Oral Surgery ISSN 1752-2471

ORIGINAL ARTICLE

Association of dental injuries with maxillofacial fractures:

a 10-year retrospective study
R. Ghosh, K. Gopalkrishnan & S. Adirajaiah
SDM College of Dental Sciences & Hospital, Dharwad, Karnataka, India

Key words:
dental injuries, facial fractures, maxillofacial
injuries
Correspondence to:
Dr. R Ghosh
SDM College of Dental Sciences & Hospital
Sattur
Dharwad 580009
Karnataka, India
Tel.: +919538081492
Email: rg_everywhere@yahoo.co.in
Accepted: 12 October 2016
doi:10.1111/ors.12253

Abstract
Aim: The aim of the study was to find the prevalence of dental injuries
in patients with facial fractures.
Materials and methods: A prospective study was conducted of patients
who reported in SDM Craniofacial Unit with maxillofacial fractures from
January 2003 until December 2013. A total of 991 patients were
included in the study. Clinical and radiological examination findings
were recorded to evaluate demographics, aetiology, presentation, and
type of facial fracture, as well as its relationship with dental injury site
and type.
Results: Among these 991 patients, 201 patients (41.8%) had associated
dental injuries, with a total of 462 injured teeth. Of the 462 injured teeth,
283 (61.2%) were in the maxilla and 179 (38.7%) in the mandible. The
central incisor was the most injured tooth for both the maxilla (150,
32.5%) and mandible (80, 17.3%). The most common type of dental
injury was avulsion (229, 44.6%). Avulsions were more common in
anterior teeth of both maxilla and mandible, whereas in posterior teeth,
Ellis Class I fracture or crown fractures were more common. Most
vulnerable teeth were maxillary central incisors in the anterior region,
whereas in posterior region, first premolars were more prone to injury in
the maxillary arch and first molars in the mandibular arch.
Conclusion: Our study shows that the occurrence of dental trauma is
significantly related to the pattern of injury and site of maxillofacial fractures.

Clinical relevance

Practical implications

Scientific rationale for study

A tooth not only plays its role as an important functional unit but also has an important role of being
an aesthetic unit, which has a great psychological
impact, so its management in facial trauma should
be discussed.

While assessing any maxillofacial injuries, we take

into consideration all the other associated injuries
but dental injuries are given least relevance. Our
aim was to find the prevalence of dental injuries in
order to portray it as an important part of initial
assessment as well for the treatment protocol.

Principal findings
Our study showed a strong correlation between
maxillofacial injuries and dental trauma having an
incidence of 41.8%.
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Introduction
Dental trauma is commonly associated with maxillofacial injuries. As good occlusion remains the main
goal of treatment for such injuries, it complicates the
treatment of facial fractures. Additional post-operative treatment may also be required which adds
to the cost and inconvenience of the patient1.
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Ghosh et al.

Our experience

Age distribution

55

ye
ar
s

ye
ar
s
Ab
ov
e

ye
ar
s

46
5
5

36
4
5

ye
ar
s
5
3

Figure 1 Age distribution in patients with facial fractures having associated dental injuries.

Results
From January 2003 to December 2013, 991 patients
reported with facial fractures in our unit, and among
them 201 (20.3%) patients had associated dental
injuries having 462 injured teeth.
1. Age and gender distribution: The commonest
age group of occurrence of dental injuries was 16
25 years of age reporting 83 cases (41.3%), followed
by 2635 years of age reporting 65 cases (32.3%),
followed by 3645 years 26 cases (12.9%), followed

26

5
2
16

15

ye
ar
s

ye
ar
s

90
80
70
60
50
40
30
20
10
0

Patients who were admitted with facial fractures

from 2003 to 2013 in SDM Craniofacial unit, Dharwad were included in the study. Information collected from these cases included age, gender
distribution, mechanism of injury, dental status of
the patient and type of dental injury.
We compared the incidence of dental injuries
according to age and gender distribution.
The mechanism of injury was further subdivided
into road traffic accidents (RTAs), falls, assault,
sports-related accidents and industrial, and their correlation with dental injuries were assessed.
The dental injuries were divided into two patterns;
one was to assess the teeth injured and second was
to assess the type of dental injury so that we can
come out with an incidence of commonest tooth
which is associated with facial injury and also the
type of dental injury.
All the data were collected in a retrospective manner by studying the medical records of these
patients.

ye
ar
s

Materials and methods

by 615 years of age reporting 15 cases (7.5%), followed by 4655 years of age reporting 8 cases (4%),
5 cases of patients between 0 and 5 years and finally
4 cases of patients above 55 years of age as shown in
Figure 1.
A greater proportion of injured patients were
males (177) compared with females (24) resulting in
a ratio of 7.4:1 as shown in Figure 2; the same proportion of gender ratio was seen in all patients with
facial fractures that is 7.9:1.
2. Aetiology: The commonest aetiology of dental
injuries is RTA reporting 123 cases (61.2%), followed
by fall reporting 60 cases (29.9%), followed by
assault reporting 8 cases (4%), followed by industrial
reporting 7 cases (3.5%), followed by sports reporting 2 cases and 1 case of other aetiology as shown in
Figure 3.
3. Commonest tooth injured: Maxillary central
incisors were the most vulnerable teeth (155,
33.8%) followed by maxillary lateral incisors (90,
19.7%), mandibular central incisors 80 (17.5%) and
mandibular lateral incisors (64, 14%). Of the posterior teeth, first premolars were more prone to injury
in maxillary arch (16) and first molars in lower arch
(16) as shown in Table 1 and Figure 4. It was also

0
5

Numerous studies have focused on the epidemiological characteristics of dental injuries. However, the
pattern and severity of dental trauma in patients
who sustain only the dentoalveolar complex injuries
are presumably different from those in patients who
present with a combination of dental injury and
facial injury require a special mention in the literature2.
In the past 10 years, there has been a lot of controversy regarding the commonest aetiology of these
dental injuries as well as the type of injury, so the
primary aim of this study was to analyse and evaluate the correlation between dental injuries and the
different patterns of maxillofacial fractures. Our aim
was also to find out the incidence of dental injuries
which are associated with facial injuries in Southern
part of India.

Gender
24
Male
177

Female

Figure 2 Gender distribution.

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Ghosh et al.

Our experience

assessed that more teeth were injured in the maxilla

283 (61.2%) than in mandible 179 (38.7%).
4. Type of dental injury: The most common type
of dental injury was avulsion: 229 (44.6%) followed
by crown fractures, that is Ellis Class I fracture: 110
Etiology
140
120
100

(21.4%) and Ellis Class III fracture: 72 (14%).

Avulsions were the commonest type of injury seen
in both maxilla and mandible (49.8%) in the anterior teeth, whereas Ellis Class I fractures or crown
fractures were more common in posterior teeth both
in maxilla and mandible (40.9%) as shown in
Table 2 and Figure 5.
5. Dental injuries were most commonly associated
with mandibular fractures than with maxillary fractures. In mandible, dental injury is mostly associated
with parasymphysis fractures as shown in Table 3.

80
60

Discussion

40

This study analysed and evaluated the correlation

between dental injuries and the pattern of maxillofacial fractures; we mainly found that the occurrence
of dental trauma is significantly related to the pattern and position of the maxillofacial fractures. The
prevalence of dental trauma in association with
maxillofacial fractures was 20%. This finding was
quite similar to findings by Lieger et al. (19.5%)1
and Thoerin et al. (16%)3 but was quite less compared to the studies done by Zhou et al. in 2013
(41.8%)2 and Gassner et al. (47.5%)4. We found that
an average of 2.3 teeth were injured per patient
which were similar to the results found by Gassner
et al. and Thoren et al. in their studies5,6.
The most frequent cause of facial fractures as well
as dental injuries in our study was RTAs, comprising
61.2% of the total number of the dental injuries.

20
0
RTA

Fall

Assault

Sports

Industrial

Figure 3 Aetiology of facial fractures associated with dental injuries.

Table 1 Teeth injured with maxillofacial injuries

Site

Maxilla

Mandible

Central incisors
Lateral incisors
First premolars
Second premolars
First molars
Second molars
Third molars
Total

150
90
16
10
8
4
0
283

80
64
7
8
16
3
1
179

160
140
120
100
Maxilla

80

Mandible
60
40
20
0
Central
incisors

Lateral
incisors

1st
2nd
1st molar
premolar premolar

2nd
molar

3rd
molar

Figure 4 Site of teeth injury.

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Ghosh et al.

Our experience

These results were similar to studies done by Zhou

et al. in 2013, Lieger et al. in 2009, Da Silva et al. in
2004 and Gassner et al. in 20031,2,4,7. In contrast,
assault-related injuries were commonest in a study
done by Thoren et al. in 20103, and sports-related
accidents were more common in the study done by
Gassner et al. in 19995.
The results of this study showed that between the
ages of 1625 years, the incidence of dental injury
associated facial trauma was highest. Similar results
were found in the studies done by Da Silva et al. and
by Thoren et al.6,7. During the 2nd and 3rd decade
of life, people indulge into maximum social activity
or sports activity which makes them more prone to
such injuries.
Table 2 Type of teeth injury
Dental Injuries

Ellis Class I fracture

Ellis Class II fracture
Ellis Class III fracture
Subluxation
Root fracture
Avulsion
Intrusion
Extrusion
Total

Anterior teeth

Posterior teeth

Maxilla

Mandible

Maxilla

Mandible

19
15
13
3
2
110
4
1
167

14
7
5

13
12
5

64
34
49
4
113
14
3
281

1
1

28

5
1
2
38

Dental trauma were analysed in two patterns:

firstly according to Ellis Classification of dental fractures and secondly according to commonest teeth
injures in both maxilla and mandible. Results
showed more teeth were injured in maxilla (61.2%)
than in the mandible (38.7%). This was similar to
studies done by Zhou et al.2, Lieger et al.1, Gassner
et al.5 and Da Silva et al.7. The preventive effect of
maxilla on the mandible is one of the reasons of less
incidence of dental injuries in mandibular arch8,9.
Another cause of less incidence of lower teeth injuries could be because of better bony anchorage
which act like wedges during forceful occlusion1.
The commonest teeth injured were maxillary central
incisors (33.8%) compared to mandibular central
incisors (17.5%). This result was similar to that of
Zhou et al. in 20132. As maxillary central incisors are
more protrusive teeth, they are more likely to hit
the ground or struck by an object10. Also the incomplete soft tissue coverage of the lip increases the risk
of injury1113.
Type of dental injuries was classified according to
the classification given by Ellis & Davey in 1970.
They have divided dental injuries into nine types
which are: Class I Simple crown fracture involving
little or no dentin; Class II Extensive fracture of
crown involving considerable dentin but no dental
pulp; Class III Extensive crown fracture involving
considerable dentin and exposing pulp; Class IV

120

100

80

60

Maxilla
Mandible

40

20

Figure 5 Type of dental injury.

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Ghosh et al.

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Table 3 Dental injuries related to pattern of fracture

Site of fracture

Dental injuries present

Maxilla
Symphysis
Parasymphysis
Body
Angle
Condyle
Coronoid
Dentoalveolar
Maxilla and mandible

46
34
101
12
10
50
2
6
80

The traumatised tooth becomes non-vital with or

without loss of crown structure; Class V Tooth lost
as a result of trauma (Avulsion); Class VI Fracture
of root with or without crown fracture; Class VII
Displacement of tooth without fracture of crown or
root (Subluxation); Class VIII Fracture of complete
crown; Class IX Traumatic injury to deciduous
tooth.
The commonest type of dental injury seen was
avulsion in anterior teeth of both maxilla and
mandible (49.8%) and the commonest type of
injury in posterior teeth was Ellis Class I fracture
(40.9%). When direct impact hits the front teeth, it
generates forces that tend to displace the coronal
portion orally and root displacement in the opposite
direction resulting in avulsion of tooth14. However,
most of the studies done reveal that avulsion is the
commonest type of injury in both anterior and posterior teeth. Such results were seen in the studies
of Zhou et al.2 and Da silva et al.7. However, contrary results were seen in other studies done by
Lieger et al.1 and Thoren et al.3 where the commonest injury was crown fracture, whereas subluxation
was the commonest type of injury according to the
studies done by Gassner et al. in 1999 and 20034,5.
It is assumed that the high number of dental avulsions and luxation injuries were probably the result
of the severity of trauma involving young individuals, who are more susceptible to high-energy
impacts7.
According to the classification and description of
the severity of dental injuries by Oikarinen et al., it
can be concluded that dental injuries in the maxilla
are more severe than those in the mandible15. Several reasons have been attributed to this phenomenon: Firstly, the large maxillary overjet and
protrusion in the sagittal plane, and secondly, the
anterior teeth in upper jaw are more prone to strike
against an object11,12,15. In contrast, lower jaw teeth
are protected by the maxilla during occlusion thus
sustaining less; consequently, the mandibular teeth
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are less seriously injured8. Our study also showed

that the injury types between anterior teeth differ
significantly from posterior teeth. More hard dental
tissue injuries occurred in posterior teeth (including
crown fractures, crownroot fractures and root fractures), which gives an impression that the more
cusps or roots in teeth, the greater the likelihood of
the occurrence of hard dental tissue injury. More
dislocation injuries (including avulsion, subluxation
and intrusive dislocation) were found in anterior
teeth.
Regarding specific types of facial fractures, we
found that patients with fractures limited to the
maxilla had a low incidence of teeth injury. This
finding was consistent with the study by Lieger
et al.1. In the maxilla, the sinus cavities are pneumatised which is an important cause for reduced dental
injuries with maxillary fractures. A high incidence of
teeth injury was found in patients with the combination fractures of the maxilla and mandible which is
also in agreement with Lieger et al.1. The high external force leading to impaction of the lower jaw
against the upper teeth could be the reason as in
these patients, the chin area most likely hit the
ground first, causing forceful closure of the jaws,
leading to dental injuries of both jaws1. When
patients sustained exclusively single mandible fracture, we found that dental injuries were associated
most frequently in patients with symphysis and
parasymphysis fractures of the mandible. Similar
findings were noted in the study done by Lieger
et al.1. Interestingly, patients who sustained exclusively mandibular angle fracture had the lowest risk
of dental trauma.

Conclusion
Our study shows a significant dental injury rate in
patients who sustained maxillofacial fractures. It also
shows that dental injuries were associated more with
mandibular fractures than with maxillary fractures
and in mandible, symphysis and parasymphysis fractures were most commonly associated with dental
injuries. The occurrence of dental trauma is also significantly related to the pattern and position of the
maxillofacial fractures, so a thorough dental examination in all patients with facial injury should be
emphasised.

Conflicts of interest
The authors confirm that there are no conflicts of
interest.
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Our experience

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