teeth in the line of mandibular fractures

Teeth in the line of mandibular fractures

Dr. Ahmed M. Adawy Professor Emeritus, Dep. Oral & Maxillofacial Surg.

Former Dean, Faculty of Dental MedicineAl-Azhar University

Approximately 60% of fractures of the mandible occur in the teeth bearing area (1). Obviously, all mandibular fractures in the teeth bearing area are compound fractures, in contact with the oral cavity through periodontal ligament and gingival sulcus. Incisors are most frequently involved teeth in the fracture line accounting for 51%. Bicuspids 13%, first and second molars 13% and third molars are involved in 25% of the teeth in fracture lines


Incisors and third molars are the most commonly

involved teeth in the fracture lines

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 pre-existing pulpal, periodontal or periapical conditions of pathology. All these factors either alone or combined can predispose the fracture to infection and may complicate healing (2)


The fate of the tooth in the fracture line and its effect on bone healing need special consideration. Whether to remove or preserve the tooth in the line of fracture is a complex process and still there is some debate about the appropriate management. Criteria for the decision should be: the mobility of the teeth in the fracture line, associated fracture of the tooth root, periapical lesions and the role of the teeth in mandibular fracture line in the stabilization and fixation of bone fragments


The management of teeth in the line of mandibular fractures has long been a matter of controversy. Some authors found a smaller rate of infection/complicationwhen a tooth in the fracture line was retained, compared when a tooth was prophylactically removed (3). In contrast, another study observed a smaller rate of infection/complication when a tooth in the fracture line was removed, compared when a tooth was retained (4)


With literature providing no definite guidelines, the benefits and risks of removing a tooth in the fracture line should be weighted against the benefits and risks of leaving it. There are some situations in which it is suggested that teeth in the line of fracture should be maintained. Intact teeth in the fracture line should be left in situ if they show no evidence of severe loosening or inflammatory change. Moreover, teeth that appear nonvital at the time of injury should be treated conservatively, keeping in mind their potential for recovery and their importance in simplifying fracture treatment and subsequent prosthodontic rehabilitation (3)


Additionally, consistent extraction of teeth in the line of mandibular fracture has no scientific basis and has distinct disadvantages. Extraction of tooth entails further trauma to bone tissue and also presents technical difficulties when the fragments are highly mobile. Further, retrospective review evaluating complications related to teeth in the lines of 207 fractures, found more complications on extracting the tooth (37.3 % in 75 fractures) than after leaving it in place (29.5 % in 132 fractures). Statistical comparison of fractures, in which teeth were removed and retained, suggested that removal of teeth in fracture lines does not minimize morbidity (5)


On the other side, there are some situations in which teeth in the line of fracture should be removed (3):1. Teeth that prevent reduction of fractures 2. Teeth with fractured roots 3. When there is extensive periodontal damage, with broken alveolar walls, resulting in the formation of a deep pocket (making optimal healing doubtful)4. A partially impacted wisdom tooth with pericoronitis5. A tooth with extensive periapical lesion


In conclusion, certain guidelines have been suggested (6):1. Intact teeth in the fracture line should be left in situ if they shown no evidence of severe loosening or inflammatory change 2. Impacted molars, especially complete bony impactions, should be left in place to provide a larger repositioning surface. Exceptions are partially erupted molars with pericoronitis or those associated with follicular cyst3. Teeth that prevent reduction of fractures should be removed4. Teeth with crown fractures may be retained provided that emergency endodontic therapy is carried out. All teeth with fractured roots must be removed


5. Teeth with exposed root apices, or where the fracture line follows the root surface from the apical region to the gingival margin, should be carefully monitored6. Teeth that appear nonvital at the time of injury should be retained7. The timing of the fracture treatment should be a factor in the decision to extract the tooth. Complication will be an exception when fracture reduction and adequate fixation is instituted as soon as possible8. Primary extraction is recommended when extensive damage to the periodontium and supporting alveolus has occurred


1. Chrcanovic BR. Factors influencing the incidence of maxillofacialfractures. Oral Maxillofac Surg. 16: 3, 2012. 2. Shankar DP, Manodh P, Devadoss P, et al. Mandibular fracture scoring system: for prediction of complications. Oral Maxillofac Surg. 16: 355, 2012.3. Gerbino G, Tarello F, Fasolis M, et al. Rigid fixation with teeth in the line of mandibular fractures. Int J Oral Maxillofac Surg. 26: 182, 1997.4. Ellis E 3rd. Outcomes of patients with teeth in the line of mandibular angle fractures treated with stable internal fixation. J Oral Maxillofac Surg. 60: 863, 2002.5. Neal DC, Wagner WF, Alpert B. Morbidity associated with teeth in the line of mandibular fractures. J Oral Surg. 36: 859, 1978.6. Shetty V, Freymiller E. Teeth in the line of fracture: A review. J Oral Maxillofac Surg. 47: 1303, 1989.

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teeth in the line of mandibular fractures

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