CLINICAL EXAMINATION

MANDIBLE FRACTURE

Classification of Mandible fracture

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.

Need

I. Location of problem to be treated.II. Diagnosis & treatment planIII. DocumentationIV. Assessment of treatmentV. Epidemiological studies

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

Site of fracture

A –Dentoalveolar B-Condyle C-Coronoid D-Ramus E-Angle F-Body G-Para symphysis H-Symphysis

Type of fracture

• Simple• Compound • Comminuted • Pathological• Green stick

Cause of fracture

a. Direct violenceb. Indirect violencec. Excessive muscular contraction

Direct violence

a. Unilateral fractureb. Bilateral fracturec. Multiple fractured. Comminuted fracture

AO CLASSIFICATION( FLOSA CLASSIFN)

1. Number of fracture /fragments ( F)2. location of fracture ( L)3. Status of occlusion (O)4. Soft tissue involvement (S)5. Associated injuries (A)

No of Fragments ( F1-F4)

• F0- Incomplete fracture• F1- Single fracture• F2-Multiple fracture• F3-Comminuted fracture• F4-Fracture with a bony defect

F2-Multiple fracture

• Category F1/F1-Bilateral fracture

F2/F0

• Unilateral segmental fracture( multiple fracture in one segment

Multiple fracture with

F2/F1 F2/F2

F3-comminuted F4- bony defect

Fracture by site (L1-L8 )

Displacement ( O0-O2)

• O0-No malocclusion• O1-Malocclusion• O2- Non existent malocclusion

Soft tissue involvement(S0-S4)

• S0-closed• S1-open intraorally• S2-open extraorally• S3-open intra and extraorally• S4-soft tissue defect

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

CLINICAL EXAMINATION 14th AUG

Clinical Examination

• Three stages- Immediate assessment and treatment of any condt constituting a threat to life General clinical examination Local examination

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

AIRWAYS Management in Head injury

Airway-Assisted

Oral airwys Nasopharyngeal

Breathing & ventilation

Circulation & Hemorrhage Control

Shock-hypovolumic

• Recognition

Central pulse –Femoral /carotid

Skin colour-pink-ashen grey-white Level of consciousness-confusion-aggression-drowsiness-

coma 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

Initi al management

• Fluid replacement- Crystalloids. Colloids, Blood

• Local-( Maxillofacial aspect) Pressure pack Ligation of Vessel Direct dental wiring at fracture region

Disability –Neurological Assessment

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

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

21St AUGClinical Examination

Local Examinati on

• 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

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 #

Swelling

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

TM JOINT EXAMINATION

Neck /Sub condylar region

LOWER BORDER PALPATION

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-#

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

OCCLUSION

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

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

INTRA ORAL EXAMN

Bi manual Symphyseal region

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

SIGN AND SYMPTOMS

SIGN ,SYMPTOMS OFMANDIBULAR FRACTURE

•

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.

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.

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.

FACIAL ASYMMETRY

Facial deformity

Fracture Sites

• Dento alveolar• Condylar• Coronoid Process• Ramus• Angle• Body• Symphysis & para symphysis• Comminuted fracture

Anatomical

Dent alveolar Fracture

• Avulsion/subluxation or fracture of tooth in association with fracture of alveolus.

• DA fracture alone• DA plus mandibular fracture

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

Laceration of Lip & cheek

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

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.

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

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.

•

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.

Condylar Fracture

• Most common overall fracture ( 20 % )• Easily missed fracture during examination

Condylar #

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

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

Inspection

• If condyle medially dislocated-when edema subsided hollow characteristic sign will be present

• Immediate post trauma-sign obscured by edema.

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

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 .

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

Bilateral condylar fracture

Guard man fracture- B/L condylar fracture with Symphy or

Parasymphysis fracture

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.

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.

CLINICAL FEATURES

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

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.

Swelling

Angle Fracture

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.

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

contd

• If gross displacement can cause Intra oral hemorrhage-IAA torned ?

• Molar & Premolar tooth-split longitudinally / vertically- considerable discomfort

Body Fracture

Muscle influence causing displacement Displaced fract fragment

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.

•

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

contd

• 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.

Parasymphysis plus angle fracturetransverse width ,condyle dislocated cross bite,

21th AUG 2015