An unusual presentation of a maxillary alveolar fracture in a child

The risk of a child sustaining a facial fracture increases with age, with 5–15% of all facial fractures occurring in children, mainly boys.^1,2 The most common cause of a facial fracture is a motor vehicle accident, but violence accounts for 4% to 61% of fractures.^1,3,4,5 The diagnosis of facial fractures in children is more difficult and is under-reported.⁶ Isolated facial fractures are noted to be less commonly seen, with maxillary fractures occurring less in the child population.¹ It is more common for children to present with fractures to the anterior maxillary segment, than the mandible.² Dento-alveolar fractures are ‘dental injuries that involve a fracture to the supporting alveolar bone’.⁷

There are four types of bone fractures, as classified by Andreasen:^3,8

• Communication of the alveolar socket: crushing of the bone ± intrusion or luxation;
• Fracture of the socket wall: often associated with luxation and avulsion injuries;
• Fracture of the alveolar process ± alveolar sockets;
• Fracture of the mandible or maxilla ± alveolar sockets.^3,8

Andreasen states that ‘one-half of fractures within the maxilla and mandible involve teeth within the fracture line’.^9,10

This case report describes an unusual presentation of a maxillary alveolar bone fracture in a child that was missed on initial examination by an accident and emergency department, despite radiographic examination.

History

The guardian of the 12-year-old boy contacted the children's dental emergency telephone clinic, after an alleged assault, which had occurred 2 days prior. It was reported that the boy had been hit by a tree log and had been unconscious for approximately half an hour. His grandmother arrived at the scene and took the child to accident and emergency (A&E) immediately. An orthopantomogram (OPG) was taken at their local hospital, but no bony fractures were noted. He was discharged by A&E and advised to see his local dentist the following day. The local dentist urgently referred him to the paediatric dentistry department after suspecting a possible maxillary alveolar bone fracture. The local community dentist had made their diagnosis based mainly on the clinical features, and an upper anterior occlusal radiograph (Figure 1). The radiograph (Figure 1) revealed a peri-apical radiolucency surrounding the UL1 and UL2, indicative of an extrusion injury.

The patient attended the children's dental emergency clinic at the Royal London Dental Hospital approximately 48 hours after the initial injury, complaining of constant pain that was disturbing his sleep, which was not relieved by analgesia. He also reported occlusal disturbances and mild mobility of his upper left permanent incisors.

His social history involved him living temporarily with his grandmother and under the care of social services. There was no contactable person with legal guardianship; hence, we informed his social worker of the incident, and any treatment was carried out in his best interests.

The patient had no relevant medical history and no known allergies.

The extra-oral examination revealed no tenderness of the facial bones or restriction in opening of the mouth. The intra-oral examination revealed a clear occlusal step deformity associated with the upper anterior segment (Figures 2 and 3). The only soft tissue trauma lesion clinically was a small upper frenal attachment tear along the attached gingivae extending down to the UR1 (Figure 4).

However, unusually, there was no obvious bruising surrounding the labial, alveolar sulcus, gingivae or mucosa, which would classically be a typical clinical feature of an alveolar bone fracture.¹⁰ The area was assessed by gentle manual pressure, to ‘assess if the segment was localized to the tooth or the bone also’.⁸ The UL1 and UL2 were grade 1 mobile and the anterior maxilla appeared locked, with no mobility on gentle manipulation.

An OPG was taken for further assessment to screen the dentition and any underlying jaw fractures (Figure 5).⁸ This revealed no obvious indication of an alveolar bone fracture, or any pathology associated with adjacent structures. However, Andreasen states that ‘evidence of a fracture’ can be difficult to diagnose radiographically.⁹ The OPG revealed possible mild luxation injuries associated with the UL1 and UL2. It was not possible to take a CT scan on the day.

A second opinion was sought by the oral and maxillofacial surgery team. They confirmed the diagnosis of an anterior maxilla alveolar bone fracture, which was impacted and interfering with the occlusion. Despite this case not presenting with many classical features of a maxillary alveolar bone fracture, the diagnosis was based on the gingival labial tear and the marked change in the occlusion, presenting with a clear step deformity.

Clinical management

Although early reduction and fixation is recommended in these cases to facilitate normal growth, the delay in presentation resulted in a more difficult manipulation.^6,9 A closed-reduction technique was used to reduce and manipulate the bony segment into its original position under local anaesthetic, which was confirmed with the child's occlusion.^8,9 There was no requirement to raise a mucoperiosteal flap in this case, therefore reducing the risk of compromising blood flow.⁸ The bony fracture was then fixated and stabilized using a 016 stainless steel rigid wire splint extending from the UL3 to the UR3 (Figure 6),^7,8 to assist with osteogenesis.¹¹

As per the British Society Paediatric Dentistry COVID-19 trauma guidance and International Association of Dental Traumatology guidelines, a 2-week remote review was completed, and the splint was removed at 4 weeks.^5,7 The patient was then reviewed at 6 and 8 weeks remotely, and face-to-face reviews were planned for 4, 6 and 12 months later.⁷ The risk of pulpal necrosis after an alveolar bone fracture at 12 months is 38%.⁷

Despite the delay in presentation, the fractured maxilla was repositioned, with an incisal discrepancy of 3 mm, as illustrated in Figure 6. At the 8-week review, the healing was good, and the step deformity remaining between the UL1 and UR1 had reduced to 2 mm. Sensibility testing revealed the teeth in the upper anterior segment to be responding. We understand that the risk of devitalization at 12 months is 38%, which increases to 45% at 10 years.⁵ Dahl et al reported that occlusion will normally correct itself within 4–6 months, and sometimes earlier in younger patients, as per the Dahl effect.⁶

Discussion

This case displays an unusual presentation of a maxillary alveolar bone fracture, which did not coincide with the expected signs, and hence, the patient was discharged to a local dentist by the A&E team. Conversely, Andreasen reports that fractures involving the alveolar process are usually easy to diagnose, displaying signs of ‘displacement and mobility of the fractured fragment, bruising within the sulcus and a dull percussion sound associated with the adjacent teeth’.⁹ In contrast, others have noted that these diagnoses in children can be more difficult,^1,2,3,4 in which case, in-depth examination is required.

Since this case presented to our department, we have highlighted the difficulties in diagnosing some maxillary alveolar bone fractures. This case has been used as a teaching case for our department and for the local A&E team. It is therefore prudent to be aware that some alveolar bone fractures are difficult to diagnose, and radiographic signs may not always be diagnostic. Therefore, clinical assessment is paramount,⁸ with careful examination of the soft tissues and occlusion being essential in diagnosing the fracture.⁹ In this case, the only true diagnostic clinical features were the tear of the gingivae and the occlusal step deformity of both upper left incisors. The UL1 and UL2 were equally displaced, compared to the adjacent teeth and moved in synchrony, which was a further clue that this was a dento-alveolar fracture of the anterior maxilla.

In this case, a rigid splint was required to aid in osteogenesis of the maxillary alveolar bone fracture. However, there are various splinting techniques available, such as: composite splints, wire (NiTi or stainless steel) and composite, resin-bonding splinting, fibre splinting, such as polyethylene or Kevlar fibre mesh, or the placement of an orthodontic bracket and wire.^9,11 In cases where there is no alveolar bone fracture, flexible and shorter-term splinting is normally recommended to allow physiological movement and reduce the risk of ankylosis.¹¹

Summary

Despite the late presentation of this case, we were still able to reposition the bone and achieve a positive functional and aesthetic outcome for this patient. Recognizing the above clinical features in this case was essential to diagnosing and managing the fracture, which, if untreated would have resulted in a far more complicated and unfavourable outcome for this patient. This case will continue to be followed up to monitor pulpal vitality over time.