Teeth in the Line of Fracture: To Retain or Remove?

Abstract

The purpose of this study was to analyze mandibular fracture site, relationship of the fracture line to the periodontium, vitality of teeth, displacement of the fracture segments and their implications, and determine whether to retain or remove the teeth in the fracture line. Fifty patients with 62 fractures were involved in this study. An electric pulp tester was used to measure the pulpal response. The degree of fracture displacement and the relationship of the fracture line to the periodontium were evaluated using panoramic radiographs. Fractures of the parasymphysis region constituted a majority of 60.87% in the gross displacement category. Four of 50 patients showed no response presurgically and minimal response postoperatively on pulp vitality testing. Patients with teeth in the fracture line showing no response on pulp vitality testing should be advised extraction to avoid further complications.

Keywords

Mandibular fractures complications

Many factors precipitate fractures occurring in the mandible although it is the heaviest and the strongest facial bone.1 The pattern and displacement of fracture depend on the amount of force, soft tissue involvement, bone density, direction of muscle pull, and vulnerable areas that represent weak anatomic structures.2 Such fractures present with pain, edema, hematoma, derangement of occlusion, displacement and mobility of the fracture segments, facial asymmetry, and disturbance in phonation.3

Injury to teeth in the fracture line may compound the fracture even more if the injury involves the periodontium.4 5 6 Injury to such teeth can result in their avulsion, subluxation, root fracture, nonvitality, and varied pathology, all of which may interfere with or complicate healing.7

The influence of teeth in a fracture line on infection is not easy to determine due to interaction with other factors.8 Root fractures, periodontal pathology near the fracture line, functionless teeth, and vertical tooth fracture are all recommended for extraction.9 The purpose of this study was to evaluate teeth in the line of fracture, clinically and radiographically, and their associated complications so as to indicate if they should be retained or removed.

Materials and Methods

The study was performed in the Department of Oral and Maxillofacial Surgery, Vinayaka Mission's Sankarachariyar Dental College, and included a group of patients with mandibular fracture in the dentate region. The sites of fractures in the mandible included symphysis, parasymphysis, body, and angle (Figs. 1 and 2) and excluded condylar fractures, all of which were treated with open reduction and internal fixation under general anesthesia.

Figure 1

Mandibular fracture—lateral view.

Figure 2

Mandibular fracture—occlusal view.

On these criteria, 50 patients from 2006 to 2008 were selected for this study. The postoperative follow-up period was 14 to 18 months with a mean of 16 months. The data collected from the patients included preoperative and postoperative radiographs, which included panoramic radiographs (Figs. 3 and 4); age at the time of injury; sex; cause of trauma; and site and type of fracture. The age of the patients ranged from 18 to 48 years with a mean of 29 years. In total, 62 fractures occurred in 50 patients. Treatment modalities included open reduction and internal fixation with conventional stainless steel8 10 11 miniplates (2.5 mm, four holes/six holes), stainless steel three-dimensional plates (2 mm, four holes/six holes), and titanium three-dimensional plates (2 mm, four holes) with 6- and 8-mm stainless steel and titanium screws, respectively. Maxillomandibular fixation was used only intraoperatively to help in achieving occlusion.13 14 15

Figure 3

Orthopantomogram revealing a parasymphysis fracture of the left side.

Figure 4

Orthopantomogram revealing an angle fracture of the right side.

Patients were administered intravenous ampicillin (Ampoxin, Unichem Laboratories, India) 500 mg, metronidazole (Flagyl, Piramal Healthcare, India) 400 mg, and intramuscular diclofenac sodium (Voveran, Novartis India Ltd, India) 50 mg postoperatively, which varied between 5 and 7 days. They were also prescribed an antiseptic mouthwash (Clohex 0.2%, Dr. Reddy's Laboratories, India) chlorhexidine for a week's time.

All patients were divided into different groups based on four categories:

Anatomic location of the fracture

Degree of displacement of fracture7 a.

Hairline (no displacement)

Minimal (1 to 2 mm)

Gross (>2 mm)

Position of fracture in relation to the apical foramen and the lateral periodontium of the involved tooth into four groups (Fig. 5) a.

Involving lateral and apical fibers completely

Involving three-quarters of the lateral fibers

Involving apical fibers completely

Involving apical one-third of lateral fibers bilaterally

Figure 5

Relationship of fracture line to the periodontium categorized into four groups.

Pulp vitality testing with the help of C-PULSE pulp tester (Foshan Coxo Medical Instrument Co. Ltd, China) (Fig. 6) was done preoperatively and postoperatively at regular follow-up intervals of 1, 2, 4, and 6 months consecutively. It was done in the mandibular teeth, and teeth not in direct line of fracture were taken as controls. Maxillary teeth were taken as controls in patients who had bilateral mandibular fractures. The teeth taken as controls showed good response, and there was no change in vitality during the follow-up.

Figure 6

Electric pulp tester C-PULSE used for pulp vitality testing of the teeth in the line of fracture.

Results

Mandibular fractures occurred more frequently in males (96%) than females (4%). Anatomic location of fractures included 10% in the symphysis region, 52% in the parasymphysis, 11% in the body, and 27% in the angle region (Fig. 7). There were 13 cases of type 2 fractures in the parasymphysis region based on the relationship of the fracture line to the periodontium, which constituted 68.42% (Fig. 8). Type 1 was the most severe type and included 8.33% in the symphysis region, 41.67% in the parasymphysis, 12.5% in the body, and 37.5% in the angle region. Parasymphysis fractures constituted the majority with 60.87% in the gross category, 48.48% in the minimal category, and 42.86% in the hairline category (Fig. 9).

Figure 7

Percentage of fractures based on the anatomic site of occurrence.

Figure 8

Relation between the fractures occurring in different sites to the periodontium.

Figure 9

Degree of displacement of fractures subdivided into three groups.

On testing the pulp vitality, 4 of 50 patients (Fig. 10) presented with no response in the teeth in the fracture line presurgically (Table 1). Three patients had their teeth in the fracture line extracted between 4 and 6 weeks after surgery as the fracture sites were infected. One patient reported with infection in relation to the fracture line after 1 year. The teeth in the fracture line that had no response included three patients with mandibular third molars and one patient with mandibular lateral incisor (Fig. 11).

Table 1

Patient Demographics

No.	Age/ Sex	Site of Fracture	Fracture in Relation to Periodontium	Degree of Displacement	Pulp Vitality				Method of Fixation	Complications
No.	Age/ Sex	Site of Fracture	Fracture in Relation to Periodontium	Degree of Displacement	Preop	Postop (4 mo)	Postop (6 mo)	Lingual Splay	Method of Fixation	Postop Paresthesia	Infection
1	24/M	Left body	Type 2	Gross	M	G	G	Titanium 3-D plates
2	32/M	Left angle	Type 3	Minimal	M	G	G	Titanium 3-D plates
3	35/M	Symphysis, right angle	Type 3	Hairline	M	G	G	SS miniplates
4	21/M	Left angle, right parasymphysis	Type 2	Minimal	M	G	G	SS miniplates
5	26/M	Symphysis, right angle	Type 1	Gross	M	G	G	Titanium 3-D plates
6	26/M	Left angle, right parasymphysis	Type 1	Gross	N, M	−, M	G	SS miniplates			*
7	40/M	Left body	Type 2	Hairline	M	G	G	Titanium 3-D plates
8	45/M	Left parasymphysis	Type 3	Hairline	M	G	G	Titanium 3-D plates
9	30/F	Symphysis	Type 3	Hairline	M	G	G	Titanium 3-D plates
10	31/M	Right parasymphysis	Type 3	Gross	M	G	G	Titanium 3-D plates
11	30/M	Symphysis	Type 3	Minimal	M	G	G	Titanium 3-D plates
12	25/M	Right parasymphysis	Type 2	Minimal	M	G	G	SS miniplates
13	25/M	Left angle	Type 2	Gross	M	G	G	Titanium 3-D plates
14	28/M	Left parasymphysis	Type 4	Minimal	M	G	G	SS miniplates
15	35/M	Right parasymphysis	Type 4	Minimal	M	G	G	SS miniplates	*
16	25/M	Right parasymphysis	Type 2	Gross	M	G	G	Titanium 3-D plates
17	32/M	Symphysis	Type 3	Minimal	M	G	G	Titanium 3-D plates
18	25/M	Left angle, right parasymphysis	Type 1	Gross	M	G	G	SS 3-D plates
19	25/M	Right parasymphysis	Type 2	Minimal	M	G	G	SS 3-D plates
20	26/M	Right angle	Type 2	Minimal	M	G	G	SS 3-D plates
21	35/F	Right parasymphysis	Type 4	Hairline	M	G	G	Titanium 3-D plates
22	27/M	Left parasymphysis	Type 2	Hairline	M	G	G	SS miniplates
23	30/M	Left parasymphysis	Type 2	Minimal	M	G	G	Titanium 3-D plates
24	20/M	Left parasymphysis	Type 2	Gross	M	G	G	SS 3-D plates
25	33/M	Left parasymphysis	Type 2	Gross	N	M	N	SS 3-D plates			*
26	27/M	Left parasymphysis	Type 2	Minimal	M	G	G	SS 3-D plates
27	27/M	Right angle, left body	Type 1	Minimal	M	G	G	SS miniplates		*
28	32/M	Bilateral parasymphysis	Type 4	Gross	M	G	G	SS miniplates
29	18/M	Left body	Type 1	Minimal	M	G	G	SS 3-D plates		*
30	30/M	Left parasymphysis	Type 2	Minimal	M	G	G	SS 3-D plates
31	47/M	Left body, right parasymphysis	Type 1	Gross	N, M	−, G	G	SS 3-D plates			*
32	44/M	Right angle	Type 3	Minimal	M	G	G	SS 3-D plates
33	20/M	Right parasymphysis	Type 2	Minimal	M	G	G	SS 3-D plates
34	33/M	Left parasymphysis	Type 2	Gross	M	G	G	SS 3-D plates	*
35	35/M	Left parasymphysis	Type 1	Gross	M	G	G	SS 3-D plates
36	24/M	Left parasymphysis	Type 4	Gross	M	G	G	SS 3-D plates	*
37	55/M	Left angle	Type 1	Gross	N	−	−	SS miniplates			*
38	18/M	Left body	Type 2	Minimal	M	G	G	SS miniplates	*	*
39	29/M	Right angle, left parasymphysis	Type 1	Minimal	M	G	G	SS miniplates	*
40	19/M	Left angle, right parasymphysis	Type 1	Minimal	M	G	G	SS miniplates
41	25/M	Bilateral parasymphysis	Type 4	Minimal	M	G	G	Titanium 3-D plates
42	33/M	Right angle	Type 1	Minimal	M	G	G	Titanium 3-D plates
43	45/M	Left parasymphysis	Type 1	Gross	M	G	G	Titanium 3-D plates
44	32/M	Symphysis	Type 1	Minimal	M	G	G	Titanium 3-D plates
45	21/M	Left body, right angle	Type 4	Gross	M	G	G	Titanium 3-D plates
46	23/M	Bilateral parasymphysis	Type 2	Minimal	M	G	G	Titanium 3-D plates
47	15/M	Right angle, left parasymphysis	Type 1	Gross	M	G	G	Titanium 3-D plates		*
48	48/M	Left angle, left parasymphysis	Type 1	Minimal	M	G	G	Titanium 3-D plates
49	34/M	Bilateral parasymphysis	Type 4	Minimal	M	G	G	SS miniplates
50	32/M	Left parasymphysis	Type 1	Minimal	M	G	G	Titanium 3-D plates

N, no response; M, minimal response; G, good response; preop, preoperative; postop, postoperative; SS, stainless steel.

Figure 10

Pulp vitality responses in presurgical and immediate postoperative (post OP) stages.

Figure 11

Relationship of the degree of displacement of fracture to pulp vitality response in immediate postoperative (post OP) stage.

The association between responses with reference to presurgical and immediate postoperative response was also analyzed using chi-square test at 5% level of significance, and the results are given with the following bivariate in Table 2 (p < 0.01; hence the result is highly significant—i.e., significant at 1% and 5% level). From the analysis, it is concluded that there is close relationship between the presurgical response and immediate postoperative response. Hence it is concluded that the majority of patients (92%) who showed minimal response presurgically (Table 3) showed good response immediately after surgery (Table 4). Those who had no response presurgically showed only minimal response immediately after surgery.

Table 2

Pulp Vitality Responses in Presurgical and Immediate Postoperative Stages

Presurgery	Immediate Postoperative Response				Total		Chi-Square Value	p
	Minimal		Good
	n	%	n	%	n	%	50	0.00^*
No response (0—3)	4	8			4	8
Minimal response (4—6)			46	92	46	92

Significant at 1% and 5%.

Table 3

Relationship of the Degree of Displacement of Fracture to Presurgical Pulp Vitality

Degree of Displacement	Presurgical Pulp vitality				Total
	No Response (0—3)		Minimal Response (4—6)
	n	%	n	%	n	%	Chi-Square Value	p
Hairline (no displacement)			6	12	6	12	7.729	0.021^*
Minimal (1—2 mm)			26	52	26	52
Gross (> 2 mm)	4	8	14	28	18	36
Total	4	8	46	92	50	100

Significant at 5%.

Table 4

Relationship of the Degree of Displacement of Fracture to Pulp Vitality Response in Immediate Postoperative Stage

Degree of Displacement	Immediately Postoperative Pulp Vitality				Total
	Minimal Response (4—6)		Good Response (> 6)
	n	%	n	%	n	%	Chi-Square Value	p
Hair line (no displacement)			6	12	6	12	7.729	0.021^*
Minimal (1—2 mm)			26	52	26	52
Gross (>2 mm)	4	8	14	28	18	36
Total	4	8	46	92	50	100

Significant at 5%.

Discussion

Correct repositioning of fractured fragments is made quicker and easier if the tooth in the line of fracture is conservatively managed. The teeth provide occlusal reference and posterior stop. They have a stabilizing effect and do not impede bone healing. If extracted, they increase the risk of fracture contamination and may sometimes be difficult to suture.16

Pulp changes like pulp fibrosis and acute pulpitis may be noted in teeth that respond to electronic pulp tester. The loss of vitality may also be reversible as vascular and neural recoveries are possible. The follow-up of ∼1 year would be sufficient for the return of temporary loss of vitality as suggested by Kahnberg and Ridell.7 In our study, all patients were followed to 18 months. The vitality of teeth improved in all patients except four for whom the teeth in the fracture line were extracted as they reported with infections.

The disposition and the presence of teeth do not directly influence complications but are influenced by the anatomic location of the fracture.17 In our study, extractions of third molars were performed as they got infected and one patient had his plate removed. One likely reason for nonvitality nearer to fracture line can be the presence of screws used for fixation of fractures. The number of screws can be limited if and when the fractures are fixed using three-dimensional plates.12

The fracture displacement showed some significance in determining pulp vitality. Fractures with gross displacement had pulp vitality with no response in the presurgical stage. In comparison, hairline fractures did not influence pulp vitality.

Extractions of teeth in the line of fractures in a few cases tend to displace the fracture segments. However, after the analysis, it was proved that a tooth in the fracture line showing no response in the presurgical stage resulted in infection of the fracture site. Hence, in such cases, it would be appropriate to proceed with extraction of such teeth followed by the management of fractures.

Conclusion

In conclusion, according to our study, a tooth that shows no response on pulp vitality testing should be advised for extraction to avoid further complications in patients presenting with mandibular fracture.

References

Patrocínio

L G.

Patrocínio

J A.

Borba

B HC

Mandibular fracture: analysis of 293 patients treated in the Hospital of Clinics, Federal University of Uberlândia

Braz J Otorhinolaryngol 2005 71 560–565

Metin

Sener

Tek

Impacted teeth and mandibular fracture

Eur J Dent 2007 1 18–20

Thapliyal

G K.

Sinha

Menon

P S.

Chakranarayan

Management of mandibular fractures

MJAFI 2008 64 218–220

Ellis

III Muniz

Anand

Treatment considerations for comminuted mandibular fractures

J Oral Maxillofac Surg 2003 61 861–870

Abreu

M ER

Viegas

V N.

Ibrahim

Treatment of comminuted mandibular fractures: a critical review

Med Oral Patol Oral Cir Bucal 2009 14 E247–E251

Smith

B R.

Johnson

J V.

Rigid fixation of comminuted mandibular fractures

J Oral Maxillofac Surg 1993 51 1320–1326

Kamboozia

A H.

Punnia-Moorthy

The fate of teeth in mandibular fracture lines. A clinical and radiographic follow-up study

Int J Oral Maxillofac Surg 1993 22 97–101

Cabrini Gabrielli

M A.

Real Gabrielli

M F.

Marcantonio

Hochuli-Vieira

Fixation of mandibular fractures with 2.0-mm miniplates: review of 191 cases

J Oral Maxillofac Surg 2003 61 430–436

Ajmal

Khan

M A.

Jadoon

Malik

S A.

Management protocol of mandibular fractures at Pakistan Institute of Medical Sciences, Islamabad, Pakistan

J Ayub Med Coll Abbottabad 2007 19 51–55

10.

Renton

T F.

Wiesenfeld

Mandibular fracture osteosynthesis: a comparison of three techniques

Br J Oral Maxillofac Surg 1996 34 166–173

11.

Tams

van Loon

J P.

Rozema

F R.

Otten

Bos

R R.

A three-dimensional study of loads across the fracture for different fracture sites of the mandible

Br J Oral Maxillofac Surg 1996 34 400–405

12.

Jimson

Sankar

Prasad

Comparative study of stainless steel miniplate, three-dimensional plate and titanium three-dimensional plate for fixation of mandibular fractures

Int J Oral Maxillofac Surg 2009 38 502–503

13.

Shinohara

E H.

Mitsuda

S T.

Miyagusko

J M.

Horikawa

F K.

Mandibular fracture reduction without intraoperative intermaxillary fixation: a technique using two modified reduction forceps

J Contemp Dent Pract 2006 7 150–156

14.

Fordyce

A M.

Lalani

Songra

A K.

Hildreth

A J.

Carton

A T.

Hawkesford

J E.

Intermaxillary fixation is not usually necessary to reduce mandibular fractures

Br J Oral Maxillofac Surg 1999 37 52–57

15.

Zachariades

Mezitis

Rallis

An audit of mandibular fractures treated by intermaxillary fixation, intraosseous wiring and compression plating

Br J Oral Maxillofac Surg 1996 34 293–297

16.

Gerbino

Tarello

Fasolis

De Gioanni

P P.

Rigid fixation with teeth in the line of mandibular fractures

Int J Oral Maxillofac Surg 1997 26 182–186

17.

Fox

A J.

Kellman

R M.

Mandibular angle fractures: two-miniplate fixation and complications

Arch Facial Plast Surg 2003 5 464–469