Dentoalveolar Fracture

Dentoalveolar fracture is a fracture of the alveolar process, with or without involvement of the tooth sockets, in which a segment bearing several teeth moves as a unit. It is the commonest fracture pattern in dental trauma that involves the supporting bone, and the anterior maxilla is the usual site.

It follows a direct blow to the teeth or jaw, seen in falls, sport, assault and road traffic collisions. It is most frequent in children and young adults.

Pathophysiology. Force transmitted through the teeth causes fracture of the thin buccal plate and alveolar bone, creating a segment of bone with teeth that moves with them.

The injury may disrupt the blood supply to the pulp, damage the periodontal ligament and the developing tooth germs in children, and extend into the sockets with fracture of the roots.

A mobile segment of alveolar bone with several teeth that move together when one tooth is pushed, malocclusion, displaced or avulsed teeth, bleeding from the gingival margin, laceration of the gingiva and lip, pain on biting, and swelling.

Teeth may be luxated, crown or root fractured, or intruded. Check the lips and tongue for embedded tooth fragments and foreign bodies, and the chin for fractures.

Airway concern from displaced teeth or blood, head injury, other facial fractures, and a contaminated wound need urgent assessment.

• Clinical examination: segment mobility (the teeth move together), occlusion, soft tissue wounds, and tooth injury.
• Periapical and occlusal radiographs, with a panoramic view. Cone beam CT for the extent of fracture and root fracture.
• Radiograph of soft tissue lacerations for retained tooth fragments.
• Pulp sensibility tests at baseline, understanding that they may be negative early on, and repeated over the following months.
• Tetanus status.

Differential diagnosis.

• Isolated tooth luxation or avulsion
• Root fracture
• Mandibular body or symphysis fracture
• Le Fort I fracture
• Alveolar bone fracture from tumour or osteomyelitis (pathological)
• Soft tissue contusion with tooth mobility
• Crown fracture

• Clean the area with saline, anaesthetise, reposition the segment into its normal position with finger pressure, and check the occlusion.
• Stabilise with a flexible splint (a wire of 0.4 mm bonded with composite, or a titanium trauma splint) for 4 weeks. A longer period of 6 weeks may be needed when root fractures or large segments are involved.
• Suture gingival and soft tissue lacerations.
• Teeth with pulp necrosis or with signs of infection need root canal treatment, with calcium hydroxide dressing in immature teeth. Remove teeth that are not salvageable.
• Antibiotics for contaminated wounds, luxation or avulsion: amoxicillin 500 mg orally three times daily for 5 to 7 days (reduce to 500 mg every 12 hours at eGFR 10 to 30), or clindamycin 300 mg four times daily in penicillin allergy. In children use amoxicillin 125 mg three times daily at 1 to 11 months, 250 mg at 1 to 4 years and 500 mg at 5 to 11 years, and doxycycline only from 12 years of age.
• Tetanus toxoid 0.5 mL intramuscularly if vaccination is incomplete or the last dose was over 10 years ago, with tetanus immunoglobulin 250 IU intramuscularly (500 IU after 24 hours or heavy contamination) for contaminated wounds when status is unknown or incomplete.
• Chlorhexidine 0.12% to 0.2% mouthwash 10 mL twice daily for 1 week, a soft diet for 2 weeks, careful brushing, and no contact sport.
• Analgesia: paracetamol 1 g every 6 hours (maximum 4 g daily) with ibuprofen 400 mg every 8 hours with food when appropriate. Children use paracetamol 15 mg/kg every 4 to 6 hours (maximum 75 mg/kg daily) and ibuprofen 5 to 10 mg/kg every 6 to 8 hours.
• Complications: pulp necrosis, root resorption, ankylosis, loss of marginal bone, tooth discolouration and damage to the permanent tooth germ in children.

Special groups. Children with injury to primary teeth need assessment for damage to the permanent germs, and a consideration of non-accidental injury when the history does not match the injury.

Monitoring. Review at 1 week and at splint removal, then check pulp vitality and radiographs at 6 to 8 weeks, 3 months, 6 months, 1 year and then yearly for 5 years.

Referral and escalation. Refer to oral and maxillofacial surgery or a dental trauma service for displaced segments, multiple teeth and mandibular or midface involvement. Urgent referral for airway compromise or associated facial fractures. Refer to child protection services when injury is suspicious.