The effects of molar tooth involvement in mandibular angle fractures treated with rigid fixation

The Evaluation of Objective and Subjective Fate of Teeth in the Mandible Fracture Line and the Management-A Center's Experience

OBJECTIVE

The decision to retain or extract teeth in the line of mandibular fractures has been a subject of debate in much of the scientific literature, and there is a need for further evidence to clear this issue. Thus, the aim of this study was to investigate both the positive and negative effects of teeth in the line of mandibular fractures provide more evidence in this field, as well as take into consideration patients' quality of life after the surgery.

METHODS

Patients after trauma with teeth in the line of mandibular fractures were included in this study. Open reduction and rigid internal fixation, elastic intermaxillary reduction were expected to achieve a satisfactory occlusion and/or anatomical reduction in the fragments as assessed by orthopantomogram, computed tomography scans, and clinical examination. The remaining cases had maxillomandibular fixation (MMF) with an arch bar and bridle wire. All the patients included in this study will take the Visual Analog Scale score evaluation before and after surgery subjectively to further verify the impact on their life qualify, as well as the further treatment needed.

RESULTS

A total of 78 patients with teeth in the line of mandibular fractures were included in this study. Open reduction and rigid internal fixation was used in 37 patients, whereas another 35 patients accepted elastic intermaxillary reduction. Six cases underwent MMF. The number of involved teeth was 83. Three of the 83 teeth involved in the fracture lines healed with complications. In the cases where the teeth had been removed before fracture treatment, or in cases of delayed extractions, no complications were noted. The majority of the patients felt good about the whole treatment, however, 4 in the MMF group complained about worry about their oral health due to MMF leading to mouth open limitation.

CONCLUSION

The factors that should be considered for removal include the condition of the teeth and alveolar bone, the timing and the type of treatment, as well as the patients' desire, if possible. This is an individual-based decision that needs to consider more objective and subjective potential risks to avoid complications.

Tooth in the line of a mandibular fracture: Retain it or remove it? Clinical case report

Defining the prognosis and treatment plan for teeth in the line of a mandibular fracture is a challenge for the maxillofacial surgeon. The periodontal ligament may provide a communication with the oral cavity and become a pathway for infection. There is currently no consensus on the management of teeth in mandibular fracture lines. This report outlines a case where a tooth was successfully retained in the line of fracture as well as providing a review of the literature on the best-accepted treatments for this scenario.

Endodontic management of traumatized permanent teeth: a comprehensive review

The pulp plays a key role in the treatment of traumatic dental injuries (TDIs) and is strongly associated with the outcome, particularly in severe cases. A correct pulp diagnosis is essential as it forms the basis for developing the appropriate management strategy. However, many TDIs are complex, and their treatment requires a profound knowledge of the physiological and pathological responses of the affected tissues. This comprehensive review will look at the dentine-pulp complex and its interaction with the surrounding tissues following TDIs. The literature up to 2020 was reviewed based on several searches on PubMed and the Cochrane Library using relevant terms. In addition to the recently revised guidelines of the International Association of Dental Traumatology, this article aims to provide background information with a focus on endodontic aspects and to gather evidence on which a clinician can make decisions on the choice of the appropriate endodontic approach for traumatized permanent teeth.

Surgical Management of Mandibular Angle Fractures: Does the Extraction of the Third Molar Lead to a Change in the Fixation Pattern? A European Multicenter Survey

PURPOSE

The authors conducted a retrospective, multicenter study to investigate the differences in the fixation patterns, in terms of number and thickness of plates, between patients in whom a third molar (3M) was maintained or removed in the line of mandibular angle fractures.

MATERIALS AND METHODS

The study was conducted in 6 European level I and II maxillofacial trauma centers. Data were collected on patients ≥ 16 years of age who underwent open reduction internal fixation (ORIF) for mandibular angle fractures (MAF) from 2008 to 2018, in whom a 3M in the fracture line was present and who had a follow-up duration of 6 months. The study population was divided into 2 groups: patients treated with ORIF in whom the 3M was maintained (group 1) and those treated with ORIF in whom the 3M was extracted (group 2) during treatment. The 2 groups were compared for differences in the internal fixation pattern, specifically in terms of the number and thickness of the plates.

RESULTS

A total of 749 patients with 774 MAF were collected. A total of 1,050 plates were placed: 849 were ≤ 1.4 mm thick (80.9%) and 201 plates ≥ 1.5 mm thick (19.1%). 548 patients were treated with ORIF and 3M maintained (group 1), and 201 treated with ORIF and 3M extracted (group 2). Statistically significant differences were seen in the number of ≤1.4 mm plates between the 2 groups for single undisplaced/displaced MAF(P value ≤ 0.5) and for undisplaced/displaced angle + parasymphysis/body fractures (P-value ≤ 0.5).

CONCLUSIONS

Analyses of data collected from 6 European maxillofacial centers indicated that the majority of surgeons of our sample perceived the MAF as being more unstable when removing the 3M during ORIF leading them to perform a rigid fixation in the angular region.

Surgical Management of Bilateral Mandibular Angle Fractures With a Third Molar in Line of Fracture: A European Multicenter Survey

PURPOSE

The aim of this survey was to investigate the surgical management of bilateral mandibular angle fracture (BMAF) in Europe.

METHODS

Data were collected from 2008 to 2018 on patients ≥ 16 years of age who underwent open reduction internal fixation (ORIF) for BMAF with a third molar in the fracture line. The study was conducted at 6 European trauma centers. The following data were recorded: sex, age, cause of the fracture, type of fracture (nondisplaced, displaced, comminuted), type of approach (intraoral, transbuccal, or extraoral), thickness of the plate (≤1.4 mm or ≥1.5 mm), number of plates, cause of plate removal, and third molar extraction status.

RESULTS

25 patients with BMAF (24 males, 1 female, 17 to 83 years old [mean: 28.2 years]) were collected. The main cause of BMAF was assault, and the main surgical approach was intraoral. The most common types of BMAF were displaced + undisplaced (11 patients), displaced + displaced (7 patients), undisplaced + undisplaced (6 patients), and comminuted + comminuted (1 patient). Osteosynthesis was performed with 2 ≤1.4 mm plates on 1 angular fracture and 1 ≤1.4 mm plate on the other fracture in 11 patients, 1 ≤1.4 mm plate on both angular fractures in 6 patients, 1 ≥1.5 mm plate on both fractures in 5 patients, and 2 ≤1.4 mm plates on both fractures in the remaining 3 patients. Out of 25 patients with BMAF, 7 third molars were extracted during ORIF. Among these patients, angular fracture fixation was performed in 3 cases with 1 ≥1.5 mm plate and in 4 patients with 2 ≤1.4 mm plates.

CONCLUSIONS

This retrospective multicenter survey indicates a trend of treating with open reduction and rigid internal fixation at least 1 angular fracture of BMAF and those cases requiring extraction of the third molar in the line of fracture.

Surgical Management of Unusual Biangular Mandibular Fractures

Bilateral mandibular angle fractures, while representing a rarity among mandibular fractures, are a huge challenge of complex management for the maxillofacial surgeon. There are still many open questions regarding the ideal management of such fractures, including the following: the removal of the third molar in the fracture line, the best surgical approach, and the fixation methods. In this report the authors present the case of 40-year-old man presenting with a bilateral mandibular angle fracture referred to the Maxillofacial Surgery Department of Turin. Open reduction and internal fixation has been made for both sides. The left side third molar was removed and the internal fixation was achieved through internal fixation with one miniplate according to Champy's technique and transbuccal access for a 4-hole miniplate at the inferior border of the mandible. Right side third molar was not removed and fixation was achieved through intraoral access and positioning of a 4-hole miniplate along the external ridge according to Champy. An optimal reduction was achieved and a correct occlusion has been restored.

Prognosis of teeth in the line of jaw fractures

BACKGROUND/AIM

The decision as to whether teeth in the line of jaw fractures should be extracted or retained remains a controversial issue. The aim of this study was to assess the prognosis of teeth directly in the line of, and adjacent to, jaw fracture sites.

MATERIALS AND METHODS

The study consisted of 50 patients with facial fractures in the dentate region, the diagnosis of which was made on the basis of clinical and radiographic examinations. A total of 124 teeth were present in 69 fracture sites (50 patients), of which 89 teeth were evaluated both, clinically (tooth mobility, pocket depth, pulp sensibility) and with periapical radiographs (degree of fracture displacement, marginal bone loss, root resorption).

RESULTS

The results revealed that 61.9% of teeth in directly in the line of fractures showed no response to electric pulp testing compared with 48.9% teeth adjacent to fractures. The maximum frequency of non-responsive teeth was observed in Type I fractures followed by Type II fractures. Response to pulp tests was highly significant at postoperative 3- and 6-month periods (Wilcoxon's test). There was continuous reduction in the measurement for mean pocket depth at both test and control sites of teeth. The measurement of marginal bone levels of teeth in the line of fractures revealed a significant reduction (P < 0.01) from preoperative to postoperative 7-day period only. In teeth adjacent to fracture sites, the mean marginal bone levels of control site and test sites were not significant at any time interval. There was no difference in postoperative complications pertaining to whether the tooth at the fracture site was extracted or retained.

CONCLUSIONS

Teeth in line of jaw fractures should not be removed on a prophylactic basis and should be followed up clinically and radiographically to determine any treatment needs.

Retrospective study of mandibular angle fractures treated with three different fixation systems

Aim:

To evaluate the outcomes of mandibular angle fractures treated with metal 2.0 mm locking, metal 2.0 mm nonlocking, and 2.5 mm resorbable systems.

Study Design:

Retrospective cohort study.

Materials and Methods:

Trauma records were screened for linear angle fractures treated with open-reduction and internal semi-rigid fixation with single metal/bioresorbable plates, and baseline variables were tabulated. The outcome variable was the presence or absence of any complication.

Statistical Analysis Used:

The Fisher's exact test and analysis of covariance (ANCOVA) using STATA 11.

Results:

A total of 60 case records of over four years were included. The mean age of the patients was 27.4 (SD 9.7) years. Fifty-five were male and five female. There were 20 nonlocking and 16 locking metal miniplates and 24 bioresorbable plates. In 55 (91.6%) cases there was a third molar in the fracture line. In 51/55 (92.7%) cases the third molar was retained. In seven patients postoperative complications were seen. There was no difference between the complication rates of the three treatment groups. Infection was the most common complication followed by delayed union and hardware failure.

Conclusions:

This retrospective study found no difference in the complication rate when fractures of the mandibular angle were treated with locking or nonlocking miniplates or bioresorbable plates.

Fixation of mandibular angle fractures: clinical studies

PURPOSE

The purpose of this study was to review the literature regarding the evolution of current thoughts on fixation of mandibular angle fractures (MAFs).

METHODS

An electronic search in PubMed was undertaken in August 2012. The titles and abstracts from these results were read to identify studies within the selection criteria. Eligibility criteria included studies from the last 30 years (from 1983 onwards) reporting clinical studies of MAFs.

RESULTS

The search strategy initially identified 767 studies. The references from 1983 onwards totaled 727 articles. Fifty-four studies were identified without repetition within the selection criteria. Two articles showing significance in the development of treatment techniques were included. Additional hand-searching yielded 13 additional papers. Thus, a total of 69 studies were included.

CONCLUSIONS

Prospective randomized controlled studies of MAFs repair techniques are scarce. The available data at best predict that complications are associated with all kinds of fixation techniques. The similar results of complications in studies using different methods of fixation indicate that biomechanics are only one factor to be considered when treating MAFs. A second fracture in the mandible (which was observed in the majority of the studies' population) can confound the outcome data because the fixation requirements of a double fracture are often different from those for an isolated fracture. It can be necessary additional effort intended for increase of stability when using biodegradable plate system to fixate MAFs. The use of 1.3 mm malleable miniplates was associated with an unacceptable incidence of plate fracture, suggesting that this is not the most adequate system to treat MAFs. The use of the 3D grid plates has shown good clinical results. The efficiency of locking miniplate system is yet to be proven because there are few clinical studies with its use to fixate MAFs, although they have shown good results. When considering the use of semirigid or rigid fixation systems, the use of two miniplates outweigh the advantages of the use of one reconstruction plate, although the use of miniplates is not recommended for displaced comminuted MAFs. Although it has been shown that absolute rigid fixation is not necessary for fracture healing, any system that provides superior stability without impacting negatively on other aspects of the procedure, i.e., time, exposure, and cost, should be favored. MAFs can be treated in a highly effective way and with a relatively low rate of complications with monocortical miniplate fixation. The large number of studies on the treatment of MAF reflects the fact that a consensus has not been reached for a single, ideal treatment method.

Teeth in the line of mandibular fractures

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 maintained in the line of fracture should be followed up clinically and radiographically for at least 1 year to ensure that any unnecessary endodontic treatment is avoided. Teeth in the line of fracture that prevents reduction of fractures, teeth with fractured roots, a partially impacted wisdom tooth with pericoronitis, and a tooth with extensive periapical lesion should be removed. Teeth in the line of MFs should also be removed when located in sites where there is extensive periodontal damage, with broken alveolar walls, resulting in the formation of a deep pocket (making optimal healing doubtful).