You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > TRAUMA Mandibular Alveolar FracturesArticle Last Updated: Sep 30, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: William D Clark, MD, DDS, Chief of Pediatric Otolaryngology, University of Texas Health Science Center San Antonio William D Clark is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, American College of Physicians, American Society for Head and Neck Surgery, and American Society of Pediatric Otolaryngology Editors: Hassan H Ramadan, MD, MSc, Professor and Vice-Chair, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Stephen G Batuello, MD, Consulting Staff, Colorado ENT Specialists; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: mandibular alveolar fractures, alveolar process, alveolar process of the mandible, alveolar process fractures, mandible fracture, mandibular fractures, alveolar fractures, mandible alveolar fractures, alveolar fracture INTRODUCTIONSection 2 of 12
  Fractures of the alveolar process of the mandible are uncommon. Unfortunately, their treatment is often fraught with problems, and uninitiated surgeons tend to underestimate these types of fractures and their problems. History of the ProcedureMandible fractures are described in early Egyptian writings. Hippocrates advocated the use of bandages and interdental wiring for the treatment of mandibular fractures. In a 3-part article published during the Civil War, Gunning wrote of using dental splints attached to elaborate external appliances. In 1881, Gilmer first described the use of bars on both arches, fixed to the teeth and each other with fine wire ligatures. Schede is credited for the first mandibular bone plating. He is said to have used a steel plate screwed to the mandible in the late 1880s. In 1934, Vorschutz described external fixation using transdermal bone screws and plaster. The Morris biphase is a refinement of that technique. The history of rigid internal fixation devices is ongoing; a new theory and a corresponding set of devices appear every few years. ProblemSimply stated, the approach to treating these injuries is to do what is necessary to reduce them and then do what is necessary to hold them in reduction until they are healed. The treatment options are somewhat limited by the lack of room for drill holes and associated hardware when the fracture involves a dentulous segment. Even with an edentulous segment, hardware is rarely practical because it usually ends up under a dental prosthesis and cannot be tolerated. FrequencyAs pertains to the prevalence of facial fractures in the The major difference in mandible fractures in countries other than the EtiologyAlveolar process fractures are the result of blunt or penetrating trauma. The 2 most common etiologies of such blunt trauma in adults are fist fights and motor vehicle accidents. Other sources of facial trauma include athletic injuries, falls, and industrial accidents. Penetrating trauma to the mandible is most commonly in the form of a gunshot wound. PathophysiologyFor blunt trauma to produce an isolated fracture of the alveolar process, the blow must be concentrated on a segment of the alveolar process; however, this is an uncommon event. Alveolar process fractures that share fracture lines with other mandibular fractures are more common, usually representing a comminution of a body of mandible fractures. ClinicalThe usual presenting reports with any fracture of the mandible as a result of trauma are localized tenderness, swelling, and malocclusion. INDICATIONSSection 3 of 12
The presence of an alveolar fracture is the indication for treatment. The mode of treatment varies among patients. RELEVANT ANATOMYSection 4 of 12
A dental alveolus is a tooth socket. The alveolar process of the mandible is defined as the portion of the mandible surrounding and supporting the teeth. After loss of teeth, the associated alveolar process undergoes atrophy. Cortical bone covers the exposed surface of the alveolar process and the underlying cancellous bone; tooth sockets and teeth fill the remainder of the process. Tooth sockets are lined with thin, compact bone that is penetrated by blood vessels, lymphatics, and nerves. This alveolar bone contains the embedded ends of the connective-tissue fibers of the periodontal membrane (ie, Sharpey fibers). CONTRAINDICATIONSSection 5 of 12
Few contraindications exist to treating alveolar fractures. A nondisplaced class I fracture requires only observation. With other alveolar fractures, the patient's general condition may prohibit definitive treatment; examples include a chronic medical condition or results of trauma sustained when the mandibular fracture occurred. Head trauma resulting in an altered state of consciousness is the most common contraindication encountered in patients with alveolar fractures. Suspected or proven cervical spine injuries are also common contraindications. Most of these contraindications resolve with time and treatment. Hopefully, the alveolar process fracture can still be treated once the patient's general condition permits. WORKUPSection 6 of 12
Lab StudiesNo lab studies are required to evaluate a fracture of the alveolar process of the mandible. Associated injuries are common and may require such studies. Imaging Studies
TREATMENTSection 7 of 12
Medical therapyMedical therapies for alveolar process fractures are for patient comfort and to prevent complications, namely infection. Mild-to-moderate analgesics may be required, taking into consideration any associated injuries that may contraindicate their use or limit their dose. Acetaminophen in liquid or tablet form may be sufficient. For an isolated alveolar process fracture, nothing stronger than acetaminophen with codeine should be required. Requests for stronger analgesia should prompt the treating surgeon to consider unrecognized injuries, complications, or substance abuse. Antibiotic therapy reduces the prevalence of infections with mandibular fractures. Penicillin, prescribed at the appropriate dose for age, is an excellent choice. For the patient who is allergic to penicillin, clindamycin is a good alternative. Surgical therapyReduction and immobilization of the fracture is mandated for alveolar process fractures.1 The specific approach depends on the specifics of the injury. Previously, no classification of these fractures has been available to guide decision making. The authors offer the following classification:
Preoperative detailsA medically stable patient with a mandible fracture should receive definitive care as soon as is practical. Numerous studies have demonstrated that delays in treatment increase the complication rate and reduce the chance of obtaining the best surgical result. The prerequisites for definitive care of these injuries are imaging studies sufficient to evaluate the injuries, a stable patient, an evaluation by the anesthetist, and informed consent. The anesthesia team must be informed that nasal intubation is required. Dental considerations exist when an alveolar process fracture involves a dentulous segment. Teeth within an alveolar segment may be fractured, especially the root portion and most especially the root tip. Imaging studies may not show dental fractures; therefore, careful inspection of the teeth, the intact portion of the mandible, and alveolar fragments is required. The usual recommendation for a tooth fracture involving the root is dental consultation or, if not practical, extraction. The consulting dentist performs an immediate root canal treatment, extracts the tooth and its fragments, or takes responsibility for long-term management. Fractures of tooth crowns are not unique to alveolar fractures and are not covered in this article. When the apical portions of the tooth roots are completely separated from their blood supply, the affected teeth are at risk of becoming devitalized and eventually producing periapical abscesses. This is a common finding in class III alveolar fractures. When practical, consult a dentist to consider urgent root canal therapy to save these teeth and help prevent complications. When a dental consultation is not practical, the treating surgeon must use his or her judgment relative to each tooth in a displaced alveolar segment. The options are extraction versus retention and later dental consultation. Since the involved teeth may survive, the authors prefer to conserve teeth that appear to be otherwise healthy. Periodontitis, as manifested by tooth mobility and periodontal pockets, should move one toward extraction, as should evidence of periapical pathology. When a splint is going to be used to stabilize a fractured alveolar segment, it needs to be fabricated during the preoperative period. Impressions of the dental arches are required and are used to make plaster models. Model surgery restores the normal anatomic relationships of the fractured segments and allows accurate splints to be fabricated. Intraoperative detailsThe patient is placed in the supine position and is nasally intubated by the anesthesia team. The surgical team usually finds that headlights offer the best illumination. Surgical treatment of mandibular fractures often includes the use of sharp objects (eg, wire, screws, arch bars); therefore, attention to detail is necessary to minimize the risk of glove puncture. True sterile preparation of the operative site for repair of mandible fractures is not possible. The extent of preparation to create a clean, disinfected field is controversial. Some clean the teeth, gingivae, and alveolar mucosae with a toothbrush and 3% hydrogen peroxide. The face is painted with povidone iodine solution. If a skin incision is required for an open reduction of another fracture, a typical povidone iodine soap scrub preparation is performed. Preoperative examinations are often impaired by tenderness and masticatory muscle spasm; therefore, a thorough reexamination of the face and oral cavity is performed before definitive therapy. The entire mandible is carefully inspected and palpated. All teeth are inspected and evaluated for injury and mobility. A survey of the dental arches is completed to detect any sockets missing teeth. The maxilla is examined to detect any previously missed injuries. For class I fractures, adequate treatment is usually as simple as digital molding of bony fragments and closing any overlaying mucosal/gingival lacerations. Class II fractures that need reduction may require a great deal of force to move into anatomic position. Posterior fragments are almost always displaced to the lingual area. Producing the needed facially directed forces by manual means can be difficult. Large, heavy forceps, such as those used for dental extractions, may prove useful to apply reducing forces on the bony fragment. Reduced fragments may be held in place by maxillomandibular fixation (MMF) or overlay splints. Class III fractures typically offer the most challenges. Reducing the displaced segment of the alveolar process can be surprisingly difficult. This is believed to be because the encompassing portion of the mandible is intact, and one must overcome the resistance produced by the interaction of the small irregularities of the bony surfaces. In other words, the space into which the fragment must be placed has no give. Occasionally, removing some of the bony irregularities of the fragment and/or the receiving space in the intact portion of the mandible may be necessary. This is usually best accomplished by use of a power drill with a suitable size bur or a fine rhinoplasty rasp. In any case, bone removal should be limited to that which is essential to accomplish the goal. Holding class III fractures in their anatomic position can also be a challenge. The general rule of facial fractures, which is that fractures that are more difficult to reduce result in more stable reductions, is less true for these fractures than for most others. Techniques to maintain reduction of these fractures include arch bars, various forms of MMF, and various splints. Class IV fractures are usually less challenging than class III fractures because the treatment of associated fractures usually gives excellent exposure; usually no physical barrier exists to reduction, and treatment of the associated fractures often accomplishes treatment for the alveolar process portion of the injury. When this is not the case, the use of techniques described for class III fractures is in order. Once alveolar segments have been reduced, they need to be stabilized until healing has occurred. One mode of stabilizing an alveolar segment is the use of an acid-etch wire composite splint. This device uses a heavy stainless steel wire fixed to the teeth within the segment and several teeth on either side. Attachment to the teeth is accomplished by use of a composite dental restorative material that adheres to both the wire and to the acid-etched dental enamel. The major limiting factor of using this material is that a dentist is required. When arch bars are used for stabilization of fragments, each sound tooth in the mandible is ligated to the arch bar with fine wire ligatures after the segments have been anatomically reduced. When splints are used to stabilize fractures, they may be ligated to sound teeth and may be further secured by 3-point circummandibular wiring. Postoperative detailsAnalgesics and antibiotics are indicated postoperatively. Analgesics are usually required for several days. Administration of antibiotics for 7-10 days postoperatively should provide good infection prevention. If MMF is used, precautions to help prevent and/or address nausea and vomiting are paramount. The nursing staff needs specific instructions on measures to take with patients who are nauseous or in whom vomiting is impending. Some use antiemetics prophylactically. Others order antiemetics be given at the first hint of nausea. If the MMF technique includes having wires hold the teeth in occlusion, a wire-cutting device should be with the patient for the first day. Many place the wire cutters on a tracheostomy tape around the patient's neck. Follow-upAfter discharge from the hospital, the patient should be seen weekly and as needed. Weekly examinations should assess nutritional status, wound healing, oral hygiene, maintenance of occlusion, and signs of infection. For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center and Teeth and Mouth Center. Also, see eMedicine's patient education articles Broken Jaw and Broken or Knocked-out Teeth. COMPLICATIONSSection 8 of 12
Malunion and malocclusion Malunion and malocclusion are the most common major complications. They result from inadequate reduction and/or loss of reduction during the healing process. Infection Infection is usually localized and typically responds to antibiotics. Collections of pus should be drained. If present, hardware may require removal. Exposure of implanted hardware This complication is uncommon because hardware is rarely used for these fractures. However, if this complication occurs, it requires removal of hardware. Nonunion Nonunion is an uncommon complication. It requires that the fracture lines be exposed and freshened with reapplication of fixation. Nonunion may require a bone graft in extreme cases. OUTCOME AND PROGNOSISSection 9 of 12
A successful outcome is achieved when the fragment is healed in the anatomic position and the teeth are in normal occlusion, display normal mobility in their sockets, and are viable. FUTURE AND CONTROVERSIESSection 10 of 12
Treatment of alveolar process fractures is essentially free of controversy. Since plating systems are rarely practical for these injuries, associated controversies are avoided. Future advances in this area may be related to refinements in the use of orthodontic techniques in the stabilization of the alveolar segments. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Mandibular Alveolar Fractures excerpt Article Last Updated: Sep 30, 2008 | |||||||||||||||||||||
