In 1989, Shetty and Freymiller [7] reviewed indications for removal of teeth in the line of fracture. They recommended the following indications: 1. Significant periodontal disease with gross mobility and periapical pathology 2. Partially erupted third molars with pericoronitis or cystic areas 3. Teeth preventing the reduction of fractures 4. Teeth with fractured roots 5. Teeth with exposed root apices or teeth in which the entire root surface from the apex to the gingival margin is exposed 6. Excessive delay from the time of fracture to the time of definitive treatment In addition to these indications, another indication that requires extraction of teeth in the line of fracture is an acute, recurring abscess at the site of the fracture despite antibiotic therapy(8)

2. Journal presentation
Department of Oral & Maxillofacial Surgery
New Horizon Dental College & Research Institute
Presented By:
Dr Kamini Dadsena

3. Teeth in the Line of Mandibular
Fractures
Gaetano Spinnato, DMD, MD*, Pamela L. Alberto, DMD
Atlas Oral Maxillofacial Surg Clin N Am 17 (2009) 15–18

4. History
In 1975, Canaro agreed with Kruger, Archer, and Rowe that each case should be
decided on its own merit; however, Clark, Ivy, and Thoma recommended the
removal of teeth within a fracture line [1].
Proponents for removal of teeth adjacent to a fracture line believe that these
teeth can potentially become a source of infection and be detrimental to a
successful outcome of mandibular fracture treatment.
Many surgeons hold the opinion that the only complication with leaving these
teeth is infection; however, many of the teeth can be retained with the proper
use of antibiotic therapy [1,2].
Canaro described the prophylactic removal of teeth leading to other problems,
including allowing greater communication of the fracture site with the oral
cavity and further distraction of the fracture segments.

5. Extraction of these teeth also could lead to secondary
displacement of the fractures, problems with
immobilization of fragments, and the need for
intraosseous fixation.
Canaro’s reason, along with the opinions of other
surgeons, for maintaining these teeth is that they may
allow easier methods of treatment. This would avoid
the need for an open reduction and the potential
complications associated with this surgery.
Many surgeons agree that teeth that are hopelessly
mobile or fractured or complicate the reduction of the
fracture should be removed.
History

6. Canero believes that if certain conditions are met, teeth
in the line of fracture can be preserved. The conditions
for maintaining teeth in the line of fractures include
maintaining antibiotic therapy, strict oral hygiene,
radiologic and clinical monitoring for evidence of
periapical infection and pulp necrosis, and endodontic
therapy for teeth that require treatment.
De Amaratunga stated that teeth in the line of fracture
could be salvaged if proper fixation techniques were
used along with antibiotic coverage [3].
History

7. Review of current studies
In 2000, Spina and Marciani listed the following pitfalls in making decisions
regarding leaving teeth in the line of fracture [4]:
(1) not treating teeth with pulpal involvement or periapical pathology,
(2) maintaining teeth that can become symptomatic and necrotic and can infect
the fracture site, and
(3) routinely extracting teeth in the fracture line to reduce fracture repair
morbidity.
They advocated considering the retention of teeth with a guarded prognosis if
they are useful for reduction or stabilization of the fracture.
Ellis found virtually no difference in the incidence of infection when teeth were
left in the line of fracture or extracted [5].
Similar conclusions were made by Chuong and colleagues [6] during their studies.

8. Indications for removal of teeth in the
line of fracture
In 1989, Shetty and Freymiller [7] reviewed indications for removal of teeth in
the line of fracture. They recommended the following indications:
1. Significant periodontal disease with gross mobility and periapical pathology
2. Partially erupted third molars with pericoronitis or cystic areas
3. Teeth preventing the reduction of fractures
4. Teeth with fractured roots
5. Teeth with exposed root apices or teeth in which the entire root surface
from the apex to the gingival margin is exposed
6. Excessive delay from the time of fracture to the time of definitive
treatment
In addition to these indications, another indication that requires extraction of
teeth in the line of fracture is an acute, recurring abscess at the site of the
fracture despite antibiotic therapy(8)

9. Use of antibiotics
• It is generally accepted by most surgeons that
antibiotic therapy should be administered when
teeth are left in the line of fracture because of
open nature and contamination of the oral cavity.
• Penicillin is still considered the drug of choice.
Many practitioners recommend a 5-day course of
antibiotics;
• However, one author advocated antibiotics
preoperatively and 24 hours after reduction,
which may be as effective as a 5-day course of
antibiotics [9].

10. Discussion

11. conservative treatment
First, author think that the only danger that exists when we leave a tooth in the
fracture area is infection, and he believe that the therapeutic means we have
today enable us to prevent and fight against infection.
Second, author believe it is potentially more dangerous to extract a tooth and allow
wide communication of the fracture area with the oral cavity, even if the tooth is
nonvital, whether as a consequence of trauma or of a pre-existing pathologic
process. In those cases, endodontic and other treatments may overcome the
problems inherent in retention of a nonvital tooth.
Third, author do not agree with other authors that advise the “prophylactic
extraction” of teeth with several roots because of the difficulties in treating these
endodontically. Specialists in this field have been able to obtain noteworthy results
even in these cases.
Archer HW. Oral and maxillofacial surgery. 5th Edition. Philadelphia: WB Saunders; 1975. p. 1069–73.

12. conservative treatment
Fourth author also disagree with those who apply “prophylactic
extraction” based on the “traumatic injury’ suffered by the dental
pulp, because it is observed that the dental pulp sometimes
recovers from this injury. Even when it fails to survive, it usually
remains without producing any infection during the period of time
it takes the fracture to heal, after which endodontic treatment may
be carried out.
Fifth, author had the opportunity of observing patients treated by
colleagues who insist on extraction and have noted that their
luxation of the tooth, particularly in the region of the mandibular
third molar. resulted in the displacement of the posterior fragment.
This forces the surgeon to use extraoral means of treatment or
intraosseous wire fixation.
Archer HW. Oral and maxillofacial surgery. 5th Edition. Philadelphia: WB Saunders; 1975. p. 1069–73.

13. conservative treatment
Sixth, the space left by the extracted tooth may be the starting point of an
imperfection in the immobilization of the fragments. or it may produce
secondary displacements, which are sometimes diflicult to correct. The
fracture lines are not always vertical, and they may even be horizontal in
many cases.
The part of the fracture line that affects the external cortex of bone may also
be related to a tooth. while the inner line may be related to another tooth
or other teeth. These latter teeth may also have injuries or periapical
lesions that are in the fracture area.
If we follow the counsel of those who advise extraction because “the naked
root allows infection to reach the interfragmentary area.“ we may then
find that we must extract a good number of teeth from bony segments in
comminuted fractures of the jaw. This results in the loss of much bone.
Among the consequences we must not forget the prosthetic future of the
patient, as we considerably diminish the height of his alveolar ridges.
Archer HW. Oral and maxillofacial surgery. 5th Edition. Philadelphia: WB Saunders; 1975. p. 1069–73.

14. conservative treatment
Seventh, in some cases might accept the advice of the
French authors who indicate a delayed extraction when
the callus is being established, in order to produce an
“osseous crystallization“ This procedure must not be
routine and must be used only when the problem
cannot be resolved by one of the means already
mentioned.
Eighth, author must point out that the so-called
pathologic fractures-i.e., those produced when there is
a predisposing cause-are not considered here, since
special problems arise.
Archer HW. Oral and maxillofacial surgery. 5th Edition. Philadelphia: WB Saunders; 1975. p. 1069–73.

15. conservative treatment
Ninth, author accept extraction when the teeth involved are
hopelessly mobile or otherwise complicate reduction of the
fracture, for example, those with advanced periodontal disease.
Only teeth decidedly useless for the fixation and stabilization
procedures should be extracted. He must emphasize that in some
cases, teeth that have been displaced have been replaced because
they would be very useful for the recovery of occlusion or to guide
in the future reconstruction of alveolar ridges.
Tenth the teeth that do remain. even those in the fracture area. may in
many cases bring about the use of easier methods, thus making it
possible even to avoid surgical intervention and its risks,
troublesome postoperative complications and prolonged
hospitalization of the patient.
Archer HW. Oral and maxillofacial surgery. 5th Edition. Philadelphia: WB Saunders; 1975. p. 1069–73.

16. Summary
• Current studies reinforce the idea that each fracture case should be
treated on its own merits.
• The routine prophylactic removal of teeth in the line of fracture
should be avoided to reduce potential fracture repair morbidity
[10,11].
• Strong consideration should be given to retaining teeth, especially
impacted third molars not communicating with the oral cavity,
which can prevent the displacement of a posterior segment or help
register the occlusion accurately in the symphyseal area [12].
• Finally, some studies have shown an increased rate of infection by
50% in fracture cases treated without antibiotics, whether treated
with a closed or open reduction.
• Antibiotics should be considered prophylactically in the treatment
of all compound/open mandibular fractures [13,14].

17. Conclusion
Teeth related to fracture area must be preserved under following conditions:
1. Long-term radiographic follow-up must always be performed, with special
attention to monitoring the pulp’s vitality, its evolution if it is a growing
element or its contribution to periapical infection or if it dies. In the latter
case endodontic treatment is indicated.
2. Antibiotic treatment, without exception, must be carried out, since this is an
area in which the constant menace of oral sepsis exists. Most jaw fractures
cause a tearing of the oral mucous membrane, thus opening an access for
penetration of saliva through the wound to the fracture area itself. This is why
author disagree with those who have recommended retention of teeth on the
fracture line without simultaneous antibiotic therapy.
3. Strict oral hygiene for all patients must be enforced, particularly during the
immobilization period. This must be taken into account, since the majority of
patients have had very poor hygienic habits.
Archer HW. Oral and maxillofacial surgery. 5th Edition. Philadelphia: WB Saunders; 1975. p. 1069–73.

18. Conclusion
4. Every tooth that can be proved to be vital must be preserved, while
radiographic vigilance and restoration of damaged crowns are
simultaneously carried out.
5. If, after a reasonable amount of time, a tooth is proved to be nonvital,
endodontic therapy must be instituted.
6. Radiographic examination should also be used to follow those teeth that
had already undergone endodontic treatment prior to fracture, thus
guarding against periapical infections.
7. For teeth with pre-existing periapical infection, endodontic treatment
must,be started as soon as the immobilization procedures will allow it. As
a last resort, delayed extraction may be utilized.
8, When the apical third of the tooth is fractured, we advise conservation of
the tooth, with endodontic treatment and apicoectomy, if indicated, after
healing of the fracture
Archer HW. Oral and maxillofacial surgery. 5th Edition. Philadelphia: WB Saunders; 1975. p. 1069–73.

19. Conclusion
• The Disadvantages These unfavorable effects include
allowing the entrance of microorganisms, or the movement
of pre-existing ones from the periapical area (e.g., in
chronic gingivitis), into the fracture area. This finally
produces infection in the area, thus delaying the healing.
• However, the presence of teeth may also be Advantageous
in preventing shifting and sliding of fragments of fracture.
This is true particularly in fractures of the angle, where a
tooth may act as a pin between two fragments.
Additionally, the isolated tooth in a fragment of fracture
can help to maintain the patient’s occlusion, which
ultimately may permit complete restoration of function.
Archer HW. Oral and maxillofacial surgery. 5th Edition. Philadelphia: WB Saunders; 1975. p. 1069–73.

20. References
• [1] Gustave O, Kruger GO. Textbook of oral and maxillofacial surgery. 5th
Edition. St. Louis: Mosby; 1979. p. 376–8.
• [2] Archer HW. Oral and maxillofacial surgery. 5th Edition. Philadelphia:
WB Saunders; 1975. p. 1069–73.
• [3] de Amaratunga NA. The effect of teeth in the line of mandibular
fractures on healing. J Oral Maxillofac Surg 1987; 45:312.
• [4] Fonseca RJ. Oral and maxillofacial surgery. Philadelphia: WB Saunders;
2000 p. 127–9.
• [5] Ellis E, Moos KF, El-Attar A. 10 years of mandibular fractures: an
analysis of 2,137 cases. Oral Surg Oral Med Oral Pathol 1985;59:120–3.
• [6] Chuong R, Donoff RB, Guralnick WC, et al. A retrospective analysis of
327 mandibular fractures. J Oral Maxillofac Surg 1983;41:305.
• [7] Shetty V, Freymiller E. Teeth in the line of fracture: a review. J Oral
Maxillofac Surg 1989;47:1303–6.

21. References
• [8] Peterson LJ, Ellis E, Hupp JR, et al. Contemporary oral and maxillofacial
surgery. 2003. p. 425.
• [9] Chole RA, Yee J. Antibiotic prophylaxis for facial fractures. Arch
Otolaryngol Head Neck Surg 1987;113:1055.
• [10] Neal DC, Wagner WF, Alpert B. Morbidity associated with teeth in the
line of fracture. J Oral Maxillofac Surg 1978;36:859.
• [11] Kahnberg KE, Ridell A. Prognosis of teeth in the line of mandibular
fractures. Int J Oral Surg 1979;8:163.
• [12] Rowe NL, Williams JLI. Maxillofacial injuries. Edinburg: Churchill
Livingstone; 1985. p. 52.
• [13] Zallen RD, Curry JT. A study of antibiotic usage in compound
mandibular fractures. J Oral Surg 1975;33:431.
• [14] Lieblich SE, Topazian RG. Infection in the patient with maxillofacial
trauma. In: Fonseca RJ, Walker RV, editors. Oral and maxillofacial trauma.
Philadelphia: Elsevier Saunders; 2005. p. 1124–5.

22. THANK YOU

23. • Position of fracture in relation to the apical foramen and the lateral periodontium of the involved
tooth into four groups
• a. Involving lateral and apical fibers completely
• b. Involving three-quarters of the lateral fibers
• c. Involving apical fibers completely
• d. Involving apical one-third of lateral fibers bilaterally