aim: Traumatic dental injuries are frequently combined with maxillofacial fractures, but literature addressing this topic is rare. In a retrospective study, the frequency of dental lesions in inpatients with traumatic facial injuries was analyzed. Material and Methods: All patients referred to the Department of Oral and Maxillofacial Surgery of the University Medical Center of the Johannes Gutenberg-University Mainz for inpatient treatment due to facial fractures between January 2001 and December 2007 were analyzed regarding the type of fracture, its localization, and potential concomitant dental injuries. In addition a systematic review was performed to compare the findings of this study with existing data. Results: Altogether 1219 facial trauma patients underwent inpatient treatment. 184 (15.87%) out of those had 451 injured teeth, and 4.9% were edentulous. The most frequent causes were assaults (25.1%), followed by falls (19.6%) and bike accidents (10.1%). Avulsion, especially of the upper incisors, occurred in most cases (27.9%). Assaults caused 1.29 dental fractures per patient, while traffic-related accidents led to three to four times higher injury-rates. Conclusions: With almost every sixth patient having at least one kind of dental injury, this study shows that a thorough anamnesis and examination of the dental status are absolutely necessary, especially in patients who suffered from high-speed impacts or collisions with low-resilience surfaces.
Injuries to the head and neck are a substantial proportion of traumatology, and the management and treatment of maxillofacial fractures in particular demands high accuracy and knowledge to restore function and esthetics (1–3). The distribution of different causes of facial fractures differs depending on the geographic region, but traffic accidents, assaults, falls, and sports injuries are the main reasons (4, 5). Facial fractures often occur with concomitant lesions such as soft tissue, dentoalveolar, or isolated dental injuries (6). As patients with combined dental and facial fractures have often sustained their injuries from high-speed impacts, the extent and severity of the traumas are extensive. Additional dental injuries might complicate the correct treatment of complex facial traumas (6–9). However, dental injuries not only influence the surgical therapy, they can also provoke issues related to postoperative physical psychological wellbeing as well as esthetic issues, potentially leading to long-lasting serious health problems and making social rehabilitation more difficult (10). To achieve early recovery, the correct diagnosis and treatment with emphasis on concomitant lesions are necessary. Many studies have been published investigating dental trauma in general (11, 12) but only few studies have © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
exclusively analyzed the incidence of dental injuries among patients with maxillofacial injuries or fractures. The aim of this study was to investigate the epidemiology and frequency of dental injuries in patients with maxillofacial fractures with regard to the cause, the type of oro-maxillofacial fracture and the dental fracture localization, and type of lesion. Furthermore, a systematic review was performed to compare this study’s results with the literature. Material and methods
In a retrospective study, all patients who were admitted for inpatient treatment because of maxillofacial fractures between January 2001 and December 2007 at the Department of Oral and Maxillofacial Surgery of the University Medical Center of the Johannes GutenbergUniversity of Mainz were analyzed. Dental injuries were classified as follows: (i) crown fracture limited to the enamel, (ii) crown fracture limited to enamel and dentin, (iii) crown fracture with involvement of the pulp, (iv) equigingival horizontal tooth fracture, (v) coronal third root fractures, (vi) mid root fracture, (vii) apical third root fractures, (viii) longitudinal/vertical crown and root fracture, (ix) avulsion, (x) oral luxation, (xi) vestibular luxation, (xii) 435
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Fig. 1. Age distribution of male (blue) and female (red) patients. The age group 14–19 was picked to combine teenagers in one bar.
intrusion, (xiii) loosening I°, (xiv) loosening II°, (xv) loosening III°, (xvi) tooth located in fracture line with luxation of the tooth, (xvii) tooth located in fracture line without luxation of the tooth, (xviii) retained tooth located in fracture line, and (xix) tooth involved as part of dental bridge. Facial fractures were classified as: (i) median mandibular fractures, (ii) paramedian mandibular fractures, (iii) fractures of the mandibular angle, (iv) fractures of the mandibular condyle, (v) fractures of the coronoid process, (vi) fractures of the alveolar process, (vii) sagittal maxillary fractures, (viii) Le Fort I, (ix) Le Fort II, (x) Le Fort III, (xi) fracture of the nasal bone, (xii) orbital fracture, (xiii) fracture of the zygomatic bone, and (xiv) fracture of the anterior wall of the maxillary sinus. Furthermore, the cause of the injury was classified as follows: (i) car accident, (ii) motorcycle accident, (iii) bike accident, (iv) horse accident, (v) accidents at work, (vi) assaults, (vii) falls, (viii) traffic accidents as a pedestrian, (ix) injuries during an epileptic-/cramp-episode, (x) household accidents, (xi) sport accidents, (xii) iatrogenic, (xiii) pathologic, and (xiv) unknown reason. In addition, a systematic review on the topic of dental traumatology in patients with fractures of the oral and maxillofacial region was performed. The keywords ‘combined dental trauma’, ‘maxillofacial fracture dental trauma’, and ‘facial fracture dental trauma’ were entered in PubMed. All German and English articles from 1990 up to December 2013 were analyzed. Only those investigating the incidence of dental trauma in patients presenting with facial fractures or facial injuries were included. Studies exclusively investigating dental traumas were excluded. The statistical analysis was restricted to a descriptive analysis only. The data from this retrospective study were handled within the principles of the Helsinki Declaration. Results
Altogether 1219 patients were treated for maxillofacial fractures in the analyzed period [average age 32.5 years 19.3, 75.1% male (30.0 years 16.8) and 24.9% female patients (40.0 years 24.0)].
4.9% were edentulous [n = 60; average age 73.5 years 17.0, 53.3% male (69.5 years 15.6), and 46.7% were female patients (75.5 years 18.2)]. Of the remaining 1159 patients, 184 [15.88%; average age 24.0 years 15.7, 76.6 male (24.0 years 13.5) and 23.4% female patients (24.0 years 21.6)] showed at least one type of the above-mentioned dental injuries. The largest number of patients belonged to the age group 20–29 years (33.7%). 0.9% were younger than 14 years (Fig. 1). Overall, 451 teeth were traumatized; 44 dental injuries (9.8%) were located in the primary dentition [nine boys and five girls; average age 3.9 years 3.8, 64.3% male (2.7 years 1.6) and 35.7% female patients (6.0 years 5.8)]. Most dental injuries were caused by assaults, followed by falls, and bike accidents. When taking all traffic-related injuries into account (car accidents, motorcycle accidents, accidents as a pedestrian and bike accidents), they represented the second largest group with 27.1% (Table 1). Table 1. Causes of dental injuries. Absolute patient numbers followed by the percentage in parentheses are shown
N Age (median) Assaults (%) Traffic-related accidents (%) Car accident (%) Motorcycle accident (%) Bike accident (%) As a pedestrian (%) Falls (%) Sports accidents (%) Horse accident (%) Accidents at work (%) Epileptic seizure related injury (%) Iatrogenic (%) Household accidents (%) Pathologic (%) Unknown reason (%)
Male
Female
Total
141 24 (13.5) 56 (39.7) 40 (28.37)
43 24 (21.6) 9 (20.9) 10 (23.26)
184 24 (15.4) 65 (35.3) 50 (27.17)
15 6 14 5 21 7 2 3 2
(10.6) (4.3) (9.9) (3.5) (14.9) (5.0) (1.4) (2.1) (1.4)
2 1 4 3 17 1 3 1 0
(4.7) (2.3) (9.3) (7.0) (39.5) (2.3) (7.0) (2.3) (0.0)
17 7 18 8 38 8 5 4 2
(9.2) (9.2) (9.8) (4.3) (20.7) (4.3) (2.7) (2.2) (1.1)
1 0 1 8
(0.7) (0.0) (0.7) (5.7)
0 1 0 1
(0.0) (2.3) (0.0) (2.3)
1 1 1 9
(0.5) (0.5) (0.5) (4.9)
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Dental injuries in maxillofacial fractures Table 2. Number of injured teeth per patient for the main causes
Assaults Traffic-related accidents Car accident Motorcycle accident Bike accident As a pedestrian Falls Sports accidents Horse accidents
Number of patients
Number of fractured teeth
Injured teeth per patient
65 50
84 173
1.29 3.46
17 7 18 8 38 8 5
48 31 66 28 121 14 19
2.82 4.43 3.67 3.50 3.18 1.75 3.75
The calculation of the number of injured teeth per patient shows that assaults led to 1.29 dental injuries, while traffic-related causes, especially those due to bike and motorcycle accidents, led to much higher injuryrates [bike 3.67, motorcycle 4.43 (Table 2)]. Among men, assaults were responsible for 39.7% of the injuries, followed by 14.9% for fall-related injuries. In female patients, 39.5% of injuries were associated with falls and 20.9% with assaults (Table 1). (a)
(b)
Fig. 2. Frequency and distribution of periodontal and dental hard tissue injuries in the (a) upper jaw (b) lower jaw. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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The 184 patients with a dental trauma had 304 facial fractures. In most cases, dental injuries occurred in combination with mandibular fractures: 31.5% (n = 96) mandibular angle, and 21.7% (n = 66) paramedian mandibular fractures. In 39 patients, combined mandibular angle and paramedian fractures were present. Altogether 168 (91.3%) patients with dental trauma had at least one type of mandibular fracture (median, paramedian, mandibular angle, alveolar process, coronoid process, or condylar process) with or without additional fractures of other facial bones. Dental injuries in combination with isolated fractures of the maxilla or combinations such as in LeFort I and II occurred in 12 cases (6.5%). The teeth most often affected were the incisors of the upper jaw and the wisdom teeth of the lower jaw. In detail, the upper medial incisors were affected in 20.6% of all cases (tooth 11/51 n = 38/11, tooth 21/61 n = 34/10), the upper lateral incisors in 14.6% (tooth 12/52 n = 26/6, tooth 22/62 n = 28/6), so that the upper incisor were affected in 35.3% of all cases (Fig. 2a,b). The lower incisors were injured in only 17.3% (n = 78) of cases. In the primary dentition, the biggest difference between the mandible and the maxilla can be seen in the region of the incisors [lower incisors n = 5, upper incisors n = 33 (Fig. 3a,b)]
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(b)
Fig. 3. Frequency and distribution of periodontal and dental hard tissue injuries in the primary dentition of the (a) upper jaw (b) lower jaw. Table 3. Distribution of periodontal and dental hard tissue injuries to the anterior and posterior teeth
Periodontal (%) Avulsion (%) Luxation (%) Intrusion (%) Loosening (I/II/III) (%) Dental hard tissue (%) Crown fracture (%) Root fracture (%) Longitudinal fracture (%) Eguigingival fracture (%)
17–14
13–23
24–27
37–34
33–43
44–47
6 4 1 0 1 11 4 0 3 4
121 54 41 8 18 56 31 4 0 21
4 2 2 0 0 11 5 1 1 4
4 2 1 0 1 10 4 0 4 2
61 26 38 0 7 13 8 2 0 3
1 1 0 0 0 9 4 2 1 2
(35.3) (23.5) (0.1) (0.0) (0.1) (64.7) (23.5) (0.0) (17.6) (23.5)
(68.4) (30.5) (23.2) (4.5) (10.2) (31.6) (17.5) (2.3) (0.0) (11.9)
The greatest difference in the primary dentition was in the incisor teeth where there were only five injured teeth in the mandible vs 33 in the anterior maxilla (Fig. 3a,b). The wisdom teeth were affected in both jaws, but were affected considerably more often in the mandible, with a predominance of the left hand side: Tooth 38: 12.4% (n = 56); and tooth 48: 6.4% (n = 29). The upper wisdom teeth were injured in only two cases (0.4%). The lower wisdom teeth in general were located very often in the fracture line. The upper wisdom teeth
(26.7) (13.3) (13.3) (0.0) (0.0) (73.3) (33.3) (6.6) (6.6) (26.7)
(28.6) (14.3) (7.1) (0.0) (7.1) (71.4) (28.6) (0.0) (28.6) (14.3)
(82.4) (35.1) (51.4) (0.0) (9.5) (17.6) (10.8) (2.7) (0.0) (4.1)
(10.0) (10.0) (0.0) (0.0) (0.0) (90) (40.0) (20.0) (10.0) (20.0)
showed a horizontal fracture on gingival level in both cases. The most often diagnosed injury types overall were avulsions (22.4%, n = 101) and luxations (14.0%, n = 63). Horizontal tooth fractures on a gingival level occurred in 9.3% of the cases (n = 42). Complicated and uncomplicated crown fractures occurred altogether in 12.6% (n = 53). Table 3 shows the distribution of periodontal and dental hard tissue injuries to the teeth. While periodontal traumatization occured more often in the anterior teeth (68.4% in the maxilla and 82.4% in the mandible), injuries to the dental hard tissue could be seen © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Dental injuries in maxillofacial fractures
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Table 4. Overview systematic review Overall incidence, %
Main cause of dental trauma
Main associated facial fracture
Main dental trauma
Most affected tooth group
Comments
Simple crown fractures
Maxillary anterior region
Facial injuries and fractures investigated Edentulous patients excluded
Luxation/ avulsion
Maxillary anterior region
Luxation
Maxillary anterior region Maxillary anterior region Maxillary anterior region Anterior/posterior maxilla equally Maxillary anterior region Maxillary anterior region Maxillary anterior region Maxillary anterior region
Author
Year/country
Number of patients
Gassner
1999/Austria
6000
48.25
Play/household
n/a
Subluxation
Lieger
2009/ Switzerland
256
19.5
Traffic accidents (bicycle)
Da Silva
2004/Brazil
340
15.29
Falls
Ignatius
1992/Finland
207
20
Traffic accidents
Mandible (symphyseal fractures) Maxillary dentoalveolar fractures Mandible
Iso-Kungas
2012/Finland
200
22.5
Marchiori
2012/Brazil
2785
19
Silvennoinen
1993/Finland
330
31
Traffic accidents (motor vehicle) Traffic accidents (bicycle) Falls
Thoren
2010/Finland
389
16
Zhou
2012/China
1131
41.8
Roccia
2013/Italy
2110
13.1
Current study
2013/Germany
1219
15.88
Traffic accidents (motor vehicle) Traffic accidents (motor vehicle) Traffic accidents (motor vehicle) Assaults
Mandible Mandible Mandible
Crown fractures Avulsion
Mandible
Crown fracture Crown fracture Avulsion
Mandible
Luxations
Mandible
Avulsion
Mandible
more often in the posterior region (69.0% in the upper jaw, 80.7% in the lower jaw). In the primary dentition, oral luxations were the most frequent injury type with 17 of 44 cases (38.6%). Avulsions were diagnosed in seven teeth (15.9%). Inpatient treatment for this age group was performed, with the exception of two cases for extended fractures of the alveolar process. Systematic Review
While searching for dental trauma, many publications can be found focusing on the epidemiology of isolated or combined dental injuries. Our search, however, concentrated only on studies that included all patients with facial fractures of the head and that then subsequently investigated associated dental injuries in detail. One thousand seven hundred and thirty-five articles were found from 1990 to present. 52 studies appeared appropriate for our study, and 10 of those matched the inclusion criteria upon closer inspection (Table 4). Four of the included studies focused on very specific aspects only: Two investigated mandibular fractures exclusively (13, 14), one included pediatric patients only (15), and one put emphasis on dental avulsion (16). One study from Zhou et al. (17, 18) was excluded as the same study population was described in another, more comprehensive paper from the same author. Altogether 14 967 patients were investigated and the average incidence rate of injured teeth was 23.85% (range: 13.1–48.25%). Aside from the studies investigating only mandibular fractures, six studies also pointed out fractures of the mandible as the most associated facial fracture (7, 9, 15, 16, 18). © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Facial injuries and fractures investigated only 7 fractures overall Only fractures of the mandible investigated Only pediatric patients investigated Emphasis on dental avulsion Only mandibular condyle fractures investigated
Only one study claimed maxillary dentoalveolar fractures as the leading combined injury. However, in that study, only seven patients of 340 suffered from facial fractures (19). Discussion
One hundred and eighty-four patients out of 1219 with facial traumas had 451 injured teeth. The most frequent causes were assaults (25.1%), falls (19.6%), and bike accidents (10.1%). Avulsion, especially of the upper incisives, occurred in most cases (27.9%). Only few studies have been published addressing the relationship of dental injuries and facial fractures, and the reported incidences vary between 13% to almost 50% (7, 20). While the causes for the injuries vary depending on the different geographic locations, fractures of the mandible seem to be the most frequent osseous injury associated with dental injuries (21–23). As many patients with facial fractures suffer from high-speed impacts, they present a broad scope of associated traumas, such as traumas of the limbs, brain, chest, spine, or abdomen (24). In the present study, 184 out of 1219 patients with oro-maxillofacial fractures had a concomitant dental injury resulting in a comparatively low incidence rate of only 15.88% and an average of 2.45 violated teeth per patient (451 injured teeth). Oikarinen et al. (25) showed that the occurrence of dental traumatization mostly depends on the impacting surface or the object provoking the fracture. Therefore, the energy, shape, and resilience seem to be crucial factors causing the difference in the effect between different forces. In our study, assaults showed only 1.29 dental fractures per
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patient, which is far below average. In turn, forces with high-speed impacts or low-resilience surfaces, as in traffic or horse-related accidents, had a three to four times higher injury-rates. These findings absolutely support the findings of Oikarinen et al. As punches often hit the mandible, this may well be the reason for the high number of wisdom teeth involved; wisdom teeth play an important role as a weak point in the mandible, making it prone for fractures of the mandibular angle (26–28).Motor vehicle accidents in our study totaled only 13%. Given that this group plays the main role for dental or maxillofacial traumatization in studies (15, 18, 29) from other countries, this number might be an argument for the high security standard, including the obligation to buckle up or wear protective headgear as a motorcyclist. The causes for injuries are not equally distributed for the genders. With almost 40%, assaults were the most frequent cause among male patients but only 20.9% for female patients. Gassner et al. (20) described similar findings in their research as well. Falls and horse-related accidents were more often observed in females. In the age group of patients older than 65 years, three out of seven patients (43%) were injured due to falls. Although Edmondson and colleagues did not investigate only patients with combined dental traumas and fractures but rather all patients with any kind of maxillofacial injury, they described a similarly high proportion of falls in this age group (30). Five out of the seven patients in this age group were female in our study. As described previously in the literature, most dental injuries are associated with either single or combined mandibular fractures (9, 13, 14). Even maxillary dental traumas occurred more often with fractures in the mandible than in the maxilla. The reason for this might be the impaction of the lower jaw against the upper teeth (9). Mid-facial fractures as one of the most common fracture types (6) only play a minor role for combined dental injuries. In the present study, only 16 patients suffered from dental traumatization in association with isolated mid-facial fractures. The anterior teeth of the maxilla were most often affected. More than one-third of all injured teeth (35.3%) were central or lateral upper incisors, which is consistent with the findings of previous studies (7, 9, 18). The third molar, as already mentioned, was usually involved by being located in the fracture line of mandibular angle fractures. Ellis et al. pointed out that there is still no consensus on the question as to whether teeth in the line of mandibular fractures should be extracted or not. However, in their study, they discovered that the rate of postoperative complications is higher when a tooth is left in the line of the fracture, although no statistical significance could be found (31). There is, however, an incongruity in terms of which type of dental injury is the most common lesion in patients with fractures of the facial skeleton. Simple or complicated crown fractures and avulsions or luxations seem to be the most prominent injury types, as seen in previous studies (7, 9, 13, 15, 16, 18, 20). In the present study, the most common injuries were avulsions and
luxations. Periodontal injuries occurred more often in the anterior region and dental hard tissue traumatization in the posterior region for both the upper and lower jaw. This is in accordance with previous studies (16, 18), and, as Lieger et al. (9) described, the direct traumaimpact on these teeth generates forces which displace the coronal portion leading to displacement of the root. As nearly every sixth patient with maxillofacial fractures has at least one type of dental trauma, the importance of a thorough examination of the dental status must be stressed; the correct treatment at the time of the injury might help to avoid later complications. Depending on the energy, shape, and resilience of the impacting force, the number of injured teeth varies. Traffic-related accidents in particular cause more fractured teeth per patient. For optimal treatment, patients with maxillofacial traumas should be seen by a physician with a dental background. Conflict of interest statement
There was no source of institutional, private or corporate financial support for this work. The authors declare no conflict of interest. References 1. Arangio P, Vellone V, Torre U, Calafati V, Capriotti M, Cascone P. Maxillofacial fractures in the province of Latina, Lazio, Italy: review of 400 injuries and 83 cases. J Craniomaxillofac Surg 2013; doi: 10.1016/j.jcms.2013.07.030 [Epub ahead of print] 2. Katarzyna B, Piotr A. Characteristics and epidemiology of zygomaticomaxillary complex fractures. J Craniofac Surg 2010 [Epub ahead of print]. 3. Ozkaya O, Turgut G, Kayali MU, Ugurlu K, Kuran I, Bas L. A retrospective study on the epidemiology and treatment of maxillofacial fractures. Ulus Travma Acil Cerrahi Derg 2009;15:262–6. 4. Al Ahmed HE, Jaber MA, Abu Fanas SH, Karas M. The pattern of maxillofacial fractures in Sharjah, United Arab Emirates: a review of 230 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:166–70. 5. van den Bergh B, Karagozoglu KH, Heymans MW, Forouzanfar T. Aetiology and incidence of maxillofacial trauma in Amsterdam: a retrospective analysis of 579 patients. J Craniomaxillofac Surg 2012;40:e165–9. 6. Gassner R, Tuli T, Hachl O, Rudisch A, Ulmer H. Cranio-maxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg 2003;31:51–61. 7. Thoren H, Numminen L, Snall J, Kormi E, Lindqvist C, Iizuka T et al. Occurrence and types of dental injuries among patients with maxillofacial fractures. Int J Oral Maxillofac Surg 2010;39:774–8. 8. Brasileiro BF, Passeri LA. Epidemiological analysis of maxillofacial fractures in Brazil: a 5-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:28–34. 9. Lieger O, Zix J, Kruse A, Iizuka T. Dental injuries in association with facial fractures. J Oral Maxillofac Surg 2009;67:1680–4. 10. Rocha MJ, Cardoso M. Traumatized permanent teeth in Brazilian children assisted at the Federal University of Santa Catarina, Brazil. Dent Traumatol 2001;17:245–9. 11. Emerich K, Nadolska-Gazda E. Dental trauma, prevention and knowledge concerning dental first-aid among Polish amateur boxers. J Sci Med Sport 2013;16:297–301.
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Dental injuries in maxillofacial fractures 12. Veire A, Nichols W, Urquiola R, Oueis H. Dental trauma: review of common dental injuries and their management in primary and permanent dentitions. J Mich Dent Assoc 2012;94:41–5. 13. Ignatius ET, Oikarinen KS, Silvennoinen U. Frequency and type of dental traumas in mandibular body and condyle fractures. Endod Dent Traumatol 1992;8:235–40. 14. Silvennoinen U, Lindqvist C, Oikarinen K. Dental injuries in association with mandibular condyle fractures. Endod Dent Traumatol 1993;9:254–9. 15. Iso-Kungas P, Tornwall J, Suominen AL, Lindqvist C, Thoren H. Dental injuries in pediatric patients with facial fractures are frequent and severe. J Oral Maxillofac Surg 2012;70:396–400. 16. Marchiori EC, Santos SE, Asprino L, de Moraes M, Moreira RW. Occurrence of dental avulsion and associated injuries in patients with facial trauma over a 9-year period. Oral Maxillofac Surg 2013;17:119–26. 17. Zhou HH, Ongodia D, Liu Q, Yang RT, Li ZB. Dental trauma in patients with single mandibular fractures. Dent Traumatol 2013;29:291–6. 18. Zhou HH, Ongodia D, Liu Q, Yang RT, Li ZB. Dental trauma in patients with maxillofacial fractures. Dent Traumatol 2013;29:285–90. 19. Da Silva AC, Passeri LA, Mazzonetto R, De Moraes M, Moreira RW. Incidence of dental trauma associated with facial trauma in Brazil: a 1-year evaluation. Dent Traumatol 2004;20:6–11. 20. Gassner R, Bosch R, Tuli T, Emshoff R. Prevalence of dental trauma in 6000 patients with facial injuries: implications for prevention. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:27–33. 21. Erol B, Tanrikulu R, Gorgun B. Maxillofacial fractures. Analysis of demographic distribution and treatment in 2901
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
22.
23.
24.
25. 26.
27.
28.
29.
30.
31.
441
patients (25-year experience). J Craniomaxillofac Surg 2004;32:308–13. Motamedi MH. An assessment of maxillofacial fractures: a 5-year study of 237 patients. J Oral Maxillofac Surg 2003;61:61–4. Sastry SM, Sastry CM, Paul BK, Bain L, Champion HR. Leading causes of facial trauma in the major trauma outcome study. Plast Reconstr Surg 1995;95:196–7. Thoren H, Snall J, Salo J, Suominen-Taipale L, Kormi E, Lindqvist C et al. Occurrence and types of associated injuries in patients with fractures of the facial bones. J Oral Maxillofac Surg 2010;68:805–10. Oikarinen K. Pathogenesis and mechanism of traumatic injuries to teeth. Endod Dent Traumatol 1987;3:220–3. Duarte BG, Assis D, Ribeiro-Junior P, Goncales ES. Does the relationship between retained mandibular third molar and mandibular angle fracture exist? an assessment of three possible causes. Craniomaxillofac Trauma Reconstr 2012;5:127–36. Bezerra TP, Silva Junior FI, Scarparo HC, Costa FW, Studart-Soares EC. Do erupted third molars weaken the mandibular angle after trauma to the chin region? A 3D finite element study. Int J Oral Maxillofac Surg 2013;42:474–80. Bezerra TP, Studart-Soares EC, Pita-Neto IC, Costa FW, Batista SH. Do third molars weaken the mandibular angle? Med Oral Patol Oral Cir Bucal 2011;16:e657–63. Kadkhodaie MH. Three-year review of facial fractures at a teaching hospital in northern Iran. Br J Oral Maxillofac Surg 2006;44:229–31. Rehman K, Edmondson H. The causes and consequences of maxillofacial injuries in elderly people. Gerodontology 2002;19:60–4. Ellis E III. Outcomes of patients with teeth in the line of mandibular angle fractures treated with stable internal fixation. J Oral Maxillofac Surg 2002;60:863–5.
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Concomitant dental injuries in maxillofacial fractures – a retrospective analysis of 1219 patients Roman K. Rahimi-Nedjat*, Keyvan Sagheb*, Christian Walter Department of Oral and Maxillofacial Surgery, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
Key words: dental injury; dental trauma; maxillofacial fractures; facial fractures Correspondence to: Roman K. Rahimi-Nedjat, Department of Oral and Maxillofacial Surgery, University Medical Center of the Johannes Gutenberg-University, Augustusplatz 2, 55131 Mainz, Rheinland-Pfalz, Germany Tel.: +(0049)6131-175086 Fax: +(0049)6131-176602 e-mail: roman.rahimi-nedjat @unimedizin-mainz.de Accepted 16 April, 2014
*Both authors contributed equally to this work.
Abstract – Background/Aim: Traumatic dental injuries are frequently combined with maxillofacial fractures, but literature addressing this topic is rare. In a retrospective study, the frequency of dental lesions in inpatients with traumatic facial injuries was analyzed. Material and Methods: All patients referred to the Department of Oral and Maxillofacial Surgery of the University Medical Center of the Johannes Gutenberg-University Mainz for inpatient treatment due to facial fractures between January 2001 and December 2007 were analyzed regarding the type of fracture, its localization, and potential concomitant dental injuries. In addition a systematic review was performed to compare the findings of this study with existing data. Results: Altogether 1219 facial trauma patients underwent inpatient treatment. 184 (15.87%) out of those had 451 injured teeth, and 4.9% were edentulous. The most frequent causes were assaults (25.1%), followed by falls (19.6%) and bike accidents (10.1%). Avulsion, especially of the upper incisors, occurred in most cases (27.9%). Assaults caused 1.29 dental fractures per patient, while traffic-related accidents led to three to four times higher injury-rates. Conclusions: With almost every sixth patient having at least one kind of dental injury, this study shows that a thorough anamnesis and examination of the dental status are absolutely necessary, especially in patients who suffered from high-speed impacts or collisions with low-resilience surfaces.
Injuries to the head and neck are a substantial proportion of traumatology, and the management and treatment of maxillofacial fractures in particular demands high accuracy and knowledge to restore function and esthetics (1–3). The distribution of different causes of facial fractures differs depending on the geographic region, but traffic accidents, assaults, falls, and sports injuries are the main reasons (4, 5). Facial fractures often occur with concomitant lesions such as soft tissue, dentoalveolar, or isolated dental injuries (6). As patients with combined dental and facial fractures have often sustained their injuries from high-speed impacts, the extent and severity of the traumas are extensive. Additional dental injuries might complicate the correct treatment of complex facial traumas (6–9). However, dental injuries not only influence the surgical therapy, they can also provoke issues related to postoperative physical psychological wellbeing as well as esthetic issues, potentially leading to long-lasting serious health problems and making social rehabilitation more difficult (10). To achieve early recovery, the correct diagnosis and treatment with emphasis on concomitant lesions are necessary. Many studies have been published investigating dental trauma in general (11, 12) but only few studies have © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
exclusively analyzed the incidence of dental injuries among patients with maxillofacial injuries or fractures. The aim of this study was to investigate the epidemiology and frequency of dental injuries in patients with maxillofacial fractures with regard to the cause, the type of oro-maxillofacial fracture and the dental fracture localization, and type of lesion. Furthermore, a systematic review was performed to compare this study’s results with the literature. Material and methods
In a retrospective study, all patients who were admitted for inpatient treatment because of maxillofacial fractures between January 2001 and December 2007 at the Department of Oral and Maxillofacial Surgery of the University Medical Center of the Johannes GutenbergUniversity of Mainz were analyzed. Dental injuries were classified as follows: (i) crown fracture limited to the enamel, (ii) crown fracture limited to enamel and dentin, (iii) crown fracture with involvement of the pulp, (iv) equigingival horizontal tooth fracture, (v) coronal third root fractures, (vi) mid root fracture, (vii) apical third root fractures, (viii) longitudinal/vertical crown and root fracture, (ix) avulsion, (x) oral luxation, (xi) vestibular luxation, (xii) 435
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Fig. 1. Age distribution of male (blue) and female (red) patients. The age group 14–19 was picked to combine teenagers in one bar.
intrusion, (xiii) loosening I°, (xiv) loosening II°, (xv) loosening III°, (xvi) tooth located in fracture line with luxation of the tooth, (xvii) tooth located in fracture line without luxation of the tooth, (xviii) retained tooth located in fracture line, and (xix) tooth involved as part of dental bridge. Facial fractures were classified as: (i) median mandibular fractures, (ii) paramedian mandibular fractures, (iii) fractures of the mandibular angle, (iv) fractures of the mandibular condyle, (v) fractures of the coronoid process, (vi) fractures of the alveolar process, (vii) sagittal maxillary fractures, (viii) Le Fort I, (ix) Le Fort II, (x) Le Fort III, (xi) fracture of the nasal bone, (xii) orbital fracture, (xiii) fracture of the zygomatic bone, and (xiv) fracture of the anterior wall of the maxillary sinus. Furthermore, the cause of the injury was classified as follows: (i) car accident, (ii) motorcycle accident, (iii) bike accident, (iv) horse accident, (v) accidents at work, (vi) assaults, (vii) falls, (viii) traffic accidents as a pedestrian, (ix) injuries during an epileptic-/cramp-episode, (x) household accidents, (xi) sport accidents, (xii) iatrogenic, (xiii) pathologic, and (xiv) unknown reason. In addition, a systematic review on the topic of dental traumatology in patients with fractures of the oral and maxillofacial region was performed. The keywords ‘combined dental trauma’, ‘maxillofacial fracture dental trauma’, and ‘facial fracture dental trauma’ were entered in PubMed. All German and English articles from 1990 up to December 2013 were analyzed. Only those investigating the incidence of dental trauma in patients presenting with facial fractures or facial injuries were included. Studies exclusively investigating dental traumas were excluded. The statistical analysis was restricted to a descriptive analysis only. The data from this retrospective study were handled within the principles of the Helsinki Declaration. Results
Altogether 1219 patients were treated for maxillofacial fractures in the analyzed period [average age 32.5 years 19.3, 75.1% male (30.0 years 16.8) and 24.9% female patients (40.0 years 24.0)].
4.9% were edentulous [n = 60; average age 73.5 years 17.0, 53.3% male (69.5 years 15.6), and 46.7% were female patients (75.5 years 18.2)]. Of the remaining 1159 patients, 184 [15.88%; average age 24.0 years 15.7, 76.6 male (24.0 years 13.5) and 23.4% female patients (24.0 years 21.6)] showed at least one type of the above-mentioned dental injuries. The largest number of patients belonged to the age group 20–29 years (33.7%). 0.9% were younger than 14 years (Fig. 1). Overall, 451 teeth were traumatized; 44 dental injuries (9.8%) were located in the primary dentition [nine boys and five girls; average age 3.9 years 3.8, 64.3% male (2.7 years 1.6) and 35.7% female patients (6.0 years 5.8)]. Most dental injuries were caused by assaults, followed by falls, and bike accidents. When taking all traffic-related injuries into account (car accidents, motorcycle accidents, accidents as a pedestrian and bike accidents), they represented the second largest group with 27.1% (Table 1). Table 1. Causes of dental injuries. Absolute patient numbers followed by the percentage in parentheses are shown
N Age (median) Assaults (%) Traffic-related accidents (%) Car accident (%) Motorcycle accident (%) Bike accident (%) As a pedestrian (%) Falls (%) Sports accidents (%) Horse accident (%) Accidents at work (%) Epileptic seizure related injury (%) Iatrogenic (%) Household accidents (%) Pathologic (%) Unknown reason (%)
Male
Female
Total
141 24 (13.5) 56 (39.7) 40 (28.37)
43 24 (21.6) 9 (20.9) 10 (23.26)
184 24 (15.4) 65 (35.3) 50 (27.17)
15 6 14 5 21 7 2 3 2
(10.6) (4.3) (9.9) (3.5) (14.9) (5.0) (1.4) (2.1) (1.4)
2 1 4 3 17 1 3 1 0
(4.7) (2.3) (9.3) (7.0) (39.5) (2.3) (7.0) (2.3) (0.0)
17 7 18 8 38 8 5 4 2
(9.2) (9.2) (9.8) (4.3) (20.7) (4.3) (2.7) (2.2) (1.1)
1 0 1 8
(0.7) (0.0) (0.7) (5.7)
0 1 0 1
(0.0) (2.3) (0.0) (2.3)
1 1 1 9
(0.5) (0.5) (0.5) (4.9)
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Dental injuries in maxillofacial fractures Table 2. Number of injured teeth per patient for the main causes
Assaults Traffic-related accidents Car accident Motorcycle accident Bike accident As a pedestrian Falls Sports accidents Horse accidents
Number of patients
Number of fractured teeth
Injured teeth per patient
65 50
84 173
1.29 3.46
17 7 18 8 38 8 5
48 31 66 28 121 14 19
2.82 4.43 3.67 3.50 3.18 1.75 3.75
The calculation of the number of injured teeth per patient shows that assaults led to 1.29 dental injuries, while traffic-related causes, especially those due to bike and motorcycle accidents, led to much higher injuryrates [bike 3.67, motorcycle 4.43 (Table 2)]. Among men, assaults were responsible for 39.7% of the injuries, followed by 14.9% for fall-related injuries. In female patients, 39.5% of injuries were associated with falls and 20.9% with assaults (Table 1). (a)
(b)
Fig. 2. Frequency and distribution of periodontal and dental hard tissue injuries in the (a) upper jaw (b) lower jaw. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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The 184 patients with a dental trauma had 304 facial fractures. In most cases, dental injuries occurred in combination with mandibular fractures: 31.5% (n = 96) mandibular angle, and 21.7% (n = 66) paramedian mandibular fractures. In 39 patients, combined mandibular angle and paramedian fractures were present. Altogether 168 (91.3%) patients with dental trauma had at least one type of mandibular fracture (median, paramedian, mandibular angle, alveolar process, coronoid process, or condylar process) with or without additional fractures of other facial bones. Dental injuries in combination with isolated fractures of the maxilla or combinations such as in LeFort I and II occurred in 12 cases (6.5%). The teeth most often affected were the incisors of the upper jaw and the wisdom teeth of the lower jaw. In detail, the upper medial incisors were affected in 20.6% of all cases (tooth 11/51 n = 38/11, tooth 21/61 n = 34/10), the upper lateral incisors in 14.6% (tooth 12/52 n = 26/6, tooth 22/62 n = 28/6), so that the upper incisor were affected in 35.3% of all cases (Fig. 2a,b). The lower incisors were injured in only 17.3% (n = 78) of cases. In the primary dentition, the biggest difference between the mandible and the maxilla can be seen in the region of the incisors [lower incisors n = 5, upper incisors n = 33 (Fig. 3a,b)]
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(b)
Fig. 3. Frequency and distribution of periodontal and dental hard tissue injuries in the primary dentition of the (a) upper jaw (b) lower jaw. Table 3. Distribution of periodontal and dental hard tissue injuries to the anterior and posterior teeth
Periodontal (%) Avulsion (%) Luxation (%) Intrusion (%) Loosening (I/II/III) (%) Dental hard tissue (%) Crown fracture (%) Root fracture (%) Longitudinal fracture (%) Eguigingival fracture (%)
17–14
13–23
24–27
37–34
33–43
44–47
6 4 1 0 1 11 4 0 3 4
121 54 41 8 18 56 31 4 0 21
4 2 2 0 0 11 5 1 1 4
4 2 1 0 1 10 4 0 4 2
61 26 38 0 7 13 8 2 0 3
1 1 0 0 0 9 4 2 1 2
(35.3) (23.5) (0.1) (0.0) (0.1) (64.7) (23.5) (0.0) (17.6) (23.5)
(68.4) (30.5) (23.2) (4.5) (10.2) (31.6) (17.5) (2.3) (0.0) (11.9)
The greatest difference in the primary dentition was in the incisor teeth where there were only five injured teeth in the mandible vs 33 in the anterior maxilla (Fig. 3a,b). The wisdom teeth were affected in both jaws, but were affected considerably more often in the mandible, with a predominance of the left hand side: Tooth 38: 12.4% (n = 56); and tooth 48: 6.4% (n = 29). The upper wisdom teeth were injured in only two cases (0.4%). The lower wisdom teeth in general were located very often in the fracture line. The upper wisdom teeth
(26.7) (13.3) (13.3) (0.0) (0.0) (73.3) (33.3) (6.6) (6.6) (26.7)
(28.6) (14.3) (7.1) (0.0) (7.1) (71.4) (28.6) (0.0) (28.6) (14.3)
(82.4) (35.1) (51.4) (0.0) (9.5) (17.6) (10.8) (2.7) (0.0) (4.1)
(10.0) (10.0) (0.0) (0.0) (0.0) (90) (40.0) (20.0) (10.0) (20.0)
showed a horizontal fracture on gingival level in both cases. The most often diagnosed injury types overall were avulsions (22.4%, n = 101) and luxations (14.0%, n = 63). Horizontal tooth fractures on a gingival level occurred in 9.3% of the cases (n = 42). Complicated and uncomplicated crown fractures occurred altogether in 12.6% (n = 53). Table 3 shows the distribution of periodontal and dental hard tissue injuries to the teeth. While periodontal traumatization occured more often in the anterior teeth (68.4% in the maxilla and 82.4% in the mandible), injuries to the dental hard tissue could be seen © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Dental injuries in maxillofacial fractures
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Table 4. Overview systematic review Overall incidence, %
Main cause of dental trauma
Main associated facial fracture
Main dental trauma
Most affected tooth group
Comments
Simple crown fractures
Maxillary anterior region
Facial injuries and fractures investigated Edentulous patients excluded
Luxation/ avulsion
Maxillary anterior region
Luxation
Maxillary anterior region Maxillary anterior region Maxillary anterior region Anterior/posterior maxilla equally Maxillary anterior region Maxillary anterior region Maxillary anterior region Maxillary anterior region
Author
Year/country
Number of patients
Gassner
1999/Austria
6000
48.25
Play/household
n/a
Subluxation
Lieger
2009/ Switzerland
256
19.5
Traffic accidents (bicycle)
Da Silva
2004/Brazil
340
15.29
Falls
Ignatius
1992/Finland
207
20
Traffic accidents
Mandible (symphyseal fractures) Maxillary dentoalveolar fractures Mandible
Iso-Kungas
2012/Finland
200
22.5
Marchiori
2012/Brazil
2785
19
Silvennoinen
1993/Finland
330
31
Traffic accidents (motor vehicle) Traffic accidents (bicycle) Falls
Thoren
2010/Finland
389
16
Zhou
2012/China
1131
41.8
Roccia
2013/Italy
2110
13.1
Current study
2013/Germany
1219
15.88
Traffic accidents (motor vehicle) Traffic accidents (motor vehicle) Traffic accidents (motor vehicle) Assaults
Mandible Mandible Mandible
Crown fractures Avulsion
Mandible
Crown fracture Crown fracture Avulsion
Mandible
Luxations
Mandible
Avulsion
Mandible
more often in the posterior region (69.0% in the upper jaw, 80.7% in the lower jaw). In the primary dentition, oral luxations were the most frequent injury type with 17 of 44 cases (38.6%). Avulsions were diagnosed in seven teeth (15.9%). Inpatient treatment for this age group was performed, with the exception of two cases for extended fractures of the alveolar process. Systematic Review
While searching for dental trauma, many publications can be found focusing on the epidemiology of isolated or combined dental injuries. Our search, however, concentrated only on studies that included all patients with facial fractures of the head and that then subsequently investigated associated dental injuries in detail. One thousand seven hundred and thirty-five articles were found from 1990 to present. 52 studies appeared appropriate for our study, and 10 of those matched the inclusion criteria upon closer inspection (Table 4). Four of the included studies focused on very specific aspects only: Two investigated mandibular fractures exclusively (13, 14), one included pediatric patients only (15), and one put emphasis on dental avulsion (16). One study from Zhou et al. (17, 18) was excluded as the same study population was described in another, more comprehensive paper from the same author. Altogether 14 967 patients were investigated and the average incidence rate of injured teeth was 23.85% (range: 13.1–48.25%). Aside from the studies investigating only mandibular fractures, six studies also pointed out fractures of the mandible as the most associated facial fracture (7, 9, 15, 16, 18). © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Facial injuries and fractures investigated only 7 fractures overall Only fractures of the mandible investigated Only pediatric patients investigated Emphasis on dental avulsion Only mandibular condyle fractures investigated
Only one study claimed maxillary dentoalveolar fractures as the leading combined injury. However, in that study, only seven patients of 340 suffered from facial fractures (19). Discussion
One hundred and eighty-four patients out of 1219 with facial traumas had 451 injured teeth. The most frequent causes were assaults (25.1%), falls (19.6%), and bike accidents (10.1%). Avulsion, especially of the upper incisives, occurred in most cases (27.9%). Only few studies have been published addressing the relationship of dental injuries and facial fractures, and the reported incidences vary between 13% to almost 50% (7, 20). While the causes for the injuries vary depending on the different geographic locations, fractures of the mandible seem to be the most frequent osseous injury associated with dental injuries (21–23). As many patients with facial fractures suffer from high-speed impacts, they present a broad scope of associated traumas, such as traumas of the limbs, brain, chest, spine, or abdomen (24). In the present study, 184 out of 1219 patients with oro-maxillofacial fractures had a concomitant dental injury resulting in a comparatively low incidence rate of only 15.88% and an average of 2.45 violated teeth per patient (451 injured teeth). Oikarinen et al. (25) showed that the occurrence of dental traumatization mostly depends on the impacting surface or the object provoking the fracture. Therefore, the energy, shape, and resilience seem to be crucial factors causing the difference in the effect between different forces. In our study, assaults showed only 1.29 dental fractures per
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patient, which is far below average. In turn, forces with high-speed impacts or low-resilience surfaces, as in traffic or horse-related accidents, had a three to four times higher injury-rates. These findings absolutely support the findings of Oikarinen et al. As punches often hit the mandible, this may well be the reason for the high number of wisdom teeth involved; wisdom teeth play an important role as a weak point in the mandible, making it prone for fractures of the mandibular angle (26–28).Motor vehicle accidents in our study totaled only 13%. Given that this group plays the main role for dental or maxillofacial traumatization in studies (15, 18, 29) from other countries, this number might be an argument for the high security standard, including the obligation to buckle up or wear protective headgear as a motorcyclist. The causes for injuries are not equally distributed for the genders. With almost 40%, assaults were the most frequent cause among male patients but only 20.9% for female patients. Gassner et al. (20) described similar findings in their research as well. Falls and horse-related accidents were more often observed in females. In the age group of patients older than 65 years, three out of seven patients (43%) were injured due to falls. Although Edmondson and colleagues did not investigate only patients with combined dental traumas and fractures but rather all patients with any kind of maxillofacial injury, they described a similarly high proportion of falls in this age group (30). Five out of the seven patients in this age group were female in our study. As described previously in the literature, most dental injuries are associated with either single or combined mandibular fractures (9, 13, 14). Even maxillary dental traumas occurred more often with fractures in the mandible than in the maxilla. The reason for this might be the impaction of the lower jaw against the upper teeth (9). Mid-facial fractures as one of the most common fracture types (6) only play a minor role for combined dental injuries. In the present study, only 16 patients suffered from dental traumatization in association with isolated mid-facial fractures. The anterior teeth of the maxilla were most often affected. More than one-third of all injured teeth (35.3%) were central or lateral upper incisors, which is consistent with the findings of previous studies (7, 9, 18). The third molar, as already mentioned, was usually involved by being located in the fracture line of mandibular angle fractures. Ellis et al. pointed out that there is still no consensus on the question as to whether teeth in the line of mandibular fractures should be extracted or not. However, in their study, they discovered that the rate of postoperative complications is higher when a tooth is left in the line of the fracture, although no statistical significance could be found (31). There is, however, an incongruity in terms of which type of dental injury is the most common lesion in patients with fractures of the facial skeleton. Simple or complicated crown fractures and avulsions or luxations seem to be the most prominent injury types, as seen in previous studies (7, 9, 13, 15, 16, 18, 20). In the present study, the most common injuries were avulsions and
luxations. Periodontal injuries occurred more often in the anterior region and dental hard tissue traumatization in the posterior region for both the upper and lower jaw. This is in accordance with previous studies (16, 18), and, as Lieger et al. (9) described, the direct traumaimpact on these teeth generates forces which displace the coronal portion leading to displacement of the root. As nearly every sixth patient with maxillofacial fractures has at least one type of dental trauma, the importance of a thorough examination of the dental status must be stressed; the correct treatment at the time of the injury might help to avoid later complications. Depending on the energy, shape, and resilience of the impacting force, the number of injured teeth varies. Traffic-related accidents in particular cause more fractured teeth per patient. For optimal treatment, patients with maxillofacial traumas should be seen by a physician with a dental background. Conflict of interest statement
There was no source of institutional, private or corporate financial support for this work. The authors declare no conflict of interest. References 1. Arangio P, Vellone V, Torre U, Calafati V, Capriotti M, Cascone P. Maxillofacial fractures in the province of Latina, Lazio, Italy: review of 400 injuries and 83 cases. J Craniomaxillofac Surg 2013; doi: 10.1016/j.jcms.2013.07.030 [Epub ahead of print] 2. Katarzyna B, Piotr A. Characteristics and epidemiology of zygomaticomaxillary complex fractures. J Craniofac Surg 2010 [Epub ahead of print]. 3. Ozkaya O, Turgut G, Kayali MU, Ugurlu K, Kuran I, Bas L. A retrospective study on the epidemiology and treatment of maxillofacial fractures. Ulus Travma Acil Cerrahi Derg 2009;15:262–6. 4. Al Ahmed HE, Jaber MA, Abu Fanas SH, Karas M. The pattern of maxillofacial fractures in Sharjah, United Arab Emirates: a review of 230 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:166–70. 5. van den Bergh B, Karagozoglu KH, Heymans MW, Forouzanfar T. Aetiology and incidence of maxillofacial trauma in Amsterdam: a retrospective analysis of 579 patients. J Craniomaxillofac Surg 2012;40:e165–9. 6. Gassner R, Tuli T, Hachl O, Rudisch A, Ulmer H. Cranio-maxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg 2003;31:51–61. 7. Thoren H, Numminen L, Snall J, Kormi E, Lindqvist C, Iizuka T et al. Occurrence and types of dental injuries among patients with maxillofacial fractures. Int J Oral Maxillofac Surg 2010;39:774–8. 8. Brasileiro BF, Passeri LA. Epidemiological analysis of maxillofacial fractures in Brazil: a 5-year prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:28–34. 9. Lieger O, Zix J, Kruse A, Iizuka T. Dental injuries in association with facial fractures. J Oral Maxillofac Surg 2009;67:1680–4. 10. Rocha MJ, Cardoso M. Traumatized permanent teeth in Brazilian children assisted at the Federal University of Santa Catarina, Brazil. Dent Traumatol 2001;17:245–9. 11. Emerich K, Nadolska-Gazda E. Dental trauma, prevention and knowledge concerning dental first-aid among Polish amateur boxers. J Sci Med Sport 2013;16:297–301.
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Dental injuries in maxillofacial fractures 12. Veire A, Nichols W, Urquiola R, Oueis H. Dental trauma: review of common dental injuries and their management in primary and permanent dentitions. J Mich Dent Assoc 2012;94:41–5. 13. Ignatius ET, Oikarinen KS, Silvennoinen U. Frequency and type of dental traumas in mandibular body and condyle fractures. Endod Dent Traumatol 1992;8:235–40. 14. Silvennoinen U, Lindqvist C, Oikarinen K. Dental injuries in association with mandibular condyle fractures. Endod Dent Traumatol 1993;9:254–9. 15. Iso-Kungas P, Tornwall J, Suominen AL, Lindqvist C, Thoren H. Dental injuries in pediatric patients with facial fractures are frequent and severe. J Oral Maxillofac Surg 2012;70:396–400. 16. Marchiori EC, Santos SE, Asprino L, de Moraes M, Moreira RW. Occurrence of dental avulsion and associated injuries in patients with facial trauma over a 9-year period. Oral Maxillofac Surg 2013;17:119–26. 17. Zhou HH, Ongodia D, Liu Q, Yang RT, Li ZB. Dental trauma in patients with single mandibular fractures. Dent Traumatol 2013;29:291–6. 18. Zhou HH, Ongodia D, Liu Q, Yang RT, Li ZB. Dental trauma in patients with maxillofacial fractures. Dent Traumatol 2013;29:285–90. 19. Da Silva AC, Passeri LA, Mazzonetto R, De Moraes M, Moreira RW. Incidence of dental trauma associated with facial trauma in Brazil: a 1-year evaluation. Dent Traumatol 2004;20:6–11. 20. Gassner R, Bosch R, Tuli T, Emshoff R. Prevalence of dental trauma in 6000 patients with facial injuries: implications for prevention. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:27–33. 21. Erol B, Tanrikulu R, Gorgun B. Maxillofacial fractures. Analysis of demographic distribution and treatment in 2901
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
22.
23.
24.
25. 26.
27.
28.
29.
30.
31.
441
patients (25-year experience). J Craniomaxillofac Surg 2004;32:308–13. Motamedi MH. An assessment of maxillofacial fractures: a 5-year study of 237 patients. J Oral Maxillofac Surg 2003;61:61–4. Sastry SM, Sastry CM, Paul BK, Bain L, Champion HR. Leading causes of facial trauma in the major trauma outcome study. Plast Reconstr Surg 1995;95:196–7. Thoren H, Snall J, Salo J, Suominen-Taipale L, Kormi E, Lindqvist C et al. Occurrence and types of associated injuries in patients with fractures of the facial bones. J Oral Maxillofac Surg 2010;68:805–10. Oikarinen K. Pathogenesis and mechanism of traumatic injuries to teeth. Endod Dent Traumatol 1987;3:220–3. Duarte BG, Assis D, Ribeiro-Junior P, Goncales ES. Does the relationship between retained mandibular third molar and mandibular angle fracture exist? an assessment of three possible causes. Craniomaxillofac Trauma Reconstr 2012;5:127–36. Bezerra TP, Silva Junior FI, Scarparo HC, Costa FW, Studart-Soares EC. Do erupted third molars weaken the mandibular angle after trauma to the chin region? A 3D finite element study. Int J Oral Maxillofac Surg 2013;42:474–80. Bezerra TP, Studart-Soares EC, Pita-Neto IC, Costa FW, Batista SH. Do third molars weaken the mandibular angle? Med Oral Patol Oral Cir Bucal 2011;16:e657–63. Kadkhodaie MH. Three-year review of facial fractures at a teaching hospital in northern Iran. Br J Oral Maxillofac Surg 2006;44:229–31. Rehman K, Edmondson H. The causes and consequences of maxillofacial injuries in elderly people. Gerodontology 2002;19:60–4. Ellis E III. Outcomes of patients with teeth in the line of mandibular angle fractures treated with stable internal fixation. J Oral Maxillofac Surg 2002;60:863–5.
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