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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