Clinical Examination

A careful, methodical approach to the clinical examination will reduce the possibility of overlooking or missing important details.

Extra-oral Examination

1) Soft Tissue: The soft tissue around the oral cavity, especially the lips and cheeks should be carefully examined for signs of injury, foreign bodies and potentially disfiguring defects which might need immediate attention.

2) Bony Landmarks: These are crucial in determining if there are fractures involving the facial bones. The maxilla, mandible, and temporomandibular joint should be examined visually and by palpation, seeking distortions, malalignment, or indications of fractures. These areas should be followed up radiographically.

Intra-oral Examination

Stepwise examination of the following should be undertaken

1) Soft Tissue Lacerations: The evaluation should be thorough and should include lips, oral mucosa, gingival, hard and soft palate and floor of the mouth. The lips, cheeks, and tongue adjacent to any fractured teeth should be carefully examined and palpated.

2) Tooth Mobility: Mobility should be evaluated and recorded. Examine the teeth for mobility in all directions, including axially. If multiple teeth move simultaneously with the tooth being tested, suspect alveolar fracture.

Root fractures often result in crown mobility, the degree depending on the proximity of the fracture to the crown. The degree of mobility can be recorded as follows: 0 for no mobility, 1 for slight mobility, 2 for marked mobility, and 3 for mobility and depressibility.

3) Occlusion: Derangement in occlusion is often due to facial fractures and may need immediate attention and or alterations in the treatment plan.

4) Clinical Crowns: The crowns of the teeth should be cleaned and examined for extent and type of injury. Crown infractions or enamel cracks can be detected by changing the light beam from side to side, shining a fiberoptic light or light cure light through the crown, or using disclosing solutions. If tooth structure has been lost, note the extent of loss: enamel only, enamel and dentin, or enamel and dentin with pulp exposure. If a crown fracture extends subgingivally, the fractured part often remains attached but loose. Also check for discoloration of the crown or changes in translucency to fiber-optic light. Both may indicate pulp change.

5) Displacement: Note any displacement of the teeth that may be intrusive, extrusive, or lateral (either labial or lingual) or complete avulsion.

6) Sensitivity to Percussion: Denotes injury to periodontal ligament and alveolus include all teeth suspected of having been injured with several adjacent and opposing ones. The results may be recorded as “normal response,” “slightly sensitive,” or “very sensitive” to percussion. Gentle tapping with a mirror handle is the norm. In cases of extensive apical periodontal damage, however, it may be advisable to use the fingertip for percussion.