Tmp2a26 TMP
Tmp2a26 TMP
Tmp2a26 TMP
DOI 10.1007/s10006-012-0369-y
REVIEW ARTICLE
Received: 30 June 2012 / Accepted: 17 October 2012 / Published online: 27 October 2012
# Springer-Verlag Berlin Heidelberg 2012
Abstract
Purpose This study aims to review the literature regarding
the evolution of current thoughts on the management of
teeth in the line of mandibular fractures (MFs).
Methods An electronic search in PubMed was undertaken in
June 2012. The titles and abstracts from these results were
read to identify studies within the selection criteriastudies
reporting clinical series of MFs in which the management of
teeth in the fracture line was analyzed.
Results The search strategy initially yielded 731 references.
Twenty-seven studies were identified without repetition
within the selection criteria. Additional hand searching
yielded 12 additional papers.
Conclusions It is suggested that rigid fixation systems and the
use of antimicrobial agents have reduced the incidence of
infection in cases of teeth in the line of MFs. Tooth buds in
the line of MFs should not be removed or replaced in the
(alleged) proper position despite the degree of displacement,
since studies showed that even tooth buds in the early stage of
calcification and those involved in widely displaced fracture
sites continued development and erupted. Its removal should
be considered in cases of infection, which is a predictive factor
of abnormality and/or impaction. Intact teeth in the fracture
line should be left in situ if they show no evidence of severe
loosening or inflammatory change. Permanent teeth maintained in the line of fracture should be followed up clinically
and radiographically for at least 1 year to ensure that any
unnecessary endodontic treatment is avoided. Teeth in the line
of fracture that prevents reduction of fractures, teeth with
B. R. Chrcanovic (*)
Department of Prosthodontics,
Faculty of Odontology, Malm University,
Carl Gustafs vg 34,
SE-205 06 Malm, Sweden
e-mail: brunochrcanovic@hotmail.com
B. R. Chrcanovic
e-mail: bruno.chrcanovic@mah.se
fractured roots, a partially impacted wisdom tooth with pericoronitis, and a tooth with extensive periapical lesion should
be removed. Teeth in the line of MFs should also be removed
when located in sites where there is extensive periodontal
damage, with broken alveolar walls, resulting in the formation
of a deep pocket (making optimal healing doubtful).
Keywords Mandibular fracture . Teeth in the fracture line .
Complications . Treatment
Introduction
About 5669 % of fractures of the mandible involve areas
with teeth [16]. Consequently, the likelihood that a tooth
will be in the fracture line is substantial. Whether teeth
situated in the line of fracture should be extracted or retained
has always been a subject of heated debate.
Fractures of the jaw in the tooth-bearing area, because of
the presence of periodontal ligaments, are always in communication with the oral cavity. The damage to the tooth or
teeth involved at the fracture site may include exposure of
the root surface, subluxation, avulsion, or root fracture. The
tooth involved may become devitalized as a result of injury
or may have a preexisting pulpal, periodontal, or periapical
condition of pathology [7]. All these factors either alone or
combined could predispose the fracture to infection and may
complicate healing [7, 8].
There are no definite guidelines in the literature for the
management of teeth in mandibular fracture (MF) lines, particularly in regard to their retention or removal at the time of
fracture treatment [7]. Authors of early studies maintained that
retained teeth in the line of fracture often become a nidus of
infection [9]. They recommended that involved teeth should
be extracted to reduce the chances of untoward sequelae such
as osteomyelitis and nonunion. Even vital teeth were routinely
removed, as it was believed that the communication of the
fracture to the oral cavity via periodontal space fosters
infection [10]. It has also been stated that teeth in the fracture
line can be left in place if certain prerequisites, such as early
treatment with a stable splint or by functionally stable osteosynthesis, are met [9]. Several more recent studies support the
view that teeth in the line of MFs can be preserved when
antibiotics are used prophylactically [1123].
As the philosophies of the treatment of maxillofacial
trauma alter over time, a periodic review of the different
concepts is necessary to refine techniques and eliminate
unnecessary procedures. This would form a basis for optimum treatment. The purpose of the study was to review the
literature regarding the evolution of current thoughts on the
management of teeth in the line of MFs.
bilateral MFs. The study could have applied maxillomandibular fixation (MMF) alone, open reduction and internal fixation (ORIF) alone, or a combination of ORIF and MMF.
Randomized controlled clinical trials, cohort studies, case
control studies, cross-sectional studies, and case series were
included. Because of the scarcity of articles with high-level
grades of evidence, all articles, including studies with few case
reports, were considered for inclusion.
Exclusion criteria
Review articles without original data were excluded, although references to potentially pertinent articles were noted
for further follow-up.
below. The main results of the included studies are presented in Table 1.
Krmer [24] evaluated 690 MFs from British soldiers
who served in the Second World War. The material was
obtained from a Plastic and Jaw Unit in England, from the
years 1940 to 1945. Probably, the first clinical study on the
subject is still one of the most detailed studies published so
far. In one group with simple linear fractures, he found that
if the fracture was not treated within 48 h, healing was
slower when a tooth in the fracture line had been spared
than when it had been extracted early. When the fracture
was reduced within 48 h, the time of extraction was of little
importance. If, on the other hand, fixation is effected after
27 days, infection will become of great significance, and
extraction ought to be done in connection with the fixation,
according to the author. He advised maintaining all teeth
except those severely infected or mobile. The authors also
stated that every tooth in the line of a gunshot fracture ought
to be extracted at the beginning of treatment (as a shot
fracture is always infected), provided that the number of
teeth left is sufficient to provide strong fixation and that
extraction can be done without any serious trauma. Considering fractures fixed after 212 weeks, the author observed
that the healing will be considerably delayed, which may
take twice or thrice the normal time.
Although described in an article published in 1987,
Chambers and Scully [25] reviewed the case notes of 124
patients with MFs treated by a major in India in 1944 and
1945, during the Second World War. Fifty-five patients
(46.2 %) had one or more teeth extracted from the line of
fracture. In most cases, the teeth removed had not themselves been fractured. This kind of approach represented the
thinking on the management of teeth in fracture lines at that
time, in the era before antibiotics were widely available.
A retrospective study by Schnberger [26] found a 6 %
rate of infection when a tooth in the fracture line was
retained compared with an 18 % infection rate after prophylactic removal. He subsequently recommended that all devitalized teeth and root pieces in the fracture line be removed,
irrespective of whether a periapical infection was present of
not. However, he indicated that vital anterior and premolar
teeth with tolerably good tooth sockets could be retained.
Gtte [27] also found more complications after prophylactic
extraction of the tooth at the fracture site (20 % of 60
patients) than when it was left in place (16.8 % of 178
patients).
Roed-Petersen and Andreasen [11] found that 25 % of
teeth in the line of fracture became necrotic; the necrosis
developed in cases when the fracture crossed the apical area
or when the fracture was treated more than 48 h after the
trauma. In the study of Ridell and strand [28], there was an
uneventful healing in 77.2 % of the involved teeth. Of the
teeth where the fracture was reduced and immobilized within
RA
PS-NCG
PCCT
1956
1959
1970
1971
1971
1976
1978
1978
1979
1979
1983
1987
1987
1990
1990
1991
1992
1992
1993
1993
1994
Schnberger [26]
Gtte [27]
Roed-Petersen and
Andreasen [11]
Amaratunga [15]
RA
RA
RA
RA
RA
RA
PCCT
RA
RA
RA
RA
PS-NCG
RA
PS-NCG
RA
RA
RA
RA
RA
1953
Krmer [24]
Study
design
Published
Authors
27
37
41
40
214
52
124
45
105
191
227
82
139
132
21
182
157
84 (123)e
NM (NM)
65 (G1)a
5 (G2)
15 (G3)
49 (G4)
48 (G5)
54 (G6)
275 (G7)
203
238
68
1570 (31)
1643 (27)
1250 (23)
1356 (NM)
883 (34)
1484 (NM)
NM (NM)
1467 (33)
NM (NM)
NM (NM)
NM (NM)
467 (29.6)
873 (NM)
NM (NM)
NM (NM)
71 patients between 0 and
24 years of age, 39 with
25 or more years of age
1029 (NM)
Patients
(n)
Table 1 Clinical series of MFs in which the management of teeth in the fracture line was analyzed
NM (NM)
NM (15 months)
14 years (NM)
NM (NM)
972 months (43)
NM (NM)
1 week38 months
(10.4 months)
Up to 6 months (NM)
NM (NM)
NM (NM)
At least 1 year (NM)
NM (NM)
NM (NM)
NM (NM)
NM (NM)
NM (NM)
17 years (3)
NM (NM)
Follow-up period
range (average)
32
37
NMk
NMk
270
75
176
45
105
226
202 (372)g
100 (66)f
139
185
30
207
199
95
65 (G1)b
5 (G2)
15 (G3)
49 (G4)
48 (G5)
54 (G6)
275 (G7)
203
238
84
MFs
21
42
78
66
10j
47
171h
54
105
226
202
66
139
185
52
207
199
165
28 (G1)
4 (G2)
10 (G3)
14 (G4)c
18 (G5)
NM (G6)
NM (G7)
203
346
110
MMF
MMF
6 weeks MMF (range, 39)
Teeth in the
line of MFs
Treatment
of the MFs
10
Oral Maxillofac Surg (2014) 18:724
RA
RA
1994
1994
1997
2000
2002
2004
2005
2006
2007
2009
2010
2010
2011
2011
270/76
Gtte [27]
6 % (when teeth
were retained)
18 % (when teeth
were removed)
NM (G7)
NM/NM (G7)
NM/NM
NM (G6)
NM/NM (G6)
30/173
4 (G5)
3/15 (G5)
Schnberger [26]
13 (G3)
NM/NM
NM/NM
NM/NM
15 (G1)d
3 (G2)
6 (G4)c
NM/NM
1/13 (G4)c
2/26 (G1)
0/4 (G2)
Krmer [24]
Delayed union/
nonunion
NM (NM)
NM (NM)
NM (NM)
NM
NM
2 patients required
bone graft (G4)
Other
complications
3
63
54
62
140
1,235
NM
593
90
650
402
121
254
3 months (3 months)
90
45
MFs
1 year (1 year)
NM (NM)
Follow-up period
range (average)
Infection
1.52.5 (2)
NM (NM)
NM (27) (retained)
NM (29) (removed)
1848 (29)
1762 (32)
1680 (32.2)
115 (NM)
1041 (24.6)
310 (6)
Antibiotics/chlorhexidine
rinses (days)
3
48
54
50
83
789
28
464
68
622
402
117
254
57
30
Patients
(n)
0/10 (G3)
Teeth retained/removed
(in the line of MFs) at
the initial treatment
Authors
PS-NCG
RA
PS-NCG
RA
RA
RA
RA
RA
PS-NCG
RA
RA
RA
RA
1994
Study
design
Published
Authors
Table 1 (continued)
NM
10 teeth required
endo
NM
Teeth that
required treatment
(endo/periodontic)
Treatment
of the MFs
12
NM
NM
3
48
54
50
In 52 patients
In 660 patients
66
593
90
650
345
121
57 (in mandibular
angle fractures)
65 (anterior region)
189 (posterior region)
16 (in 15 fractures)
Teeth in the
line of MFs
Teeth retained/removed
(in the line of MFs) at
the initial treatment
110/0
138/27
199/0
49/3
132/75
99/40
172/13
34/32
152/50
124/102
116/55
Authors
Roed-Petersen and
Andreasen [11]
Amaratunga [15]
Table 1 (continued)
NM/NM
14/0
7/0
96 patients received
antibiotics. No
posology was reported/0
100 patients received
penicillin for 10 days/0
5/0
95 % of patients had
prophylactic antibiotics
therapy/NM
5/NM
714/0
NM/NM
NM/NM
13 (retained)
2 (removed)
50
54/15
10/1 (retained)
7/3 (removed)
6/0 (removed)
6 (retained)
4 (removed)
7/1 (retained)
(retained)
2 (removed)
2 (retained)/0
1 (retained)
9 (removed)
NM/NM
8/0 (removed)
16 (removed)
30
18/0 (retained)
7 %/NM
9 (retained)
6/0
NM/NM
NM/NM
Delayed union/
nonunion
Short-term prophylactic
antibiotics therapy
used in 43 patients/0
Infection
Antibiotics/chlorhexidine
rinses (days)
15 malunion or
malocclusion
2 dehiscences (removed)
No
NM
No
Loss of marginal
bone support, 3 %
(incisors and
premolars), 42 %
(canines), and 4 %
(molars)
1 tooth had
root resorption
Other
complications
NM
NM
NM
NM
NM
NM
NM
19
NM
22
NM
NM
14 %
11 (5 of these teeth
were extracted for
other reasons than
the mandibular
fracture)
NM
45 %
NM
7 teeth required
endo; 15 teeth had
bone pockets
16 (out of 63
evaluated) teeth
required endo
Teeth that
required treatment
(endo/periodontic)
12
Oral Maxillofac Surg (2014) 18:724
710/0
1/9j
29/18
60/18
63/3
42/0
5/16
16/0
57/0
Kamboozia and
Punnia-Moorthy [7]
5/0
69/36
0/0
Antibiotic regimen
started within hours of
hospital admission/0
NM
0/0
7 (anterior region)
32m
NMl
NM
0/0
5/1
0/6
NM
Delayed union/
nonunion
11
antibiotic cover/0
7/7
6 (retained)
6 (removed)
13j
23 % (retained)
19 % (removed)i
NM
Infection
5/0
7/0
Antibiotics/chlorhexidine
rinses (days)
Teeth retained/removed
(in the line of MFs) at
the initial treatment
Authors
Table 1 (continued)
mobility
Occlusal interferences
were observed in
38 % of teeth in the
line of MFs and in
28 % of teeth of the
control group
Iliac bone grafts
were used in the
reconstruction of 9
fibrous unions in
8 patients
18 % of the dentition
involved in the line
of fracture exhibited
either delayed
eruption or noneruption with
resorption of the
tooth bud
5 malocclusions
No
6 sequestrations
11 obliteration of the
pulp chamber, 8 loss
of marginal alveolar
bone, 2 root resorption,
6 teeth with increased
Other
complications
NM
NM
NM
NM
NMl
NM
NM
NM
15
NMl
NM
NM
NM
NM
NM
NM
Teeth that
required treatment
(endo/periodontic)
121/0
66/00
63/37 %
40/12 (patients)
50/0
3/0
34/14
87/258
Ellis [19]
375/275
78/12
96/80 (posterior)
Teeth retained/removed
(in the line of MFs) at
the initial treatment
Authors
Table 1 (continued)
14.71 % (retained)
8.72 % (removed) i
20 (posterior region)
Infection
NM
Antibiotics were
prescribed/0
57/7
Minor complications:
7.5 % (retained);
16.7 % (removed).
Revision surgery: 30 %
(retained); 25 %
(removed)i
4
NM
0/0
NM
15/in 55 %
of the cases,
nonunion of
the mandible
was caused
by infection
NM
0/0
1 crown malformation,
1 arrested root
formation
No
Abnormal findings in 30
of 66 developing teeth
(45 %), including
deficient root
formation, abnormal
bend of the root,
nodule formation on
the root, partial
obliteration of the pulp
cavity, impaction,
growth arrest, and
external resorption
No
No
No
No
NM
4 wound dehiscences, 1
malocclusion, 4 tooth
mobility
4 malocclusions
(anterior region)
16 malocclusions
(posterior region)
2/3 (anterior
region)
0/2 (posterior
region)
0/0
Other
complications
Delayed union/
nonunion
9 (retained)
19 (removed)
Yes/yes (number of
days not informed)
Antibiotics were
used in all cases/0
NM
5/0
75
Antibiotics were
administered on
admission to the hospital/0
5/0
0
NM
7/0
Antibiotics/chlorhexidine
rinses (days)
NM
NM
NM
NM
NM
19
Teeth that
required treatment
(endo/periodontic)
NM
NM
NM
NM
19
14
Oral Maxillofac Surg (2014) 18:724
30/24
Antibiotics/chlorhexidine
rinses (days)
4 (retained)
3 (removed)
Infection
0/0
Delayed union/
nonunion
1 malocclusion, 10
apical resorptions
Pain/tenderness at
the fracture site:
4 (retained), 3
(removed); 4 teeth
with mobility; 2 root
resorptions
Other
complications
Teeth that
required treatment
(endo/periodontic)
NM
Of the 49 patients in group G4, Krmer [24] analyzed the data from 33 of them
In 12 patients, all teeth involved by the fracture were extracted primarily. Of the 111 remaining patients, 84 were examined after
The authors reported the complication rates comparing extraction and retention of the tooth. The types of complication were not reported
From the 124 patients with 176 fractures, five patients were edentulous
The authors evaluated the occlusal interferences in association with teeth in the line of MFs. Other complications were not informed
The authors informed the number of teeth in the fracture line. They did not inform the exact number of MFs
The authors evaluated only the fate of tooth buds in the line of MFs in children. Other complications were not evaluated
The authors evaluated only patients with mandibular fibrous union. Thus, all 32 fractures had fibrous unions. The definition of fibrous union included those inadequate unions previously classified
as delayed union, nonunion, or pseudoarthrosis
From the 270 MFs, the authors analyzed the 13 cases with infection. From these 13 cases, 10 were dentate, and 13, edentulous. Teeth had been extracted from the fracture line before the
osteosynthesis procedure in 9 of the 10 dentulous mandibles
Krmer [24] mentions that several sequestrectomies were performed in his patients. It is assumed that the number of performed sequestrectomies is equal to the number of local infections because,
somewhere in the text, he mentions that the tooth in the line of fracture had caused infection which led to sequestrectomy
It is not known for sure how many fractures occurred in each group because 511 cases were reported in the text of the manuscript, although 690 jaw fractures were mentioned in the title of the
paper. Thus, all data in this present table were registered, considering these 511 cases
Krmer [24] divided his treatment patients in seven groups: (G1) linear fractures with teeth on all fragments; (G2) gunshot fractures; (G3) fractures fixed after 2 to 12 weeks; (G4) fractures with
short edentulous fragment; (G5) multiple fractures with short posterior edentulous fragment; (G6) partial or alveolar fractures; and (G7) multiple and comminuted fractures
NM not mentioned, MFs mandibular fractures, MMF maxillomandibular fixation, ORIF open reduction and internal fixation, RA retrospective analysis, PS-NCG prospective study with no control
group, PCCT prospective controlled clinical trial
Observation was that two studies were not included in this table for the following reasons: Wolujewicz [33] studied the link between the type of impaction of the lower third molar and the direction
and displacement of lines of fracture in this region; in his paper, he did not provide most of the information needed for this table. Donker et al. [44] collected information about how 102 dental
surgeons in the Netherlands deal with teeth in the line of MFs; thus, it was a questionnaire study, not a clinical study
Teeth retained/removed
(in the line of MFs) at
the initial treatment
Authors
Table 1 (continued)
16
Complications were more frequent after inadequate reposition of the fracture compared to optimally reduced fracture
fragments. Teeth without pathological complications were
found to be significantly more frequent in optimally repositioned fractures than in fractures with persistent dislocation.
There was an increasing rate of complications with increasing severity of periodontal involvement. Teeth with exposed
root apices or with complete exposure of the root surface
had a poor prognosis. The authors believed that conservatively treated teeth involved in the line of MFs have a
favorable prognosis, especially if optimal reduction of the
fragments is achieved.
Wagner et al. [32] analyzed 100 consecutive extraoral
open reductions of MFs in an attempt to evaluate the morbidity of this technique and demonstrate possible predisposing factors. There was an overall complication rate of 13 %
consisting of infection, delayed union, and hypertrophic
scarring. All occurred at sites enclosing teeth. Nine of the
13 complications involved extraction, and eight of those
nine occurred at fractures of the angle. They had 37 cases
of mandibular angle fractures (MAFs) with teeth in the line
of fracture which were treated with an open reduction and
found a complication rate of 11.8 % in those fractures in
which the teeth were retained and 35 % when teeth were
removed. Thus, it appeared to be an increased incidence of
those complications in MAFs with teeth in the line of injury
when the teeth were extracted in conjunction with extraoral
open reduction. No complication appeared in the open
reductions of 33 fractures not associated with teeth.
Wolujewicz [33] studied 47 patients with MAFs involving LTMs. The author attempted to find a link between the
type of impaction of the LTM and the direction and displacement of lines of fracture in this region. Fractures
through erupted LTMs, and particularly, those molars which
were vertically impacted, generally required more elaborate
methods of treatment. The authors observed that no advantage was gained in attempting to achieve stability by retaining these teeth. Their retention carried the risks of delayed
union and infection of the fracture. Of 21 fractures with
vertically impacted LTMs, the tooth was extracted in 15
cases to achieve satisfactory results (internal wire fixation
was used in 14 of these 15 cases). He concluded that LTMs
that are vertically impacted should be removed, and those
which are in a horizontal or mesioangular orientation should
be retained partly because they appear to stabilize the fracture and partly because treatment of the fracture without the
extraction of the tooth is less extensive.
Chuong et al. [14] delineated the relationship between the
location of the fracture, disposition of the teeth, and subsequent development of complications in a study of 327 MFs.
There was not any significant difference in the rate of
complication between cases where the teeth in the line of
injury were retained (11 % of 152 cases), and when they
17
18
approximately 14 days, and no surgical treatment was required. The 46 patients available at 1-year follow-up showed
no cases of pseudoarthrosis, and no abnormalities were present around the roots of the involved LTMs. Although the
authors stated that the closed treatment regimen adopted produces good healing and less morbidity compared with cases in
which ORIF is used and movement of the jaws permitted
immediately, they did not performed ORIF treatment in their
study in order to make a comparison.
Thaller and Mabourakh [40] found that neither the location of the fracture nor retention or extraction of the tooth
had a statistically significant effect on the success rate of
surgical repair. There was little difference in the outcome of
fracture management whether the teeth were routinely
extracted or retained as long as ORIF was employed for
stabilization of the fracture segments.
The reasons for extraction in the study of Gerbino et al.
[41] were dislocated tooth, repositioning impossible (three);
tooth fractured (three); tooth with poor periodontal condition (two); tooth seriously damaged by caries (two); and
partially or totally impacted wisdom tooth evaluated as an
obstacle to reducing the fracture (two). Eleven fracture sites
gave rise to complications in nine patients; four patients
developed infection requiring extended hospitalization with
antimicrobial treatment; four developed wound dehiscence,
and one, malocclusion. The complications observed were in
3/12 fractures in which the tooth was extracted and in 8/78
when the tooth was retained. At follow-up of the 78 fracture
sites where the teeth had been kept at surgery, eight teeth
had subsequently been extracted; 19 had been subjected to
endodontic treatment because of loss of vitality or infection,
and tooth mobility was seen in further four cases. The
overall incidence of complications revealed no statistical
correlation with management of the tooth in the line of
fracture, degree of displacement, and time elapsed between
trauma and treatment. It is of the authors opinion that
prophylactic extraction of teeth in the line of fracture
should be avoided when plates and screws are used.
Atanasov and Vuvakis [42] conducted a retrospective
study of patients with 650 MFs crossing the LTM. The
results showed no statistically significant difference in the
complication frequency associated with the extraction of
unerupted or erupted wisdom teeth (12.50 and 8.37 %,
respectively). In treatment of fractures with retention of the
wisdom tooth in the fracture line, the complications with the
totally erupted LTMs were more frequent than those with
unerupted LTMs (20.70 vs 7.69 %, P<0.001). In patients
submitted to ORIF, 20 and 24.13 % of them showed
complications in cases with unerupted and erupted teeth,
respectively. With conservative treatment (CTR), the complications were 7.30 % with the unerupted and 11.33 % with
the erupted wisdom teeth. Thus, a higher complication rate
was observed in patients treated by ORIF in comparison
19
Discussion
What to do with tooth buds directly involved in the line
of mandibular fractures?
The fate of tooth buds (the developing teeth within the tooth
follicles) that are directly involved in fractures of the jaw is
an important matter of concern. The impaction or marked
deformation of the affected teeth which sometimes results
from such injuries can cause esthetic and functional disturbances of the dentition. In some cases, repeated monitoring
may be necessary throughout the entire period of tooth
development [23] to ensure that surgical, orthodontic, or
prosthetic treatment is provided at the appropriate time [43].
Some studies reported a high incidence of abnormalities
in developing teeth involved in fractures, such as 55 % (21
of 38 teeth) [49], 51 % (19 of 37) [50], and 45 % (30 of 66
teeth) [43]. However, the incidence of impaction was relatively low (016 %) in these studies. Although the incidence
of abnormalities was relatively high, most of the abnormalities did not have significant deleterious effects on the
dentition. Ranta and Ylipaavalniemi [50] pointed out that
teeth in which root development had already started at the
time of fracture appear to erupt normally. This may occur
due to the fact that the developing follicle is more elastic
than the surrounding bone and better able to survive mechanical injury [39]. However, Ranta and Ylipaavalniemi
[50] also observed that marked deformation of the crown
and roots occurred in teeth located on the fracture line when
calcification of the crown was still in progress at the time of
the fracture. In contrast, Suei et al. [43] observed no relationship between the occurrence of abnormalities and the
developmental stage of tooth buds at the time of the injury.
Even tooth buds in the early stage of calcification and those
involved in widely displaced fracture sites continued development and erupted. Thus, it may be suggested that tooth
20
They still stated that there might be other possible contributing factors involved in the development of postoperative
complications in this particular location such as bone quality
and thickness, biting forces, nutritional oral hygienic status
of the patient, and patient compliance.
On the other side, when there are impacted LTMs with
pericoronal infection, these should be removed. It is highly
probable that significantly higher complication rates would
be observed if fractured, carious, grossly infected, or loose
LTM involved in MAFs is retained instead of removed [45].
However, some authors [17, 41] suggested that impacted
wisdom teeth (even if infected at the surgery) may be
extracted once healing is complete, possibly at the time of
removal of the miniplate 3 months after fracture reduction.
Ellis [19] made an interesting comment, saying that because
most teeth in the line of a MAF are nonfunctional LTMs, he
did not make an effort to retain such teeth whose apices
were exposed to the fracture. Thus, the criteria for extraction
may be therefore more aggressive for MAFs than for other
regions of the mandible.
Thus, it should be suggested by the literature review
that impacted LTMs, especially complete bony impactions, should be left in place to provide a larger repositioning surface. Exceptions are non-erupted teeth,
making reduction of fragments difficult or impossible,
and partially erupted LTMs with pericoronitis or associated with a follicular cyst [55]. There is another
possible exception. When ORIF of a MAF is needed,
the presence of an impacted LTM influences the positioning of bicortical screw or plate fixation, limiting the
areas for placement of screws or plates [56]. Thus, the
removal of the LTM may be necessary because, unfortunately, the configuration of the screw placement or
screws placed in areas of thin bone can lead to poor
fixation [57]. Where extraction is indicated, osteosynthesis may first be completed, and the tooth subsequently be extracted, unless it forms an obstacle when
reducing the fracture [35, 41]. It is difficult to say if
Wolujewiczs [33] orientations should be followed as a
rule because the type of impaction is not the only a
factor of evaluation to be considered in these cases.
One important observation to make here is that patients
with MAFs involving a LTM should be counseled properly in the preoperative period about the chances of
having additional surgical intervention(s) regardless of
the LTM involvement or selective removal of the involved teeth [45].
When teeth in the line of mandibular fractures should
be maintained?
There are some situations in which it is suggested that teeth
in the line of MFs should be maintained. Intact teeth in the
21
22
oral hygiene, the patients may also rinse their mouths twice
a day with a 0.2 % chlorhexidine solution for at least 7 days.
Ryberg [58] considered early treatment with complicationfree stabilization of the fragments an important prerequisite for avoiding fracture infections. Supportive antibiotic
therapy was certainly advantageous but did not have the
same value as the early treatment of the fracture.
Rybergs investigations showed that the earlier the fracture was immobilized, the better were the chances for
preservation of a tooth lying in the fracture line. Other
studies showed that treatment of MFs within 48 h has a
better prognosis for the teeth in the line of fracture [11,
24, 58]. However, more recent studies [20, 41] demonstrated that the overall incidence of complications
revealed no statistical correlation with the time elapsed
between trauma and treatment.
For teeth in the line of fracture which were not removed,
when is the best time to evaluate the need for an endodontic
treatment?
There are some observations concerning the need of
future endodontic treatment of teeth located in the line
of MFs. The findings of Kamboozia and Punnia-Moorthy
[7] suggest that when the fracture line follows the root
surface from the apical region to the gingival margin
with denudation of the root surface and when the tooth
is located in grossly displaced fractures, there is a high
probability (65 and 64 %, respectively) of future endodontical treatment of the tooth involved. However, in the
study of Kahnberg and Ridell [13], 23 % of the teeth
which responded negatively to electric stimulation at the
time of injury showed positive sensibility after a varying
time period after fracture healing. Thus, a follow-up of
about 1 year would be sufficient to allow for the return of
temporary loss of vitality, thus ensuring that any unnecessary
endodontic treatment is avoided [13, 48].
Kamboozia and Punnia-Moorthy [7] demonstrated that
the incidence of nonvitality of teeth associated with MFs
was significantly higher with ORIF than with MMF. The
authors stated that the most likely reasons for such an
increase in tooth nonvitality with plating are the open nature
of the procedure in which the fracture site is completely
exposed by the elevation of a mucoperiosteal flap and the
increased degree of manipulation of fragments which is
generally required to achieve precise anatomic reduction of
the fracture. Additionally, a screw placed near the apex of
the root of the tooth and mandibular canal might damage the
innervation or blood supply to the teeth [7].
Although teeth whose apices were exposed to the fracture
site can then be managed with endodontic treatment or
selective extraction, the some patient population may not
have ready access to such therapeutic measures [19]. Thus,
Conclusions
It is suggested that rigid fixation systems and the use of
antimicrobial agents have reduced the incidence of infection
in cases of teeth in the line of MFs. Although no randomized
controlled clinical trials were conducted to test the influence
of antibiotic use in the incidence of infection in MFs lines
bearing teeth, it is suggested that antiseptic mouthwash
(0.2 % chlorhexidine for at least 7 days) and antibiotic
prophylaxis may be important treatment adjuvants.
Tooth buds in the line of MFs should not be removed or
replaced in the (alleged) proper position despite of the
degree of displacement, since studies showed that even
tooth buds in the early stage of calcification and those
involved in widely displaced fracture sites continued development and erupted. In cases of infection, its removal
should be considered, since the presence of infection is a
predictive factor of abnormality and/or impaction.
Fully erupted permanent teeth associated with MF should
not be removed on a prophylactic basis to reduce the risk of
infection of fracture sites. Intact teeth in the fracture line
should be left in situ if they show no evidence of severe
loosening or inflammatory change. Permanent teeth maintained in the line of fracture should be followed up clinically
and radiographically for at least 1 year to ensure that any
unnecessary endodontic treatment is avoided, unless an
acute apical inflammatory lesion appears.
The decision to extract teeth must be taken individually on
the basis of the clinical situation. Teeth in the line of fracture
which prevent reduction of fractures, teeth with fractured
roots, a partially impacted wisdom tooth with pericoronitis,
and a tooth with extensive periapical lesion should be removed. Teeth in the line of MFs should also be removed when
located in sites where there is extensive periodontal damage,
with broken alveolar walls, resulting in the formation of a
deep pocket (making optimal healing doubtful).
Acknowledgments This work was supported by CNPq, Conselho
Nacional de Desenvolvimento Cientfico e Tecnolgico, Brazil. The
author would like to thank Dr. Kysti Oikarinen, Dr. Per strand, Dr.
Boyan S. Vladimirov, Dr. S. Ferrara, Dr. Philip A. Van Damme, Dr.
Ditimar T. Atanasov, and Dr. Seth R. Thaller for having sent me their
articles.
Conflict of interest None.
23
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