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Etiology and Incidence

Dentoalveolar injuries commonly occur in the pediatric, teenage, and adult populations. Each
group has specific etiologies that pertain to age, sex, and demographics. In the pediatric group,
the primary cause of these injuries is falls. Possibly during the first years of life, the early anatomic
development and skeletal weight distribution cause the poor coordination that leads to falls. In the
larger surveys, the pediatric population accounts for 5% of all facial fractures.4 Andreasen reported
a bimodal trend in the peak incidence of dentoalveolar trauma in children aged 2 to 4 years and 8
to 10 years. Likewise, there was an overall prevalence of 11 to 30% in the children with primary
dentition. Those with permanent or mixed dentition ranged from 5 to 20%. The ratio of men to
women was 2:1.5 Children and adolescents overlap with respect to the etiology of dentoalveolar
injury. Contact sports and playground activities lead to most injuries. In fact, approximately one-
third of all dental trauma is secondary to sporting accidents.6

The use of mouthguards and appropriate head gear, however, has helped to decrease sport related
injuries.7 Child abuse appears to be another significant cause of dentoalveolar and facial injury.
An alarming census of child abuse is documented in the literature. In the year 2000 an estimated
879,000 children were abused. Of these, 19.3% were physically abused.8 In the United
States,over 50% of physical trauma in child abuse occurs in the head and neck region.
Internationally, about 7% of all physical injuries involve the oral cavity, with 9% between ages 0
and 19 years.9,10 Generally, adult injuries are caused by motor vehicle collisions, contact sports,
altercations or assaults, industrial accidents, and iatrogenic medical or dental misadventures.
Demographic and behavioral research has increased the profession’s understanding of
psychosocial issues that relate to facial trauma. Leathers and colleagues reported on orofacial
injury profiles in an inner-city hospital. They found that most orofacial injuries resulted from
intentional violence, and the victims were primarily socially and economically disadvantaged
groups in the minority populations.11,12 Black and colleagues related substance abuse
specifically alcohol and “street drugs”—with orofacial injuries. They found that a significantly
greater proportion of patients who screened positive for drug and alcohol abuse at the time of
injury had a previous history of head injury and/or orofacial injury. Further, we should consider
the high rate of recidivism in this population as another behavioral factor.13 Other groups that
are at increased risk of dentoaveolar trauma are those with seizure disorders, mental disorders,
and congenital maxillofacial abnormalities. Lockhart and colleagues reported findings, by the
Risk Management Foundation, indicated that damage to the teeth was the most frequent
anesthesia-related claim, often resulting in litigation.14 Poor laryngoscopy technique and the
unmonitored biting force of the comatose patient also potentially caused dentoalveolar
injury.15,16 With direct trauma, maxillary incisors are the most frequently traumatized teeth,
especially if they are associated with a Class II Division 1 malocclusion.Trauma to the primary
dentition usually results in various luxations (~ 75%), whereas in permanent dentition, crown or
crown-root fractures are the normal (39%).17 Indirect trauma to the dentition usually results
from the forceful impact of the mandible with the maxilla, following a blow to the chin region.
These traumas will often result in injury to the posterior teeth (Figure 21-2).5
Classification of Dentoalveolar Injuries

Once the diagnosis of dentoalveolar injury is made, the injury is classified for ease of communication and
treatment planning. Many classification systems have been proposed over the years based on the anatomic
site of injury, the cause, the treatment alternatives, or a combination of these. The two most common
systems are those developed by Ellis and Davey (Figure 21-4) and Andreasen (Figures 21-5–21-7). The
most commonly used simple and comprehensive classification of dentoalveolar injuries is one that was
developed by Andreasen and originally adopted by the World Health Organization system for disease
classification, using the International Classification of Diseases codes. The classification can be applied to
both permanent and primary dentition. It includes descriptions of injuries to teeth, supporting structures,
and gingival and oral mucosa. Injuries to the teeth and supporting structures are divided into dental
tissues, pulp, periodontal tissues, and supporting bone as follows:

Dental tissues and pulp


• Crown infraction (ie, a craze line or crack in the tooth without loss of tooth substance)
• Crown fracture that is confined to enamel, or enamel and dentin, with no root exposure (uncomplicated)
• Crown fracture producing a pulp exposure (complicated)
• Fracture involving the enamel, dentin, and cementum without pulp exposure (uncomplicated crown root
fracture)
• Fracture involving the enamel, dentin, and cementum with pulp exposure (complicated crown-root
fracture)
• Root fracture involving the dentin and cementum and producing a pulp exposure (root fracture)

Injuries to periodontal tissues ; commonly referred to as subluxations and avulsions.

• Concussion: defined as an injury to the periodontium producing sensitivity to percussion without


loosening or displacement of the tooth
• Subluxation: the tooth is loosened but not displaced
• Luxation (ie, lateral, intrusion, and extrusion) dislocation, or partial avulsion: the tooth is displaced
without an accompanying comminution or fracture of the alveolar socket

Injuries to the supporting bone


• Comminution of the alveolar housing, often occurring with an intrusive or lateral luxation
• Fracture of a single wall of an alveolus
• Fracture of the alveolar process, en bloc, in a patient having teeth but without the fracture line
necessarily extending through a tooth socket
• Fracture involving the main body of the mandible or maxilla

Categories of injuries to the gingival or oral mucosa area

• Abrasion
• Contusion
• Laceration

(Flynn, 2004)Flynn, T. (2004). Principles of management of odontogenic infections. Peterson’s


principles of oral and maxillofacial surgery.