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Emergency Medicine Australasia (2014) 26, 439–445
doi: 10.1111/1742-6723.12267
REVIEW ARTICLE
Review article: Maxillofacial emergencies: Dentoalveolar and temporomandibular joint trauma Adrian F DEANGELIS,1 Roland A BARROWMAN,1 Richard HARROD2 and Alf L NASTRI1 1 Maxillofacial Surgery Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia, and 2Emergency Medicine Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
Abstract Dentoalveolar trauma and dislocations of the temporomandibular joint are common reasons for patients to present to EDs in Australia. The majority of medical practitioners receive very little formal training in the management of these injuries and might not have ready access to dental services out of hours for advice. This article focuses on the emergency assessment, triage and non-specialist management of dentoalveolar trauma and injuries to the temporomandibular joint. Key words: maxillofacial, splinting, teeth, temporomandibular joint, trauma.
Introduction Injury to the teeth and supporting structures following blunt trauma is a common reason for presentation to hospital EDs and general medical practice and often a medical practitioner will be the initial care provider for such injuries.1,2 Recreational activities such as skateboarding, skating, cycling, trampolines and contact sports are frequently implicated as is interpersonal violence that is often related to alcohol and illicit drug use.3–9 Unlike bony injuries, most dental injuries are permanent and require replacement with expensive prosthetic
materials and devices.1 These prostheses eventually fail and need to be replaced by more complex devices.1,8,10 Early assessment and intervention can significantly minimise or eliminate the need for complex intervention later.1,2,11 Likewise, untreated temporomandibular joint (TMJ) injuries might lead to ongoing pain and dysfunction.12 The aim of this paper is to discuss the presentation of dentoalveolar and TMJ trauma to the ED and outline the principles of its management.
• Avulsed permanent teeth should be replanted as soon as practically possible. Never replant primary teeth. • Possible aspiration should always be considered when avulsed teeth or fragments cannot be accounted for. • Condylar fractures with malocclusion require treatment. Those without malocclusion may be managed conservatively.
History Mechanism of injury Most dentoalveolar trauma is obvious on initial examination. The mechanism of injury helps identify less obvious injuries, such as soft tissue degloving, TMJ trauma and closed neck, skull and facial fractures.9,13 An important differentiation is made between high and low-energy injuries as high-energy mechanisms predispose to unusual patterns of trauma.14 One should always be suspicious of abuse if the provided mechanism of injury does not fit with the clinical signs, especially in children.9,14
Surrounding events An accurate account of the events surrounding a traumatic episode is valu-
Correspondence: Dr Adrian F DeAngelis, Maxillofacial Surgery Unit, Royal Melbourne Hospital, Parkville, VIC 3050, Australia. Email: [email protected] Adrian F DeAngelis, BDSc (Hons), MBBS, PGDipOMS, Maxillofacial Surgery Resident; Roland A Barrowman, BDS, MBBS, PGDipOMS, Maxillofacial Surgery Registrar; Richard Harrod, MBBS, FACEM, Consultant Emergency Physician; Alf L Nastri, MDSc, MBBS, FRACDS (OMS), Head of Oral & Maxillofacial Surgery. Accepted 11 June 2014
Key findings
able as many conditions, such as cardiac arrhythmias or seizures, especially in the elderly, might have their first presentation to hospital as dentoalveolar trauma.15 Relevant details include if the injury was witnessed, periods of unconsciousness and symptoms of concussion (nausea, vomiting or visual disturbance). Accurate documentation of the manner in which an injury is alleged to have occurred, use of alcohol or other illicit substances is important medicolegally and might affect the outcome of court proceedings or insurance claims.10,16,17 For tooth avulsion, it is necessary to document the time of injury, the type of transport media used and the time of replantation as this has longterm consequences for treatment and prognosis.10,13
Initial assessment Treatment setting Most patients with isolated dentoalveolar or TMJ injuries will be able to be managed in an ED or outpatient setting. 12 The main
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
440
AF DEANGELIS ET AL.
severe or in children in which case a maxillofacial surgeon or specialist paediatric dentist should be involved.
Soft tissue injuries
Figure 1. Comparison of same patient visualised on PA mandible and reverse Towne’s plain films. Note that the condylar head and neck is obscured by the mastoid air cells on the PA view.
exceptions are paediatric patients who might not tolerate treatment under local anaesthesia. Inpatient admission is usually only indicated for severe injuries, cervical spine injuries, overnight monitoring after head injury, facial or other fractures.17
Investigations A thorough clinical examination is the best tool available for assessing dentoalveolar injuries.9 The imaging available in EDs provides little added information but is useful to exclude other injuries where there is a high index of suspicion of an injury being present. The most useful imaging modality is the orthopantomogram (OPG), which visualises the jaws and entire dentition.12,14 The OPG is poor for identifying dentoalveolar trauma but is valuable for excluding mandibular pathology and fractures.9 As the projection of plain films might make fractures difficult to identify, a second film at 90° should be ordered whenever these are suspected. For dentoalveolar and TMJ trauma, the projection of choice is the reverse Townes view, which ensures that the head of the mandibular condyles is not obscured by the shadow of the mastoid process (Fig. 1). Dedicated TMJ projections are difficult to acquire, difficult to interpret and of no value in trauma.14,18 Although CT is excellent for identifying TMJ pathology, dentoalveolar and supporting bone injuries, it is rarely ever indicated as a first-line examination unless being performed for another clinical indication.14 MRI has
Figure 2. Magnified view of chest X-ray revealing aspiration of a tooth.
little role in the emergency assessment of these injuries.19 The possibility of aspiration of a tooth fragment or dental prosthesis must be considered whenever there has been a period of unconsciousness with a dentoalveolar injury or avulsion of teeth. If missing teeth, tooth fragments or prosthetic components cannot be accounted for then a chest X-ray should be performed to exclude aspiration (Fig. 2).9,20,21
Dentoalveolar injuries Dentoalveolar injuries include injuries to teeth and supporting structures. Although rarely life threatening, the proximity of the oral cavity to the airway and its rich vascular supply can lead to significant haemorrhage and airway compromise.9,20,21 Most dentoalveolar injuries can be managed on an outpatient basis unless
Unlike soft tissue injuries of the face, intra-oral soft tissue injuries might not be immediately obvious and can be easily missed. They can be a source of ongoing haemorrhage, especially in patients with an acquired or hereditary coagulopathy.9,12,14,18 Swallowed blood from the oral cavity is highly irritating to the gastrointestinal tract and can lead to nausea, vomiting and aspiration.22 It is important to lift the lips during examination to identify intraoral lip lacerations and gingival degloving injuries.14 Full and partial thickness lacerations often occur with direct trauma and concomitant dental injury. Degloving injuries that occur following a slide during a fall can be extensive and difficult to repair. There might also be permanent loss of facial sensation if there is laceration or avulsion of the infraorbital or mental nerves.9,12,14 As the oral cavity is a contaminated site and wounds might be further contaminated with tooth fragments, gravel or dirt, these injuries should ideally be debrided and repaired within 24 h. It is also recommended for anything other than minor injuries that tetanus prophylaxis be provided and antibiotics considered. Drugs that are active against oral organisms, such as amoxycillin or clindamycin, in combination with metronidazole are preferred.9,10,23 Tongue lacerations, like scalp lacerations, are extremely vascular, tend to gape and can lead to significant blood loss. 24–26 Although repair is usually straightforward, it must be closed with heavier suture material (3-O) to prevent later dehiscence because of muscular action.25 Intubation might be required to protect the airway and prevent further injury in unconscious patients who repeatedly bite their tongue.
Dental injuries In adults, trauma might result in fracture of one or more teeth, which might
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
441
DENTOALVEOLAR AND TEMPOROMANDIBULAR JOINT TRAUMA
be aspirated if allowed to remain mobile in the oral cavity.9,20,21 Most dental injury classification systems are aimed at dental practitioners and are of little practical use in primary care or emergency settings.17 It is most useful to adapt the classification of Andreasen and Andreasen and divide crown fractures (the portion of the tooth visible above the gingiva) into two categories: complicated and uncomplicated.13 In an uncomplicated crown fracture the injury does not propagate into the dental pulp. If easily removable, the mobile tooth fragment may be discarded and definitive treatment performed in an outpatient setting.13,27,28 In complicated fractures the injury propagates into the dental pulp and a central red area will be visible beneath the mobile or fractured tooth fragment.9,13,27 If easily removable, the mobile tooth fragment may be discarded. If the remaining tooth sits above the gingiva it should be flushed with sterile saline and the exposed pulp covered with glass ionomer cement.1,27,28 Root fractures (the portion of the tooth below the gingiva) usually only require outpatient dental treatment and rarely need splinting.13,27 A root fracture may be identified clinically as a mobile tooth without a palpable impulse in the gingiva on mobilisation. The presence of a palpable impulse implies that the root is still in continuity with the crown. Movement of the alveolar bone with the tooth suggests a supporting bone injury.9 If the tooth is very mobile (more than 3 mm) or there is a bony injury then the tooth should be splinted to nearby stable teeth.1,27 In an unconscious patient where this is not possible, the mobile tooth may pose an airway risk and is best removed. It is important to warn the patient after suffering a dental injury of the risk of late discolouration and possible necrosis of the dental pulp. In children where the tooth roots are still forming (
Emergency Medicine Australasia (2014) 26, 439–445
doi: 10.1111/1742-6723.12267
REVIEW ARTICLE
Review article: Maxillofacial emergencies: Dentoalveolar and temporomandibular joint trauma Adrian F DEANGELIS,1 Roland A BARROWMAN,1 Richard HARROD2 and Alf L NASTRI1 1 Maxillofacial Surgery Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia, and 2Emergency Medicine Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
Abstract Dentoalveolar trauma and dislocations of the temporomandibular joint are common reasons for patients to present to EDs in Australia. The majority of medical practitioners receive very little formal training in the management of these injuries and might not have ready access to dental services out of hours for advice. This article focuses on the emergency assessment, triage and non-specialist management of dentoalveolar trauma and injuries to the temporomandibular joint. Key words: maxillofacial, splinting, teeth, temporomandibular joint, trauma.
Introduction Injury to the teeth and supporting structures following blunt trauma is a common reason for presentation to hospital EDs and general medical practice and often a medical practitioner will be the initial care provider for such injuries.1,2 Recreational activities such as skateboarding, skating, cycling, trampolines and contact sports are frequently implicated as is interpersonal violence that is often related to alcohol and illicit drug use.3–9 Unlike bony injuries, most dental injuries are permanent and require replacement with expensive prosthetic
materials and devices.1 These prostheses eventually fail and need to be replaced by more complex devices.1,8,10 Early assessment and intervention can significantly minimise or eliminate the need for complex intervention later.1,2,11 Likewise, untreated temporomandibular joint (TMJ) injuries might lead to ongoing pain and dysfunction.12 The aim of this paper is to discuss the presentation of dentoalveolar and TMJ trauma to the ED and outline the principles of its management.
• Avulsed permanent teeth should be replanted as soon as practically possible. Never replant primary teeth. • Possible aspiration should always be considered when avulsed teeth or fragments cannot be accounted for. • Condylar fractures with malocclusion require treatment. Those without malocclusion may be managed conservatively.
History Mechanism of injury Most dentoalveolar trauma is obvious on initial examination. The mechanism of injury helps identify less obvious injuries, such as soft tissue degloving, TMJ trauma and closed neck, skull and facial fractures.9,13 An important differentiation is made between high and low-energy injuries as high-energy mechanisms predispose to unusual patterns of trauma.14 One should always be suspicious of abuse if the provided mechanism of injury does not fit with the clinical signs, especially in children.9,14
Surrounding events An accurate account of the events surrounding a traumatic episode is valu-
Correspondence: Dr Adrian F DeAngelis, Maxillofacial Surgery Unit, Royal Melbourne Hospital, Parkville, VIC 3050, Australia. Email: [email protected] Adrian F DeAngelis, BDSc (Hons), MBBS, PGDipOMS, Maxillofacial Surgery Resident; Roland A Barrowman, BDS, MBBS, PGDipOMS, Maxillofacial Surgery Registrar; Richard Harrod, MBBS, FACEM, Consultant Emergency Physician; Alf L Nastri, MDSc, MBBS, FRACDS (OMS), Head of Oral & Maxillofacial Surgery. Accepted 11 June 2014
Key findings
able as many conditions, such as cardiac arrhythmias or seizures, especially in the elderly, might have their first presentation to hospital as dentoalveolar trauma.15 Relevant details include if the injury was witnessed, periods of unconsciousness and symptoms of concussion (nausea, vomiting or visual disturbance). Accurate documentation of the manner in which an injury is alleged to have occurred, use of alcohol or other illicit substances is important medicolegally and might affect the outcome of court proceedings or insurance claims.10,16,17 For tooth avulsion, it is necessary to document the time of injury, the type of transport media used and the time of replantation as this has longterm consequences for treatment and prognosis.10,13
Initial assessment Treatment setting Most patients with isolated dentoalveolar or TMJ injuries will be able to be managed in an ED or outpatient setting. 12 The main
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
440
AF DEANGELIS ET AL.
severe or in children in which case a maxillofacial surgeon or specialist paediatric dentist should be involved.
Soft tissue injuries
Figure 1. Comparison of same patient visualised on PA mandible and reverse Towne’s plain films. Note that the condylar head and neck is obscured by the mastoid air cells on the PA view.
exceptions are paediatric patients who might not tolerate treatment under local anaesthesia. Inpatient admission is usually only indicated for severe injuries, cervical spine injuries, overnight monitoring after head injury, facial or other fractures.17
Investigations A thorough clinical examination is the best tool available for assessing dentoalveolar injuries.9 The imaging available in EDs provides little added information but is useful to exclude other injuries where there is a high index of suspicion of an injury being present. The most useful imaging modality is the orthopantomogram (OPG), which visualises the jaws and entire dentition.12,14 The OPG is poor for identifying dentoalveolar trauma but is valuable for excluding mandibular pathology and fractures.9 As the projection of plain films might make fractures difficult to identify, a second film at 90° should be ordered whenever these are suspected. For dentoalveolar and TMJ trauma, the projection of choice is the reverse Townes view, which ensures that the head of the mandibular condyles is not obscured by the shadow of the mastoid process (Fig. 1). Dedicated TMJ projections are difficult to acquire, difficult to interpret and of no value in trauma.14,18 Although CT is excellent for identifying TMJ pathology, dentoalveolar and supporting bone injuries, it is rarely ever indicated as a first-line examination unless being performed for another clinical indication.14 MRI has
Figure 2. Magnified view of chest X-ray revealing aspiration of a tooth.
little role in the emergency assessment of these injuries.19 The possibility of aspiration of a tooth fragment or dental prosthesis must be considered whenever there has been a period of unconsciousness with a dentoalveolar injury or avulsion of teeth. If missing teeth, tooth fragments or prosthetic components cannot be accounted for then a chest X-ray should be performed to exclude aspiration (Fig. 2).9,20,21
Dentoalveolar injuries Dentoalveolar injuries include injuries to teeth and supporting structures. Although rarely life threatening, the proximity of the oral cavity to the airway and its rich vascular supply can lead to significant haemorrhage and airway compromise.9,20,21 Most dentoalveolar injuries can be managed on an outpatient basis unless
Unlike soft tissue injuries of the face, intra-oral soft tissue injuries might not be immediately obvious and can be easily missed. They can be a source of ongoing haemorrhage, especially in patients with an acquired or hereditary coagulopathy.9,12,14,18 Swallowed blood from the oral cavity is highly irritating to the gastrointestinal tract and can lead to nausea, vomiting and aspiration.22 It is important to lift the lips during examination to identify intraoral lip lacerations and gingival degloving injuries.14 Full and partial thickness lacerations often occur with direct trauma and concomitant dental injury. Degloving injuries that occur following a slide during a fall can be extensive and difficult to repair. There might also be permanent loss of facial sensation if there is laceration or avulsion of the infraorbital or mental nerves.9,12,14 As the oral cavity is a contaminated site and wounds might be further contaminated with tooth fragments, gravel or dirt, these injuries should ideally be debrided and repaired within 24 h. It is also recommended for anything other than minor injuries that tetanus prophylaxis be provided and antibiotics considered. Drugs that are active against oral organisms, such as amoxycillin or clindamycin, in combination with metronidazole are preferred.9,10,23 Tongue lacerations, like scalp lacerations, are extremely vascular, tend to gape and can lead to significant blood loss. 24–26 Although repair is usually straightforward, it must be closed with heavier suture material (3-O) to prevent later dehiscence because of muscular action.25 Intubation might be required to protect the airway and prevent further injury in unconscious patients who repeatedly bite their tongue.
Dental injuries In adults, trauma might result in fracture of one or more teeth, which might
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
441
DENTOALVEOLAR AND TEMPOROMANDIBULAR JOINT TRAUMA
be aspirated if allowed to remain mobile in the oral cavity.9,20,21 Most dental injury classification systems are aimed at dental practitioners and are of little practical use in primary care or emergency settings.17 It is most useful to adapt the classification of Andreasen and Andreasen and divide crown fractures (the portion of the tooth visible above the gingiva) into two categories: complicated and uncomplicated.13 In an uncomplicated crown fracture the injury does not propagate into the dental pulp. If easily removable, the mobile tooth fragment may be discarded and definitive treatment performed in an outpatient setting.13,27,28 In complicated fractures the injury propagates into the dental pulp and a central red area will be visible beneath the mobile or fractured tooth fragment.9,13,27 If easily removable, the mobile tooth fragment may be discarded. If the remaining tooth sits above the gingiva it should be flushed with sterile saline and the exposed pulp covered with glass ionomer cement.1,27,28 Root fractures (the portion of the tooth below the gingiva) usually only require outpatient dental treatment and rarely need splinting.13,27 A root fracture may be identified clinically as a mobile tooth without a palpable impulse in the gingiva on mobilisation. The presence of a palpable impulse implies that the root is still in continuity with the crown. Movement of the alveolar bone with the tooth suggests a supporting bone injury.9 If the tooth is very mobile (more than 3 mm) or there is a bony injury then the tooth should be splinted to nearby stable teeth.1,27 In an unconscious patient where this is not possible, the mobile tooth may pose an airway risk and is best removed. It is important to warn the patient after suffering a dental injury of the risk of late discolouration and possible necrosis of the dental pulp. In children where the tooth roots are still forming (
