Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine, Al-Azhar University. Approximately 60% of fractures of the mandible occur in the teeth bearing area. Incisors and third molars are the most commonly involved teeth on the fracture lines. The damaged to the tooth involved at the fracture site may include exposure of the root surface subluxation, avulsion or root fracture. This may lead to the vitalization, consequent infection and complicated healing of the fraction. Wether to remove or preserve the tooth in line of fraction is discussed. Certain guidelines have been suggested.

2. Dr. Ahmed M. Adawy
Professor Emeritus, Dep. Oral & Maxillofacial Surg.
Former Dean, Faculty of Dental Medicine
Al-Azhar University

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

4. Incisors and third molars
are the most commonly
involved teeth in the
fracture lines

5. The damage to the tooth or teeth involved at the
fracture site may include exposure of the root surface,
subluxation, avulsion or root fracture. The tooth
involved may become devitalized as a result of injury
or may have a pre-existing pulpal, periodontal or
periapical conditions of pathology. All these factors
either alone or combined can predispose the fracture
to infection and may complicate healing (2)

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

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

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

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

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

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

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

14. 1. Chrcanovic BR. Factors influencing the incidence of maxillofacial
fractures. Oral Maxillofac Surg. 16: 3, 2012.
2. Shankar DP, Manodh P, Devadoss P, et al. Mandibular fracture scoring
system: for prediction of complications. Oral Maxillofac Surg. 16: 355, 2012.
3. Gerbino G, Tarello F, Fasolis M, et al. Rigid fixation with teeth in the line of
mandibular fractures. Int J Oral Maxillofac Surg. 26: 182, 1997.
4. Ellis E 3rd. Outcomes of patients with teeth in the line of mandibular angle
fractures treated with stable internal fixation. J Oral Maxillofac Surg. 60: 863,
2002.
5. Neal DC, Wagner WF, Alpert B. Morbidity associated with teeth in the line
of mandibular fractures. J Oral Surg. 36: 859, 1978.
6. Shetty V, Freymiller E. Teeth in the line of fracture: A review. J Oral
Maxillofac Surg. 47: 1303, 1989.