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| IMC Wiki | Alveolar process fractures

Alveolar process fractures

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Definition

Alveolar process fractures are fractures of the tooth-bearing part of the jaw.
Alveolar process fractures are often associated with complete or partial luxation of teeth and/or with a fracture of the body of the jaw (Kübler and Mühling 1998).
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Classification

  • Partial alveolar process fracture (fracture of the vestibular or oral alveolar wall)
  • Complete alveolar process fracture (fracture of the vestibular and oral alveolar wall) without displacement
  • Complete alveolar process fracture with displacement

Diagnosis

General diagnosis
  • Inspection
    • occasional heavy gingival bleeding
    • occasional malocclusion associated with the fracture
  • Palpation
  • Sensitivity testing of the teeth
    The vitality of the affected teeth is often lost following alveolar process fractures. Sensitivity testing may have to be repeated later on.
  • Sensitivity testing of the trigeminal nerve
  • X-ray (OPG, intra-oral (periapical) views, panoramic radiography)
Further examinations
  • X-ray in a second plane
  • Computerised tomography
  • Modelling of both jaw bones with preparation of a model to simulate reduction, and possibly for the preparation of individual splints
Every single tooth in the fragment and those adjacent must be examined carefully.

Indications for treatment

  • Clinical and/or radiographic evidence of an alveolar process fracture
    (fragment displacement and abnormal mobility are sure clinical signs of fracture)
  • Impaired masticatory function
  • Damage to adjacent soft tissue (e.g. gingival laceration)
  • Sensory disturbances
  • Tooth fracture or mobility

Treatment

The aim of treatment is the preservation of all bony fragments.
Treatment should be initiated as soon as possible.

In case of displacement, the reduction of the alveolar process fragments followed by a control X-ray is required before splinting.
The major part of mobile alveolar bone fragments is attached to periosteum. The removal of these bone fragments is not indicated as they usually heal.
This treatment is generally possible under local anaesthesia.

Conservative treatment

Closed reduction #pic#
  • Immobilisation using a splint for 4 - 6 weeks
  • Soft/liquid diet, depending on the location of the fracture
  • Monitoring healing progress, with regular clinical and radiological examination
  • Antibiotic treatment for 7 days
  • Immediate tetanus prophylaxis, if possible and required
Immobilisation using a splint

Fixation is obtained using a splint as long as a sufficient number of immobile teeth are present in the jaw. The teeth of the reduced area are splinted, connected to various teeth of undamaged parts of the jaw on either side.
The period required for splinting is 4 - 6 weeks.
Isolated alveolar process fractures do not require mandibulo-maxillary fixation (intermaxillary immobilisation).
Fractured or severely damaged teeth are left in place at first in order to not further traumatise the bone.
Damaged teeth are treated according to the basic rules for treatment of dental trauma.
After splint removal, tests for vitality and control X-rays are required. Later on, extractions, apicectomy or root fillings may be indicated.

Selection of the splint

In alveolar process fractures, rigid splints should be used to ensure stabilisation of fragments, unlike the semi-rigid or flexible splints used for treatment of dental trauma (Ebeleseder and Glockner 1998).

Splinting system requirements:
  • Must be easy to manufacture and apply
  • Must not damage gingival and periodontal tissues
  • Must not interfere with occlusion; must avoid causing abnormal positions
  • Must allow good oral hygiene and be comfortable to wear
  • Must permit endodontic treatments
  • Must provide adequate fixation depending on the individual indication during the period of immobilisation
  • Must provide adequate rigidity depending on the individual indication
Triple-stranded, braided wire inserts (0.8 x 1.8) are suitable for rigid fixation.



Overview of splinting systems (Berhold 2002)
Splint type Description Comments
Arch wire splints Fixing of arch wires (bent either freehand or in a laboratory) with various dimensions, usually using wire ligatures, sometimes coated with chemically hardening synthetic materials
  • Gingival irritation possible
  • Demanding on oral hygiene
  • Endodontic treatment usually possible
  • Rigid
  • Can be manufactured directly; difficult
  • Aesthetically conspicuous
  • Easily corrected in case of incorrect reduction
Bracket splints Fixing of arch wires or splints using Edgewise or orthodontic button brackets attached to the teeth using acid etching techniques and synthetic materials
  • Relatively easy hygiene
  • No gingival irritation
  • Endodontic treatment possible
  • Flexible, depending on the splint wire used
  • Can be manufactured directly
  • Relatively expensive
  • Demanding on the dentist
  • Not usually used by "normal" dentists
  • Aesthetically mildly displeasing
Bonded ring splints used with acid etching technique and composite Bonded ring splints are made of silica wire or titanium, the shape of which is anatomically adjusted to the interdental spaces in the maxilla and mandible. The splint is bonded to the teeth by means of acid etching and composite.
  • Relatively rigid
  • Direct and relatively easy application
  • High amount of material required
  • Expensive
  • Good hygiene features
  • No gingival trauma
  • Endodontic treatment possible
  • Removal is rather demanding
Composite used with acid etching technique and enforced with wire Use of chemically or light hardening composite materials for splinting, preparation of the surface of the teeth using acid etching technique to improve attachment to the tooth; synthetics used for fillings and temporary crown and bridge materials are used, as well as various wires in order to minimise the risk of breakage and to adapt the splint systems to the underlying conditions.
  • Direct, easy application
  • Normal materials
  • Inexpensive
  • Endodontic treatment possible
  • No gingival trauma
  • Good hygiene features
  • Flexible/rigid, as desired
  • Removal is rather demanding
  • Relatively aesthetic
  • Comfortable to wear

Surgical treatment

Alveolar process fracture
#pic# #pic#

The following are indications for open reduction:
  • Significantly displaced fracture
  • Unstable fracture
  • If closed reduction is not successful:
  • Complex trauma with concomitant damage to soft tissue
  • Fractures were there has been bone loss
  • Sensory disturbances
  • Missing teeth (e.g. due to trauma or mixed dentition)
  • Exact positioning of fracture fragments using a dental splint or occlusion is not possible (e.g. partially edentulous jaw)
If osteosynthesis is required for fixation of fragments, mini-plates or micro-plates are used. The alveolar process is barely subjected to muscle forces.

Additional measures

  • Treatment of damaged teeth (damaged teeth are treated according to the basic rules for treatment of dental trauma).
  • Antibiotic treatment
  • Pain management

Risk factors

  • Haemorrhage
  • Occlusion impaired or deficient
  • Fractured teeth
  • Tooth within the fracture line
  • Periodontal disease or infection
  • Size of fragments
  • Displacement
  • Insufficient blood supply of fracture fragments and/or adjacent soft tissue
  • Concomitant trauma making primary treatment of the alveolar process fracture impossible (e.g. polytraumatised patients)
  • Time elapsing before treatment of the fracture
  • Pre-trauma bone damage (metabolic disorders, irradation)

Complications

  • Tooth loss
  • Periodontal defects following splint treatment
  • Devitalisation of teeth
  • Fracture healing is not achieved
  • Scar formation
  • Functional disorders
  • Malocclusion
  • Impaired masticatory function
  • Dysphagia
  • Impaired speech
  • Chronic pain
  • Chronic infection (osteomyelitis)
  • Chronic impaired neurological function
  • Oro-antral or oro-nasal fistula

Recommendation

Ambulant treatment is usually appropriate. If several teeth are affected or soft tissue is also damaged, hospital treatment may be indicated.