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. I. Location of problem to be treated.
II. Diagnosis & treatment plan
III. Documentation
IV. Assessment of treatment
V. Epidemiological studies

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

7. • Simple
• Compound
• Comminuted
• Pathological
• Green stick

8. a. Direct violence
b. Indirect violence
c. Excessive muscular contraction

9. a. Unilateral fracture
b. Bilateral fracture
c. Multiple fracture
d. Comminuted fracture

10. 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)

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

12. • Category F1/F1-Bilateral fracture

13. • Unilateral segmental fracture( multiple fracture in one
segment

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

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

19. • 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

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

22. • 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

24. Oral airwys Nasopharyngeal

27. • 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

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

31. • 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. • If fracture mandible pt in
shocked, very unusual,
• Some more serious
condition other than
fracture mandible should be
suspected and treated
• first

34. • 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. 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
#

38. • 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

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

45. 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. • 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. Bi manual Symphyseal region

48. • 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. •

50.  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.  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. • 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 deformity

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

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

56. • 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

58. • 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. • 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. • 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. • 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. • +-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. • Most common overall fracture ( 20 % )
• Easily missed fracture during examination

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

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

67. • 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. 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. • 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

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

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

75. • 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.

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

81. Muscle influence causing
displacement Displaced fract fragment

82. • 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.  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. • 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.