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I. Introduction
Dentoalveolar (DA) trauma is a common dentofacial injury, with a prevalence of 11%-30% among children and 5%-20% among adults1-5. It involves tooth trauma, alveolar bone fractures, or a combination of the two and constitutes a dental emergency. DA trauma can be due to falls, sports injuries, road traffic accidents, etc.6. Prompt diagnosis and early management of these injuries are crucial for ensuring the best possible outcomes7.
In clinical practice, DA fracture management is a two-stage procedure. The first stage involves the manual reduction of alveolar bone and repositioning or replantation of teeth, if required, followed by splinting for stabilization. Stabilization can be achieved with wire, an arch bar, fiber with composite material, or acrylic capping. The second stage involves whatever restorative, endodontic, or rehabilitative procedures are needed for each case. The timing and type of endodontic treatment depends on the associated injuries, fracture severity, and overall tooth and supporting structure condition8. Various novel and minimally invasive techniques have recently been introduced. The management of DA fractures depends on many factors, such as the site; type and extent of the fracture; associated dental trauma; tooth staging; adjacent available teeth; patient age, medical condition and willingness; patient compliance; presentation timing; choice of splint fixation; available resources; and surgeon preferences and expertise9.
In routine practice, general physicians in emergency settings often encounter these fractures and lack a detailed understanding of the emergency procedures for management, which can lead to delay in treatment and referral to specialists such as maxillofacial surgeons, pediatric dentists, or endodontists for definitive management10. These fractures often occur with other facial bone fractures, and they are usually managed together11. Isolated DA fracture cases receive limited attention in the emergency department and they are generally referred for specialist treatment on an outpatient basis12,13. This systematic review was conducted to summarize the literature on management strategies for and outcomes of isolated DA fractures in pediatric and adult populations.
II. Materials and Methods
The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were followed to ensure the rigor and transparency of the systematic review process14. The PICO (Population, Intervention, Comparison, and Outcome) criteria were used. The population was individuals (pediatric and adult groups) with isolated DA fractures. The interventions were the various methods used for splinting. No comparisons were considered. The outcomes were basic demographic data, etiology, site involvement, associated dental trauma and its immediate treatment, type and duration of splinting, complications, and timing of endodontic treatment. The inclusion criteria for this systematic review encompassed prospective, retrospective, and comparative studies; case series; and case reports. Studies of DA fractures associated with other facial bone fractures were excluded. When institutions published multiple studies with overlapping patient populations or varying lengths of follow-up, only the most comprehensive reports were included for analysis to prevent the duplication of results. Studies in non-English languages, in vitro and animal studies, reviews, book chapters, and studies with insufficient or missing data were excluded to ensure reliability and minimize publication bias.
1. Search strategy
Electronic searches were conducted in PubMed, Google Scholar, Semantic Scholar, and Cochrane Library for studies published between January 1980 and December 2022 to ensure a comprehensive analysis of the available literature. To achieve maximum sensitivity and ensure the inclusion of all relevant studies, the search was conducted in a staged manner using individual and combined search terms, such as “dentoalveolar fracture,” “dentoalveolar trauma,” “splinting,” “bridle wire,” “wiring,” “arch bar,” “composite splint,” “fiber splinting,” “teeth splinting,” “semi-rigid,” “rigid,” “flexible,” “splint retainer,” and “orthodontic retainer”.(Table 1) Duplicate studies were removed from the combined results of the databases. The reference lists of all final retrieved articles were carefully reviewed to identify other potentially relevant studies that met the inclusion criteria.
2. Data collection
Data collection and analysis involved examining studies that met the specified inclusion and exclusion criteria. Two reviewers (S.B. and B.L.) analyzed the studies independently at the title, abstract, and full-text levels. Any discrepancies or conflicts were resolved through mutual consensus.
The following data were extracted for analysis: the study type, total number of patients, age group (≤12 years and >12 years), sex of patients, mechanism of injury, site of involvement, investigations conducted, time elapsed between injury and splinting, type of splint used, duration of splint placement, late dental management, complications encountered, and follow-up duration.
3. Risk of bias in individual studies
The risk of bias was assessed using the Joanna Brigs University tool15. A high risk of bias was identified when ≤49% of the answers were positive; moderate risk of bias was assumed when 50%-69% of the answers were positive, and a low risk of bias was identified when more than 70% of the answers were positive.
III. Results
The selection process is depicted in Fig. 1 (PRISMA flowchart). A total of 78 studies were included for full-text reading by the two investigators. Data extraction and analysis were done for 26 studies. For simplicity and better insights, two groups were made based on age: the 2-12 years age group (pediatric) and the older than 12 years age group (adult)16-41.(Tables 2, 3)
1. Pediatric (2-12 years)
Eighteen case reports were analyzed (male 9, female 9). Fall (n=14) was the most common reported etiology. The anterior maxilla (n=10) was the most reported site, followed by the anterior mandible (n=6). Orthopantomogram (OPG) (n=11) was the most frequently conducted radiographic investigation. The reported dental injuries were avulsion (n=9), luxation (n=4), extrusion (n=1), intrusion (n=3), and enamel/crown fracture (n=3). Among the 9 cases of tooth avulsion, replantation was done in 4 permanent teeth, repositioning (n=7) was done in cases of luxation or intrusion and composite restoration (n=3) was done for fractured teeth.
Splinting was done within 24 hours in 7 cases, but the timeframe was not mentioned in the others. The splinting types were a composite resin-bonded splint (n=9), acrylic resin splint (n=5), circummandibular wiring with maxillomandibular fixation (n=1), suture (n=1), titanium mesh (n=1), and vacuum splint (n=1), and splinting was done under either local anesthesia (n=13) or general anesthesia (n=5). The splinting duration was mostly 2-4 weeks (n=13), although it differed among the studies. Endodontic intervention (n=6) was performed between 3 days and 12 weeks after the initial injury. Rehabilitation used removable partial dentures in one case. Complications such as resorption (n=2), abscess (n=1), and gingival recession (n=1) were reported. Follow-up ranged between 1 month and 42 months.
2. Adult (>12 years)
Eight studies were included (male 7, female 3). Fall (n=5) was the most common reported etiology. The anterior maxilla (n=6) was the most reported site, followed by the anterior mandible (n=1). OPG (n=3) was the most conducted radiographic investigation. Dental injuries included avulsion (n=1), luxation (n=1), and enamel/crown fracture (n=3). Replantation was done in one patient, repositioning (n=3) was conducted in cases of luxation, and selective grinding was done in one case.
Splinting was done within 48 hours in 4 patients, and the timeframe was not mentioned in the other studies. Splinting was done with a composite resin-bonded splint (n=4), bone screw stabilization (n=1, 3 cases), and an Erich’s arch bar with wire (n=3) under local anesthesia (n=6, 7 cases) or general anesthesia (n=2). The splinting duration varied between 2-4 weeks (n=4) and 6-8 weeks (n=2). Endodontic intervention (n=4) was performed between 2 and 12 weeks after the initial injury. A porcelain veneer (n=2) was done for fractured teeth, and rehabilitation used removable partial dentures in one study (3 cases). Follow-up ranged between 3 months and 60 months. Comparative results are depicted in Table 4.
3. Risk of bias assessment
Among the included studies (n=26), 22 had a low risk of bias, and four had a moderate risk of bias (Martins and Fávaro31, Al-Hadad et al.40, Nyárády et al.39, Ali et al.36).(Supplementary Table 1)
IV. Discussion
DA fractures involve the alveolar bone, teeth, and associated soft tissue structures42. They can occur in isolation or in association with other facial bone fractures. Cases involving concurrent injuries often present as emergencies and are managed in accordance with established protocols. In contrast, isolated DA cases might not promptly report to an emergency department, and when they do, they might not receive prompt attention. In fact, these cases should be considered sub-acute emergencies because the intervention timing directly influences the prognosis of the affected teeth and bones. In addition, injuries to primary teeth affect the permanent dentition43. Whenever feasible, it is important to expeditiously address such injuries to enhance the long-term outcomes and restoration of normal function and esthetics. Evidence on the epidemiology and management of isolated DA fractures is limited. Therefore, this systematic review was conducted to pool the data on DA management and outcomes in pediatric and adult patients.
The incidence of DA fractures is challenging to estimate because they often occur in conjunction with dental injuries and/or craniofacial trauma. Falls were the most common etiology reported. The pediatric population is more prone to falls during activities such as cycling19,25,26 and playing20,23,24,28,33 and to accidental falls at home16,17,29,31. In contrast, the adult population is susceptible to injuries due to falling under the influence of alcohol, assault, or sports-related activities34,36.
Determining the extent of DA trauma and associated dental injuries through clinical and radiographic examination can facilitate prompt treatment. The present review reveals that alveolar fractures most frequently occur in association with dental trauma. The International Association of Dental Traumatology (IADT) guidelines advise the use of a periapical radiograph and two additional radiographs in angulations to diagnose alveolar fractures, supplemented by panoramic and cone-beam computed tomography (CBCT), if necessary. However, various radiographic investigations were reported in the included studies: intraoral periapical radiographs (IOPA)20,24,25,27,36, OPG16,18-21,23,24,27,29,30,33,35, posteroanterior skull radiographs (PA skull)17, CBCT37,38, and non-contrast computed tomography17,18,29. Among them, OPG was most commonly reported in both age groups. This preference for OPG might be attributed to the emergency settings in which DA fractures typically present, where periapical radiographs are often unavailable, and OPG can reveal a horizontal fracture level above the tooth apices. IOPA helps to diagnose and monitor individual tooth injuries. Computed tomography can help to identify the degree of displacement and make alveolar fractures more apparent. PA skull has a limited role in such injuries. In certain cases, a clinician might perform the initial treatment after clinical examination without radiographic examination to prevent delays.
The anterior maxilla was the most common site in both groups, which can be attributed to its anatomical alignment, which makes it vulnerable. The literature suggests a decrease in the overall incidence of DA injury when improved safety equipment, such as mouth guards and face masks, is used44,45. Among the associated dental injuries, avulsion, luxation, extrusion, and intrusion were more prevalent within the pediatric population, and crown and enamel fractures were more common in the adult group. This might be attributed to differences between pediatric and adult patients in tooth-housing bone. The forces are directly transmitted to the teeth in adults due to their strong bone base.
The management of DA fractures and associated dental trauma requires a comprehensive approach tailored to each patient and should be guided by the tooth type and stage of tooth development, which is of greater clinical relevance and significance than chronological age46-48. Repositioning in luxation or intrusion injuries should be performed before the reduction of alveolar bone because they might hinder reduction. However, the replantation of avulsed teeth and repositioning of intruded teeth are not recommended for primary teeth. The flowchart compiled from the literature evidence outlines the recommended actions to be undertaken in emergency settings for strategic management of isolated DA trauma49-57.(Fig. 2) This chart might help clinicians and dental practitioners in emergency settings make prompt decisions for effective management and timely referrals.
Following reduction, stabilization can be achieved by a variety of methods such as composite resin-bonded splints, acrylic resin, suture, titanium mesh, vacuum splints, and circummandibular wires for the pediatric population and Erich arch bars with wires, screw stabilization, titanium mini plates and bonded splints for the adult population. Splinting can aid in the immobilization of both tooth and DA fractures. The choice of a splint depends on patient compliance and the surgeon’s preference. Short-term, non-rigid splints are advised53. Interestingly, composite resin-bonded splints were commonly used in both populations, possibly due to their high patient compliance. Arch bars can pose challenges in hygiene maintenance and can thus affect gingival health. The evidence indicates that the splint type is not significantly related to treatment outcomes58. This review reveals that splinting was typically done for 2-4 weeks using rigid splints in cases of concomitant dental and alveolar fractures, which warrants further research. The IADT guidelines provide distinct recommendations about the duration and type of splinting for alveolar fractures and dental trauma as separate entities. However, scientific evidence is lacking about the best splinting time for combined injuries and the effects on pulpal and periodontal healing. The choice between local and general anesthesia depends on patient factors, such as low compliance, high anxiety, and timing delays that can complicate manipulation under local anesthesia. Both age groups were treated with both types of anesthesia, and general anesthesia was sometimes used for debridement and suturing of associated soft tissue injuries.
Independent of the type of splinting, the timing of splinting is crucial. In the included studies, splinting was done within 24-48 hours, revealing a delay in the management of sub-acute emergencies. The duration of splinting varies between the pediatric and adult populations. A splinting duration of 2-4 weeks was commonly reported in both groups, which contrasts with the IADT recommendation of 4 weeks for all ages. However, bone healing rates and tooth development vary between children and adults. Typically, pediatric cases required shorter splinting durations (2-3 weeks), and adults needed longer splinting periods (3-4 weeks)59. The period of immobilization can also vary on a case-to-case basis depending on the severity of the fracture.
Late dental injury management includes endodontic treatment, definitive restoration, and rehabilitation. Not all cases require additional treatment. The timing and type of endodontic treatment depend on the patient’s age and root development. In pediatric patients with immature teeth, apexification or apexogenesis techniques are used to promote the formation of a natural apical barrier, enabling successful root canal treatment60. In contrast, adults typically have fully formed roots, allowing for standard endodontic procedures. Composite restorations were used to repair tooth, enamel, and crown fractures in both age groups. Veneers or crowns were reported only in the adult group; however, they can also be used in pediatric patients as needed. Rehabilitation procedures such as removable partial dentures were used in cases of permanent tooth loss in both groups, and space maintainers can be used in cases of primary tooth loss61. A detailed algorithm for late treatment is provided in Fig. 2.
Unfavorable outcomes, such as submental abscess17, replacement root resorption23, and gingival recession25, were reported in pediatric patients, but none were reported in adults in the included studies. This emphasizes the need for specialized attention, patient compliance, and follow-up in pediatric populations. Follow-up periods were between one month and five years. Long-term follow-up is crucial because DA structures continue to grow, and achieving functional occlusion is essential for oral function.
This systematic review included isolated DA fractures and their management. Although it offers valuable insights, the limited number of studies and potential for selection bias restrict the generalizability of these results. Persistent efforts and policies are required to raise awareness and thus prevent DA trauma and improve its management in emergency settings.
V. Conclusion
In conclusion, isolated DA trauma should be considered a sub-acute emergency condition that requires immediate attention for optimal outcomes. These injuries are more prevalent among children than adults, and fall is the most common cause for all ages. The upper anterior teeth and maxilla are commonly involved. Staged treatment by specialists and regular follow-up are the keys to overall management, which should be tailored the age of the patient, stage of tooth development, time elapsed since injury, and availability of resources. DA injuries can be prevented by spreading awareness about the importance of safety measures for children during activities such as cycling and playing. Policies should be developed to create awareness and sensitize physicians in emergency settings about the management of DA fractures and prompt referral to specialists.
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