How to assess and manage bone fractures?

This summary is based on the article published in the Australian Dental Journal: Bone fractures: assessment and management (March 2016)

L Lim; P Sirichai

Context

Severe dental traumatic injuries often involve the supporting bone and soft tissues. These bone fractures often present with a combination of other dental injuries such as luxation, avulsion and tooth root fractures.¹

Purpose of the Article

Present an overview of current concepts in the management of dentoalveolar fractures to assist the general dental practitioner in the overall understanding of dental trauma.

Key Points

Bone Fractures²

• Comminution of the alveolar socket: crushing of the bone, usually associated with intrusive or lateral luxation.
• Fracture of the socket wall: a fracture confined to the facial or lingual socket wall – often associated with luxation and avulsion injuries.
• Fracture of the alveolar process: alveolar process fracture which may or may not involve the alveolar sockets.
• Fracture of the mandible or maxilla: may or may not involve the alveolar sockets.

Patient Assessment

• Exclude possible head injury
• Tetanus prophylaxis – determine if tetanus immunization is up to date.
• Details of the accident including the time of injury to determine potential replantation of traumatized teeth.⁷
• Account for all missing teeth and tooth fragments to eliminate the possibility of inhaling fragments.

Examination

• Assess extraorally, taking note of jaw integrity, lip lacerations, gingival lacerations, displacement of the alveolus and teeth, and the occlusion.
• Assess the floor of the mouth and tongue for lacerations and swelling.
• Suction gently with a large bore blunted end suction device on low to remove blood clots intraorally and pooling of saliva to allow adequate visualization.
• Manually assess the degree of mobility and displacement of the fractured segments.
• If the entire alveolus be mobile and move together with the tooth or teeth, then a bone fracture should be diagnosed.

Radiographic Assessment

• A panoramic radiograph:  give a general overview of the dentition, as well as possibly any underlying jaw fractures.
• Periapical radiographs: determine any associated tooth fractures. However, often they may not diagnose alveolar bone fractures because, unless extremely displaced, it can be difficult to visualize the line of fracture within the socket or at the alveolar level.¹¹

Management

• Reduction: the alveolar bone fracture must be reduced back into its original anatomic position: manual pressure to disengage and reposition displaced bone segments and teeth.
• Fixation: the bone, attached teeth and soft tissues must be stabilized with rigid fixation. More rigid fixation is required with increased time of fixation (6 weeks) for complete bone union.¹²
• Suturing: due to the increase in forces and severity of impact, dentoalveolar fractures are often associated with soft tissue lacerations including the gingivae and lips.

Start by reducing the fracture, splinting the teeth and bone fractures, followed by suturing of the gingival tissues and then lastly, suture any lacerations of the lip. The exception will be if there is significant bleeding from the lips which may require initial basic suturing for haemostasis.

Treatment Planning

Two broad principles:

• Can this injury be treated by closed reduction or is open reduction required?
• Can the patient be treated under local anesthetic in the dental setting or does the patient require a general anesthetic in a hospital setting?

Treatment Principles

• In case of multiple severely injured or displaced teeth, the principles of repositioning and retaining as many teeth as possible despite the appearance that their long-term prognosis may be poor should be kept in mind.¹⁴
• More importantly, for long-term success of prosthetic replacement, to try and maintain as much bone and soft tissue support as possible.

References

List of references (PDF)