Definition
• A fracture is a disruption in the continuity of a
bone stressed beyond its elastic modulus, with
the formation of two or more fragments.
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Location of problem to be treated.
Diagnosis & treatment plan
Documentation
Assessment of treatment
Epidemiological studies
• Direct or indirect
• Complete or incomplete
• Mechn- bending, torsion, shear, contrecoup. avulsion and
burst type
• Site
• Displacement
• Number-single ,multiple or comminuted
• Integument- closed or open
• Shape- transverse ,oblique butterfly,
• oblique surface fracture
A –Dentoalveolar
B-Condyle
C-Coronoid
D-Ramus
E-Angle
F-Body
G-Para symphysis
H-Symphysis
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Simple
Compound
Comminuted
Pathological
Green stick
a. Direct violence
b. Indirect violence
c. Excessive muscular contraction
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b.
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d.
Unilateral fracture
Bilateral fracture
Multiple fracture
Comminuted fracture
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2.
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Number of fracture /fragments
location of fracture
Status of occlusion
Soft tissue involvement
Associated injuries
( F)
( L)
(O)
(S)
(A)
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F0- Incomplete fracture
F1- Single fracture
F2-Multiple fracture
F3-Comminuted fracture
F4-Fracture with a bony defect
• Category F1/F1-Bilateral fracture
• Unilateral segmental fracture( multiple fracture in one
segment
• O0-No malocclusion
• O1-Malocclusion
• O2- Non existent malocclusion
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S0-closed
S1-open intraorally
S2-open extraorally
S3-open intra and extraorally
S4-soft tissue defect
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A0-None
A1-Fracture or loss of tooth
A2-Nasal bone
A3-Zygoma
A4-Le Fort I
A5-Le Fort II
A6-Le Fort III
• Three stages
Immediate assessment and treatment of
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constituting a threat to life
General clinical examination
Local examination
any condt
• Mf injuries may associated with body injuries may constitute threat to life
than facial trauma
• Rapid survey & Assessment
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A-Airway
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B-Breathing & Ventilation
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C-Circulation & Hemorrhage control
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D-Disability-Neurological assessment
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E-exposure to external environment
Oral airwys
Nasopharyngeal
• Recognition
 Central pulse –Femoral /carotid
 Skin colour-pink-ashen grey-white
 Level of consciousness-confusion-aggression-drowsinesscoma
 Pulse- 120/min ( very thready)
 Respiratory rate-20/min- Tachypnea
 Weakness-due to hypoxia ,acidosis
 Urinary out put- >30 ml/hr- 0-10 ml/hr
• Fluid replacement- Crystalloids. Colloids, Blood
• Local-( Maxillofacial aspect)
 Pressure pack
 Ligation of Vessel
 Direct dental wiring at fracture region
• Careful clinical examination and no operative intervention
without rule out additional more serious injuries
• If cerebral hemorrhage , loss of consciousness
• Additional injuries required urgent treatment than MF injuries
• In polytrauma pt treated concurrently
• Major injuries- careful inspection/palpation reveal their
presence –treated accordingly
• If fracture mandible pt in
shocked, very unusual,
• Some more serious
condition other than
fracture mandible should be
suspected and treated
• first
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Preparation for examination
Face-gently cleaned with warm water
Remove road dirt etc-evaluation of soft tissue injury
Mouth-loose ,broken teeth,or dentures,any congealed blood
removed with swab in nontooth forcep
• If denture-full/ pieces reassemble piece so portion should be
missing-possibly displaced down into throat
• Complete extra & intra oral cleaning-assess full extent of injury
• During cleaning cranium and cervical spine should be carefully
inspected and palpated for sign of injury
Extravsation of blood from
injured bone resulted swelling
of face-more swelling increase
capillary permeability and
edema
Swelling+ecchymosis-fracture
Facial deformity-fracture &
displaced fragment
Open hang mouth-B/L condylar
#
• Conscious pt- support his jaw with own hand
• Compound fracture- blood stained saliva may dribbled out from
corner of mouth
• Palpation-begin from bilateral condylar regiondownwards posterior along lower border of mandible.
• Any bone tenderness- pathognomic of fracture
• Deformity /bony cerpitus present
• Anesthesia/ paresthesia- injury to IAN- reduced or absent sensation
On one or both side of the lower lip
Intra Oral Examination
Clean oral cavity-lukewarm mouth
wash/ cleaned with moistened
swab
Congealed blood,fragments of
tooth,alveolus,denture removed
with forcep/ suction tip
Buccal & Libgual sulciecchymossis,submucosal
extravastion of blood-#
• Any lingual mucosa hematoma-#
• Bec lingual mucosa directly overlied periosteum of mandible
• Linear hematoma in third molar reg-indi fracture
Edentoulus/ alv ridge
Step in occlusion,laceration in
overlying mucosa
Toothluxation/subluxation,crown
fracture/dentine/pulp exposed ?
Any loose filling,fine crack/split
tooth
Missing-tooth,f illing, crown,
denture, portion of toothCHEST X-RAYS
• Fracture site- mobility placing
finger and thumb on each side
and using pressure to elicit
mobility
• Any pain in jaw movement
recorded.
• Flat of both hands placed over
two angles of mandible and
gentle pressure exerted-if pain
• If crack fracture is present
Bi manual
Symphyseal region
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Direction and intensity of the traumatic force.
Site of fracture
Direction of fracture line
Muscle pull exerted on the fractured fragments
Presence or absence of tooth.
Extent of soft tissue wounds
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 Injury
 Pain- pain upon movement r remote from the site of injury
 Abnormal mobility-abn mobility in dental arches r during jaw
movement.
 Bleeding- active bleeding / hematoma or ecchymosis may
follow a fracture process.
 Crepitus- Cracking, grating sound can be detected during
palpation of injury site.
 Deformity-facial deformity depending upon degree and
direction of impact, also direction of fracture line and muscle
pull also.
 Ecchymosis- and edma- seen extra orally and intraorally
depending upon impact and site of fracture.
 Loss of function or interference with function-Mastication
problem, speech and difficulty in swallowing.
• Paresthesia/ hypoesthesia of lower lip- fracture between
mental foramen and ramus region
• Radiographic evidence-all suspected cases must be
radiographed. help as diagnostic aid and addition
confirmation also for medico legal documentation and as
evidence.
Facial deformity
Anatomical
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Dento alveolar
Condylar
Coronoid Process
Ramus
Angle
Body
Symphysis & para symphysis
Comminuted fracture
• Avulsion/subluxation or fracture of tooth in
association with fracture of alveolus.
• DA fracture alone
• DA plus mandibular fracture
• Laceration, full thickness wound of lower lip-imp low
teeth
• complete loss of soft tissue
• Bruising with embeded tooth portion/ foreign body
• Alv margin-laceration of gingiva, deformity of alveolus
• Degloving injury
• Impaction of point of chin on some resilient surface-soft earth
• Jaw does not fracture but soft tissue rotated violently over
point of chin. horizontal tear at junction of attached & free
gingiva
• Tooth- lost, recent extn wound-knocked out
• Split/ Fracture- premolar & Molars- horizontal / vertical split
below the gingival margin-indirect trauma from opposing
dentition
• Crown- fracture, embedded into soft tissue, swallowed or
inhaled.
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If pulp/near pulp exp-immediate treatment
Root- fracture, excessive mobile tooth, subluxated ?
IOP Xrays
Thermal sensitivity-unreliable to test injury to pulp
Trauma/ force –disturb the function of nerve endings
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Isolated fracture
With injury to tooth
Gross comminution of Alveolus
Alv fracture consists one or two fragments containing teeth
Complete Alv Fr+ Teeth segment displaced into soft tissue of
the floor of mouth covered by mucosa.
• +-Difficult to differentiate alveolar fracture from symphysis
fracture• Unless palpate at lower border of mandible.
• During examn easy to reposition the alveolar fracture
fragment in position-better prognosis.
• Most common overall fracture ( 20 % )
• Easily missed fracture during examination
• Unilateral / Bilateral
• Intra capsular / Extra capsular( condylar Neck).
• Extra capsular type-with or without dislocation
• Inspection• Swelling over joint - +
• bleeding from ear( laceration of antr wall of EAM
• D/D-bleeding from middle ear +CSF otorrhoea- Petrus
temporal bone #
• Ecchymosis of skin below mastoid process-when hematoma
surrounding fractured condyle tracked down to EAM.
• D/D Battle Sign ( Base of Skull # )
• If mandible locked- when condyle impacted through glenoid
fossa
• If condyle medially dislocated-when edema subsided hollow
characteristic sign will be present
• Immediate post trauma-sign obscured by edema.
• Tenderness over condylar area
• EAM palpation –when condyle is dislocated from glenoid fossa.(standing
in front of pt both little can be hooked into each EAM ).
• Rarely hemorrhage from condylar region track across the base of skullexert pressure on mand. Divin. Of Vth N at F.Ovale-paresthesia of lower lip
• D/D-Fracture of Body / Angle region of mandible rule out
Condyle dislocated resulted
ramus height shorteningMolar gagging of the occlusion.
Deviation of mandible towards fracture side.
Painful movements- Lateral excursion to
opposite side
-Protrusive movement .
• Extra orally- same sign & symptoms bilaterally
• Mandibular movement restricted.
• Intra orally• In intra capsular fracture bilaterally- if any ramal shortening but normal
occlusion.
• Extracapsular #- b/L condylar dislocation- B/L ramus shortening
/overriding of fracture fragments- Antr open bite.
• Painful & limited opening movements.
• Painful & restricted protusion n lateral excursions
Guard man fracture- B/L condylar fracture with Symphy or
Parasymphysis fracture
• Rare fracture
• Result from reflux contracture of powerful antr fibres of
temporalis muscle.
• Direct trauma to ramus- # coronoid process
• Tip #-pulled upwards into infratemporal space ( Temp M )
• Sometime- surgery of cyst r large tumor of the ramus.
• Palp-tenderness over antr part of ramus, tell-tele hematoma
• Painful, limited protrusive movement.
• Not common- two types
• Single fracture- Low condylar fracture-both condyle &
coronoid process on upper fragment.
• Comminuted Fracture- direct violence from gun shot/missile
injury- fragments splinted between masseter muscle and
medial pterygoid muscles with little or no displacement.
 Swelling & ecchymosis extra & intraorally.
 Tenderness over the ramus .
 Severe trismus present ?
• Inspection
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Swelling
Facial deformity
I/O step deformity behind last molar
Presence of hematoma Buccal r lingual side or both adjacent
to fracture.
 Anesthesia or paresthesia of the lower lip.
 Occlusion-deranged.
• Palpation Tenderness present at angle region
 Movement /crepitus at fracture site ( if ramus steadied
between finger and thumb and body of mandible
moved gently with the other hand) .
 Step may palpated.
 Painful restricted jaw movements.
• Swelling
• Tenderness
• Displaced fractured fragment, causes derangement of occlusion
• Premature contacts in distal fragment (displacing action of muscles
attached to Ramus)
• Occlusion Derangement.
• Gingival tear due to its firm attachment -displaced fragments
• If gross displacement can
cause Intra oral
hemorrhage-IAA torned ?
• Molar & Premolar toothsplit longitudinally /
vertically- considerable
discomfort
Muscle influence causing
displacement
Displaced fract fragment
• Commonly associated with one /both condyle.
• Presence of bony tenderness & lingual hematoma important
sign• Bec antr mandible thickness between often ensure fine
cracks with little displacement.
• May be missed if occlusion is undisturbed locally.
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 Bony tenderness and small lingual hematoma may be only
physical sign present
 Severe impact( direct violence-oblique fracture-displaced
fragments. Which allows over riding of the fragments with
lingual inversion of the occlusion on each side.
 Always associated soft tissue injury of chin and lower lip
• Detachment of genioglossus M – may contribute loss of
tongue control.
• Airway obstruction.
• If Pt Conscious- voluntarily control of tongue
prevent obstruction.
• If unconscious- stay suture of tongue/airway
to prevent tongue fall.
• No paresthesia of skin of mental region unless
mental nerve is involved.