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 criteria—studies 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 main- tained 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 fractured roots, a partially impacted wisdom tooth with peri- coronitis, 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 56–69 % of fractures of the mandible involve areas with teeth [1–6]. 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 com- munication 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, par- ticularly 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 B. R. Chrcanovic (*) Department of Prosthodontics, Faculty of Odontology, Malmö University, Carl Gustafs väg 34, SE-205 06 Malmö, Sweden e-mail: [email protected]B. R. Chrcanovic e-mail: [email protected]Oral Maxillofac Surg (2014) 18:7–24 DOI 10.1007/s10006-012-0369-y
Transcript
REVIEWARTICLE
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
AbstractPurpose This study aims to review the literature regardingthe evolution of current thoughts on the management ofteeth in the line of mandibular fractures (MFs).Methods An electronic search in PubMed was undertaken inJune 2012. The titles and abstracts from these results wereread to identify studies within the selection criteria—studiesreporting clinical series of MFs in which the management ofteeth in the fracture line was analyzed.Results The search strategy initially yielded 731 references.Twenty-seven studies were identified without repetitionwithin the selection criteria. Additional hand searchingyielded 12 additional papers.Conclusions It is suggested that rigid fixation systems and theuse of antimicrobial agents have reduced the incidence ofinfection in cases of teeth in the line of MFs. Tooth buds inthe 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 ofcalcification and those involved in widely displaced fracturesites continued development and erupted. Its removal shouldbe considered in cases of infection, which is a predictive factorof abnormality and/or impaction. Intact teeth in the fractureline should be left in situ if they show no evidence of severeloosening or inflammatory change. Permanent teeth main-tained in the line of fracture should be followed up clinicallyand radiographically for at least 1 year to ensure that anyunnecessary endodontic treatment is avoided. Teeth in the lineof fracture that prevents reduction of fractures, teeth with
fractured roots, a partially impacted wisdom tooth with peri-coronitis, and a tooth with extensive periapical lesion shouldbe removed. Teeth in the line of MFs should also be removedwhen located in sites where there is extensive periodontaldamage, with broken alveolar walls, resulting in the formationof a deep pocket (making optimal healing doubtful).
Keywords Mandibular fracture . Teeth in the fracture line .
Complications . Treatment
Introduction
About 56–69 % of fractures of the mandible involve areaswith teeth [1–6]. Consequently, the likelihood that a toothwill be in the fracture line is substantial. Whether teethsituated in the line of fracture should be extracted or retainedhas always been a subject of heated debate.
Fractures of the jaw in the tooth-bearing area, because ofthe presence of periodontal ligaments, are always in com-munication with the oral cavity. The damage to the tooth orteeth involved at the fracture site may include exposure ofthe root surface, subluxation, avulsion, or root fracture. Thetooth involved may become devitalized as a result of injuryor may have a preexisting pulpal, periodontal, or periapicalcondition of pathology [7]. All these factors either alone orcombined could predispose the fracture to infection and maycomplicate healing [7, 8].
There are no definite guidelines in the literature for themanagement of teeth in mandibular fracture (MF) lines, par-ticularly in regard to their retention or removal at the time offracture treatment [7]. Authors of early studies maintained thatretained teeth in the line of fracture often become a nidus ofinfection [9]. They recommended that involved teeth shouldbe extracted to reduce the chances of untoward sequelae suchas osteomyelitis and nonunion. Even vital teeth were routinelyremoved, as it was believed that the communication of thefracture to the oral cavity via periodontal space fosters
B. R. Chrcanovic (*)Department of Prosthodontics,Faculty of Odontology, Malmö University,Carl Gustafs väg 34,SE-205 06 Malmö, Swedene-mail: [email protected]
infection [10]. It has also been stated that teeth in the fractureline can be left in place if certain prerequisites, such as earlytreatment with a stable splint or by functionally stable osteo-synthesis, are met [9]. Several more recent studies support theview that teeth in the line of MFs can be preserved whenantibiotics are used prophylactically [11–23].
As the philosophies of the treatment of maxillofacialtrauma alter over time, a periodic review of the differentconcepts is necessary to refine techniques and eliminateunnecessary procedures. This would form a basis for opti-mum treatment. The purpose of the study was to review theliterature regarding the evolution of current thoughts on themanagement of teeth in the line of MFs.
Materials and methods
Objective
This study aims to review the literature regarding the evo-lution of current thoughts on the management of teeth in theline of MFs.
Data source and search strategies
An electronic search without date or language restrictionswas undertaken in June 2012, in PubMed website (USNational Library of Medicine, National Institutes of Health).The following terms were used in the search strategy:
{Subject AND Adjective}{Subject: (tooth OR teeth [text words])ANDAdjective: (line fracture OR line mandibular fracture[text words])}
All reference lists of the selected and review studies werehand searched for additional papers that might meet theeligibility criteria for inclusion in this study. The titles andabstracts (when available) from these results were read foridentifying studies, meeting the eligibility criteria. For stud-ies appearing to meet the inclusion criteria or for whichthere were insufficient data in the title and abstract to makea clear decision, the full report was obtained and assessed.
Inclusion criteria
Eligibility criteria included studies reporting clinical series ofMFs in which the management of teeth in the fracture line wasanalyzed. The studies could have been conducted on patientshaving tooth buds, fully erupted permanent teeth, or impactedlower third molars (LTMs), also having displaced or undis-placed, comminuted or non-comminuted, and unilateral or
bilateral MFs. The study could have applied maxillomandib-ular fixation (MMF) alone, open reduction and internal fixa-tion (ORIF) alone, or a combination of ORIF and MMF.Randomized controlled clinical trials, cohort studies, case–control studies, cross-sectional studies, and case series wereincluded. Because of the scarcity of articles with high-levelgrades of evidence, all articles, including studies with few casereports, were considered for inclusion.
Exclusion criteria
Review articles without original data were excluded, al-though references to potentially pertinent articles were notedfor further follow-up.
Results
The study selection process is summarized in Fig. 1. Thesearch strategy outlined above identified 731 studies. Theinitial screening of titles and abstracts resulted in 123 full-text papers; 91 were cited in more than one research ofterms. Thus, 32 studies were identified without repetition.Five of these 32 papers were excluded for being reviewarticles or letters to the editor. Additional hand searchingof the reference lists of selected studies yielded 12 addition-al papers. The literature review is based on these 39 articles,and the important points of these studies are presented
Fig. 1 Study screening process
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below. The main results of the included studies are pre-sented in Table 1.
Krømer [24] evaluated 690 MFs from British soldierswho served in the Second World War. The material wasobtained from a Plastic and Jaw Unit in England, from theyears 1940 to 1945. Probably, the first clinical study on thesubject is still one of the most detailed studies published sofar. In one group with simple linear fractures, he found thatif the fracture was not treated within 48 h, healing wasslower when a tooth in the fracture line had been sparedthan when it had been extracted early. When the fracturewas reduced within 48 h, the time of extraction was of littleimportance. If, on the other hand, fixation is effected after2–7 days, infection will become of great significance, andextraction ought to be done in connection with the fixation,according to the author. He advised maintaining all teethexcept those severely infected or mobile. The authors alsostated that every tooth in the line of a gunshot fracture oughtto be extracted at the beginning of treatment (as “a shotfracture is always infected”), provided that the number ofteeth left is sufficient to provide strong fixation and thatextraction can be done without any serious trauma. Consid-ering fractures fixed after 2–12 weeks, the author observedthat the healing will be considerably delayed, which maytake twice or thrice the normal time.
Although described in an article published in 1987,Chambers and Scully [25] reviewed the case notes of 124patients with MFs treated by a major in India in 1944 and1945, during the Second World War. Fifty-five patients(46.2 %) had one or more teeth extracted from the line offracture. In most cases, the teeth removed had not them-selves been fractured. This kind of approach represented thethinking on the management of teeth in fracture lines at thattime, in the era before antibiotics were widely available.
A retrospective study by Schönberger [26] found a 6 %rate of infection when a tooth in the fracture line wasretained compared with an 18 % infection rate after prophy-lactic removal. He subsequently recommended that all devi-talized teeth and root pieces in the fracture line be removed,irrespective of whether a periapical infection was present ofnot. However, he indicated that vital anterior and premolarteeth with tolerably good tooth sockets could be retained.Götte [27] also found more complications after prophylacticextraction of the tooth at the fracture site (20 % of 60patients) than when it was left in place (16.8 % of 178patients).
Roed-Petersen and Andreasen [11] found that 25 % ofteeth in the line of fracture became necrotic; the necrosisdeveloped in cases when the fracture crossed the apical areaor when the fracture was treated more than 48 h after thetrauma. In the study of Ridell and Åstrand [28], there was anuneventful healing in 77.2 % of the involved teeth. Of theteeth 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 treatedlater. Of the 23 teeth which were partly of completely retainedor unerupted at the time of the injury, only one belonged to theunsuccessful group. Treatment was unsuccessful in 18.4 % ofthose cases where fracture dislocation was mild comparedwith 23.5 % of those where the dislocation was substantial.The authors stated that many of the teeth classified asunsuccessful, which had periapical lesions and minormarginal bone pockets, may become fully functionalby adequate treatment, bringing the rate of successfultreatment of the teeth up to 80–90 %.
Schneider and Stern [12] found only a 5 % complicationrate (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, stablefracture fixation, and antibiotic therapy, teeth could beretained to aid in fixation and ultimately in function, i.e.,teeth that are loose and have exposed roots, or periapicalinfection can be retained, if they serve a purpose.
Ewers et al. [29] evaluated the periodontal conditions ofthe 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, and45 % of the teeth required further periodontal treatment.The authors stated that retention of the teeth in thefracture line does not provide an increased risk of com-plications when ORIF is used.
Neal et al. [30] evaluated complications related to teeth inthe lines of MFs in a retrospective review of 207 fractures;32.3 % resulted in some form of morbidity. They foundmore complications on extracting the tooth (37.3 % in 75fractures) than after leaving it in place (29.5 % in 132fractures). Statistical comparison of fractures, in which teethwere removed and retained, suggested that removal of teethin fracture lines does not minimize morbidity.
Rink and Stoehr [31] observed that fully erupted teethproduced occasionally an infection of the fracture line;partially retained teeth in the fracture line frequently led toinfections, and retained teeth or tooth germs caused no caseof infection. Thus, they recommended that the partiallyerupted teeth be extracted in conjunction with the treatmentof the fracture. As the retained teeth or tooth germs did notresult in any case of infection, the authors stated that theseshould not be removed.
Kahnberg and Ridell [13] correlated the frequency andcharacter of the complications among teeth in the fractureline to different fracture types in an attempt to define thecorrect approach to involved teeth. Treatment consisted ofMMF or wiring+MMF. In 23 % of the teeth in the nonvitalgroup, there was a change in sensibility from initially neg-ative sensibility at the time of fracture to positive reaction atthe time of reexamination (minimum of 12 months).
Complications were more frequent after inadequate reposi-tion of the fracture compared to optimally reduced fracturefragments. Teeth without pathological complications werefound to be significantly more frequent in optimally reposi-tioned fractures than in fractures with persistent dislocation.There was an increasing rate of complications with increas-ing severity of periodontal involvement. Teeth with exposedroot apices or with complete exposure of the root surfacehad a poor prognosis. The authors believed that conserva-tively treated teeth involved in the line of MFs have afavorable prognosis, especially if optimal reduction of thefragments is achieved.
Wagner et al. [32] analyzed 100 consecutive extraoralopen reductions of MFs in an attempt to evaluate the mor-bidity of this technique and demonstrate possible predispos-ing factors. There was an overall complication rate of 13 %consisting of infection, delayed union, and hypertrophicscarring. All occurred at sites enclosing teeth. Nine of the13 complications involved extraction, and eight of thosenine occurred at fractures of the angle. They had 37 casesof mandibular angle fractures (MAFs) with teeth in the lineof fracture which were treated with an open reduction andfound a complication rate of 11.8 % in those fractures inwhich the teeth were retained and 35 % when teeth wereremoved. Thus, it appeared to be an increased incidence ofthose complications in MAFs with teeth in the line of injurywhen the teeth were extracted in conjunction with extraoralopen reduction. No complication appeared in the openreductions of 33 fractures not associated with teeth.
Wolujewicz [33] studied 47 patients with MAFs involv-ing LTMs. The author attempted to find a link between thetype of impaction of the LTM and the direction and dis-placement of lines of fracture in this region. Fracturesthrough erupted LTMs, and particularly, those molars whichwere vertically impacted, generally required more elaboratemethods of treatment. The authors observed that no advan-tage was gained in attempting to achieve stability by retain-ing these teeth. Their retention carried the risks of delayedunion and infection of the fracture. Of 21 fractures withvertically impacted LTMs, the tooth was extracted in 15cases to achieve satisfactory results (internal wire fixationwas used in 14 of these 15 cases). He concluded that LTMsthat are vertically impacted should be removed, and thosewhich are in a horizontal or mesioangular orientation shouldbe retained partly because they appear to stabilize the frac-ture and partly because treatment of the fracture without theextraction of the tooth is less extensive.
Chuong et al. [14] delineated the relationship between thelocation of the fracture, disposition of the teeth, and subse-quent development of complications in a study of 327 MFs.There was not any significant difference in the rate ofcomplication between cases where the teeth in the line ofinjury 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 inseverely distracted fragments or, interfered with reductionor fixation of the fractures, were those that were extracted.
In the study of Amaratunga [15], the criteria for removalof teeth in the line of the fracture were as follows: (1)excessive mobility, (2) root exposure due to distraction ofthe fracture, (3) tooth fracture with pulp exposure, and (4)caries with pulp exposure. The number of patients whodeveloped complications was 13.7 % in the “tooth re-moved” 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 MFscan be preserved when antibiotics are used prophylactically.
Oikarinen et al. [16] retrospectively evaluated MF patientswith 54 teeth in the fracture line. At the follow-up examina-tion, 18 (38 %) teeth had pulp necrosis, which was foundmore frequently in the older patients, in cases in which thetime elapsing between the injury and the follow-up waslonger, in cases in which the fracture line ran through theapex, and in cases with dislocation of the fracture after theinjury. The authors stated that a tooth lying in a MF line canbe saved in most cases and that such a tooth can serve as ananchorage and help to maintain the original occlusion.
When comparing open and closed reductions of theMAF associated with an impacted or partially eruptedLTM, Rubin et al. [34] found that the incidence ofcomplications in the open reduction group was 25 %,and in the closed reduction group, it was 20 %, show-ing no statistical significance. When comparing extrac-tion and retention of the tooth, the complication ratewas 19 and 23 %, respectively, also showing no statis-tical significance. There seemed to be a trend toward anincreased incidence of complications for those who weretreated with retention of the tooth combined with openreduction (complication rate 44 %). This treatmentshowed a higher incidence of complications when com-pared with retention of the LTM with closed reduction(20 %), with extraction of the LTM with closed reduc-tion (20 %), and with extraction of the LTM with openreduction (19 %).
Iizuka et al. [35] analyzed 214 patients with MFstreated by ORIF. Thirteen patients (6.1 %) developedpostoperative infection. All but one of the infectedfractures were in the angular region of the mandible.Teeth (second or third molars) had been extracted fromthe fracture line before the osteosynthesis procedure in9 of the 10 dentulous mandibles. The authors stated thatthis not only allows greater increase of oral contamina-tion but also reduces the stability even more. Moreover,they said that a tooth in the fracture line can give goodsupport when the fracture is reduced, and extraction ofthe tooth makes reduction difficult and decreases the
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cross-sectional surface of the fracture site. Thus, a toothshould probably not be extracted before the osteosyn-thesis is completed when rigid fixation is used. Finally,they stated that a tooth, even an impacted LTM, eithercan safely be retained or else extracted immediatelyafter the osteosynthesis.
Anderson and Alpert [36] reported a high incidence ofinfection (16 %) of the fracture sites. The authors attributedthis to involvement of teeth in the line of fractures and toimproper application of rigid fixation. All infections were infractures associated with teeth. In 18 instances, the teethwere removed before or at the time of reduction; this grouphad 6 of the 12 infections. In 29 fractures, the teeth wereretained; this group experienced the other six infections.Thus, 25.5 % of fractures associated with teeth becameinfected. No infection occurred in fractures fixed within24 h of injury. Eight of the 12 infections occurred in the26 fractures treated between 4 and 7 days post-injury. Onlythree of 33 managed within 72 h, and none of the 13 treatedwithin 24 h became infected. Five of 22 fractures treated byan extraoral approach became infected, compared with sev-en of 53 treated by an intraoral approach.
In the study of Berg and Pape [17], 13 of the 59 retainedteeth (22 %) in the line of fracture were found to be nonvital.Radiographic evidence of root resorption was observed in5 % of the patients. The author also evaluated the periodon-tal condition of teeth retained in the fracture line; 88 % ofpatients showed no increase in pocket depth around suchteeth when compared with the corresponding contralateraltooth. Concerning this, they concluded that there is no obviousreason why such teeth should show an increase in gingivalpocket depth after postoperative healing is complete.
Kamboozia and Punnia-Moorthy [7] conducted a verydetailed study, comparing the morbidity of permanent teethassociated with MFs treated with ORIF with those treatedwith MMF. Fractures involving LTMs were excluded. Sixty-three teeth (34 in ORIF group and 29 in MMF group) in theline of fractures were investigated; 68 % of teeth in the lineof fracture were in the ORIF group, and 41 % in the MMFgroup were nonvital, while 71 % of teeth adjacent to thefracture line were nonvital in the ORIF group, as comparedwith 14 % in the MMF group. Of the total of 35 nonvitalteeth in the whole group, 49 % were related to minimal, and51 %, to gross displacement of fractures. However, thefrequency of tooth vitality was closely related to the degreeof displacement between the fragments; out of 33 teeth inthe line of minimally displaced fractures, 17 teeth (52 %)were nonvital, and of 28 teeth in the line of grossly dis-placed fractures, 18 teeth (64 %) were nonvital. Two teethassociated with the hairline type of fracture were vital; 50out of 104 (total of adjacent and in the line of fractures) teeth(48 %) were found to be nonvital. None of them weresymptomatic; only 19 teeth in the whole group were found
to have small, chronic, apical, inflammatory lesions (18 %),and all of them were amenable to root canal therapy. Theresults showed a significant increase in nonvitality of teethin the line (P00.018) and adjacent (P00.0004) to the frac-tures of the mandible which were treated by ORIF, ascompared with MMF. The most common type of fractureline was the fracture which line follows the root surfacefrom the apical region to the gingival margin with denuda-tion of the root surface (55 %), and nonvitality of teeth wasmost frequently associated with this (65 %; 22 out of 34teeth) type of fracture. Despite these findings, the authorsrecommended retention of teeth associated with fracturelines unless there is an absolute indication for removal.
Oikarinen and Raustia [37] investigated whether teethleft in the line of MF could predispose to occlusal interfer-ences. They evaluated 37 patients, all treated by MMF. Agroup of 27 healthy dental students served as controls.Occlusal interferences were observed in 38 % of teeth inthe line of MFs, in 38 % of their anterior, in 32 % of theirposterior ones, and in 28 % of teeth of the control group.They concluded that the higher incidence of occlusal inter-ferences in teeth that were in the line of MFs could havebeen caused by the injury and/or its treatment. The authorssuggested that the interferences should be corrected withocclusal adjustment to prevent further pathological changesin these teeth and in the function of the masticatory system.
Haug and Schwimmer [38] correlated postoperativeinfections with the presence of a tooth in the fracture line.They identified 27 patients with 32 fibrous unions within apopulation of 714 patients with MFs. Of the 24 patients whowere surgically treated for their fractures, 21 had a tooth inthe line of fracture. Only five of these 21 patients (24 %) hadteeth removed at the time of the initial surgical procedure.Eleven of the 24 patients (46 %) developed a late postoper-ative infection. However, there was a high frequency ofsocial or medical risk factors between these patients, whichmay also have influenced the high incidence of postopera-tive infection. Nevertheless, the authors suggested that teethin the line of fracture should always be removed and thatORIF is the better option of treatment in these cases.
Koenig et al. [39] evaluated 30 pediatric patientswith 45 MFs, and 15 (33 %) of these fractures involved16 non-erupted teeth. Normal eruption was exhibited by82 % of the tooth buds in the line of MF. The other18 % exhibited either delayed eruption or non-eruptionwith resorption of the tooth bud.
Marker et al. [18] evaluated the viability of retainedLTMs 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; thisoccurred roughly 5 weeks after fixation in all three. In allthree cases, the infection was treated with an antibiotic for
Oral Maxillofac Surg (2014) 18:7–24 17
approximately 14 days, and no surgical treatment was re-quired. The 46 patients available at 1-year follow-up showedno cases of pseudoarthrosis, and no abnormalities were pres-ent around the roots of the involved LTMs. Although theauthors stated that the closed treatment regimen adopted pro-duces good healing and less morbidity compared with cases inwhich ORIF is used and movement of the jaws permittedimmediately, they did not performed ORIF treatment in theirstudy in order to make a comparison.
Thaller and Mabourakh [40] found that neither the loca-tion of the fracture nor retention or extraction of the toothhad a statistically significant effect on the success rate ofsurgical repair. There was little difference in the outcome offracture management whether the teeth were routinelyextracted or retained as long as ORIF was employed forstabilization 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 condi-tion (two); tooth seriously damaged by caries (two); andpartially or totally impacted wisdom tooth evaluated as anobstacle to reducing the fracture (two). Eleven fracture sitesgave rise to complications in nine patients; four patientsdeveloped infection requiring extended hospitalization withantimicrobial treatment; four developed wound dehiscence,and one, malocclusion. The complications observed were in3/12 fractures in which the tooth was extracted and in 8/78when the tooth was retained. At follow-up of the 78 fracturesites where the teeth had been kept at surgery, eight teethhad subsequently been extracted; 19 had been subjected toendodontic treatment because of loss of vitality or infection,and tooth mobility was seen in further four cases. Theoverall incidence of complications revealed no statisticalcorrelation with management of the tooth in the line offracture, degree of displacement, and time elapsed betweentrauma and treatment. It is of the author’s opinion that“prophylactic” extraction of teeth in the line of fractureshould be avoided when plates and screws are used.
Atanasov and Vuvakis [42] conducted a retrospectivestudy of patients with 650 MFs crossing the LTM. Theresults showed no statistically significant difference in thecomplication frequency associated with the extraction ofunerupted or erupted wisdom teeth (12.50 and 8.37 %,respectively). In treatment of fractures with retention of thewisdom tooth in the fracture line, the complications with thetotally erupted LTMs were more frequent than those withunerupted LTMs (20.70 vs 7.69 %, P<0.001). In patientssubmitted to ORIF, 20 and 24.13 % of them showedcomplications in cases with unerupted and erupted teeth,respectively. With conservative treatment (CTR), the com-plications were 7.30 % with the unerupted and 11.33 % withthe erupted wisdom teeth. Thus, a higher complication ratewas observed in patients treated by ORIF in comparison
with patients treated by CTR, regardless of the position ofthe tooth.
Ellis [19] examined the relationship between postopera-tive infection and/or need for plate removal with the pres-ence and management of teeth in the line of MAFs. Of the345 teeth in the line of fracture, 258 (75 %) were extractedduring the surgery to repair the fracture. Postsurgical infec-tion occurred in 19 % of the fractures, the same percentageof cases in which removal of internal fixation hardware wasrequired. The incidence of infection in patients, who had notooth associated with the MAF, was 15.8 % compared with19.1 % in those who did. For fractures associated with atooth, when the tooth was retained, the incidence of infec-tion was 19.5 % compared with 19.0 % when the tooth wasremoved. Both were not statistically significant. The sameoccurred when the incidence of hardware removal wasrelated to the presence or absence of tooth in the line offracture or to the removal of maintenance of teeth.
Baykul et al. [20] analyzed the records of 117 patients with121 MFs, having an unerupted tooth remaining in the fractureline. Time between injury and treatment made no difference inthe results. No nonunion or malocclusion was observed. Theauthors are of the opinion that removal of asymptomaticimpacted teeth is an additional trauma, allowing displacementof fragments as well as increased infection risk.
Vladimirov and Petrov [21] investigated the associationbetween various factors and the decision to extract or pre-serve the tooth. Teeth in/with the following situations weresignificantly extracted more often; if a local preoperativeinfection was present, the time from trauma to treatment wasmore than 72 h; there was a significant displacement of thefracture; the dental root was fractured; periapical pathologyor periodontal disease was present; the tooth was multi-rooted (first or second molar), completely erupted LTM; ortreatment consisted of ORIF.
Suei et al. [43] evaluated in a long-term radiographicfollow-up records of patients with MFs involving toothbuds. Abnormal findings were observed in 30 of 66 devel-oping teeth (45 %; in 21 patients); these included deficientroot formation, abnormal bend of the root, nodule formationon the root, partial obliteration of the pulp cavity, impaction,growth arrest, and external resorption. No relationship wasfound between the occurrence of abnormalities and thedevelopmental stage of tooth buds at the time of the injuryor the degree of displacement of the fracture line. However,infection, rotation of the tooth bud, and a surgical wirepassing through the follicular space were associated witharrested growth and impaction.
Malanchuk and Kopchak [22] observed that a tooth in theline of the fracture had no significant influence on the infec-tion rate—infection occurred in 25 % of the patients with atooth in the fracture line and in 22 % of the patients withfractures located in the edentulous parts of the tooth-bearing
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area. Accompanying pathological disorders also contributedto the infection rate. The statistical analysis indicated thatdelayed medical care and preexisting medical disorders werethe strongest predictors for infection development. The infec-tion rate was 42.7 % in the patients with a preexisting diseasevs 22.4 % in the others.
By means of a questionnaire, Donker et al. [44] collectedinformation about how 102 dental surgeons in the Nether-lands deal with teeth in the line of MFs. Generally, therespondents strove to preserve a tooth in the MF line. Onlyin case of a LTM in the fracture line and in case of fracturetreatment in a child there was a small group who opted forremoval of the teeth in the fracture line. The main reason tomaintain the tooth in the fracture line was for easier fixation/stabilization of the fracture sections. The small group ofrespondents, who chose to remove the tooth, gave “lesschance of posttraumatic infection” as the main reason. Therespondent’s choice of treatment did not depend on age,gender, university clinic at which the respondent was trainedto be a dental surgeon, year of registration as a specialist,place of work, and position.
The results of Ramakrishnan et al. [45] showed that arevision surgery was necessary in 28.9 % of the fractureswith molar tooth involvement compared to 12.9 % when notooth was involved (P00.084). Moreover, when a tooth wasinvolved in the fracture, the revision surgery rate was 25 %when it was removed and 30 % when it was preserved (P00.734). Both comparisons showed that postoperative com-plications may not increase by involvement of LTMs in thefracture line. Removal of the tooth had no effect on the rateof minor complications or the rate of secondary surgery.
In the study of Samson et al. [46], of the four patientswho presented with no pulp vitality response in the teeth inthe fracture line presurgically, three had their teeth in thefracture line extracted between 4 and 6 weeks after surgeryas the fracture sites were infected. The authors suggestedthat a tooth that shows no response on pulp vitality testingshould be advised for extraction to avoid further complica-tions in patients presenting with MF.
Yamamoto et al. [23] presented three cases of severelydislocated mandibular symphyseal fractures in infants. Thefractures were treated by manual reduction and fixationusing a splint and circumferential wiring and healed un-eventfully in all patients. In one patient, a crown malforma-tion was observed in one central incisor. In another patient, aroot formation was arrested in one of the permanent teeth onthe fracture line. This tooth was subsequently lost early aftereruption. The remained patient did not have any complica-tions. As the fate of the permanent tooth buds was differentin each case, the authors stated that the development of toothbuds on the fracture line is not predictable.
Mangone et al. [47] evaluated 48 patients presenting aLTM in the line of MAFs. Of the 48 teeth in the line of
fracture, 14 were removed at the surgery. Moreover, threeteeth were subsequently removed (two due to infection andone due to malocclusion). At the follow-up, 15 teeth pre-sented no pulp vitality response, and 10 teeth showed radio-logical signs of apical resorption.
In a prospective study, Rai and Pradhan [48] compared twogroups of patients with a LTM in the line of aMAF. There wasa higher incidence of pain/tenderness after 12 weeks in thegroup in which the tooth was preserved. The presence ofinfection was higher in this same group till the sixth week.The difference was not significant after the sixth week till theend of 2 years of follow-up. A total of eight out of 30 teethwere diagnosed nonvital preoperatively. Six out of these eightnonvital teeth showed a slow return of vitality, whereas twoshowed no sign of vitality at the end of 24 weeks.
Discussion
What to do with tooth buds directly involved in the lineof mandibular fractures?
The fate of tooth buds (the developing teeth within the toothfollicles) that are directly involved in fractures of the jaw isan important matter of concern. The impaction or markeddeformation of the affected teeth which sometimes resultsfrom such injuries can cause esthetic and functional distur-bances of the dentition. In some cases, repeated monitoringmay be necessary throughout the entire period of toothdevelopment [23] to ensure that surgical, orthodontic, orprosthetic treatment is provided at the appropriate time [43].
Some studies reported a high incidence of abnormalitiesin developing teeth involved in fractures, such as 55 % (21of 38 teeth) [49], 51 % (19 of 37) [50], and 45 % (30 of 66teeth) [43]. However, the incidence of impaction was rela-tively low (0–16 %) in these studies. Although the incidenceof abnormalities was relatively high, most of the abnormal-ities did not have significant deleterious effects on thedentition. Ranta and Ylipaavalniemi [50] pointed out thatteeth in which root development had already started at thetime of fracture appear to erupt normally. This may occurdue to the fact that the developing follicle is more elasticthan the surrounding bone and better able to survive me-chanical injury [39]. However, Ranta and Ylipaavalniemi[50] also observed that marked deformation of the crownand roots occurred in teeth located on the fracture line whencalcification of the crown was still in progress at the time ofthe fracture. In contrast, Suei et al. [43] observed no rela-tionship between the occurrence of abnormalities and thedevelopmental stage of tooth buds at the time of the injury.Even tooth buds in the early stage of calcification and thoseinvolved in widely displaced fracture sites continued devel-opment and erupted. Thus, it may be suggested that tooth
Oral Maxillofac Surg (2014) 18:7–24 19
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 worthmentioning an important remark made by Krømer [24]60 years ago; a permanent tooth germ situated in the lineof fracture should not be removed without strong reasons,provided that reduction is not obstructed, and early and rigidfixation is performable.
Therefore, it is difficult to predict the fate of tooth budsbased on an evaluation of the condition of the tooth buds andthe fracture. The presence of infection, however, is a predic-tive factor of abnormality [43]. Of three infected teeth in thestudy by Lenstrup [49], two were embedded, and one wasextracted. Of the four infected teeth in the study of Suei et al.[43], three exhibited arrested growth, and two were embed-ded. Considering these observations, Suei et al. [43] suggestedthat odontogenic cells in the dental follicle have a tolerance formechanical stress but are severely damaged by infection.Thus, the importance of antibiotic prophylaxis in cases offractures should be emphasized, not only to achieve successfulhealing of the injured soft tissue and bone but also tosustain the development of the involved tooth buds [51].
MFs that occur during mixed dentition can be associatedwith subsequent failed eruption of permanent teeth when thefracture line is reduced using an open surgical approach[52]. Nixon and Lowey [52] reported two cases of impactionassociated with a miniplate and a wire that were placed forthe treatment of fractures. Sueli et al. [43] reported impac-tion in one tooth bud in which a surgical wire had passedthrough the follicular space. However, Suei et al. [43] statedthat careful surgical procedures can prevent impaction of theteeth in most cases.
What to do with third molars directly involved in the lineof mandibular angle fractures?
Regarding the adult mandible, MAFs deserves an importantconsideration. Because the mandibular angle is one of themost frequent sites for fractures of the jaw [1–6], impactedmolars have received special attention [53]. There has beena debate about the most appropriate treatment for thosefractures when the teeth are present. Should they beretained, or should they be removed? There is no consensuson this question.
Krømer [24] was the first to analyze this issue, and hestated that as MAFs offer great problem of fixation, the useof antibiotics may be justifiable to keep a tooth in the line offracture when this is needed for the immobilization of theposterior fragment. Krüger [54] recommended that a com-pletely unerupted LTM be left in the fracture line if it is notopen to the oral cavity and if it does not impede the reduc-tion of the fragments, a suggestion that many surgeonsfollow until today. Wagner et al. [32] reinforced this
suggestion. From their results, it appeared to be an increasedincidence of those complications in MAFs with teeth in theline of injury when the teeth were extracted in conjunctionwith extraoral open reduction. However, Atanasov andVuvakis [42] showed no statistically significant differencein the complication frequency associated with the extractionof unerupted or erupted wisdom teeth, although a highercomplication rate was observed in patients treated by ORIFin comparison with patients treated by CTR, regardless ofthe position of the tooth.
Wolujewicz [33] tried to find a correlation between thetype of impaction of the LTM and the direction and dis-placement of lines of fracture in this region. The authorsuggested that vertically impacted LTM in the line of frac-ture should be removed because these cases require moreelaborate methods of treatment in order to properly reduce,stabilize, and fixate the fracture. On the other hand, thoseLTMs which are in a horizontal or mesioangular orientationin an undisplaced angular fracture should be retained be-cause they appear to stabilize the fracture. Baykul et al. [20]agreed with Wolujewicz’s [33] observation and stated thatthe forces applied during the surgical removal may causedisplacement of the fragments although they are appliedcarefully. Baykul et al. [20] also stated that removal of thebone in the fracture line may reduce the contacting bonesurfaces between the fragments. Thus, this condition mayincrease the secondary healing surfaces and may lead todelayed healing.
Some studies demonstrated no differences in postopera-tive complications related to the retention or extraction ofLTMs in the line of MAFs. When comparing extraction ofthe 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 atrend toward an increased incidence of complications forthose who were treated with retention of the tooth combinedwith open reduction. Although Marker et al. [18] stated thatthe closed treatment produces good healing and less mor-bidity compared with cases in which ORIF is used andmovement of the jaws permitted immediately, they did notperformed ORIF treatment in their study in order to make acomparison. In the study of Ellis [19], the incidence ofinfection in patients who had no tooth associated with theMAF was 15.8 % compared with 19.1 % in those who did.Their results also indicated that the risk of infection andneed for hardware increase when there is a tooth present inthe fracture line, but the increase in risk is not statisticallysignificant. Ramakrishnan et al. [45] showed that postoper-ative complications may not increase by involvement ofLTM in the line of MAFs. The authors stated that involve-ment of LTMs in the fracture line may not be solely heldresponsible for relatively common infectious or hardware-related complications seen after the treatment of MAFs.
20 Oral Maxillofac Surg (2014) 18:7–24
They still stated that there might be other possible contrib-uting factors involved in the development of postoperativecomplications in this particular location such as bone qualityand thickness, biting forces, nutritional oral hygienic statusof the patient, and patient compliance.
On the other side, when there are impacted LTMs withpericoronal infection, these should be removed. It is highlyprobable that significantly higher complication rates wouldbe observed if fractured, carious, grossly infected, or looseLTM involved in MAFs is retained instead of removed [45].However, some authors [17, 41] suggested that impactedwisdom teeth (even if infected at the surgery) may beextracted once healing is complete, possibly at the time ofremoval of the miniplate 3 months after fracture reduction.Ellis [19] made an interesting comment, saying that becausemost teeth in the line of a MAF are nonfunctional LTMs, hedid not make an effort to retain such teeth whose apiceswere exposed to the fracture. Thus, the criteria for extractionmay be therefore more aggressive for MAFs than for otherregions of the mandible.
Thus, it should be suggested by the literature reviewthat impacted LTMs, especially complete bony impac-tions, should be left in place to provide a larger repo-sitioning surface. Exceptions are non-erupted teeth,making reduction of fragments difficult or impossible,and partially erupted LTMs with pericoronitis or asso-ciated with a follicular cyst [55]. There is anotherpossible exception. When ORIF of a MAF is needed,the presence of an impacted LTM influences the posi-tioning of bicortical screw or plate fixation, limiting theareas for placement of screws or plates [56]. Thus, theremoval of the LTM may be necessary because, unfor-tunately, the configuration of the screw placement orscrews placed in areas of thin bone can lead to poorfixation [57]. Where extraction is indicated, osteosyn-thesis may first be completed, and the tooth subsequent-ly be extracted, unless it forms an obstacle whenreducing the fracture [35, 41]. It is difficult to say ifWolujewicz’s [33] orientations should be followed as arule because the type of impaction is not the only afactor of evaluation to be considered in these cases.One important observation to make here is that patientswith MAFs involving a LTM should be counseled prop-erly in the preoperative period about the chances ofhaving additional surgical intervention(s) regardless ofthe LTM involvement or selective removal of the in-volved teeth [45].
When teeth in the line of mandibular fractures shouldbe maintained?
There are some situations in which it is suggested that teethin the line of MFs should be maintained. Intact teeth in the
fracture line should be left in situ if they show no evidenceof severe loosening or inflammatory change. Moreover,teeth that appear nonvital at the time of injury should betreated conservatively, keeping in mind their potential forrecovery and their importance in simplifying fracture treat-ment and subsequent prosthodontic rehabilitation [55].Teeth with small periapical lesions, which may be givenendodontic treatment in the early phase or extracted oncehealing is complete, may be conserved [41]. Ridell andÅstrand [28] also stated that many of the teeth classified asunsuccessful which had periapical lesions and minor mar-ginal bone pockets may become fully functional by ade-quate treatment.
Several authors found a smaller rate of infection/compli-cation when a tooth in the fracture line was retained, com-pared when a tooth was prophylactically removed [14, 26,27, 30, 32, 36, 41], or small complication rates when theteeth were retained [12]. In contrast, some studies observeda smaller rate of infection/complication when a tooth in thefracture line was removed, compared when a tooth wasprophylactic retained [15, 19, 34], but not statistically dif-ferent. Some others found no difference [40, 45]. Malan-chuk and Kopchak [22] showed that tooth in the line of thefracture had no significant influence on the infection ratewhen compared with fractures located in the edentulousparts of the tooth-bearing area. Ramakrishnan et al. [45]showed that postoperative complications may not increaseby involvement of LTM in the line of MAFs. All theseprevious results favor the belief that teeth in the line offracture should not be extracted. Others believed that con-servatively treated teeth involved in the line of MFs have afavorable prognosis, especially if optimal reduction of thefragments is achieved [13]. Moreover, some authors statethat extraction of the tooth entails further trauma to bonetissue and also presents technical difficulties when the frag-ments are highly mobile. Stabilization of a fracture is unfa-vorably influenced by extraction of teeth, which may helpthe treatment by providing a posterior stop, by permittingproper alignment of the dental arch, and by preventingcollapsing or telescoping of the fragments [30, 55]. In addi-tion, certain teeth might be considered strategic in the finalrestorative plan [30].
The implementation of antibiotic treatment certainly fa-vored more conservative treatments with respect to the teethin the fracture line. In the pre-antibiotic era, many teeth inthe line of fractures were removed to prevent the devastatingconsequences of osteomyelitis and nonunion. Recommen-dations in the post-antibiotic era have been on the conser-vative side, retaining teeth when possible [19]. A number ofstudies [11–23] have indicated that the routine use of anti-biotic treatment in cases of compound fractures also reducesthe frequency of complications in cases of fully eruptedpermanent teeth in the line of fracture. In order to increase
Oral Maxillofac Surg (2014) 18:7–24 21
oral hygiene, the patients may also rinse their mouths twicea day with a 0.2 % chlorhexidine solution for at least 7 days.
Ryberg [58] considered early treatment with complication-free stabilization of the fragments an important prerequi-site for avoiding fracture infections. Supportive antibiotictherapy was certainly advantageous but did not have thesame value as the early treatment of the fracture.Ryberg’s investigations showed that the earlier the frac-ture was immobilized, the better were the chances forpreservation of a tooth lying in the fracture line. Otherstudies showed that treatment of MFs within 48 h has abetter prognosis for the teeth in the line of fracture [11,24, 58]. However, more recent studies [20, 41] demon-strated that the overall incidence of complicationsrevealed no statistical correlation with the time elapsedbetween 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 endodontictreatment?
There are some observations concerning the need offuture endodontic treatment of teeth located in the lineof MFs. The findings of Kamboozia and Punnia-Moorthy[7] suggest that when the fracture line follows the rootsurface from the apical region to the gingival marginwith denudation of the root surface and when the toothis located in grossly displaced fractures, there is a highprobability (65 and 64 %, respectively) of future endo-dontical treatment of the tooth involved. However, in thestudy of Kahnberg and Ridell [13], 23 % of the teethwhich responded negatively to electric stimulation at thetime of injury showed positive sensibility after a varyingtime period after fracture healing. Thus, a follow-up ofabout 1 year would be sufficient to allow for the return oftemporary loss of vitality, thus ensuring that any unnecessaryendodontic treatment is avoided [13, 48].
Kamboozia and Punnia-Moorthy [7] demonstrated thatthe incidence of nonvitality of teeth associated with MFswas significantly higher with ORIF than with MMF. Theauthors stated that the most likely reasons for such anincrease in tooth nonvitality with plating are the open natureof the procedure in which the fracture site is completelyexposed by the elevation of a mucoperiosteal flap and theincreased degree of manipulation of fragments which isgenerally required to achieve precise anatomic reduction ofthe fracture. Additionally, a screw placed near the apex ofthe root of the tooth and mandibular canal might damage theinnervation or blood supply to the teeth [7].
Although teeth whose apices were exposed to the fracturesite can then be managed with endodontic treatment orselective extraction, the some patient population may nothave ready access to such therapeutic measures [19]. Thus,
the removal of teeth in the line of MFs in such situationsmay be the best option for the patient.
In which situations teeth in the line of mandibular fracturesshould be removed?
On the other side, there are also some situations in which itis suggested that teeth in the line of MFs should be removed.According to the literature, the following are the main con-ditions that suggest that teeth in the line of fracture shouldbe removed:
1. Teeth that prevent reduction of fractures [12, 14, 18, 36,41, 47, 55];
3. When there is extensive periodontal damage, with bro-ken alveolar walls, resulting in the formation of a deeppocket (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 thetooth with extensive exposure of the root/apex [12, 14, 18];
7. Poor general medical status of the patient with acute andchronic alcoholism and drug abuse, as well as associat-ed poor hygiene [40].
How much the mobility of the fragments affects the post-fixation infection rate when there is involvement of teethin the line of fractures?
There is another issue that must be analyzed carefully. Manyof the previous reviewed studies treated MFs by MMF andwire osteosynthesis. The result was a semirigid fixation thatallows slight movement of the fragments due to muscularactivity [59]. There is increased susceptibility to infection inthe damaged region if absolute immobility is not maintainedacross the fracture line [60]. Anderson and Alpert [36]attributed the high incidence of infection of the fracture sitesin their study due to improper application of rigid fixation(and involvement of teeth in the line of fractures). Thisimmobility takes on particular importance in the mandiblebecause all fractures in the dentulous region are contami-nated with bacteria. The attached gingiva, which is firmlyconnected to the periosteum, tears at the slightest displace-ment of the break. Any small movement of the fragmentsalso causes saliva, which is high in bacterial content, to bepumped into the fracture gap. A mobile tooth in this com-promised region increases the danger of infection [55].Thus, the rates of infection demonstrated by some of the
22 Oral Maxillofac Surg (2014) 18:7–24
studies reviewed here, caused by teeth in the line of fracturewhich has been maintained after reduction, would not havebeen as high if the fracture had been treated with ORIF(plates) instead of semirigid fixation (MMF and wire osteo-synthesis). This reflects in a growing acceptance of the factthat susceptibility to infection is directly dependent on themobility of the fragments.
Conclusions
It is suggested that rigid fixation systems and the use ofantimicrobial agents have reduced the incidence of infectionin cases of teeth in the line of MFs. Although no randomizedcontrolled clinical trials were conducted to test the influenceof antibiotic use in the incidence of infection in MFs linesbearing teeth, it is suggested that antiseptic mouthwash(0.2 % chlorhexidine for at least 7 days) and antibioticprophylaxis may be important treatment adjuvants.
Tooth buds in the line of MFs should not be removed orreplaced in the (alleged) proper position despite of thedegree of displacement, since studies showed that eventooth buds in the early stage of calcification and thoseinvolved in widely displaced fracture sites continued devel-opment and erupted. In cases of infection, its removalshould be considered, since the presence of infection is apredictive factor of abnormality and/or impaction.
Fully erupted permanent teeth associated with MF shouldnot be removed on a prophylactic basis to reduce the risk ofinfection of fracture sites. Intact teeth in the fracture lineshould be left in situ if they show no evidence of severeloosening or inflammatory change. Permanent teeth main-tained in the line of fracture should be followed up clinicallyand radiographically for at least 1 year to ensure that anyunnecessary endodontic treatment is avoided, unless anacute apical inflammatory lesion appears.
The decision to extract teeth must be taken individually onthe basis of the clinical situation. Teeth in the line of fracturewhich prevent reduction of fractures, teeth with fracturedroots, a partially impacted wisdom tooth with pericoronitis,and a tooth with extensive periapical lesion should be re-moved. Teeth in the line ofMFs should also be removed whenlocated in sites where there is extensive periodontal damage,with broken alveolar walls, resulting in the formation of adeep pocket (making optimal healing doubtful).
Acknowledgments This work was supported by CNPq, ConselhoNacional de Desenvolvimento Científico e Tecnológico, Brazil. Theauthor would like to thank Dr. Kyösti Oikarinen, Dr. Per Åstrand, 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 theirarticles.
Conflict of interest None.
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