Alveolar Fracture: Findings, Treatment & Trauma Assessment Example

Clinical Note: Dental Trauma Assessment Alveolar Fracture Example

Chief Complaint: ______________________________

History of Trauma

• Date and Time: ______________________________
• Location of Injury: ___________________________
• Mechanism of Injury: (e.g., fall, sports, accident): ____________________________
• Initial Care Provided: ________________________

Medical History

• Allergies: _________________________________
• Medications: ______________________________
• Tetanus Status: ___________________________
• Relevant Medical History: ______________________

Dental History

• Previous Dental Injuries: ___________________________

Intraoral Findings

Soft Tissues:

• Lacerations: Yes (lacerations noted on the labial gingiva adjacent to tooth #8).
• Bleeding: Localized bleeding observed in the gingival area and surrounding mucosa.
• Swelling: Moderate swelling present over the labial and alveolar regions.

Tooth Findings:

• Tooth #8,#9:
  • Displacement: The teeth were displaced along with an associated alveolar bone segment.
  • Mobility: Significant mobility of teeth #8,#9 and the surrounding bone fragment.
  • Percussion: Tender to percussion.
  • Sensitivity Testing (cold, electric pulp test): Negative response, suggesting possible pulpal damage.

Radiograph

• Periapical and CBCT Imaging:
  • Alveolar bone fracture observed involving the labial and apical regions near tooth #8,9.
  • Disruption of the periodontal ligament space around tooth #8,9.
  • Intact root structure with no evidence of fracture.

Plan

Immediate Management:

1. Repositioning:
   • The displaced alveolar bone segment, along with tooth #8,9, was gently repositioned into the correct anatomical position using manual digital pressure.
2. Stabilization:
   • Applied a flexible splint to stabilize the fractured alveolar segment and tooth #8,9.
   • Splint duration: 4 weeks.
3. Pulp Monitoring:
   • Advised regular monitoring of pulp vitality for tooth #8,9.
   • Root canal therapy to be initiated if signs of necrosis develop.
4. Pain Management:
   • Prescribed analgesics (e.g., ibuprofen 400-600 mg every 6-8 hours as needed) for pain relief.
5. Antibiotics:
   • Prescribed antibiotics (e.g., amoxicillin or metronidazole) to minimize the risk of infection due to the extent of the trauma.
6. Oral Hygiene:
   • Recommended the use of chlorhexidine rinse (0.12%) twice daily to aid in soft tissue healing and prevent infection.
   • Advised the patient to maintain a soft diet and avoid biting with the affected area.

Follow-Up Schedule:

• 2 Weeks: Reassess splint stability, pulp vitality and healing of soft tissues.
• 4 Weeks: Remove splint; assess mobility and pulp vitality of tooth #8,9 and alveolar bone stability.
• 6-8 Weeks: Perform radiographic evaluation to monitor for signs of resorption, pulp necrosis, or healing complications.
• 6 Months, 1 Year, 5 Years: Periodic monitoring for long-term complications such as ankylosis, delayed healing, or root resorption.

Warning About Risks Associated with Dental Trauma

Alveolar fractures may result in complications such as delayed bone healing, pulp necrosis, root resorption, or ankylosis of the affected tooth. Regular follow-ups and prompt reporting of symptoms like pain, mobility, or discoloration are essential for successful recovery.

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