Mandibular Fractures

**85**

**Chapter 5**

**Abstract**

**1. Introduction**

processes [2].

**2. Brief historical overview**

and external bandaging.

Evaluation and Management of

The mandibular bone is an important component of the facial bone, which has a unique role in digestive system, speech, and facial esthetics. For these important functions of mandibular bone, it is vital that surgeons should not only treat function but also consider the esthetics together. Mandibular fractures are among the most common traumatic injuries of the maxillofacial region. Even though treatment modalities are well established and being practiced for a long time, untreated and postoperative complications still decrease the patient's quality of life. This chapter aims to describe the cause, clinical presentations, diagnoses, and current treatment

The mandibular bone, which is an important anatomical and functional structure, constitutes the lower height and width of the facial skeleton. The mandible is a complex bony structure and has a vital anatomical articulation with other cranio-maxillofacial components. It has a fundamental function in digestive system and also plays an important role in speech and facial expression. The mandible is a v-shaped bone articulating with the temporal bone at the temporomandibular joint

The cartilaginous mandibular bone is a v-shaped bone articulating with the temporal bone at the temporomandibular joint (TMJ) [1]. Mandibular bone has a horizontal and vertical portion. The horizontal portion of mandible has two main structures, the basal and alveolar (tooth bearing) bones. Symphysis, parasymphysis, the body, and the alveolar bone compose the horizontal section of the mandible. The vertical mandible consists of the angle, ramus, condylar, and coronoid

The first description of a mandibular fracture diagnosis and treatment goes back to the Egyptians in 1650 BC. Hippocrates described the reapproximation of fracture fragments and immobilization of the fractured mandible using circumdental wires

**Keywords:** mandibular fracture, open reduction, rigid fixation, trauma

(TMJ). Mandibular bone has a horizontal and vertical portion.

Mandibular Fracture

methods on the basis of resent literature.

*Guhan Dergin, Yusuf Emes and Buket Aybar*

#### **Chapter 5**

## Evaluation and Management of Mandibular Fracture

*Guhan Dergin, Yusuf Emes and Buket Aybar* 

#### **Abstract**

The mandibular bone is an important component of the facial bone, which has a unique role in digestive system, speech, and facial esthetics. For these important functions of mandibular bone, it is vital that surgeons should not only treat function but also consider the esthetics together. Mandibular fractures are among the most common traumatic injuries of the maxillofacial region. Even though treatment modalities are well established and being practiced for a long time, untreated and postoperative complications still decrease the patient's quality of life. This chapter aims to describe the cause, clinical presentations, diagnoses, and current treatment methods on the basis of resent literature.

**Keywords:** mandibular fracture, open reduction, rigid fixation, trauma

#### **1. Introduction**

 The mandibular bone, which is an important anatomical and functional structure, constitutes the lower height and width of the facial skeleton. The mandible is a complex bony structure and has a vital anatomical articulation with other cranio-maxillofacial components. It has a fundamental function in digestive system and also plays an important role in speech and facial expression. The mandible is a v-shaped bone articulating with the temporal bone at the temporomandibular joint (TMJ). Mandibular bone has a horizontal and vertical portion.

The cartilaginous mandibular bone is a v-shaped bone articulating with the temporal bone at the temporomandibular joint (TMJ) [1]. Mandibular bone has a horizontal and vertical portion. The horizontal portion of mandible has two main structures, the basal and alveolar (tooth bearing) bones. Symphysis, parasymphysis, the body, and the alveolar bone compose the horizontal section of the mandible. The vertical mandible consists of the angle, ramus, condylar, and coronoid processes [2].

#### **2. Brief historical overview**

The first description of a mandibular fracture diagnosis and treatment goes back to the Egyptians in 1650 BC. Hippocrates described the reapproximation of fracture fragments and immobilization of the fractured mandible using circumdental wires and external bandaging.

Since then, many effective treatment methods and devices have been introduced to maxillofacial traumatology for the treatment of mandibular fracture including the facial bandage, extra oral fixation apparatus, intraoral acrylic, and metal splints, wires, arch bars, and stainless steel and titanium plate osteosynthesis. More recently resorbable screws and plates have been used for fracture management [3].

#### **3. Etiology (epidemiology)**

Mandible fractures have many different etiologies such as interpersonal violence, traffic accidents, gunshot wounds, sport accidents, work accidents, and falls [3]. The etiology of mandibular fractures varies from time to time, culture to culture. Students in different periods demonstrate differences in etiology depending on the age, demographic pattern of countries, and environmental conditions and social, socioeconomic, and cultural configurations. In developed countries, vehicle and sport accidents are main causes of mandibular fractures, while in developing countries and rural areas, inter personal violence, gunshot wounds, and falls in foregrounds [3–7].

#### **4. Clinical and radiological assessment**

#### **4.1 Clinical**

Complete history trauma should be obtained after cardiopulmonary and vital neurological functions of the patient are stabilized. Checking the airway by securing cervical spine is vital before assessment. Depending on the consciousness or neurologic status of the patient, history can be obtained from the patient or accompanying family members. Assessments including time, cause of trauma, pain, function of cranial nerves and altered sensation, visual changes, malocclusion, and general systemic conditions should be noted. Some mandibular fractures accompanying multiple injuries, as in traffic accidents, frequently require trauma team evaluation and consultation.

A neurologic examination is a vital point in the assessment of maxillofacial trauma. Functions of cranial nerves such as altered sensation, pupillary reflex, visual changes, and extraocular movements should be evaluated. Motor function of facial expression (nerve VII), symmetrical tongue movements, and mastication muscle (nerve V) should be checked. Sensation of the face should be also noted.

The mandible should be carefully evaluated by extraoral palpation. Mandibular contours such as ramus, lateral and inferior borders, and symphysis and parasymphysis area should be checked, and continuity of the mandibular bone should be noted. Movements of fragments can be evaluated by bidigital palpation. Ecchymosis and crepitation should be assessed. Check mandibular movements. Deviations and restriction of movements should be evaluated considering condylar trauma. Also the condylar head should be evaluated by palpation to check if it is in the articular fossa or not.

Mucosal laceration, oral bleeding, ecchymosis, and sublingual hematomas should be checked by the intraoral inspection. Rule out fresh oral bleeding in the sublingual space or bilateral symphysis fracture to secure airway, especially for anticoagulant drug users. Examination of the occlusion including loose, fractured, or missing teeth should be performed carefully.

#### **4.2 Radiological**

In most cases clinical examination cannot be sufficient to intensively evaluate the entire fractures lines, displaced small fragments, root fractures of teeth, and neighboring anatomical structures [8]. Plain films, OPTG, and computed tomography (CT) can provide additional data about the fracture for better evaluation of the patient. Periapical or occlusal radiographs are useful and practical imagining techniques for viewing specific areas of concern [9].

Although it is expensive, computed tomography (CT) is the most comprehensive imagining technique for evaluation of maxillofacial traumas. Detailed 0.5 mm thick slices provide excellent axial, coronal, and sagittal assessments of fracture lines, neighboring anatomical structures such as nerves. Also high velocity impaction traumas with multiple injuries require extensive stabilization of the patient. Additionally, 3D evaluations help to provide models for reconstruction and they are essential for proper approximations of fracture fragments with prepended titanium plates. Nowadays the use of cone-beam computed tomography (CBCT) in maxillofacial surgery has been providing less radiation and an accurate and reliable imagining alternative to conventional CT [10, 11].

Rarely, angiography and embolization can be used in the treatment of displaced TMJ fracture. Also MRI imagining can be helpful to evaluate soft tissue injuries such as TMJ disc.

#### **4.3 Classification of mandibular fractures**

Mandible fractures have a unique property within the maxillofacial traumas considering their history and treatment approach. The cornerstone of understanding the mandibular fractures is the classification of mandibular fractures. There are many fracture classifications in literature based on the type of fracture, cause of the fracture, reducibility, anatomic site, condition and inter-fragmental situation, and the presence of dentate or edentate segments. Some of these classifications are more widely accepted and used, and some of them are mostly seen in books but not used practically. Mandibular fractures are most commonly described as their anatomic location [3].

#### **4.4 Fracture classifications based on anatomic site**


#### *Trauma in Dentistry*

Fractures can be also classified as pathologic Fractures and traumatic fractures. Pathological fractures occur due to the failure of the bone which has lost its mechanical strength as a result of a pathological condition such as tumors, cysts, infections, etc. Traumatic fractures occur due to an impact which disrupts the continuity of the osseous tissue.

#### **5. Biomechanics**

The mandibular bone is exposed to many kinds of linear and angular forces underload such as compression and tension, shear, torsion, and bending [12]. External forces cause mandibular bone to undergo plastic and elastic deformation. On the other hand, muscles have some vertical and horizontal forces on fragments. These forces may cause displacement of fragments or may act as a stabilizer for fragments. The temporalis, masseter, and medial pterygoid muscle pull are responsible for vertical displacements of fragments. Horizontal displacements are mainly caused by lateral and medial pterygoid muscle pull. Some muscles have complex force on fragments such as mylohyoid, digastric, and geniohyoid which have a torsion effect on fragments.

Champy and co-workers described a zone of tension in the alveolar part of the mandible and a zone of compression on the lower border. This information allowed ideal lines for mandibular internal fixation to be identified along the physiological tension lines [3].

#### **5.1 Muscle forces**

Muscles have pull direction, and this pull effect may compress fragments to each other and prevent displacement. Fractures under the effect of these kinds of muscle pull vector are called favorable fractures.

On the other hand, some muscle pulls cause displacements of fragment. Fractures at these kinds of disadvantageous situations are called unfavorable

**Figure 1.**  *Horizontally favorable fractures.* 

*Evaluation and Management of Mandibular Fracture DOI: http://dx.doi.org/10.5772/intechopen.83024* 

 fractures. Favorable/unfavorable fracture concept is essential for mandibular fracture treatment decision which will be discussed later in this chapter.

*Horizontally favorable fractures***:** reduced biomechanically by the masseter and temporalis muscle pull (**Figure 1**).

*Horizontally unfavorable fractures:* Displacement of fracture fragments increased or is provoked by the masseter and temporalis muscle pull (**Figure 2**).

*Vertically favorable fractures:* The pull vector of the pterygoid muscle promotes the reduction of the fracture segments (**Figure 3**).

**Figure 2.**  *Horizontally unfavorable fractures.* 

**Figure 3.**  *Vertically favorable fractures.* 

 **Vertically unfavorable***:* The actions of the pterygoids tend to displace the fracture (**Figures 3 and 4**).

#### **5.2 Tension and compression zones**

Pulling force applied by muscles of oro-maxillofacial region creates zone of compression and tension within the mandible. The superior portion of the mandible is termed as the tension zone, and the inferior portion is termed as the compression zone (**Figure 5**). Champy's principle of osteosynthesis lines is based on these tension

**Figure 4.**  *Vertically unfavorable fractures.* 

**Figure 5.**  *Tension zone marked in red (−) and compression zones marked in blue (+).* 

*Evaluation and Management of Mandibular Fracture DOI: http://dx.doi.org/10.5772/intechopen.83024* 

**Figure 6.**  *Champy's principle of osteosynthesis lines.* 

and compressions zones which has been proven to be the guiding line to establish effective treatment for open reduction of mandibular facture (**Figure 6**) [3, 13].

#### **6. Principle of mandibular fracture treatment**

 The trauma patient should first be provided with airway clearance. In a patient lying in the supine position, foreign bodies such as missed pieces of broken teeth and intraoral bleedings may create a danger of closing the airway. Although the blood in the mouth may be swallowed by the unconscious patient at first, it may cause vomiting as time passes. Breathing can be provided by pulling the mandible forward with a properly positioned cervical collar. It must be kept in mind that in patients with compound fractures, it may be difficult to position the lower jaw with the help of a cervical collar.

Antibiotics are preferred especially in open fractures and delayed healing. The patient should be given anti-inflammatory drugs, and if there are no clean wounds, the necessity of tetanus vaccine should be considered.

#### **6.1 Prognosis of the teeth in the fracture line**

Fractures of the fracture line, excessively displaced, and teeth which have their cement exposed, if they are not to be temporarily held in the mouth to maintain occlusion, must be extracted [14].

The teeth with apical infection and teeth with excessive periodontal defects, teeth with root fractures, and teeth that prevent the reduction of fracture segments should be extracted [15] (**Figure 7**).

#### **6.2 Aim of fracture treatment**

The purpose of fracture treatment is to return the mechanical strength of the fracture site to its healthy state and to achieve an improvement in the masticatory muscles' normal functions.

The first stage of treatment is to return the fracture parts to their normal anatomic position (reduction). The second stage is the fixation of the parts in their

**Figure 7.**  *Teeth that prevent the reduction of fracture segments.* 

normal anatomical position (fixation). If the history of the trauma does not exceed 8–10 days, the fixation of the fractures can be done manually. In order to control the pain, local anesthesia can be applied. Mobile dentoalveolar structures must be fixed using wires or similar methods [16].

#### **6.3 Closed versus open treatment**

Fractures of the mandible can be treated either with open method or closed method.

#### *6.3.1 Closed reduction*

 Anatomically restoration of the fragments without visualization the fracture line is called closed reduction. In closed reduction both tooth-borne and bone-borne stabilization can be used to immobilize fracture to obtain correct maxilla-mandibular relation which is called intermaxillary fixation (IMF). Intermaxillary fixation (IMF) which is also called maxillomandibular fixation (MMF) is usually the basis of closed methods. Intermaxillary fixation is fixing the mandible and maxilla together when the teeth are occluded so that the patient cannot open his/her mouth for a certain period to allow secondary healing. The patient should be prescribed analgesics. One week of antibiotic use is required if there is an open fracture. The treatment continues until the hard callus is formed (4–6 weeks). Optimum bony union can be established in 4–6 weeks, but in complicated fractures, or compromised patients longer treatment periods can be required for healing. Closed method is still used today due to the advantage of elastic traction which helps successful repositioning of the fragments and its low cost. Arch bars, IVY loops, and intermaxillary fixation screws are all well-known appliances for closed reduction methods [17].

The use of vacuum-formed splints has also been recommended in the past for closed reduction.

 In the closed methods, arch bars are often used with ligature wires. The wire is passed through the interdental gap. One end of the wire is passed under the arch bar, and the other end is passed over the arch bar. With a fine-tipped tool, the wire is placed under the cingulum of the tooth, and the wire is bent to secure the arch bar to the tooth.

Intermaxillary fixation screws are also used to obtain the occlusion in open reduction. However iatrogenic root injury is a major concern for this method. Also loosening of the screw and covering of the screw head with oral mucosa and screw fractures have been reported as complications regarding the use of IMF screws.

#### *Evaluation and Management of Mandibular Fracture DOI: http://dx.doi.org/10.5772/intechopen.83024*

 The most important disadvantage of closed therapy is the continuation of intermaxillary fixation for 4 weeks. This may lead to undernourishment of the patient and weight loss. Also the patient must be informed about oral hygiene due to difficulty in cleaning the teeth under IMF. Non-displaced favorable fractures and grossly comminuted fractures with soft tissue lost can be the candidate of closed reduction. Edentulous mandibular fractures are also controversial cases which mostly require periosteal blood supply. Some authors suggest closed reduction with gunning splints and circummandibular wires. On the other hand, some other authors claim that open reduction with minimum periosteal striping can be a good alternative for such cases [18].

#### *6.3.2 Open reduction*

Open reduction is preferred when closed treatment is not possible or has failed. In open reduction, there is a surgical approach to the fracture, and the fracture segments are repositioned to their anatomical positions. This stage is called reduction. This is followed by the fixation step. Fixation can be either rigid or semirigid in open reduction. Compression plates and bicortical screws are used in rigid fixation.

While this is a reliable method and allows the patient to quickly return to daily functions, this technique has some disadvantages [19].

Semirigid fixation is performed using mini-plates. These smaller plates are placed on the stress areas in the fracture area. It is thought that micromovements caused by semirigid fixation have a positive effect on the callus formation. Monocortical screws are used so that anatomical structures are preserved. It may be possible to perform even under local anesthesia and with an intraoral approach. Occasionally occlusion can be obtained using intermaxillary fixation and elasticity.

The patient is given a soft diet during semirigid fixation. It is not mandatory to remove the plates after healing [20].

#### *6.3.2.1 Indications for closed reduction*


#### *6.3.2.2 Disadvantages of rigid fixation*


#### *6.3.2.3 Condyle fractures*

When closed reduction is delayed in condyle fracture patients, open reduction may be required. The delaying of closed reduction causes muscles to spasm and prevent a successful repositioning of the fragments. Also medial pterygoid and temporalis muscles may get fibrotic when the treatment is delayed. As more time passes, the risk of ankylosis increases in the untreated condyle fracture patient.

When an open reduction of the condyle fracture is planned, usually and extraoral approach is required. The most common incision fort his procedure is the preauricular incision which directly leads to the temporomandibular joint. Another approach is the submandibular incision which does not involve the temporal mandibular joint directly.

Sometimes, to obtain reduction of the fragments, an intraoral incision at the sigmoid notch region may be used [21, 22].

#### *6.3.2.4 Ramus fractures*

Ramus fractures rarely require reduction. Chewing muscles adhering to the area effectively splint fractures. Elastic IMF is applied if occlusion is affected (**Figure 8**).

#### *6.3.2.5 Angulus fractures*

 Triangular in shape, mandibular angle is the anatomic region between anterior border of masseter ligaments attachments and the most posterior superior attachment of masseter muscle. Angle fractures are anatomically unique regions that are developed laterally by the masseter and medially by medial pterygoid muscles which may stabilize the fracture in same situations. Vertical and horizontal fracture lines of this kind of fracture are essential fort the reduction of choice. Also the presence of unerupted third molars in this region is the weak point of this anatomical region. Unfavorable fractures of angle fracture may displace medially. Accompanying fractures such as condyle may alter the displacement of angle fractures.

 Access to the site is provided through various incisions, and incisions are made along the external oblique line. The plates should be placed so that they will not be directly under the incision line. Sometimes a transbuccal approach using a trocar may be required. Extraoral approaches may also be rarely used for angulus comminuted or pathological fracture reduction with Risdon incision just 1 cm bellow the angulus. Open reduction or closed reduction both can be used for this kind of fractures considering the complexity, age, displacement, and accompanying fractures to the angulus fracture. In open reduction monocortical single plate at the superior border of angulus as Champy's method or bicortical two mini-plates

**Figure 8.**  *Parasymphysis fractures accompanying ramus fractures, rarely require reduction.* 

*Evaluation and Management of Mandibular Fracture DOI: http://dx.doi.org/10.5772/intechopen.83024* 

can be selected as treatment method. Also the presence of uncontinuity defect or pathological fracture reconstruction plates should be consider fort the fracture managements. Load-sharing and load-bearing principles of fracture treatment must be the main guide as in all mandibular fractures [23] (**Figures 9** and **10**).

#### *6.3.2.6. Symphysis/parasymphysis fractures*

Considering the treatment plan, it should be noted that this region is under the influence of torsion forces. Open reduction, especially for unfavorable displaced fractures, is mostly preferred because of the easy access and complex forces upon symphysis/parasymphysis region. Also closed reduction can be used for favorable and non-displaced fracture. Champy's two-plate technique, one on tension and another on compression zone, is ideal for open reduction (**Figures 11–13**). Arch bar with one mini-plate at compression zone is also acceptable for fracture management. Anterior mandibular traumas should be evaluated very carefully.

**Figure 9.**  *Angulus fracture.* 

**Figure 10.**  *Open reduction with monocortical single plate at the superior border of angulus as Champy's method.* 

#### *Trauma in Dentistry*

#### **Figure 11.**

*Open reduction with monocortical with double plate, one at the superior border and the other at compression zone, as Champy's principle.* 

**Figure 12.**  *Open reduction with mini plates.* 

#### **Figure 13.**

*Radiological view of open reduction of right parasymphysis fractures accompanying left angulus fracture.* 

Accompanying uni- or bilateral condyle fracture to symphysis/parasymphysis fractures is not rare.

Symphysis fractures can be treated either with closed or open reduction. Even though mini-plates are successful in the management of symphyseal fractures,

*Evaluation and Management of Mandibular Fracture DOI: http://dx.doi.org/10.5772/intechopen.83024* 

some clinicians prefer lag screws for rigid fixation. Lag screws have the advantage of needing minimal time and a minimal intraoral incision similar to the incision for genioplasty, which has cosmetic advantages [24].

In the 1990s the use of 3D plates for the management of mandibular fractures has started to be recommended. Unlike compression plates and mini-plates, these 3D plates are placed on the week parts of the bone.

Even though not conclusive, recent studies show that 3D plates have better results in the condyle region with relatively poorer results in the body of the mandible, especially if the body is dentate.

#### *6.3.2.7. Mandibular body fractures*

Treatment principles of mandibular body fractures are based on Champy's line of osteosynthesis especially for simple fractures of the body. Intraoral access to this fracture is not difficult. One mini-plate at tension zone is sufficient for load-sharing fixation. Comminuted fractures may require additional mini-plates and screws. Also continuity defects such as pathological fractures need further load-bearing fixation systems such as reconplates. Mandibular continuity defects are defined as loss of the continuity of mandibular bone through a bone gap. Fractures close to mental foramen require additional care not to injure the mental nerve [17].

#### **7. Timing of the surgical management**

Just like other anatomical regions, all fractures involving the mandible should be treated as soon as possible. However, an immediate intervention is rarely applicable.

In patients who do not have airway problems and who do not have severe painful fractures, treatment can be delayed to the next day even though in cases of open fractures, the risk of infection increases as the time passes.

#### **8. Complications**

 Infection is the most common complication within fracture management, especially in comminuted fractures and gunshots. Infection rates of authors vary between 0.4 and 32% [17, 25]. Postoperative infection increases the risks of the ununion and fibrous union of the fractures. Infection is not only the cause of the ununion or fibrous union of fractures, mobility and unstable fixation techniques also enhance ununion and fibrous unions in fractures. Fractures because of highimpact traumas, gunshot, or pathological fractures may cause hard and soft tissue lost which can result in esthetical and functional problems. In such cases extraoral surgical approaches may cause facial nerve damages. Inferior alveolar nerve injurious can be rarely seen in open reduction of parasymphysis and mandibular body fracture repairs. Hardware-related postoperative complications are hardware fails, screws and plate fractures, and tooth roots jeopardized by fixation screws.

#### **9. Conclusion**

Mandibula is one of the the main skeletal component of the face and their fractures are among the most common traumatic injuries of the maxillofacial region which jeopardize both esthetic and function patients. The occlusion, form, and function should be all considered in the managements of mandibular fractures.

*Trauma in Dentistry* 

#### **Author details**

Guhan Dergin1 \*, Yusuf Emes2 and Buket Aybar2

1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Marmara University, Turkey

2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Istanbul University, Turkey

\*Address all correspondence to: guhandergin@yahoo.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Evaluation and Management of Mandibular Fracture DOI: http://dx.doi.org/10.5772/intechopen.83024* 

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Section 6 Orthodontics

**103**

**Chapter 6**

*Sanaz Sadry*

was given in this chapter.

**1. Introduction**

**Abstract**

Orthodontic Approach in Facial

In this review, the prevalence of dental trauma, prevention and diagnosis of traumatic injuries, the effects of dental trauma in patients in need of orthodontic treatment, orthodontic intervention to dental traumatized teeth, and treatment options for poor anterior teeth due to trauma are discussed. Dental trauma is a condition that is frequently encountered in dentistry. When orthodontic treatment of traumatized teeth is planned, the orthodontist should be considered before orthodontic treatment and during orthodontic treatment. Prognosis is divided into two types as treatment options of bad anterior teeth, retaining the tooth in the mouth or pulling the tooth and restoration of the opening. The multidisciplinary teamwork and the role of the orthodontist in this team are important in order to achieve optimal results in the clinical intervention of these cases. Autotransplantation, orthodontic closure, or opening of the space are discussed when tooth extraction and toothless space restoration are required. It is very important to decide if orthodontic forces should be applied or not, and if orthodontic force is necessary, when should it be applied. Information on orthodontic forces applied to traumatized teeth

**Keywords:** orthodontic approach, dental trauma, tooth movement,

Dental trauma (traumatic dental injury) affects the teeth and soft and hard tissues around the oral cavity. According to research worldwide, dental trauma is often seen as a result of sporting activities, falls, traffic accidents, and fights and often requires emergency intervention [1, 2]. Because of the high rate of trauma in patients presenting with orthodontic treatment today, the orthodontist should plan how to perform dental movements in these patients and consider the long-term prognosis of these teeth before starting treatment. The orthodontists in the multidisciplinary team who intervenes in the trauma have a major role in obtaining optimal results in the traumatic tooth [3]. While interfering with dental trauma cases, treatment guidelines may not be applicable as standard for each patient. Each case should be evaluated and treated accordingly. General health of the patient, severity and type of the trauma, chronological and dental age of the patient, dental and anatomical development status, and whether the patient carries a device in the mouth during trauma are some of the factors determining the treatment. It is important to decide whether orthodontic force can be applied to dental traumatized teeth, and if it is to be applied, it will be applied after the trauma. Excessive amount of orthodontic force on dental teeth

autotransplantation, orthodontic space closure

and Dental Trauma

#### **Chapter 6**

## Orthodontic Approach in Facial and Dental Trauma

*Sanaz Sadry*

#### **Abstract**

 In this review, the prevalence of dental trauma, prevention and diagnosis of traumatic injuries, the effects of dental trauma in patients in need of orthodontic treatment, orthodontic intervention to dental traumatized teeth, and treatment options for poor anterior teeth due to trauma are discussed. Dental trauma is a condition that is frequently encountered in dentistry. When orthodontic treatment of traumatized teeth is planned, the orthodontist should be considered before orthodontic treatment and during orthodontic treatment. Prognosis is divided into two types as treatment options of bad anterior teeth, retaining the tooth in the mouth or pulling the tooth and restoration of the opening. The multidisciplinary teamwork and the role of the orthodontist in this team are important in order to achieve optimal results in the clinical intervention of these cases. Autotransplantation, orthodontic closure, or opening of the space are discussed when tooth extraction and toothless space restoration are required. It is very important to decide if orthodontic forces should be applied or not, and if orthodontic force is necessary, when should it be applied. Information on orthodontic forces applied to traumatized teeth was given in this chapter.

**Keywords:** orthodontic approach, dental trauma, tooth movement, autotransplantation, orthodontic space closure

#### **1. Introduction**

 Dental trauma (traumatic dental injury) affects the teeth and soft and hard tissues around the oral cavity. According to research worldwide, dental trauma is often seen as a result of sporting activities, falls, traffic accidents, and fights and often requires emergency intervention [1, 2]. Because of the high rate of trauma in patients presenting with orthodontic treatment today, the orthodontist should plan how to perform dental movements in these patients and consider the long-term prognosis of these teeth before starting treatment. The orthodontists in the multidisciplinary team who intervenes in the trauma have a major role in obtaining optimal results in the traumatic tooth [3]. While interfering with dental trauma cases, treatment guidelines may not be applicable as standard for each patient. Each case should be evaluated and treated accordingly. General health of the patient, severity and type of the trauma, chronological and dental age of the patient, dental and anatomical development status, and whether the patient carries a device in the mouth during trauma are some of the factors determining the treatment. It is important to decide whether orthodontic force can be applied to dental traumatized teeth, and if it is to be applied, it will be applied after the trauma. Excessive amount of orthodontic force on dental teeth

 can cause undesirable effects such as root resorption [4, 5]. Patients with orthodontic attachments at the mouth during orthodontic treatment may also be exposed to dental trauma. When dental trauma occurs during orthodontic treatment, the path to be followed for treatment is based on clinical experience and individual case reports presented in the literature [3, 6, 7]. Dental injuries vary widely from simple enamel fractures to complicated fractures and often require complicated treatment of more than one type of injury. The knowledge and skills of the physician are very important in cases where such emergency treatment is required, and the first treatment is extremely important on prognosis [8].

#### **2. Prevalence**

Most of the dental trauma data available have been collected retrospectively from cross-sectional studies or from longitudinal studies of patient records. The prospective studies are based on subpopulations such as school children [9–12], children presenting to a pediatric dental service, or patients presenting to an accident and emergency department [13–15]. Permanent incisors of children that sustain damage by accident in the United Kingdom increases with age from 5% at age 8 to 11% by age 12, and injuries are more frequent in males than females [16–19]. Two comprehensive national studies conducted in the United States reported that one of six adolescents and one of four adults suffered traumatic dental injuries [20]. The majority of permanent tooth injuries occur in the age group of 6–15 and especially between the ages of 8 and 11 years. The upper teeth, especially the central incisors, are affected more by the lower teeth. This occurs more in boys than girls [21].

The researchers found that the injuries were mostly caused by traffic accidents, sports, and violence as a result of the incidents, and mostly due to falling in girls; they reported an uncomplicated crown fracture (55.4%), fracture (8.6%), complicated crown fracture (5.5%), luxation (4.3%), and avulsion (2.0%). Although the oral region of the human body constitutes 1% of the whole body, the statistics indicate that one fourth of the school age children and one third of the adults suffer from trauma [22].

#### **3. Etiology**


The risk of trauma was found to increase as the amount of overjet increased. Incidence of trauma in the maxillary incisors was four times higher than the mandibular incisors. When the overbite was 0 mm, the risk of trauma in the mandibular incisors was the highest [23].

### **4. Classification**

The WHO system was modified by Andreasen and Andreasen to further clarify the luxation and intrusion groups. This classification is as follows:


The treatment plan for patients with traumatized tooth is evaluated in two parts as the prognosis of the traumatized tooth and the treatment of possible malocclusion [24].

#### **5. Examination and diagnosis**

 Before an orthodontic treatment, a thorough anamnesis must be taken to determine whether the patient has suffered dental injuries. Before the examination, a comprehensive patient history is taken. The general health status of the patient, time of injury, and direct or indirect trauma are determined. In order to determine the state of the healing capacity of the tissues, whether the patient has been traumatized in the same area before, if any treatment has been performed in which the area, the tooth showing the damage in the support tissues or pulp, the sensitivity to spontaneous toothache, and hot-cold and sweet-sour foods are questioned. In the clinical examination, extraoral tissues, intraocular tissue, periodontal tissues, alveolar bone, and teeth are examined carefully. Abnormalities in the occlusion indicate a fracture in the alveolar and jaw. Sensitivity of the teeth during contact and whether the teeth are luxated are determined. According to the localization of the root fractures, there is luxation in the teeth. The mobility of the root fracture increases as the fracture line approaches the crown. Sensitivity to percussion refers to injuries in periodontal fibers. Thermal tests and vitalometer applications are used to determine the vitality of pulp in teeth injured due to trauma.

It is not always possible for the patient to remember whether he has had a dental injury, so that the patient should be evaluated clinically and radiographically prior to the treatment, and this evaluation should include the following:

 The tooth should be checked for coloration and recorded. Crown yellow colorations, pulp canal obliteration; dark coloring may be a sign of pulpal hemorrhage or necrosis. It should be examined whether there is mobility in horizontal and vertical direction. With palpation, the apical area of the teeth should be checked for sensitivity. Percussion should be examined. In percussion, metallic sounds may be a sign of ankylosis, and blunt sounds may be a sign of root fracture. Thermal and electrical pulp tests and pulp response should be considered. Thermal tests were used to determine the neurovascular support of the traumatic tooth pulp; electrical pulp test plays an important role in determining the pulp necrosis of the tooth.

Radiographs are an important factor in the diagnosis of traumatic dental injuries. Depending on the type of malposition (e.g., lateral luxation) and the type of fracture (specimen, root fracture), it is important to take periapical film from various angles to perform an accurate examination.

Unexpectedly developing dental trauma may affect the oral function and psychology of the patient. It is necessary to eliminate the negative effects of pain and trauma on the teeth and periodontal tissues as soon as possible after dental trauma occurs in individuals receiving fixed orthodontic treatment. Regardless of the stage of fixed orthodontic treatment, dental trauma during treatment disrupts the routine functioning of active orthodontic treatment. The first emergency intervention in the trauma area is relieving of the pain, and the orthodontic force is rapidly removed from the teeth in the trauma area. Then, according to the severity of dental trauma, treatment is carried out with an individual approach that includes multidisciplinary treatment methods [20].

 Brin et al. reported that increased overjet and insufficient lip closure were the greatest risk factors for dental trauma and that early orthodontic treatment to reduce overjet would reduce the risk of dental trauma. The use of mouthguard in individuals interested in contact sports is also an application that reduces the risk of dental injury [23, 24]. Bauss et al. reported different treatment approaches according to the type of dental trauma in patients with dental trauma during orthodontic treatment [7].

#### **6. Treatment sequence and timing**

Orthodontic treatment should usually be initiated during mixed dentition. When trauma occurs at an early age, the treatment will be shorter and less complicated, given the age, dental and skeletal development, and maturity of the patient [20].

#### **7. Observation periods before orthodontic treatment**

#### **7.1 Crown and crown-root fractures**

If crowns and crown-root fractures without pulp are treated appropriately, their prognosis is good. Before the orthodontic treatment, the 3-month observation period is sufficient. Crown and crown-root fractures containing the pulp can be treated orthodontically after partial pulpectomy and hard tissue barrier formation. Hard tissue barrier is observed radiographically 3 months after treatment [20].

This type of fracture includes enamel, dentin, and cement. Pulp may or may not be exposed. As a result of the traumatic forces that come out of the teeth, crown-root fractures are frequently encountered [25]. It has been reported that vertical crown-root fractures should be extracted. In diagonal crown-root fractures, the broken tooth must be orthodontically extruded to expose the subgingival fracture line [26]. The distance of healthy gingival tissue on the alveolar bone is defined as the biological width. This width is ideally considered to be equal to the sum of the connective tissue attachment (1 mm) to the sum of the epithelial attachment (1 mm). The extraction of the fractured tooth by obtaining the biological width is important for the ideal restoration of the tooth [25].

#### **7.2 Luxated teeth**

Clinical experiences showed that light injuries such as confusion and subluxation require at least a 3-month observation period. The need for endodontic treatment usually arises after moderate to severe limb injuries. Radiographic improvement revealed that orthodontic treatment should be postponed until it is out.

#### **7.3 Endodontically treated teeth**

 Wickwire and colleagues compared root resorption of endodontically treated teeth with vital teeth after orthodontic treatment, and more root resorption was found in devital teeth [27]. Mirabella and Arthun suggested that endodontic application is a protective treatment and that root canal-filled teeth are resorbed for unknown reasons [28]. Hunter and colleagues in their study showed no difference between the vitality of vital and devital teeth root resorption after orthodontic treatment [29]. Hamilton and Gutman stated that if the root canal filling is properly shaped three dimensionally and cleaned, minimal resorption will be seen during the movement of orthodontic teeth [28].

#### **7.4 Root canal calcified teeth**

Calcification of the root canal is usually seen after autotransplantation of immature teeth, and these teeth can be moved in a limited manner. However, closely monitoring the root canal calcified teeth during orthodontic treatment is extremely important [20].

#### **8. Special treatment principles in various trauma types**

It is essential that radiographic examination is performed before starting orthodontic treatment, even in light injuries such as uncomplicated crown fracture. If the vitality of pulp is suspected, it is recommended to undergo a 3-month observation period before orthodontic treatment [20].


#### *Trauma in Dentistry*


 Observation period prior to orthodontic treatment of the teeth with root fracture is determined as 2 years. Clinical experience has shown that most complications, such as pulp necrosis, occur 1 year after trauma. If no complication occurs, the observation period may be shortened. There are two types of treatment options, orthodontic or surgical extrusion, in teeth with complicated crown-root or cervical root fracture [20]. The orthodontic success of teeth with root fractures depends on the localization of the fracture and the type of healing. Radiographic and histological examinations showed that different types of healing are seen after root fractures: (1) Recovery with calcified tissues, (2) connective healing, and (3) improvement of bone growth between fractures. Healing with calcified tissues is the healing of the fracture with dentin and cement. Full interlocking of the fracture may not be completed, but the fracture has been combined. The orthodontic movement of the teeth with a hard tissue callus and a fractured root fracture can occur without the fracture line. The fracture margins are covered with cement and periodontal ligaments in the healing of the intervening tissues. Orthodontic movement of teeth with root fractures and broken pieces is separated from the connective tissue to move away from each other. In the orthodontic treatment plan of fractured teeth root with intervening connective tissues, the tooth should be seen as a short-rooted. This means that the teeth broken from apical one third have sufficient periodontal support for orthodontic tooth movement [37].


soon as possible. Storing the avulsed tooth in milk for more than 60 minutes or 30 minutes dry causes ankylosis in the tooth after reimplantation [38, 39]. Orthodontic movement of the tooth is not recommended until after the reimplantation periodontal recovery is complete (6 months). It should be emphasized that the tooth may be ankylosis if orthodontic force is not performed as expected [3]. Replantation is considered primarily when the avulsed tooth is intact. Replantation is the insertion of the avulsed tooth into the alveoli with acute trauma. The loss of the permanent tooth after trauma is a condition that requires an orthodontic treatment plan. The main question is whether the cavity will be preserved for dental autotransplantation, implant placement, or bridge. Autotransplantation can be performed with both mature and immature teeth. However, in most cases with autotransplantation, the best prognosis is observed if the 3/4 of the tooth germ is formed or if the entire root is formed, but the apex is open. At this stage, the pulp maintains its vitality and continues its root development. Transplanted teeth lose only a small portion of the root length [21]. Bone-supported implants have been widely used instead of lost anterior teeth in recent years. Implants are fixated within the jaw and do not erupt during dental and alveolar development. For this reason, growth and development must be completed before implant placement [20].

 • Space closure: Space formed of loss maxillary lateral incisors can be closed by positioning the maxillary canine in the lateral cutting region. Rather than the tooth that has been lost, rather than a prosthetic lateral tooth, the closure of the lateral tooth leads to more esthetic results periodontally. Canines are bled, to achieve more esthetic results. The length of the clinical crown can be changed through gingivectomy [40]. Following the orthodontic closure of the lost central tooth, if the shifted teeth are decided to be reshaped, the lateral tooth intrusion and the canine tooth are extruded to obtain the gingival contour of the central and lateral teeth [41]. In cases where the maxillary central teeth are lost, it is a complex condition where the lateral tooth is replaced by the mesial movement of the central tooth. The space is not fully closed, which poses risk. In cases where laterals are replacing the centrals, the lateral cutter should be raised in the mesiodistal direction, and the buccal root torque is required [42]. Extrusion of the canine tooth and intrusion of premolar teeth are performed in order to obtain the optimum gingival marginal contour of the anterior teeth. Lateral root torque is applied to the canine tooth and canine root torque to the repositioned premolar. Canine tooth is worn as composite or porcelain (porcelain veneers are more suitable and preferable) and restored to give it lateral form. The width of the canine tooth is reduced to provide optimal esthetic and functional occlusion by increasing the length and width of the first premolar teeth that are extruded and mesialized by composite restorations. The canine tooth with a more yellow color is bleached after its mesialization to the lateral tooth position [41].

In cases where the incisors are lost, the esthetic and functional results cannot be obtained by closing the space, and the completion of jaw growth should be expected. In this case, space should be maintained, and set-up models should be studied for different alternatives of tooth positions [43].

• Maintaining the space: The space can be maintained if it is not suitable. In patients with normal occlusion and dysesthesia with poorly aligned normal occlusion if more than one incisor is lost in the same arch, in class II division or class III patients who have lost one tooth in the upper jaw, there is a large discrepancy between the crowns of the central and lateral incisors and the space may be maintained in

 patients with lip deficiency [44]. Various space maintainers can be used to protect the space. The best option is to use the traumatized tooth as space maintainer when the prognosis is poor. But teeth should be checked. In case of ankylosing, it should be extracted without a severe infraocclusion [45].


The incidence of replacement resorption in intrusive cutters varies between 5 and 31%. The relationship between the severity of the intrusion and the type of root

#### *Orthodontic Approach in Facial and Dental Trauma DOI: http://dx.doi.org/10.5772/intechopen.83015*

resorption was examined, and a significantly higher rate of replacement resorption was seen in the severely intrusive apex closed teeth [33].

Treatment: In the case of closed and severely intramedullary apex closed teeth, the tooth should be immediately placed in the previous alveolar position (early orthodontic extrusion) to allow the extirpation of non-vital pulp and to prevent the formation of inflammatory resorption. Since active surgery or orthodontic extrusion will cause a secondary trauma in the periodontal ligament, the teeth should be spontaneously re-erupted in individuals under 17 years of age who have suffered low and moderate trauma [39]. In 2 weeks, active extrusion may be considered if no movement occurs in the tooth. A serious intrusion force may compress the tooth in alveolus, thus the tooth can be lightly luxated prior to orthodontic extrusion [3].

Early orthodontic extrusion: For orthodontic extrusion of 1–2 teeth that have been intrinsic, extrusion force may be applied by using a movable apparatus and vertical elasticities between the teeth attached to the tooth. With this application, the reactive forces are aimed to be absorbed by the palatal mucosa under the acrylic instead of the adjacent teeth [50]. It is important to avoid anchoring from the neighboring teeth as much as possible in the treatment of a tooth affected by the intrusion. The use of conventional brackets and wire methods is not suitable in such cases, since the extent of the trauma that affected these teeth is unknown [50].

Success rate: early orthodontic extrusion prevents ankylosis [51].


occurs if it occurs between the ages of 10 and 12. In such cases, the ankylosing tooth should be removed after 2 to 3 weeks following diagnosis [45].

• Extraction of ankylosing incisors: Decoronation technique has been developed to prevent bone loss in the extraction of ankylosing teeth. The crown of the ankylosing tooth is removed, and the stem is left in the alveoli. In children, a new marginal bone is formed to resorb the coronal root. Thus, the height of the alveolar bone increases vertically and is also preserved faciolingually [60].

### **9. The effect of orthodontic tooth movements on traumatized teeth**


#### **9.1 Prognosis**

In mild to moderate luxation injuries (such as confusion or subluxation) of the teeth, if the orthodontic treatment is performed carefully, the risk of root resorption is reduced. After severe luxation (extrusion, lateral luxation, intrusion, and replantation), it is more dangerous to move the tooth. Orthodontic treatment is important to assess the risk of root resorption 6 months after onset. If progressive resorption is observed at this stage, treatment may be interrupted for 3 months to reduce the risk of severe resorption [66].

In conclusion, the prognosis of the whole treatment can be summarized as follows;


#### **9.2 Retention**

 During treatment, closure or preservation of the space is decided according to the retention period. Retention plan can be divided into three groups: group with limited retention and partial permanent retention. The need for retention of patients who are traumatically injured and undergoing orthodontic treatment depends on many factors. The most important ones [20] are the elimination of the cause of malocclusion, appropriate occlusion, reconstruction and reorganization of soft tissues and bone around placed teeth, and correcting skeletal deviations during growth development period. The need for retention is limited if these goals are achieved.

### **10. Result**

Dental injuries are considered an emergency in dentistry. Increased overjet reduction and the use of mouthguard are protective applications that reduce the risk of dental trauma. The knowledge of the physician is of paramount importance in cases of dental trauma that require urgent treatment, and the first treatment is extremely important on prognosis. In trauma cases, the prognosis of traumatized tooth with existing malocclusion should be evaluated. After the treatment of traumatized teeth, the teeth should be evaluated clinically and radiographically at the end of the observation period required for orthodontic treatment. Dental trauma is generally seen in individuals who continue to grow and develop, and orthodontic treatment, which is a conservative method in the treatment of traumatized teeth, is an ideal treatment option that meets the esthetic and functional needs of patients.

### **Author details**

Sanaz Sadry Department of Orthodontics, Dentistry Faculty of Istanbul Aydin University, Istanbul, Turkey

\*Address all correspondence to: sanazsadry@aydin.edu.tr

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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