Tooth in fracture line: extract or maintain?

THIAGO MARQUES DE MESQUITA 1,2 | BASÍLIO DE ALMEIDA MILANI 1,3 | THAIS BENEDETTI HADDAD CAPPELLANES 1,4 | ROSANY GUARNNETTI DOS SANTOS 1,5 | TALITA LOPES 1,6

ABSTRACT

Fractures located in the mandibular angle may contain teeth in the fracture line and, over the years, different opinions have been observed on the need for extraction or maintenance of these teeth in the fracture line. The objective of this study was to report two cases of treatment of mandibular fractures, with tooth presence in the fracture line, discussing the indications of maintenance and extraction of these teeth. In the first case, it was decided to perform the extraction of the tooth associated with mandibular fracture line. In the second patient, it was opted to maintain this tooth in the fracture line. As a result, we have succeeded in the treatment both in the case where the tooth was maintained and in the case where tooth extraction was performed. We have concluded that must be extracted during surgery teeth that do not have any condition that allows its maintenance, or to prevent the reduction of the fracture. Sound teeth or teeth that facilitate the reduction and fixation of mandibular fractures, even present in mandibular fracture line, must be preserved. The preservation of a tooth in the mandibular fracture line does not increase the chance of infection, provided there is no indication of dental extraction.

Keywords: Tooth. Mandibular fractures. Tooth extraction.

1 Hospital Municipal do Campo Limpo (São Paulo/SP, Brazil).

2 Especialista em Cirurgia e Traumatologia Bucomaxilofacial, Hospital Municipal do Campo Limpo (São Paulo/SP, Brazil).

3 Especialista em Cirurgia e Traumatologia Bucomaxilofacial e Mestre em Clínicas Odontológicas, Universidade de São Paulo, Faculdade de Odontologia (São Paulo/SP, Brazil).

4 Mestre em Odontologia, Universidade de Taubaté (Taubaté/SP, Brazil).

5 Especialista em Ortodontia, Sindicato de Odontologia do Estado de São Paulo, Centro de Aperfeiçoamento Profissional e Especialização (São Paulo/SP, Brazil).

6 Especialista em Cirurgia e Traumatologia Bucomaxilofacial, Universidade de São Paulo, Faculdade de Odontologia (São Paulo/SP, Brazil).

How to cite: Mesquita TM, Milani BA, Cappellanes TBH, Santos RG, Lopes T. Tooth in fracture line: extract or maintain? J Braz Coll Oral Maxillofac Surg. 2019 Jan-Apr;5(1):36-40. DOI: https://doi.org/10.14436/2358-2782.5.1.036-040.oar

Submitted: 09/04/2015 - Revised and accepted: 25/01/2018

» The authors report no commercial, proprietary or financial interest in the products or companies described in this article.

» Patients displayed in this article previously approved the use of their facial and intraoral photographs.

Contact address: Thiago Marques de Mesquita Rua José Afonso de Melo, 118, Harmony Trade Center, sala 214 Jatiúca, Maceió/AL – CEP: 57.036-510 E-mail: thiagomesquita.bucomaxilo@gmail.com

INTRODUCTION

Mandibular fractures are among the most common types of fracture in facial trauma, ranking second among bones of the maxillofacial skeleton. These fractures can occur in different regions of the mandible, including the body/parasymphysis (33%); condyle (29.3%); angle (23.1%); symphysis (8.4%); and coronoid process (4.8%). 1

Among the mandibular fractures, those affecting the angle have the highest rate of complications, associated with several factors, such as tooth in the fracture line and biomechanics of the region. 2

Fractures at the mandibular angle may contain a tooth in the fracture line, and divergent opinions have been observed over the years regarding the need for extraction or maintenance of teeth in the fracture line. 3

For the adequate treatment of mandibular fractures, it is fundamental to obtain satisfactory reduction of fractured sides and correct reestablishment of dental occlusion. In many situations, the tooth in the fracture line does not preclude fracture reduction and may also be an adjunct transoperatively, providing an optimal occlusal reference. 4

The correct management of patients presenting teeth involved in mandibular fractures is fundamental to achieve treatment success, since both extraction and improper maintenance can lead to treatment failure. 5

Thus, this paper reports two clinical cases of treatment of mandibular fractures with tooth in the fracture line. In the first case, we decided to extract the tooth associated with the mandibular fracture line. In the second, it was decided to maintain the tooth in the fracture line. Additionally, the indications for maintenance and extraction of these teeth are discussed. As a result, treatment was successful in both cases where the tooth was maintained and where it was extracted.

CASE REPORT 1

A 30-year-old male patient attended the Oral and Maxillofacial Surgery and Traumatology Service at Hospital Municipal do Campo Limpo/SP with a history of motorcycle accident about 30 days before, reporting initial care at another hospital, being submitted to tracheostomy and hospitalized for four weeks, partly in the ICU. Physical examination revealed facial asymmetry, with volume increase in the right preauricular region, slight limitation in mouth opening, and a tracheostomy cannula in the cervical region. Intraoral examination revealed significant dental disocclusion. Radiographic and tomographic examinations (Fig 1) evidenced the presence of mandibular fractures in the symphysis and right mandibular angle, also showing the presence of a tooth located in the mandibular angle fracture.

Due to the long period without treatment, the fractured sides had already consolidated. The patient was then submitted to general anesthesia, with intubation through the tracheostomy, for fracture reduction and fixation. Mandibular anterior and right submandibular buccal accesses were performed. The fractures were then mobilized and reduced; maxillomandibular block was performed, and then the fractures were fixated with miniplates of systems 2.0 and 2.4. Transoperatively, the impossibility to main tooth 48 was evidenced, since it presented exposure of the root surface, presence of dental calculus and loss of bone insertion, yet without mobility, thus extraction was performed. Three days postoperatively, the patient was discharged and referred for outpatient control returns (7, 21, 35, 45 and 90 days). At the first return visit, the patient had no pain complaint; he presented mild edema, slight limitation of mouth opening, good dental occlusion, sutures without dehiscence and no signs of infection. After 45 days, the patient was reevaluated and presented normal dental occlusion, normal healing and absence of infection. After 90 days postoperatively the patient presented the same clinical signs of normality and a new radiograph was evaluated, which presented normal bone healing, with the osteosynthesis material in place (Fig 2).

Figure 1: Mandibular angle fracture and associated tooth 48.

Figure 2: Panoramic radiography three months postoperatively.

CASE REPORT 2

A 16-year-old male patient was admitted to the Oral and Maxillofacial Surgery and Traumatology Service of Hospital Municipal do Campo Limpo/ SP with a history of physical aggression. Physical examination of the face showed edema on the left mandibular angle and limited mouth opening. Intraoral examination revealed ecchymosis in the region of tooth 38, which was included and impacted, as well as dental disocclusion. Radiographic and tomographic examinations evidenced a left mandibular angle fracture, with slight displacement, and presence of tooth 38 in the fracture line (Fig 3).

The patient was then submitted to general an-

Figure 3: Preoperative radiograph with tooth 38 in the fracture line.

esthesia with nasotracheal intubation, for mandibular reduction and osteosynthesis. By intraoral access, the fracture was reduced and fixated with two plates of system 2.0, being one in the zone of tension and the other in the zone of compression. Tooth 38 did not interfere with fracture reduction and presented normal aspect; thus, it was decided to keep it in place. Evaluation of the immediate postoperative tomography evidenced correct reduction of the fracture, with osteosynthesis material in correct position and tooth 38 present in the fracture line.

On the second postoperative day, the patient was discharged and referred for outpatient control returns (7, 21, 35 and 45 days). At the end of 45 days, the patient had normal dental occlusion, good mouth opening and no complaints, and was instructed to return after 6 months for reassessment and possible extraction of tooth 38.

DISCUSSION

There is an increasing tendency of the surgeons to maintain teeth involved in the mandibular fracture line. This choice is based on a growing number of researches showing no statistically significant difference when teeth present in mandibular fracture line are maintained, compared to fractures in which these teeth are extracted. 6-10

However, in some situations, the indication for extraction of the involved tooth was present even before the fracture. In such situation, and if there is no damage to fracture reduction, there are no reasons that justify the maintenance of this tooth.

According to Shetty and Freymiller, 4 the indications for removal of teeth located in the mandibular fracture line are as follows: » Significant periodontitis with marked dental mobility. » Third molars partially erupted and associated with pericoronitis. » Teeth that prevent fracture reduction. » Teeth with exposed root tips or complete exposure of the root surface. » Excessive delay between fracture and definitive treatment.

Ellis, 6 in a study on 402 patients among whom 85% had a tooth in the mandibular fracture line, concluded that there is increased risk of postoperative complications when a tooth is present, even though this increase is not statistically significant. The author also showed that there is no increase in postoperative complications or need to remove the fixation material when tooth extraction is indicated.

It should be noted that, after large scale utilization of miniplate fixation systems and administration of antimicrobial agents, there was a reduction in the prevalence of infection in teeth in the fracture line. 5

A careful clinical and radiographic evaluation is necessary to reduce the rate of complications after treatment of teeth maintained in place in the mandibular fracture line. When there is indication for extraction, this should not be neglected, which might jeopardize the treatment performed. 8

In some cases, transoperative extraction of a third molar present in the mandibular fracture line, for example, might transform a stable fracture with little displacement into an unstable fracture, complicating the reduction and osteosynthesis. In these cases, the best option would be to keep the tooth in place and extract it later, after bone healing at the fracture site.

It should be mentioned that teeth play a fundamental role in the realignment and retention of bone fragments, thanks to their occlusion, avoiding an inadequate fracture consolidation. The faster the immobilization and retention of bone fragments and consequently of the tooth involved in the bone fracture, the

greater will be the chances of maintaining this tooth during fracture consolidation. 6

It is advisable to follow the vitality of teeth present in the mandibular fracture line, when these are maintained in place, for at least one year postoperatively, to prevent possible complications in case the loss of vitality of these teeth is a determining factor for infection. 9

CONCLUDING REMARKS

Teeth should be extracted transoperatively if they present any condition precluding their maintenance, such as significant periodontitis with marked dental mobility; partially erupted third molars and with pericoronitis; teeth that preclude the fracture reduction; teeth with exposed root apices, complete root surface exposure, or in cases of excessive delay between fracture and definitive treatment.

Teeth present in the mandibular fracture line that are healthy or that facilitate reduction and fixation of the mandibular fracture should be maintained.

The preservation of a tooth in the mandibular fracture line does not increase the chance of infection, as long as there is no indication for extraction.

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