1. CLINICAL EXAMINATION
MANDIBLE FRACTURE

2. Classification of Mandible fracture

3. 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.

4. Need Location of problem to be treated. Diagnosis & treatment plan
Documentation
Assessment of treatment
Epidemiological studies

5. Approaches 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

6. Site of fracture A –Dentoalveolar B-Condyle C-Coronoid D-Ramus E-Angle
F-Body
G-Para symphysis
H-Symphysis

7. Type of fracture
Simple
Compound
Comminuted
Pathological
Green stick

8. Cause of fracture Direct violence Indirect violence
Excessive muscular contraction

9. Direct violence Unilateral fracture Bilateral fracture
Multiple fracture
Comminuted fracture

10. AO Classification( FLOSA classifn)
Number of fracture /fragments ( F)
location of fracture ( L)
Status of occlusion (O)
Soft tissue involvement (S)
Associated injuries (A)

11. No of Fragments ( F1-F4) F0- Incomplete fracture F1- Single fracture
F2-Multiple fracture
F3-Comminuted fracture
F4-Fracture with a bony defect

12. F2-Multiple fracture
Category F1/F1-Bilateral fracture

13. F2/F0
Unilateral segmental fracture( multiple fracture in one segment

14. Multiple fracture with
F2/F1
F2/F2

15. F3-comminuted
F4- bony defect

16. Fracture by site (L1-L8 )

17. Displacement ( O0-O2) O0-No malocclusion O1-Malocclusion
O2- Non existent malocclusion

18. Soft tissue involvement(S0-S4)
S0-closed
S1-open intraorally
S2-open extraorally
S3-open intra and extraorally
S4-soft tissue defect

19. Associated fractures( A0-A6)
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

20. CLINICAL EXAMINATION 14th AUG

21. Clinical Examination Three stages-
Immediate assessment and treatment of any condt
constituting a threat to life
General clinical examination
Local examination

22. Primary survey
Mf injuries may associated with body injuries may constitute threat to life than facial trauma
Rapid survey & Assessment
A-Airway
B-Breathing & Ventilation
C-Circulation & Hemorrhage control
D-Disability-Neurological assessment
E-exposure to external environment

23. AIRWAYS Management in Head injury

24. Airway-Assisted
Oral airwys
Nasopharyngeal

25. Breathing & ventilation

26. Circulation & Hemorrhage Control

27. Shock-hypovolumic Central pulse –Femoral /carotid Recognition
Skin colour-pink-ashen grey-white
Level of consciousness-confusion-aggression-drowsiness-coma
Pulse /min ( very thready)
Respiratory rate-20/min- Tachypnea
Weakness-due to hypoxia ,acidosis
Urinary out put- >30 ml/hr ml/hr

28. Initial management Fluid replacement- Crystalloids. Colloids, Blood
Local-( Maxillofacial aspect)
Pressure pack
Ligation of Vessel
Direct dental wiring at fracture region

29. Disability –Neurological Assessment

31. General Clinical Examination
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

32. General clinical examn
If fracture mandible pt in shocked, very unusual,
Some more serious condition other than fracture mandible should be suspected and treated
first

33. 21St AUG Clinical Examination

34. Local Examination 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

35. During cleaning cranium and cervical spine should be carefully inspected and palpated for sign of injury

36. Extra Oral Examination
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 #

37. Swelling

38. General Examn
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 region- downwards 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

39. TM Joint examination

40. Neck /Sub condylar region

41. Lower border palpation

42. 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 sulci-ecchymossis,submucosal extravastion of blood-#

43. Sulci & floor of mouth Any lingual mucosa hematoma-#
Bec lingual mucosa directly overlied periosteum of mandible
Linear hematoma in third molar reg-indi fracture

44. occlusion

45. Occlusal surface Edentoulus/ alv ridge
Step in occlusion,laceration in overlying mucosa
Tooth-luxation/subluxation,crown fracture/dentine/pulp exposed ?
Any loose filling,fine crack/split tooth
Missing-tooth,f illing, crown, denture, portion of tooth-
CHEST X-RAYS

46. Bi manual palpation
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

47. Intra Oral Examn Bi manual Symphyseal region
mobility placing finger and thumb on each side and using pressure to elicit mobility

48. Displacement of fracture
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

49. SIGN AND SYMPTOMS SIGN ,SYMPTOMS OFMANDIBULAR FRACTURE

50. Common Sign & symptoms 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.

51. Contd
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.

52. Contd
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.

53. FACIAL Asymmetry
Facial deformity

54. Fracture Sites Anatomical Dento alveolar Condylar Coronoid Process
Ramus
Angle
Body
Symphysis & para symphysis
Comminuted fracture

55. Dent alveolar Fracture
Avulsion/subluxation or fracture of tooth in association with fracture of alveolus.
DA fracture alone
DA plus mandibular fracture

56. Soft tissue Injuries
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

57. Laceration of Lip & cheek

58. Degloving injury Mandible
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

59. Damage to tooth 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.

60. Tooth injuries 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

61. Alveolar Fracture 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.

62. AVL Fracture
+-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.

63. Condylar Fracture Most common overall fracture ( 20 % )
Easily missed fracture during examination

64. Condylar # Unilateral / Bilateral
Intra capsular / Extra capsular( condylar Neck).
Extra capsular type-with or without dislocation

65. Unilateral Condylar Fracture
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

66. Inspection
If condyle medially dislocated-when edema subsided hollow characteristic sign will be present
Immediate post trauma-sign obscured by edema.

67. Contd 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 skull-exert 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

68. INTRAORALLY- Condyle dislocated resulted ramus height shortening-
Molar gagging of the occlusion.
Deviation of mandible towards fracture side.
Painful movements- Lateral excursion to
opposite side
-Protrusive movement .

69. Bilateral 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

70. Bilateral condylar fracture

71. Guard man fracture- B/L condylar fracture with Symphy or Parasymphysis fracture

72. Coronoid process 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.

73. Fracture of the Ramus 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.

74. CLINICAL FEATURES Swelling & ecchymosis extra & intraorally.
Tenderness over the ramus .
Severe trismus present ?

75. Fracture of Angle Inspection- 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.

76. Swelling

77. Angle Fracture

78. Contd 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.

79. Fracture of the Body( Molar & Premolar region
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

80. contd
If gross displacement can cause Intra oral hemorrhage-IAA torned ?
Molar & Premolar tooth-split longitudinally / vertically- considerable discomfort

81. Body Fracture Displaced fract fragment
Muscle influence causing displacement
Displaced fract fragment

82. Symphysis & Parasymphysis
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.

83. contd
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

84. contd Airway obstruction.
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.

85. Parasymphysis plus angle fracture transverse width ,condyle dislocated cross bite,

86. 21th AUG 2015