Tmp2a26 TMP

Oral Maxillofac Surg (2014) 18:724
DOI 10.1007/s10006-012-0369-y
REVIEW ARTICLE
Teeth in the line of mandibular fractures

Bruno Ramos Chrcanovic
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.
Materials and methods

Results
Objective
This study aims to review the literature regarding the evolution of current thoughts on the management of teeth in the
line of MFs.
Data source and search strategies
An electronic search without date or language restrictions
was undertaken in June 2012, in PubMed website (US
National Library of Medicine, National Institutes of Health).
The following terms were used in the search strategy:
The study selection process is summarized in Fig. 1. The

search strategy outlined above identified 731 studies. The
initial screening of titles and abstracts resulted in 123 fulltext papers; 91 were cited in more than one research of
terms. Thus, 32 studies were identified without repetition.
Five of these 32 papers were excluded for being review
articles or letters to the editor. Additional hand searching
of the reference lists of selected studies yielded 12 additional papers. The literature review is based on these 39 articles,
and the important points of these studies are presented
{Subject AND Adjective}

{Subject: (tooth OR teeth [text words])
AND
Adjective: (line fracture OR line mandibular fracture
[text words])}
All reference lists of the selected and review studies were
hand searched for additional papers that might meet the
eligibility criteria for inclusion in this study. The titles and
abstracts (when available) from these results were read for
identifying studies, meeting the eligibility criteria. For studies appearing to meet the inclusion criteria or for which
there were insufficient data in the title and abstract to make
a clear decision, the full report was obtained and assessed.
Inclusion criteria
Eligibility criteria included studies reporting clinical series of
MFs in which the management of teeth in the fracture line was
analyzed. The studies could have been conducted on patients
having tooth buds, fully erupted permanent teeth, or impacted
lower third molars (LTMs), also having displaced or undisplaced, comminuted or non-comminuted, and unilateral or
Fig. 1 Study screening process
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
48 h of the accident, treatment was unsuccessful in 16 %

compared with 25 % of those where the fracture was treated
later. Of the 23 teeth which were partly of completely retained
or unerupted at the time of the injury, only one belonged to the
unsuccessful group. Treatment was unsuccessful in 18.4 % of
those cases where fracture dislocation was mild compared
with 23.5 % of those where the dislocation was substantial.
The authors stated that many of the teeth classified as
unsuccessful, which had periapical lesions and minor
marginal bone pockets, may become fully functional
by adequate treatment, bringing the rate of successful
treatment of the teeth up to 8090 %.
Schneider and Stern [12] found only a 5 % complication
rate (consisting of infection, delayed union, and odontalgia)
in a series of 199 fractures in which the teeth were retained.
They concluded that with appropriate case selection, stable
fracture fixation, and antibiotic therapy, teeth could be
retained to aid in fixation and ultimately in function, i.e.,
teeth that are loose and have exposed roots, or periapical
infection can be retained, if they serve a purpose.
Ewers et al. [29] evaluated the periodontal conditions of
the teeth next to the line of MFs, all treated by ORIF; 94 %
of the teeth adjacent to the fracture line were not extracted.
Only 14 % of the teeth were not worth keeping, and
45 % of the teeth required further periodontal treatment.
The authors stated that retention of the teeth in the
fracture line does not provide an increased risk of complications when ORIF is used.
Neal et al. [30] evaluated complications related to teeth in
the lines of MFs in a retrospective review of 207 fractures;
32.3 % resulted in some form of morbidity. They 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.
Rink and Stoehr [31] observed that fully erupted teeth
produced occasionally an infection of the fracture line;
partially retained teeth in the fracture line frequently led to
infections, and retained teeth or tooth germs caused no case
of infection. Thus, they recommended that the partially
erupted teeth be extracted in conjunction with the treatment
of the fracture. As the retained teeth or tooth germs did not
result in any case of infection, the authors stated that these
should not be removed.
Kahnberg and Ridell [13] correlated the frequency and
character of the complications among teeth in the fracture
line to different fracture types in an attempt to define the
correct approach to involved teeth. Treatment consisted of
MMF or wiring+MMF. In 23 % of the teeth in the nonvital
group, there was a change in sensibility from initially negative sensibility at the time of fracture to positive reaction at
the time of reexamination (minimum of 12 months).
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]
Ridell and strand [28]
Schneider and Stern [12]
Ewers et al. [29]

Neal et al. [30]
Rink and Stoehr [31]

Kahnberg and Ridell [13]
Wagner et al. [32]
Chuong et al. [14]
Amaratunga [15]
Chambers and Scully [25]

Oikarinen et al. [16]
Rubin et al. [34]
Iizuka et al. [35]

Anderson and Alpert [36]
Berg and Pape [17]

Kamboozia and
Punnia-Moorthy [7]
Oikarinen and Raustia [37]
Haug and Schwimmer [38]
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)
2156 (36.3) (retained)

1945 (32.6) (removed)
1853 (28)
1341 (22.3)
NM (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 age range

(average, years)
Patients
(n)
Table 1 Clinical series of MFs in which the management of teeth in the fracture line was analyzed
NM (NM)
9106 months (41)
NM (15 months)
14 years (NM)
449 months (NM)

NM (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)
5 months11 years (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
None (3 patients), 6 weeks or

less of MMF (51), longer
period of MMF (30)
MMF (167 MFs), ORIF
(32; wire, plates, or
Steinmann pins)
ORIF (plates)
MMF (most cases),
ORIF (some cases)
MMF
58 weeks MMF
(some cases), MMF + wire
osteosynthesis (most cases)
Wire osteosynthesis
(96 MFs), vitallium plates (2),
titanium mesh (2)
MMF (200 MFs), ORIF (161)
None (11)
4 weeks of MMF (182 MFs),
wire osteosynthesis (44 MFs)
MMF (92 %), none (8 %)
MMF
MMF (65 MFs), wire
osteosynthesis (40 MFs)
ORIF (plates or lag screws)
ORIF (plates, 70 MFs;
lag screws, 5 MFs)
ORIF (plates)
46 weeks MMF (50 %),
ORIF (50 %; miniplates)
MMF, average 35 days
(range, 2247)
None (3 patients), MMF (5),
external pin fixation (4)
MMF + ORIF (5; plates/4;
wire), ORIF (6; plates)
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
Only those cases have been

used that were known with
certainty to have had rigid
fixation. MMF was also
mentioned in the text
MMF
MMF
6 weeks MMF (range, 39)
Teeth in the
line of MFs
Treatment
of the MFs
10
RA
RA
1994
1994
1997
2000
2002
2004
2005
2006
2007
2009
2010
2010
2011
2011
Marker et al. [18]
Thaller and Mabourakh [40]
Gerbino et al. [41]

Atanasov and Vuvakis [42]
Ellis [19]
Baykul et al. [20]
Vladimirov and Petrov [21]
Suei et al. [43]
Malanchuk and Kopchak

[22]
Ramakrishnan et al. [45]
Samson et al. [46]
Yamamoto et al. [23]

Mangone et al. [47]
Rai and Pradhan [48]
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
010 years (NM)

NM (NM)
2 years (2 years)
1418 months (16)
112 months (2.5)
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)
6 months1 year (NM)

NM (NM)
6208 weeks (17.5)
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)
The authors informed

the number of patients
in age groups
NM (NM)
1463 (NM)
1256 (28)
The authors informed
the number of patients
in age groups
577 (30)
1041 (24.6)
310 (6)
Patients age range

(average, years)
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
Koenig et al. [39]
Study
design
Published
Authors
Table 1 (continued)
NM
10 teeth required
endo
NM
Teeth that
required treatment
(endo/periodontic)
MMF (91 %), ORIF

(9 %; wire or plates)
ORIF (13 patient; wire or
miniplate), closed reduction
MMF (81.2 %), ORIF
(18.8 %; miniplates)
ORIF (miniplates and
3-D grid plates)
ORIF (miniplates and
3-D grid plates)
Splint + circumferential wiring
ORIF (miniplates)
ORIF (miniplates)
+ 710 days MMF
MMF (15 %), MMF +

transosseous wire (32 %),
ORIF (53 %; miniplates)
ORIF (miniplates)
MMF, wire osteosynthesis
ORIF (6 different techniques)
MMF (114 patients), ORIF
(3 patients; miniplates)
ORIF (33 %), MMF or

lingual splint (67 %)
MMF (average of 42 days)
Treatment
of the MFs
12
NM
NM
Teeth not worth

keeping (additional
teeth removed)
after fracture
treatment
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

11
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]
Ridell and strand [28]
Schneider and Stern [12]
Ewers et al. [29]
Neal et al. [30]
Rink and Stoehr [31]
Kahnberg and Ridell [13]
Wagner et al. [32]
Chuong et al. [14]
Amaratunga [15]
Chambers and Scully [25]
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
When teeth were

retained, 2 % when
using penicillin, 26 %
when not using
penicillin. When teeth
were removed: 13 %
when using penicillin,
28 % when not using
penicillin
Loss of marginal bone
support and pulp
necrosis were
evaluated. Local
bone infection was
not evaluated.
4
Penicillin was used in

102 patients, but the
author did not report
which posology
was used/0
Short-term prophylactic
antibiotics therapy
used in 43 patients/0
Infection
rinses (days)
15 malunion or
malocclusion
Pain in the teeth in 3

cases (retained)
2 dehiscences (removed)
Severe loss of marginal

bone in 10 teeth
1 hypertrophic scar
(retained), 7 unsightly
scars (removed)
4 dehiscences (retained)
No
6 pain and swelling,

4 tooth mobility,
1 malocclusion
(retained)
Four malocclusion
(removed)
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
21 teeth required endo
NM
22
NM
NM
14 %
11 (5 of these teeth
were extracted for
other reasons than
the mandibular
fracture)
NM
Teeth not worth

keeping (additional
teeth removed)
after fracture
treatment
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
710/0
1/9j
29/18
60/18
63/3
42/0
5/16
16/0
57/0
Iizuka et al. [35]
Anderson and Alpert [36]
Berg and Pape [17]
Kamboozia and
Punnia-Moorthy [7]
Oikarinen and Raustia [37]
Haug and Schwimmer [38]
Koenig et al. [39]
Marker et al. [18]
Thaller and Mabourakh [40] 46/19 (anterior)
5/0
69/36
Rubin et al. [34]
7/patients rinsed their

mouths twice a day during
the period of fixation
NM
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
19 (if considering the

nonvital teeth with apical
lesion)
NMl
1 (one tooth required

extraction due to a postoperative
infection)
antibiotic cover/0
7/7
6 (retained)
6 (removed)
13j
23 % (retained)
19 % (removed)i
NM
Infection
5/0
7/0
47/6 (+1 avulsed)
Oikarinen et al. [16]
rinses (days)
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
3 apical root resorption,

1 external root
resorption,1
obliteration of the
root canal, increase in
gingival pocket depth
in 7 teeth
Marginal bone loss
(46 mm) in 10 teeth
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

(pulp necrosis)
NM
Teeth not worth

keeping (additional
teeth removed)
after fracture
treatment
Teeth that
required treatment
(endo/periodontic)

13
121/0
414/174 (+5 avulsed)
66/00
63/37 %
40/12 (patients)
50/0
3/0
34/14
Suei et al. [43]
Malanchuk and Kopchak

[22]
Ramakrishnan et al. [45]
Samson et al. [46]
Yamamoto et al. [23]
Mangone et al. [47]
87/258
Ellis [19]
Baykul et al. [20]
375/275
Atanasov and Vuvakis [42]
Vladimirov and Petrov [21]
78/12
96/80 (posterior)
Gerbino et al. [41]
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
106 (patients with)

osteomyelitis
89 (patients with)
paramandibular abscesses
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
rinses (days)
NM
NM
9 teeth required endo;

periodontal disease:
91 teeth
NM
NM
NM
19
Teeth that
required treatment
(endo/periodontic)
NM
NM
NM
NM
19
Teeth not worth

keeping (additional
teeth removed)
after fracture
treatment
14
30/24
Rai and Pradhan [48]
0/yes (number of days

not informed)
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
Teeth not worth

keeping (additional
teeth removed)
after fracture
treatment
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
From the 372 MFs, 202 were associated with teeth
From the 100 MFs, 66 were associated with teeth
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
Authors
Table 1 (continued)

15
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
were extracted (14 % of 50 cases). Teeth in the line of injury,

which were significantly mobile, had root exposures in
severely distracted fragments or, interfered with reduction
or fixation of the fractures, were those that were extracted.
In the study of Amaratunga [15], the criteria for removal
of teeth in the line of the fracture were as follows: (1)
excessive mobility, (2) root exposure due to distraction of
the fracture, (3) tooth fracture with pulp exposure, and (4)
caries with pulp exposure. The number of patients who
developed complications was 13.7 % in the tooth removed group and 16.1 % in the tooth retained group.
There was no significant difference between these groups.
The author advocated the idea that teeth in the line of MFs
can be preserved when antibiotics are used prophylactically.
Oikarinen et al. [16] retrospectively evaluated MF patients
with 54 teeth in the fracture line. At the follow-up examination, 18 (38 %) teeth had pulp necrosis, which was found
more frequently in the older patients, in cases in which the
time elapsing between the injury and the follow-up was
longer, in cases in which the fracture line ran through the
apex, and in cases with dislocation of the fracture after the
injury. The authors stated that a tooth lying in a MF line can
be saved in most cases and that such a tooth can serve as an
anchorage and help to maintain the original occlusion.
When comparing open and closed reductions of the
MAF associated with an impacted or partially erupted
LTM, Rubin et al. [34] found that the incidence of
complications in the open reduction group was 25 %,
and in the closed reduction group, it was 20 %, showing no statistical significance. When comparing extraction and retention of the tooth, the complication rate
was 19 and 23 %, respectively, also showing no statistical significance. There seemed to be a trend toward an
increased incidence of complications for those who were
treated with retention of the tooth combined with open
reduction (complication rate 44 %). This treatment
showed a higher incidence of complications when compared with retention of the LTM with closed reduction
(20 %), with extraction of the LTM with closed reduction (20 %), and with extraction of the LTM with open
reduction (19 %).
Iizuka et al. [35] analyzed 214 patients with MFs
treated by ORIF. Thirteen patients (6.1 %) developed
postoperative infection. All but one of the infected
fractures were in the angular region of the mandible.
Teeth (second or third molars) had been extracted from
the fracture line before the osteosynthesis procedure in
9 of the 10 dentulous mandibles. The authors stated that
this not only allows greater increase of oral contamination but also reduces the stability even more. Moreover,
they said that a tooth in the fracture line can give good
support when the fracture is reduced, and extraction of
the tooth makes reduction difficult and decreases the
cross-sectional surface of the fracture site. Thus, a tooth

should probably not be extracted before the osteosynthesis is completed when rigid fixation is used. Finally,
they stated that a tooth, even an impacted LTM, either
can safely be retained or else extracted immediately
after the osteosynthesis.
Anderson and Alpert [36] reported a high incidence of
infection (16 %) of the fracture sites. The authors attributed
this to involvement of teeth in the line of fractures and to
improper application of rigid fixation. All infections were in
fractures associated with teeth. In 18 instances, the teeth
were removed before or at the time of reduction; this group
had 6 of the 12 infections. In 29 fractures, the teeth were
retained; this group experienced the other six infections.
Thus, 25.5 % of fractures associated with teeth became
infected. No infection occurred in fractures fixed within
24 h of injury. Eight of the 12 infections occurred in the
26 fractures treated between 4 and 7 days post-injury. Only
three of 33 managed within 72 h, and none of the 13 treated
within 24 h became infected. Five of 22 fractures treated by
an extraoral approach became infected, compared with seven of 53 treated by an intraoral approach.
In the study of Berg and Pape [17], 13 of the 59 retained
teeth (22 %) in the line of fracture were found to be nonvital.
Radiographic evidence of root resorption was observed in
5 % of the patients. The author also evaluated the periodontal condition of teeth retained in the fracture line; 88 % of
patients showed no increase in pocket depth around such
teeth when compared with the corresponding contralateral
tooth. Concerning this, they concluded that there is no obvious
reason why such teeth should show an increase in gingival
pocket depth after postoperative healing is complete.
Kamboozia and Punnia-Moorthy [7] conducted a very
detailed study, comparing the morbidity of permanent teeth
associated with MFs treated with ORIF with those treated
with MMF. Fractures involving LTMs were excluded. Sixtythree teeth (34 in ORIF group and 29 in MMF group) in the
line of fractures were investigated; 68 % of teeth in the line
of fracture were in the ORIF group, and 41 % in the MMF
group were nonvital, while 71 % of teeth adjacent to the
fracture line were nonvital in the ORIF group, as compared
with 14 % in the MMF group. Of the total of 35 nonvital
teeth in the whole group, 49 % were related to minimal, and
51 %, to gross displacement of fractures. However, the
frequency of tooth vitality was closely related to the degree
of displacement between the fragments; out of 33 teeth in
the line of minimally displaced fractures, 17 teeth (52 %)
were nonvital, and of 28 teeth in the line of grossly displaced fractures, 18 teeth (64 %) were nonvital. Two teeth
associated with the hairline type of fracture were vital; 50
out of 104 (total of adjacent and in the line of fractures) teeth
(48 %) were found to be nonvital. None of them were
symptomatic; only 19 teeth in the whole group were found
17
to have small, chronic, apical, inflammatory lesions (18 %),

and all of them were amenable to root canal therapy. The
results showed a significant increase in nonvitality of teeth
in the line (P00.018) and adjacent (P00.0004) to the fractures of the mandible which were treated by ORIF, as
compared with MMF. The most common type of fracture
line was the fracture which line follows the root surface
from the apical region to the gingival margin with denudation of the root surface (55 %), and nonvitality of teeth was
most frequently associated with this (65 %; 22 out of 34
teeth) type of fracture. Despite these findings, the authors
recommended retention of teeth associated with fracture
lines unless there is an absolute indication for removal.
Oikarinen and Raustia [37] investigated whether teeth
left in the line of MF could predispose to occlusal interferences. They evaluated 37 patients, all treated by MMF. A
group of 27 healthy dental students served as controls.
Occlusal interferences were observed in 38 % of teeth in
the line of MFs, in 38 % of their anterior, in 32 % of their
posterior ones, and in 28 % of teeth of the control group.
They concluded that the higher incidence of occlusal interferences in teeth that were in the line of MFs could have
been caused by the injury and/or its treatment. The authors
suggested that the interferences should be corrected with
occlusal adjustment to prevent further pathological changes
in these teeth and in the function of the masticatory system.
Haug and Schwimmer [38] correlated postoperative
infections with the presence of a tooth in the fracture line.
They identified 27 patients with 32 fibrous unions within a
population of 714 patients with MFs. Of the 24 patients who
were surgically treated for their fractures, 21 had a tooth in
the line of fracture. Only five of these 21 patients (24 %) had
teeth removed at the time of the initial surgical procedure.
Eleven of the 24 patients (46 %) developed a late postoperative infection. However, there was a high frequency of
social or medical risk factors between these patients, which
may also have influenced the high incidence of postoperative infection. Nevertheless, the authors suggested that teeth
in the line of fracture should always be removed and that
ORIF is the better option of treatment in these cases.
Koenig et al. [39] evaluated 30 pediatric patients
with 45 MFs, and 15 (33 %) of these fractures involved
16 non-erupted teeth. Normal eruption was exhibited by
82 % of the tooth buds in the line of MF. The other
18 % exhibited either delayed eruption or non-eruption
with resorption of the tooth bud.
Marker et al. [18] evaluated the viability of retained
LTMs located in the line of a MAF. Thirty-one (55 %)
patients were treated within the first 24 h, and 43 (75 %)
patients, within 48 h. Infection was diagnosed in three (5 %)
patients, and two of the cases (3.5 %) were MAFs; this
occurred roughly 5 weeks after fixation in all three. In all
three cases, the infection was treated with an antibiotic for
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
with patients treated by CTR, regardless of the position of

the tooth.
Ellis [19] examined the relationship between postoperative infection and/or need for plate removal with the presence and management of teeth in the line of MAFs. Of the
345 teeth in the line of fracture, 258 (75 %) were extracted
during the surgery to repair the fracture. Postsurgical infection occurred in 19 % of the fractures, the same percentage
of cases in which removal of internal fixation hardware was
required. The incidence of infection in patients, who had no
tooth associated with the MAF, was 15.8 % compared with
19.1 % in those who did. For fractures associated with a
tooth, when the tooth was retained, the incidence of infection was 19.5 % compared with 19.0 % when the tooth was
removed. Both were not statistically significant. The same
occurred when the incidence of hardware removal was
related to the presence or absence of tooth in the line of
fracture or to the removal of maintenance of teeth.
Baykul et al. [20] analyzed the records of 117 patients with
121 MFs, having an unerupted tooth remaining in the fracture
line. Time between injury and treatment made no difference in
the results. No nonunion or malocclusion was observed. The
authors are of the opinion that removal of asymptomatic
impacted teeth is an additional trauma, allowing displacement
of fragments as well as increased infection risk.
Vladimirov and Petrov [21] investigated the association
between various factors and the decision to extract or preserve the tooth. Teeth in/with the following situations were
significantly extracted more often; if a local preoperative
infection was present, the time from trauma to treatment was
more than 72 h; there was a significant displacement of the
fracture; the dental root was fractured; periapical pathology
or periodontal disease was present; the tooth was multirooted (first or second molar), completely erupted LTM; or
treatment consisted of ORIF.
Suei et al. [43] evaluated in a long-term radiographic
follow-up records of patients with MFs involving tooth
buds. Abnormal findings were observed in 30 of 66 developing teeth (45 %; in 21 patients); these included 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 relationship was
found between the occurrence of abnormalities and the
developmental stage of tooth buds at the time of the injury
or the degree of displacement of the fracture line. However,
infection, rotation of the tooth bud, and a surgical wire
passing through the follicular space were associated with
arrested growth and impaction.
Malanchuk and Kopchak [22] observed that a tooth in the
line of the fracture had no significant influence on the infection rateinfection occurred in 25 % of the patients with a
tooth in the fracture line and in 22 % of the patients with
fractures located in the edentulous parts of the tooth-bearing
area. Accompanying pathological disorders also contributed

to the infection rate. The statistical analysis indicated that
delayed medical care and preexisting medical disorders were
the strongest predictors for infection development. The infection rate was 42.7 % in the patients with a preexisting disease
vs 22.4 % in the others.
By means of a questionnaire, Donker et al. [44] collected
information about how 102 dental surgeons in the Netherlands deal with teeth in the line of MFs. Generally, the
respondents strove to preserve a tooth in the MF line. Only
in case of a LTM in the fracture line and in case of fracture
treatment in a child there was a small group who opted for
removal of the teeth in the fracture line. The main reason to
maintain the tooth in the fracture line was for easier fixation/
stabilization of the fracture sections. The small group of
respondents, who chose to remove the tooth, gave less
chance of posttraumatic infection as the main reason. The
respondents choice of treatment did not depend on age,
gender, university clinic at which the respondent was trained
to be a dental surgeon, year of registration as a specialist,
place of work, and position.
The results of Ramakrishnan et al. [45] showed that a
revision surgery was necessary in 28.9 % of the fractures
with molar tooth involvement compared to 12.9 % when no
tooth was involved (P00.084). Moreover, when a tooth was
involved in the fracture, the revision surgery rate was 25 %
when it was removed and 30 % when it was preserved (P0
0.734). Both comparisons showed that postoperative complications may not increase by involvement of LTMs in the
fracture line. Removal of the tooth had no effect on the rate
of minor complications or the rate of secondary surgery.
In the study of Samson et al. [46], of the four patients
who presented with no pulp vitality response in the teeth in
the fracture line presurgically, three had their teeth in the
fracture line extracted between 4 and 6 weeks after surgery
as the fracture sites were infected. The authors suggested
that a tooth that shows no response on pulp vitality testing
should be advised for extraction to avoid further complications in patients presenting with MF.
Yamamoto et al. [23] presented three cases of severely
dislocated mandibular symphyseal fractures in infants. The
fractures were treated by manual reduction and fixation
using a splint and circumferential wiring and healed uneventfully in all patients. In one patient, a crown malformation was observed in one central incisor. In another patient, a
root formation was arrested in one of the permanent teeth on
the fracture line. This tooth was subsequently lost early after
eruption. The remained patient did not have any complications. As the fate of the permanent tooth buds was different
in each case, the authors stated that the development of tooth
buds on the fracture line is not predictable.
Mangone et al. [47] evaluated 48 patients presenting a
LTM in the line of MAFs. Of the 48 teeth in the line of
19
fracture, 14 were removed at the surgery. Moreover, three

teeth were subsequently removed (two due to infection and
one due to malocclusion). At the follow-up, 15 teeth presented no pulp vitality response, and 10 teeth showed radiological signs of apical resorption.
In a prospective study, Rai and Pradhan [48] compared two
groups of patients with a LTM in the line of a MAF. There was
a higher incidence of pain/tenderness after 12 weeks in the
group in which the tooth was preserved. The presence of
infection was higher in this same group till the sixth week.
The difference was not significant after the sixth week till the
end of 2 years of follow-up. A total of eight out of 30 teeth
were diagnosed nonvital preoperatively. Six out of these eight
nonvital teeth showed a slow return of vitality, whereas two
showed no sign of vitality at the end of 24 weeks.
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
buds after MFs should not be removed or replaced in the

(alleged) proper position despite the degree of displacement.
However, the MF should be properly reduced. It is worth
mentioning an important remark made by Krmer [24]
60 years ago; a permanent tooth germ situated in the line
of fracture should not be removed without strong reasons,
provided that reduction is not obstructed, and early and rigid
fixation is performable.
Therefore, it is difficult to predict the fate of tooth buds
based on an evaluation of the condition of the tooth buds and
the fracture. The presence of infection, however, is a predictive factor of abnormality [43]. Of three infected teeth in the
study by Lenstrup [49], two were embedded, and one was
extracted. Of the four infected teeth in the study of Suei et al.
[43], three exhibited arrested growth, and two were embedded. Considering these observations, Suei et al. [43] suggested
that odontogenic cells in the dental follicle have a tolerance for
mechanical stress but are severely damaged by infection.
Thus, the importance of antibiotic prophylaxis in cases of
fractures should be emphasized, not only to achieve successful
healing of the injured soft tissue and bone but also to
sustain the development of the involved tooth buds [51].
MFs that occur during mixed dentition can be associated
with subsequent failed eruption of permanent teeth when the
fracture line is reduced using an open surgical approach
[52]. Nixon and Lowey [52] reported two cases of impaction
associated with a miniplate and a wire that were placed for
the treatment of fractures. Sueli et al. [43] reported impaction in one tooth bud in which a surgical wire had passed
through the follicular space. However, Suei et al. [43] stated
that careful surgical procedures can prevent impaction of the
teeth in most cases.
What to do with third molars directly involved in the line
of mandibular angle fractures?
Regarding the adult mandible, MAFs deserves an important
consideration. Because the mandibular angle is one of the
most frequent sites for fractures of the jaw [16], impacted
molars have received special attention [53]. There has been
a debate about the most appropriate treatment for those
fractures when the teeth are present. Should they be
retained, or should they be removed? There is no consensus
on this question.
Krmer [24] was the first to analyze this issue, and he
stated that as MAFs offer great problem of fixation, the use
of antibiotics may be justifiable to keep a tooth in the line of
fracture when this is needed for the immobilization of the
posterior fragment. Krger [54] recommended that a completely unerupted LTM be left in the fracture line if it is not
open to the oral cavity and if it does not impede the reduction of the fragments, a suggestion that many surgeons
follow until today. Wagner et al. [32] reinforced this
suggestion. From their results, 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. However, Atanasov and
Vuvakis [42] showed no statistically significant difference
in the complication frequency associated with the extraction
of unerupted or erupted wisdom teeth, although a higher
complication rate was observed in patients treated by ORIF
in comparison with patients treated by CTR, regardless of
the position of the tooth.
Wolujewicz [33] tried to find a correlation between the
type of impaction of the LTM and the direction and displacement of lines of fracture in this region. The author
suggested that vertically impacted LTM in the line of fracture should be removed because these cases require more
elaborate methods of treatment in order to properly reduce,
stabilize, and fixate the fracture. On the other hand, those
LTMs which are in a horizontal or mesioangular orientation
in an undisplaced angular fracture should be retained because they appear to stabilize the fracture. Baykul et al. [20]
agreed with Wolujewiczs [33] observation and stated that
the forces applied during the surgical removal may cause
displacement of the fragments although they are applied
carefully. Baykul et al. [20] also stated that removal of the
bone in the fracture line may reduce the contacting bone
surfaces between the fragments. Thus, this condition may
increase the secondary healing surfaces and may lead to
delayed healing.
Some studies demonstrated no differences in postoperative complications related to the retention or extraction of
LTMs in the line of MAFs. When comparing extraction of
the tooth and retention of the tooth, Rubin et al. [34]
reported a complication rate of 19 and 23 %, respectively,
showing no statistical significance. The authors observed a
trend toward an increased incidence of complications for
those who were treated with retention of the tooth combined
with open reduction. Although Marker et al. [18] stated that
the closed treatment 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. In the study of Ellis [19], the incidence of
infection in patients who had no tooth associated with the
MAF was 15.8 % compared with 19.1 % in those who did.
Their results also indicated that the risk of infection and
need for hardware increase when there is a tooth present in
the fracture line, but the increase in risk is not statistically
significant. Ramakrishnan et al. [45] showed that postoperative complications may not increase by involvement of
LTM in the line of MAFs. The authors stated that involvement of LTMs in the fracture line may not be solely held
responsible for relatively common infectious or hardwarerelated complications seen after the treatment of MAFs.
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
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 [55].
Teeth with small periapical lesions, which may be given
endodontic treatment in the early phase or extracted once
healing is complete, may be conserved [41]. Ridell and
strand [28] also stated that many of the teeth classified as
unsuccessful which had periapical lesions and minor marginal bone pockets may become fully functional by adequate treatment.
Several authors found a smaller rate of infection/complication when a tooth in the fracture line was retained, compared when a tooth was prophylactically removed [14, 26,
27, 30, 32, 36, 41], or small complication rates when the
teeth were retained [12]. In contrast, some studies observed
a smaller rate of infection/complication when a tooth in the
fracture line was removed, compared when a tooth was
prophylactic retained [15, 19, 34], but not statistically different. Some others found no difference [40, 45]. Malanchuk and Kopchak [22] showed that tooth in the line of the
fracture had no significant influence on the infection rate
when compared with fractures located in the edentulous
parts of the tooth-bearing area. Ramakrishnan et al. [45]
showed that postoperative complications may not increase
by involvement of LTM in the line of MAFs. All these
previous results favor the belief that teeth in the line of
fracture should not be extracted. Others believed that conservatively treated teeth involved in the line of MFs have a
favorable prognosis, especially if optimal reduction of the
fragments is achieved [13]. Moreover, some authors state
that extraction of the tooth entails further trauma to bone
tissue and also presents technical difficulties when the fragments are highly mobile. Stabilization of a fracture is unfavorably influenced by extraction of teeth, which may help
the treatment by providing a posterior stop, by permitting
proper alignment of the dental arch, and by preventing
collapsing or telescoping of the fragments [30, 55]. In addition, certain teeth might be considered strategic in the final
restorative plan [30].
The implementation of antibiotic treatment certainly favored more conservative treatments with respect to the teeth
in the fracture line. In the pre-antibiotic era, many teeth in
the line of fractures were removed to prevent the devastating
consequences of osteomyelitis and nonunion. Recommendations in the post-antibiotic era have been on the conservative side, retaining teeth when possible [19]. A number of
studies [1123] have indicated that the routine use of antibiotic treatment in cases of compound fractures also reduces
the frequency of complications in cases of fully erupted
permanent teeth in the line of fracture. In order to increase
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,
the removal of teeth in the line of MFs in such situations

may be the best option for the patient.
In which situations teeth in the line of mandibular fractures
should be removed?
On the other side, there are also some situations in which it
is suggested that teeth in the line of MFs should be removed.
According to the literature, the following are the main conditions that suggest that teeth in the line of fracture should
be removed:
1. Teeth that prevent reduction of fractures [12, 14, 18, 36,
41, 47, 55];
2. Teeth with fractured roots [15, 18, 21, 22, 28, 36, 40, 41,
47, 55];
3. When there is extensive periodontal damage, with broken alveolar walls, resulting in the formation of a deep
pocket (making optimal healing doubtful) [17, 21, 22,
28, 36, 41, 47, 55];
4. A partially impacted wisdom tooth with pericoronitis
[12, 18, 21, 41, 47];
5. A tooth with extensive periapical lesion [17, 21, 22,
28, 41];
6. Markedly distracted fractures with displacement of the
tooth with extensive exposure of the root/apex [12, 14, 18];
7. Poor general medical status of the patient with acute and
chronic alcoholism and drug abuse, as well as associated poor hygiene [40].
How much the mobility of the fragments affects the postfixation infection rate when there is involvement of teeth
in the line of fractures?
There is another issue that must be analyzed carefully. Many
of the previous reviewed studies treated MFs by MMF and
wire osteosynthesis. The result was a semirigid fixation that
allows slight movement of the fragments due to muscular
activity [59]. There is increased susceptibility to infection in
the damaged region if absolute immobility is not maintained
across the fracture line [60]. Anderson and Alpert [36]
attributed the high incidence of infection of the fracture sites
in their study due to improper application of rigid fixation
(and involvement of teeth in the line of fractures). This
immobility takes on particular importance in the mandible
because all fractures in the dentulous region are contaminated with bacteria. The attached gingiva, which is firmly
connected to the periosteum, tears at the slightest displacement of the break. Any small movement of the fragments
also causes saliva, which is high in bacterial content, to be
pumped into the fracture gap. A mobile tooth in this compromised region increases the danger of infection [55].
Thus, the rates of infection demonstrated by some of the
studies reviewed here, caused by teeth in the line of fracture

which has been maintained after reduction, would not have
been as high if the fracture had been treated with ORIF
(plates) instead of semirigid fixation (MMF and wire osteosynthesis). This reflects in a growing acceptance of the fact
that susceptibility to infection is directly dependent on the
mobility of the fragments.
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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Oral Maxillofac Surg (2014) 18:724

Teeth in the line of mandibular fractures

Oral Maxillofac Surg (2014) 18:724

Materials and methods

The study selection process is summarized in Fig. 1. The

{Subject AND Adjective}

Fig. 1 Study screening process

Oral Maxillofac Surg (2014) 18:724

48 h of the accident, treatment was unsuccessful in 16 %

Ridell and strand [28]

Schneider and Stern [12]

Ewers et al. [29]

Rink and Stoehr [31]

Wagner et al. [32]

Chuong et al. [14]

Chambers and Scully [25]

Iizuka et al. [35]

Berg and Pape [17]

Haug and Schwimmer [38]

2156 (36.3) (retained)

Patients age range

9106 months (41)

449 months (NM)

5 months11 years (NM)

None (3 patients), 6 weeks or

Only those cases have been

Marker et al. [18]

Thaller and Mabourakh [40]

Gerbino et al. [41]

Vladimirov and Petrov [21]

Suei et al. [43]

Malanchuk and Kopchak

Samson et al. [46]

Yamamoto et al. [23]

010 years (NM)

1418 months (16)

112 months (2.5)

6 months1 year (NM)

The authors informed

Patients age range

Koenig et al. [39]

MMF (91 %), ORIF

MMF (15 %), MMF +

ORIF (33 %), MMF or

Teeth not worth

Oral Maxillofac Surg (2014) 18:724

Ridell and strand [28]

Schneider and Stern [12]

Ewers et al. [29]

Neal et al. [30]

Rink and Stoehr [31]

Kahnberg and Ridell [13]

Wagner et al. [32]

Chuong et al. [14]

Chambers and Scully [25]

When teeth were

Penicillin was used in

Pain in the teeth in 3

Severe loss of marginal

6 pain and swelling,

21 teeth required endo

Teeth not worth