Mandibular Alveolar Fractures Treatment & Management

Updated: Sep 26, 2018
  • Author: William D Clark, MD, DDS; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Treatment

Medical Therapy

Medical 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.

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Surgical Therapy

Reduction and immobilization of the fracture is mandated for alveolar process fractures. [5] 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:

  • Class I fracture of the alveolar process: This involves a fracture of the edentulous segment.

  • Class II fracture of the alveolar process: The fracture involves dentulous segment with little, if any, displacement.

  • Class III fracture of the alveolar process: The fracture involves dentulous segment with moderate-to-severe displacement.

  • Class IV fracture of the alveolar process: The alveolar process fracture shares one or more fracture lines with other fractures of the tooth-bearing facial skeleton.

  • Class I to IV fractures are depicted in the image below.

    The various classes of alveolar fractures (per Cla The various classes of alveolar fractures (per Clark).
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Preoperative Details

A 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.

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Intraoperative Details

The 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.

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Postoperative Details

Analgesics 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, although a study by Schaller et al found that in patients who underwent surgery for mandibular fractures involving the alveolus, the incidence of infection at 6-month follow-up did not differ significantly between those who received a 1-day postoperative course of antibiotics (29 patients) and those who received a 5-day course (30 patients). [6]

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.

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Follow-up

After 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 patient education resources, see the Breaks, Fractures, and Dislocations Center and Teeth and Mouth Center, as well as Broken Jaw and Broken or Knocked-out Teeth.

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Complications

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.

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Outcome and Prognosis

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.

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Future and Controversies

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.

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