J Oral Mamllofac 48.1045-1047,
Surg
1990
Morbidity Associated With Incompletely Erupted Third Molars in the Line of Mandibular Fractures MITCHELL
M. RUBIN, DMD,* TIMOTHY J. KOLL, DDS,t AND RORY S. SADOFF, DDS$
A retrospective analysis of 105 mandibular fractures associated with incompletely erupted third molars was undertaken. It was found that there was no difference in the rates of complication if the teeth were retained or extracted, or if an open or closed reduction was performed. The combination of tooth retention with open reduction, however, shows a trend toward being the treatment most prone to postoperative complications.
Considerable controversy still exists as to whether impacted or partially erupted mandibular third molar teeth associated with fractures of the mandibular angle should be removed at the time of fracture reduction. Some authors believe that all third molar teeth in the line of mandibular fracture having any communication with the mouth should be extracted. The lower third molar having a connection with the mouth, regardless of how small, is very prone to recurrent infection, as it is a region in which debris collects. A fracture through this region adds additional tissue insult and produces a hematoma that serves as a culture medium. All too frequently, if the tooth has not been removed, an infection results when antibiotic therapy has been discontinued. Some of these infections are of a very serious nature and develop into osteomyelitis. ’ Others argue, however, that extraction demands surgical interference, resulting in further trauma to the region. This could very possibly open the wound to oral bacteria, and, subsequently, infection might spread deep into healthy bone.2
As recently as 1965, Bradley3 stated that teeth in the line of fracture delay union and should be removed. Since the advent of antibiotics, however, surgeons have become bolder with respect to retention of teeth.4 Schneider and Stern’ found that most clinically intact teeth in the line of mandibular fractures could be maintained with the use of antibiotics and application of stable fixation. Neal et al4 reported a statistical comparison of mandibular fractures in which teeth were removed and those in which teeth were retained, finding that removal of teeth in the fracture line did not minimize morbidity. Chuong et al,(j in their review of 327 cases of mandibular fractures, also found no significant difference in the rate of complication when cases with teeth in the line of injury treated by extraction were compared with those treated with retention of teeth. A review of the literature, however, found no study specifically designed to determine the morbidity associated with retaining the particularly infectionprone partially erupted or impacted third molar tooth associated with mandibular fracture. Controversy also exists as to the morbidity associated with open versus closed reduction of the fractured mandibular angle when a partially erupted or impacted third molar tooth is in the line of fracture. A variety of relative indications exist for open reduction with internal fixation, including better approximation of the ends of the bone, which results in endosteal healing and more rapid union, prevention of displacement and movement of the proximal segment, and a more precise restoration of the occlusion. Bochlogyros,’ in his review of 1,521 man-
Received from the Department of Oral and Maxillofacial Surgery, Nassau County Medical Center, East Meadow, NY. * Attending, in private practice, Rockville Centre. NY. t Chief Resident. j Director of Advanced Training. Address correspondence and reprint requests to Dr Rubin: South Shore Oral Surgery Associates, P.C., 155 West Merrick Rd. Freeport.
NY 11520.
C 1990 American geons
Association
of Oral and Maxillofacial
Sur-
0278-2391/90/4810-0006$3.00/O
1045
1046
THIRD MOLARS IN THE LINE OF FRACTURES
dibular fractures, found the incidence of infection after open reduction not to be significantly greater than that following nonsurgical treatment. Wagner et al,* however, found that open reduction of the mandibular angle associated with teeth removed from the fracture line produced the greatest incidence of complications both quantitatively and qualitatively. James et al’ found that complications were influenced more by location of the fracture than by specific open or closed reduction, or whether the tooth in the line of fracture was extracted or not. Considering the lack of agreement in the literature, we undertook a retrospective study of 105 mandibular angle fractures with associated impacted or partially erupted third molar teeth to determine how treatment modality correlated with postoperative morbidity. Materials and Methods From July 1980 to July 1989, 105 mandibular angle fractures associated with impacted or partially erupted third molars were treated by the Oral and Maxillofacial Surgery department at the Nassau County Medical Center. Those patients without complete records or postoperative follow-up care were eliminated from the study. All patients received the appropriate antibiotics from the time of admission until at least the 5th day after reduction. All patients had maxillary and mandibular arch bars applied with maxillomandibular fixation. Morbidity (defined as clinical signs of infection requiring medical or surgical intervention, and as delayed healing requiring greater than 6 weeks of maxillomandibular fixation to obtain clinical nonmobility) was analyzed according to retention versus extraction of the third molar tooth at the time of fracture reduction and closed versus extraoral open reduction with internal fixation using wire osteosynthesis. Results Twenty-three of the 105 fractures had postoperative complications as defined by the study protocol. When comparing open and closed reduction of the mandibular angle fracture associated with an impacted or partially erupted third molar tooth, the incidence of complications in the open reduction group was 25% and in the closed reduction group was 20% (Table 1). Using a x2 analysis, no statistical significance was found at P = .05 level; therefore, neither treatment modality appears to increase the likelihood of a postoperative complication. When comparing extraction of the tooth and retention of the tooth, the complication rate was 19% and
Table 1. Complication Rates in Open vs Closed Reductions of the Fractured Mandible Associated With Partially Erupted Third Molar Teeth Total Cases Open reductions Closed reductions
Cases With Complications
40 65
10 13
Complication Rate 25% 205%
23%, respectively (Table 2). Using a x2 statistic, no statistical significance was found at the P = .05 level; therefore, neither of these treatment modalities appears to increase the likelihood of a postoperative complication. The interaction of the two factors, extraction/ retention and open/closed reduction, could not be tested statistically based on the small sample size. In those who were treated with retention of the tooth combined with open reduction, however, there seems to be a trend toward an increased incidence of complications (Table 3). This complication rate of 44% appears very high when compared with 20% for retention of the third molar with closed reduction, 20% for extraction of the third molar with closed reduction, and 19% for extraction of the third molar with open reduction. Discussion
The overall complication rate of 21% in this series of cases may seem high at first glance. This is owing to essentially the same factors Neal et al4 reported, of which the most significant is that the Nassau County Medical Center treats the majority of the county’s large indigent population. Failure to comply with postoperative instructions, missing followup visits, and removing maxillomandibular fixation prematurely are common problems encountered with patients at the institution. Another factor is the retrospective study design, which includes all complications, even relatively minor problems for which antibiotics may have been inappropriately prescribed by residents. This study found that in particularly infectionprone, partially erupted third molar teeth found in Table 2. Complication Rates in Extraction vs Retention of Partially Erupted Third Molars Associated With Mandibular Fracture Total Cases Extraction of third molar Retention of third molar
Cases With Complications
Complication Rate
36
7
19%
69
16
23%
1047
RUBIN ET AL
Table 3. Complication Rates of Procedures Used to Treat the Fractured Mandible Associated With a Partially Erupted Third Molar
Open reduction
Closed reduction
Extraction of Third Molar
Retention of Third Molar
Six complications in 31 cases; 19% complication rate One complication in 5 cases; 20%~ complication rate
Four complications in 9 cases; 44% complication rate Twelve complications in 60 cases; 20% complication rate
the line of mandibular fracture, there was no difference in postoperative morbidity regardless of whether the tooth was extracted or retained. The study also revealed that treatment of this type of fracture showed no difference in postoperative morbidity regardless of whether an open or closed reduction was performed. An unexpected finding was the extraordinarily high rate of complications in those treated by tooth retention with open reduction of the fracture. Although this combination of factors seems to result in higher morbidity, the small group treated in this manner precludes statistical analyses. This warrants further investigation with a larger sample size. It is interesting to note that in our study few people had an open reduction without extraction of the third molar. We believed that if an open reduction with internal fixation was planned, removal of the potentially problematic third molar should be achieved via distal elevation into the fracture site before the reduction. If the fracture was displaced by the manipulation associated with the extraction, it subsequently could be reduced during the open surgery. Conversely, if a closed reduction was planned, then the tooth was generally retained because of the possibility that the manipulation associated with the extraction would necessitate an
open procedure to obtain an adequate reduction. In many of the latter cases, the tooth also acted as a proximal stop, giving further incentive to retain it. Hence, the two largest treatment modalities were closed reduction with tooth retention and open reduction with tooth extraction. This study refutes Wagner et al8 who concluded that complications are most likely to occur in the angle fracture in which an involved tooth was removed in conjunction with open reduction and internal fixation. Wagner et al had 37 cases of mandibular angle fractures with teeth in the line of fracture that were treated with an open reduction and found a complication rate of 11.8% in those fractures in which the teeth were retained and 35% when teeth were removed. Although the sample size in their study also was not large enough for statistical analyses, they believed the data suggested an important finding: impacted third molars in the line of mandibular fracture should be retained. Our study does not support this contention. References 1. Irby WB: Facial Trauma and Concomitant
2.
3. 4.
5. 6.
7. 8.
9.
Problems: Evaluation and Treatment (ed 2). St Louis. Mosby, 1979, pp 53-57 Lewis KG, Perutsea SC: The complex mandibular fracture. Am J Surg 97:283, I959 Bradley RL: Treatment of fractured mandible. Am Surg 3 I :289. 1965 Neal DC. Wagner WF, Alpert B: Morbidity associated with teeth in the line of mandibular fractures. J Oral Surg 36:859, 1978 Schneider SS, Stern M: Teeth in the line of mandibular fractures. J Oral Surg 29:107, 1971 Chuong R, Donoff RB, Guralnick WC: A retrospective analysis of 327 mandibular fractures. J Oral Maxillofac Surg 41:305. 1983 Bochlogyros PN: A retrospective study of 1,521 mandibular fractures. J Oral Maxillofac Surg 43:597. 1985 Wagner WF. Neal DC. Alpert B: Morbidity associated with extraoral open reduction of mandibular fractures. J Oral Surg 37197, 1979 James RB, Fredrickson C. Kent JN: Prospective study of mandibular fractures. J Oral Surg 39:275, 1981
Surg
1990
Morbidity Associated With Incompletely Erupted Third Molars in the Line of Mandibular Fractures MITCHELL
M. RUBIN, DMD,* TIMOTHY J. KOLL, DDS,t AND RORY S. SADOFF, DDS$
A retrospective analysis of 105 mandibular fractures associated with incompletely erupted third molars was undertaken. It was found that there was no difference in the rates of complication if the teeth were retained or extracted, or if an open or closed reduction was performed. The combination of tooth retention with open reduction, however, shows a trend toward being the treatment most prone to postoperative complications.
Considerable controversy still exists as to whether impacted or partially erupted mandibular third molar teeth associated with fractures of the mandibular angle should be removed at the time of fracture reduction. Some authors believe that all third molar teeth in the line of mandibular fracture having any communication with the mouth should be extracted. The lower third molar having a connection with the mouth, regardless of how small, is very prone to recurrent infection, as it is a region in which debris collects. A fracture through this region adds additional tissue insult and produces a hematoma that serves as a culture medium. All too frequently, if the tooth has not been removed, an infection results when antibiotic therapy has been discontinued. Some of these infections are of a very serious nature and develop into osteomyelitis. ’ Others argue, however, that extraction demands surgical interference, resulting in further trauma to the region. This could very possibly open the wound to oral bacteria, and, subsequently, infection might spread deep into healthy bone.2
As recently as 1965, Bradley3 stated that teeth in the line of fracture delay union and should be removed. Since the advent of antibiotics, however, surgeons have become bolder with respect to retention of teeth.4 Schneider and Stern’ found that most clinically intact teeth in the line of mandibular fractures could be maintained with the use of antibiotics and application of stable fixation. Neal et al4 reported a statistical comparison of mandibular fractures in which teeth were removed and those in which teeth were retained, finding that removal of teeth in the fracture line did not minimize morbidity. Chuong et al,(j in their review of 327 cases of mandibular fractures, also found no significant difference in the rate of complication when cases with teeth in the line of injury treated by extraction were compared with those treated with retention of teeth. A review of the literature, however, found no study specifically designed to determine the morbidity associated with retaining the particularly infectionprone partially erupted or impacted third molar tooth associated with mandibular fracture. Controversy also exists as to the morbidity associated with open versus closed reduction of the fractured mandibular angle when a partially erupted or impacted third molar tooth is in the line of fracture. A variety of relative indications exist for open reduction with internal fixation, including better approximation of the ends of the bone, which results in endosteal healing and more rapid union, prevention of displacement and movement of the proximal segment, and a more precise restoration of the occlusion. Bochlogyros,’ in his review of 1,521 man-
Received from the Department of Oral and Maxillofacial Surgery, Nassau County Medical Center, East Meadow, NY. * Attending, in private practice, Rockville Centre. NY. t Chief Resident. j Director of Advanced Training. Address correspondence and reprint requests to Dr Rubin: South Shore Oral Surgery Associates, P.C., 155 West Merrick Rd. Freeport.
NY 11520.
C 1990 American geons
Association
of Oral and Maxillofacial
Sur-
0278-2391/90/4810-0006$3.00/O
1045
1046
THIRD MOLARS IN THE LINE OF FRACTURES
dibular fractures, found the incidence of infection after open reduction not to be significantly greater than that following nonsurgical treatment. Wagner et al,* however, found that open reduction of the mandibular angle associated with teeth removed from the fracture line produced the greatest incidence of complications both quantitatively and qualitatively. James et al’ found that complications were influenced more by location of the fracture than by specific open or closed reduction, or whether the tooth in the line of fracture was extracted or not. Considering the lack of agreement in the literature, we undertook a retrospective study of 105 mandibular angle fractures with associated impacted or partially erupted third molar teeth to determine how treatment modality correlated with postoperative morbidity. Materials and Methods From July 1980 to July 1989, 105 mandibular angle fractures associated with impacted or partially erupted third molars were treated by the Oral and Maxillofacial Surgery department at the Nassau County Medical Center. Those patients without complete records or postoperative follow-up care were eliminated from the study. All patients received the appropriate antibiotics from the time of admission until at least the 5th day after reduction. All patients had maxillary and mandibular arch bars applied with maxillomandibular fixation. Morbidity (defined as clinical signs of infection requiring medical or surgical intervention, and as delayed healing requiring greater than 6 weeks of maxillomandibular fixation to obtain clinical nonmobility) was analyzed according to retention versus extraction of the third molar tooth at the time of fracture reduction and closed versus extraoral open reduction with internal fixation using wire osteosynthesis. Results Twenty-three of the 105 fractures had postoperative complications as defined by the study protocol. When comparing open and closed reduction of the mandibular angle fracture associated with an impacted or partially erupted third molar tooth, the incidence of complications in the open reduction group was 25% and in the closed reduction group was 20% (Table 1). Using a x2 analysis, no statistical significance was found at P = .05 level; therefore, neither treatment modality appears to increase the likelihood of a postoperative complication. When comparing extraction of the tooth and retention of the tooth, the complication rate was 19% and
Table 1. Complication Rates in Open vs Closed Reductions of the Fractured Mandible Associated With Partially Erupted Third Molar Teeth Total Cases Open reductions Closed reductions
Cases With Complications
40 65
10 13
Complication Rate 25% 205%
23%, respectively (Table 2). Using a x2 statistic, no statistical significance was found at the P = .05 level; therefore, neither of these treatment modalities appears to increase the likelihood of a postoperative complication. The interaction of the two factors, extraction/ retention and open/closed reduction, could not be tested statistically based on the small sample size. In those who were treated with retention of the tooth combined with open reduction, however, there seems to be a trend toward an increased incidence of complications (Table 3). This complication rate of 44% appears very high when compared with 20% for retention of the third molar with closed reduction, 20% for extraction of the third molar with closed reduction, and 19% for extraction of the third molar with open reduction. Discussion
The overall complication rate of 21% in this series of cases may seem high at first glance. This is owing to essentially the same factors Neal et al4 reported, of which the most significant is that the Nassau County Medical Center treats the majority of the county’s large indigent population. Failure to comply with postoperative instructions, missing followup visits, and removing maxillomandibular fixation prematurely are common problems encountered with patients at the institution. Another factor is the retrospective study design, which includes all complications, even relatively minor problems for which antibiotics may have been inappropriately prescribed by residents. This study found that in particularly infectionprone, partially erupted third molar teeth found in Table 2. Complication Rates in Extraction vs Retention of Partially Erupted Third Molars Associated With Mandibular Fracture Total Cases Extraction of third molar Retention of third molar
Cases With Complications
Complication Rate
36
7
19%
69
16
23%
1047
RUBIN ET AL
Table 3. Complication Rates of Procedures Used to Treat the Fractured Mandible Associated With a Partially Erupted Third Molar
Open reduction
Closed reduction
Extraction of Third Molar
Retention of Third Molar
Six complications in 31 cases; 19% complication rate One complication in 5 cases; 20%~ complication rate
Four complications in 9 cases; 44% complication rate Twelve complications in 60 cases; 20% complication rate
the line of mandibular fracture, there was no difference in postoperative morbidity regardless of whether the tooth was extracted or retained. The study also revealed that treatment of this type of fracture showed no difference in postoperative morbidity regardless of whether an open or closed reduction was performed. An unexpected finding was the extraordinarily high rate of complications in those treated by tooth retention with open reduction of the fracture. Although this combination of factors seems to result in higher morbidity, the small group treated in this manner precludes statistical analyses. This warrants further investigation with a larger sample size. It is interesting to note that in our study few people had an open reduction without extraction of the third molar. We believed that if an open reduction with internal fixation was planned, removal of the potentially problematic third molar should be achieved via distal elevation into the fracture site before the reduction. If the fracture was displaced by the manipulation associated with the extraction, it subsequently could be reduced during the open surgery. Conversely, if a closed reduction was planned, then the tooth was generally retained because of the possibility that the manipulation associated with the extraction would necessitate an
open procedure to obtain an adequate reduction. In many of the latter cases, the tooth also acted as a proximal stop, giving further incentive to retain it. Hence, the two largest treatment modalities were closed reduction with tooth retention and open reduction with tooth extraction. This study refutes Wagner et al8 who concluded that complications are most likely to occur in the angle fracture in which an involved tooth was removed in conjunction with open reduction and internal fixation. Wagner et al had 37 cases of mandibular angle fractures with teeth in the line of fracture that were treated with an open reduction and found a complication rate of 11.8% in those fractures in which the teeth were retained and 35% when teeth were removed. Although the sample size in their study also was not large enough for statistical analyses, they believed the data suggested an important finding: impacted third molars in the line of mandibular fracture should be retained. Our study does not support this contention. References 1. Irby WB: Facial Trauma and Concomitant
2.
3. 4.
5. 6.
7. 8.
9.
Problems: Evaluation and Treatment (ed 2). St Louis. Mosby, 1979, pp 53-57 Lewis KG, Perutsea SC: The complex mandibular fracture. Am J Surg 97:283, I959 Bradley RL: Treatment of fractured mandible. Am Surg 3 I :289. 1965 Neal DC. Wagner WF, Alpert B: Morbidity associated with teeth in the line of mandibular fractures. J Oral Surg 36:859, 1978 Schneider SS, Stern M: Teeth in the line of mandibular fractures. J Oral Surg 29:107, 1971 Chuong R, Donoff RB, Guralnick WC: A retrospective analysis of 327 mandibular fractures. J Oral Maxillofac Surg 41:305. 1983 Bochlogyros PN: A retrospective study of 1,521 mandibular fractures. J Oral Maxillofac Surg 43:597. 1985 Wagner WF. Neal DC. Alpert B: Morbidity associated with extraoral open reduction of mandibular fractures. J Oral Surg 37197, 1979 James RB, Fredrickson C. Kent JN: Prospective study of mandibular fractures. J Oral Surg 39:275, 1981
