Received Date : 28-Jun-2016

Revised Date : 24-Nov-2016

Accepted Article
Accepted Date : 25-Nov-2016

Article type : Original Article

PROGNOSIS OF TEETH IN THE LINE OF JAW FRACTURES

Kamaldeep K. Aulakh, Tejinder Kaur and Sumeet Sandhu

Authors’ institutional affiliations including city and country: Department of Oral and Maxillofacial Surgery, Sri
Guru Ram Das Institute of Dental Sciences and Research (SGRDIDSR), Amritsar, Punjab, India 143001

Name and address of the department or institution to which the work should be attributed: Department of Oral
and Maxillofacial Surgery, Sri Guru Ram Das Institute of Dental Sciences and Research (SGRDIDSR),
Amritsar, Punjab, India 143001

Name, address, telephone and fax numbers, and e-mail address of the author responsible for correspondence and
to whom requests for offprints should be sent:
Kamaldeep K. Aulakh, Department of Oral and Maxillofacial Surgery, Dasmesh Institute of Research and
Dental Sciences, Faridkot, Punjab, India, 151203.
Email Id: aulakh.kamal@yahoo.co.in

Running Title: Fate of Fracture Line Teeth.

Key words: Fracture, teeth, prognosis, vitality, complications

Acknowledgements

Authors thank all patients who gave their written consent and the Ethical Committee of SGRDIDSR for

approving the design and conduct of the present study. The use of various facilities of SGRDIDSR including

laboratories, X-ray units and operation theatre is acknowledged.

Conflicts of Interest

None

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/edt.12314
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 Funding
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The study was self-funded by authors and there was no external funding.

ABSTRACT

Background/Aim: The decision as to whether teeth in the line of jaw fractures should be extracted or retained

remains a controversial issue. The aim of this study was to assess the prognosis of teeth directly in the line of,

and adjacent to jaw fracture sites.

Materials and Methods: The study consisted of 50 patients with facial fractures in the dentate region, the

diagnosis of which was made on the basis of clinical and radiographic examinations. A total of 124 teeth were

present in 69 fracture sites (50 patients), of which 89 teeth were evaluated both, clinically (tooth mobility,

pocket depth, pulp sensibility) and with periapical radiographs (degree of fracture displacement, marginal bone

loss, root resorption).

Results: The results revealed that 61.9% of teeth in directly in the line of fractures showed no response to

electric pulp testing compared to 48.9% teeth adjacent to fractures. The maximum frequency of non responsive

teeth was observed in Type I fractures followed by Type II fractures. Response to pulp tests was highly

significant at postoperative 3- and 6-month periods (Wilcoxon’s test). There was continuous reduction in the

measurement for mean pocket depth at both test and control sites of teeth. The measurement of marginal bone

levels of teeth in the line of fractures revealed a significant reduction (p<0.01) from pre-operative to post-

operative 7 day period only. In teeth adjacent to fracture sites, the mean marginal bone levels of control site and

test sites were not significant at any time interval. There was no difference in post-operative complications

pertaining to whether the tooth at the fracture site was extracted or retained.

Conclusions: Teeth in line of jaw fractures should not be removed on a prophylactic basis and should be

followed up clinically and radiographically to determine any treatment needs.

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 INTRODUCTION

Fractures of the jaws are documented to be one of the most commonly encountered injuries of the facial
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skeleton. Precise reduction and adequate immobilization is the fundamental principle of fracture management

and pre-requisite for normal healing. Apart from providing an accurate guide for reduction of the fracture, the

teeth present in the line of fracture serve as a potential source of infection. These teeth may provide a route of

ingress for oral microbes by way of the periodontal ligament or through the root canal particularly in cases of

pulp infection or periapical pathology (1). The tooth in the fracture line may become necrosed due to traumatic

severance of the neurovascular supply to the pulp as a result of the injury (2). Also there is increased

susceptibility to infection in the damaged region whenever absolute immobility is not maintained across the

fracture line with wire osteosynthesis or intermaxillary fixation (3). This mechanical instability potentiates the

irritation potential of the tooth in the line of fracture (4). Keeping these factors in view, in the pre-antibiotic era,

it was recommended that all teeth present in the line of fracture be extracted (5).

The prognosis of teeth retained in the fracture line has significantly improved with the advent of

antimicrobial agents and use of semirigid and rigid fixation devices which allow precise anatomic reduction and

three dimensional stable fixation. However, teeth lying within the fracture line may be associated with certain

complications, which include marginal bone loss, periodontal pocket formation, tooth mobility and pulp

necrosis (6). Thus, there is a need to follow up these teeth so that they can be treated optimally.

Several studies have investigated the prognosis of teeth directly in the fracture line in mandibular

fractures (1, 2, 4). Kamboozia and Punnia-Moorthy (1) demonstrated the need to assess the fate of teeth in line

of, as well as adjacent to, mandibular fracture sites. However, such information pertaining to the morbidity of

teeth in the line of, and those adjacent to, maxillary fractures is lacking.

The aim of the present study was to clinically and radiographically assess the prognosis of teeth in the

line of, and adjacent to, both maxillary and mandibular fractures and to evaluate the incidence and type of

complications associated with such teeth.

MATERIALS AND METHODS

The study included 50 patients with facial fractures in the dentate region over a period of three years. Diagnosis

of the fracture was made on the basis of clinical and radiographic examinations. Informed written consent was

obtained from all patients. The Ethical Committee of Sri Guru Ram Das Institute of Dental Sciences and

Research, Amritsar, Punjab, India approved the design and conduct of the study. Patients with known systemic

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 or skeletal disorders, those managed with closed reduction, and those who failed to report for recall ups were

excluded from the study.

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A standardized surgical protocol was followed for all the patients. Antibiotic prophylaxis included

intravenous administration of 1.2 g Augmentin (Galaxo Smithkline pharmaceuticals) twice daily from the day of

hospitalization until the second post-operative day. Subsequently, one Augmentin 625 mg tablet was given

orally three times a day for one week. In cases of infected fractures, intravenous Metrogyl 100 ml (Flagyl,

Piramal Healthcare, India) thrice daily was additionally used as required. The fractures sites were exposed

through an intraoral or extraoral incision or through existing lacerations.

After exposure of the fracture site, the tooth present in the line of fracture was either extracted or

retained as indicated. The criteria for extraction of teeth included vertical fracture of the crown and root, root

fracture, infected root stumps, grossly carious with pulp involvement, or a tooth interfering with fracture

reduction. Fracture segments were reduced and fixed using 2 mm and 1.5 mm titanium miniplates with 6 mm

and 8 mm titanium screws for mandibular and maxillary fractures, respectively. After fracture fixation, maxillo-

mandibular fixation applied for the reduction of the fracture, was released in all patients. The patients were

advised regarding intake of a nutritious diet, Chlorhexidine mouthwash (0.12%) twice daily and to restrain from

tobacco use and smoking. Additionally, for patients who developed infrabony pockets during the study period,

periodontal procedures such as curettage and root planning were carried out.

The retained teeth were categorized into two groups (1):

• Group A: - Teeth directly in the line of the fracture

• Group B: - Teeth adjacent to the fracture

The clinical and radiographic parameters of all teeth of Group A and Group B were evaluated pre-operatively

and post-operatively at 7th day, 1-month and 3-months.

The clinical parameters included: (a) position of the tooth, (b) state of eruption of the tooth, (c) discolouration of

the tooth, (d) degree of tooth mobility, and (e) pocket depth. The degree of tooth mobility was assessed by

grasping the tooth between two instrument handles and moving it from side to side. Mobility was classified as

Grade 1 (first distinguishable sign of movement greater than normal), Grade 2 (tooth movement as much as

1mm in a buccolingual direction) and Grade 3 (tooth movement more than 1mm in a buccolingual direction or

could be depressed into its socket). Pocket depth was measured in millimeters in both the mesial and distal sulci

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 of tooth in the line of the fracture using a WHO colour-coded probe (API Germany) with a sensing force

between 10-20 gm. The sulci of the uninvolved side of the tooth in the line of fracture served as control.
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The radiographic parameters included: (a) position of the fracture line in relation to the apical foramen and

lateral periodontium, (b) degree of displacement of fracture fragments, (c) marginal bone loss, (d) root

resorption, (e) pulp canal obliteration, and (f) tooth malposition. Position of the fracture line in relation to the

apical foramen and lateral periodontium of the involved tooth was assessed pre-operatively from

orthopantomograph (OPG) and intra-oral periapical radiographs (IOPAR) and categorized into four types -

Type I to Type IV (Fig. 1). Degree of displacement of fracture fragments was assessed on the OPG and

classified as hairline, minimal (1-2mm) or gross (>2mm).

The other radiographic parameters were evaluated on the IOPAR taken with a bisecting-angle

technique. The marginal bone level was determined by measuring the distance from the cemento-enamel

junction to the alveolar crest, at both the mesial and distal sides of the tooth involved in the fracture. This

distance of the uninvolved side of the tooth served as control to calculate the marginal bone loss of the involved

side of the tooth. Root resorption was divided into three groups as Class I (No sign of resorption, normal

periodontal space), Class II (root resorption penetrating less than half the distance between the root surface and

the pulp) and Class III (root resorption penetrating more than half the distance between the root surface and the

pulp).

Pulp sensibility was assessed both pre-operatively and post-operatively at the 7th day, 1-month, 3-months and 6

months. Pulp sensibility was tested with an electric C-PULSE Pulp Tester (Foshan Coxo Medical instrument

Co. Ltd. China) and correlated radiographically with (a) position of the fracture line in relation to the apical

foramen and lateral periodontium, and (b) degree of displacement of the fracture fragments.

All statistical analyses were performed using SPSS software (7). Statistical analysis was done using Paired-t test

and Wilcoxon’s test to compare the significance of change from the baseline. The Pearson Chi-Square test was

used to evaluate the statistical differences amongst different fracture types. Probability (P) values of <0.05 and

<0.01 were considered significant and highly significant, respectively.

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 RESULTS

Of the 50 patients, there were 47 male (94%) and 3 female (6%) patients. The peak incidence of fracture was
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observed in the 21-30 years age group. A total of 69 fracture sites were encountered, with the most frequent

fracture site being in the mandibular parasymphysis region (n=28) followed by mandibular angle (n=24),

mandibular body region (n=12), maxillary mid-palatal split (n=4) and mandibular symphysis region (n=1).

A total of 124 teeth were present in 69 fracture sites, of which 72 teeth were assigned to Group A and

52 teeth to Group B. In Group A, 3 teeth avulsed during injury, 12 teeth were extracted and 15 teeth were

impacted. Therefore, the number of teeth evaluated was 42. In Group B, the number of teeth evaluated was 47

as 2 teeth avulsed during injury, one tooth was extracted and 2 teeth were impacted. Hence, a total of 89 teeth

were evaluated.

Tooth mobility of varying grades was present in 19 teeth (45.2%) of Group A and 16 teeth (34.0%) of

Group B, pre-operatively (Fig. 2). However, post-operatively, mobility decreased progressively and after 3-

months, it was only 19.0% in Group A and 10.6% in Group B. Paired ‘t’ test revealed a highly significant

difference in mobility at all post-operative intervals (p<0.01).

Pocket depth in Group A showed continuous significant reduction (p<0.01) from pre-operative to

post-operative 7 days and after one month, and at the control site from post-operative 7 day to one month

period (Fig. 3). In Group B, there was a significant reduction (p<0.05) in pocket depth from post-operative 7

days to one month, and at the control site from post-operative one month to 3 months.

Among the 69 fracture sites, Type I fracture (57.8%) was the most common type, followed by Type II

(27.5%), Type IV (11.6%) and Type III (2.9%) (Table 1). The measurement of marginal bone level in Group A

revealed a significant reduction (p<0.01) from pre-operative to post-operative 7 day period only but no

significant change at the control site at any of the follow-up periods (Fig. 4). In Group B, the mean marginal

bone levels of the control and test sites did not show significant difference at any time interval (Fig. 4).

Radiographic assessment of root resorption revealed that 83 teeth (93.2%) had Class I, 5 teeth (5.6%)

had Class II and only one tooth (1.1%) had Class III resorption. No cases of tooth malposition or pulp canal

obliteration were observed.

The pulp sensibility of teeth varied with different fracture types. In Group A, pre-operatively out of 42

teeth, 26 teeth (61.9%) did not respond to electric pulp testing and 16 teeth (38.0%) had clinically normal

pulps. Most of the non-responsive teeth were associated with Type I fractures (69.2%) followed by Type II

(23.1%) and Type IV (7.7%) fractures (Fig. 5). The Pearson Chi-Square test revealed significant differences

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 between Type I and Type II both pre-operatively (p<0.02) and at post-operative 7th day (p<0.01) but it was

insignificant at post-operative 1, 3 and 6-months. Conversely, there was a highly significant difference between
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Type I and Type IV both pre-operatively (p<0.01) and at post-operative 7th day (p<0.01). This difference

became significant only at 5% (x2 =4.46) both at 3-months and 6-months follow up (x2 =4.54). In Group B

(n=47), pre-operatively, 23 teeth (48.9%) did not respond to electric pulp testing and 24 teeth (51.1%) had

clinically normal pulps. The higher number of non-responsive teeth was observed in Type I fractures (56.5%)

followed by Type II fractures (26.1%) and the least common was with Type IV fractures (17.4%) (Fig. 5). The

Pearson Chi-Square test revealed no significant difference between Type I and Type II, both pre-operatively

and at all post-operative follow up periods.

The frequency of pulp sensibility was also related to the degree of displacement of the fractured

fragments (Fig. 6). Pearson Chi-Square analysis between grossly and minimally displaced fractures for pre-

operative and post-operative periods revealed insignificant difference for both groups. However, the difference

between minimal and hairline fractures was significant pre-operatively (p<0.01) in both groups but was less

significant (p<0.02) in Group A and nonsignificant (p>0.05) in Group B at post-operative 3-months period.

There was no significant difference regarding pulp responses of teeth between minimal and hairline fractures at

post-operative 6-months for both groups (p>0.05).

Only 40 of 89 teeth (44.9%) had clinically normal pulps pre-operatively and at the end of the 6-

months teeth (74.2%) subsequently responded to electric pulp tests (Fig. 7). The Wilcoxon’s test, applied to

evaluate the pulp responses of teeth in both groups, showed significant differences after one month and highly

significant improvement at 3- and 6-months.

Of the 69 fracture sites, complications occurred at 9 sites (13.0%) in 7 patients. Teeth were retained

at 52 fracture sites. Of the remaining 17 fracture sites, 13 teeth were extracted from 12 sites while 5 teeth were

avulsed at the time of trauma from 5 sites. The incidence of complications pertaining to whether the tooth was

extracted or retained was 11.76% (2/17) and 13.46% (7/52), respectively. There was no incidence of tooth

discoloration in any of the teeth during the period of study.

DISCUSSION

In the present study, most of the teeth in both Group A and B showed varying grades of pre-operative mobility

(Fig. 2), periodontal pocket depths (Fig. 3) and marginal bone levels (Fig. 4), which subsequently changed at

the post-operative periods. Disruption of the periodontium during trauma, different interdental splinting

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 procedures and soft tissue manipulation during surgical intervention may affect the periodontal health and

render teeth in the fracture line more prone to gingival detachment resulting in infrabony pockets (2, 6).
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Subsequent lodgment of food debris and calculus, and inadequate reduction of fracture segments, can lead to

alveolar bone loss resulting in tooth mobility. These results imply that avoidance of incisions directly over

already breached gingiva, adequate reduction of fracture segments, gentle handling and adequate repositioning

of the soft tissues, decreased post-operative use of wiring and meticulous oral hygiene minimize tooth mobility,

periodontal pocket formation and marginal bone loss. Additionally, teeth in the fracture line that extrude or

luxate during trauma, should be precisely placed back into their sockets and, if required, superficial enamel

recontouring should be done to avoid trauma from occlusion.

The assessment of pulp sensibility is a critical diagnostic procedure. The pulp status depends on normal

blood flow and transcapillary fluid exchange but in cases of trauma there is an elevation of tissue pressure that

can result in venous stasis and ischemia. As the edema resolves and the inflammatory process subsides, both

neural compression and/or ischemia are relieved, which suggests that a latency period of 4-6 weeks (8) is the

ideal time period to obtain a valid response from pulp sensibility testing in traumatized teeth. Apart from this,

the pulp response is also related to the (a) position of fracture line in relation to the apical foramina (9,10), (b)

degree of displacement of the fractured segments (1,11), and (c) open reduction and fixation methods (1).

In the present study, the most common fracture line was Type I followed by Type II, Type IV and the

least common was Type III (Table 1) which is consistent with other studies (1, 12). However, in case of

maxillary fractures, the incidence of occurrence for Type I and Type II was equal. Additionally, at both pre-

operative and post-operative follow up periods, the incidence of no response to pulp testing was maximum in

Type I fractures followed by Type II and least in Type IV fractures (Fig. 5). This can be attributed to impaired

or severed neurovascular supply to the pulp, and/or it may be due to bacteria present in the fracture line which

can gain access to the pulp leading to pulpitis and then necrosis (9, 10).

The frequency of no response to pulp test of teeth in Group A and Group B was highest in grossly

displaced fractures (Fig. 6). This could be due to the tooth/fracture line relationship being mainly Type I and

because small changes can cause tearing of nerve and blood vessels leading to permanent changes in the pulp

(11). The open reduction and fixation method followed in the current study involved elevation of a

mucoperiosteal flap for exposure and reduction of fracture fragments, which could presumably result in

impaired neurovascular supply causing pulp necrosis (1). Additionally, the screw placed near the apex of the

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 tooth root and mandibular canal might inadvertently damage the blood supply and neural innervation to the

tooth (1).
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In this study, the pulp sensibility of initially non-responsive teeth of Group A and B continued to

increase over time, and at the end of 6-months period, sixty-six teeth (74.2%) were responding to pulp tests (Fig.

7), which confirms that recovery from inferior alveolar sensory disturbance usually starts between 6 weeks to 2

months post-injury and can proceed for 2-3 years (13). Thus it is strongly implied that teeth involved in jaw

fractures should not be submitted to endodontic treatment or extracted during the initial stages and they should

not be considered as having pulp necrosis until clinical and radiographic signs of infection are evident (14).

In this study, the complications included (a) wound dehiscence associated with plate exposure at 4

fracture sites, (b) intra-oral draining sinus associated with two fracture sites, (c) extra-oral draining sinus

associated with one fracture site, (d) one submandibular space infection, and (e) a periapical radiolucency of

the tooth directly involved in the fracture line at one fracture site. All sites of wound dehiscence associated

with exposure of bone plates healed secondarily by regular application of Coe-Pack (GC Fuji Coe-Pak)

dressings. Similar incidences of wound dehiscence have also been reported by others (15, 16, 17). However,

Lamphier et al. (18) reported a high incidence of wound dehiscence in miniplate fixation group and observed

that plates fixed at the superior border near or under the incision line lead to marginal breakdown of the wound

owing to inadequate blood supply and tension on the wound margins. The present study clearly demonstrates

thattight closure without tension is critical and the implementation of rigorous antibiotic therapy and daily oral

irrigation prevented infection and failure of fixation and potential non-union. Accessory protocols such as

adequate nutrition, restraint from tobacco and smoking along with the patient’s oral hygiene should also be

considered.

In the two cases with intraoral draining sinuses adjacent to the tooth directly in the line of fracture, the

plates were removed from both sites along with extraction of the involved carious and Grade III mobile tooth

from one fracture site. These results support that in cases of post-operative infection associated with

carious/periodontally compromised teeth in the fracture line, the offending tooth should be removed along with

the rigid fixation (19). However, teeth that are mandatory for fracture reduction and stabilization can be

retained with guarded prognosis (for example pulpectomy). An extra-oral draining sinus occurred in one case

where the tooth in the fracture line was removed and the fracture was treated via an extra-oral incision. In such

cases, the fracture site and the hardware are exposed to the oral cavity flora resulting in infection (20) and

therefore rigorous antibiotic protocol is recommended.

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 Sub-mandibular space infection developed in one patient, in whom the tooth in the line of fracture had

been avulsed at the time of injury and who also reported 4 days after trauma. The development of such
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infection could be due to the pumping action of the unsecured fractured ends and entry of microbes into the

fracture site during the long time lapse between injury and surgical intervention (21). The formation of a

periapical radiolucency around the tooth directly in the fracture line might have resulted from inadequate

approximation of the fractured segments leading to trauma from occlusion and causing vertical bone loss,

widening of the lamina dura, increased mobility and formation of the periapical radiolucency (22).

The results of the present study confirm that there is no difference in post-operative infections,

whether the tooth in the line of fracture was extracted or retained.

CONCLUSIONS

The study reveals that teeth involved in jaw fractures undergo various long term sequelae ranging from pulp

necrosis, marginal bone loss, periodontal pocket formation, root resorption to periapical radiolucencies and that

their prognosis affects the overall management of the fractures. There was an increasing proportion of positive

response to pulp test of initially non-responsive teeth over time. The incidence of postoperative infection was

not enhanced by retaining the teeth directly in the line of and adjacent to the fractures.

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LEGENDS TO TABLES

Table 1. Distribution of fractures into different fracture types based on the relationship of the fracture line to the
apical foramina and lateral periodontium of the involved teeth.

LEGENDS TO FIGURES

Figure 1. Line diagrams and corresponding radiographs of four different types of relationships of the fracture
line to the apical foramen and the periodontium. Type I - The fracture line involves the lateral
periodontium and the apical foramina, Type II - The fracture line involves only the lateral
periodontium without involving the apical foramina, Type III -The fracture line involves only the
apical foramina, and Type IV - The fracture line runs in the interdental bone on one side of the tooth,
fractures the root of the tooth, continues on the other side of the tooth and continues towards the
basal bone.

Figure 2. Change in the mobility of teeth (% of teeth in Group A and Group B) with time period. Group A -
Teeth directly in the line of fracture site, and Group B - Teeth adjacent to the fracture site.

Figure 3. Mean pocket depth of Control and Test Sites of teeth in Group A and Group B.
Control Site- Sulci of uninvolved side of tooth in fracture site, Test Site- Sulci of involved side of tooth
in fracture site

Figure 4. Mean marginal bone level of Control and Test Sites of teeth in Group A and Group B.
Control Site- Uninvolved side of tooth in fracture site, Test Site- Involved side of tooth in fracture site

Figure 5. Evaluation of the pulp status of teeth with the type of fracture in relation to the involved tooth in
Group A and Group B.

Figure 6. Evaluation of the pulp status of teeth with the degree of fracture displacement in Group A and Group
B.

Figure 7. Evaluation of pulp responses of teeth over time.

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 Table 1. Distribution of fractures into different fracture types based on the relationship of the fracture line to the
apical foramina and lateral periodontium of the involved teeth.
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Fracture site Number of Number of fracture types .
fracture sites Type I Type II Type III Type IV

Mandibular symphysis 1 (61.4%)# 0 1 0 0

Mandibular parasymphysis 28 (40.6%) 15 9 1 3

Mandibular body 12 (17.4%) 7 3 0 2

Mandibular angle 24 (34.8%) 16 4 1 3

Maxillary palatal split 4(5.8%) 2 2 0 0

Total 69 40 (57.8%) 19 (27.5%) 2 (2.9%) 8 (11.6%)

#
Values in parentheses are % of total 69 fracture sites

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