Teeth in the fracture line
Stefan Berg, Hans-Dieter Pape Department of Maxillo-Facial Surgery, University of Cologne, Germany
S. Berg, H.-D. Pape." Teeth in the fracture line. Int. J. Oral Maxillofac. Surg. 1992; 21: 145-146. Abstract. The department of maxillo-facial surgery in Cologne University has, for some 15 years, routinely treated patients with mandibular fractures, in which a tooth lies in the fracture line, by means of Champy miniplates. A review of such cases was conducted to determine the viability of such teeth not electively extracted at the time of fracture reduction. It was found that only rarely did the "salvaged" tooth subsequently require extraction and we believe our results should encourage the clinician to attempt to retain "fracture line" teeth unless there is an absolute contraindication.
The indications for extracting teeth in the fracture line, as well as the prognosis for such teeth as are retained, have been the subject of many papers 3,6,7,1°. The large number of trauma cases seen in our maxitlo-facial unit provided the opportunity for conducting a retrospective survey of the fate of "fracture line" teeth. Since 1977 patients with mandibular fractures have been treated in the department by means of small-plate osteosynthesis ~. To minimise the risk of infection, any cases where a tooth lay in the fracture line were treated under antibiotic cover 5 Material and methods From 1977 to 1990, 1,341 patients with a total of 1,995 mandibular fractures have been treated in the department. A total of 178 patients treated in the years 1988-89 for fractures involving a tooth in the fracture line were invited to attend a reviewclinic. Of these patients 41 attended, giving us a total of 78 "fracture line" teeth to consider. The involvement of a particular tooth in a fracture was checked by analysis of preoperative X-rays and notes made at the time of operation. Vitality testing of the tooth was conducted according to the method described by MAYER9. The depth of the gingival cuff around the tooth was measured by probing and compared with the corresponding contra-lateral tooth. Similarly comparisons were made between 'fracture line' teeth and their contra-lateral counterparts for analysis of tooth mobility following ORBANH. A radiographic examination of the teeth was also made using both panoramic and intraoral views and comparing these with previous X-rays. Results The 41 patients reviewed consisted of 33 males and 8 females. They had an
average age of 23 years with a range from 12 to 50 years. The mean period of treatment from presentation to final review was 15 months. These patients had originally presented a total of 78 "fracture line" teeth, 18 of which had been removed at the time of fracture reduction (9 being impacted wisdom teeth and 6 having fractured crowns). It was found that only one tooth had subsequently required extraction due to a post-operative infection, leaving a total of 59 retained teeth for examination. Thirteen of these 59 teeth were found to be non-vital when subjected to the provotest. Radiographic examination revealed apical root resorption in 3 cases, external root resorption in one case and a further tooth demonstrated obliteration of the root canal. None of the non-vital teeth showed any radiographic evidence of periapical osteitis. At the time of post-treatment discharge all 59 teeth had been stable within the mandible and no differences in tooth mobility were found in comparison with the corresponding contralateral teeth. With regard to gingival pocket depth t tooth in comparison with its contralateral counterpart showed an increase of 2 mm, 6 teeth showed increases of 1 mm, whilst for the other 52 teeth there was no recordable increase in pocket depth. Discussion The policy within the maxillo-facial unit in Cologne University has been to extract as part of the primary procedure any "fracture line" teeth which demon-
Key words: trauma; mandibular fractures;
teeth in fracture line Accepted for publication 21 February 1992
strate apical or marked periodontal bone loss, or which are badly damaged either by caries or trauma. Further, it has been our general practice to remove impacted wisdom teeth from the fracture line, unless they can be utilised for the fixation of a small-plate osteosynthesis, or their removal would cause a loss of bone from the fracture margins. In the former circumstances the wisdom tooth is removed together with the osteosynthesis material in a second procedure under local anaesthetic 3 months after fracture reduction. Following the application of these criteria 23% (n = 18) of the 78 "fracture line" teeth were extracted as a primary measure, a result comparable to that of G0YTI~R et al. 6 (Table 1). Only one of the teeth electively retained subsequently required extraction, so that 98% (n = 58) were successfully salvaged. Our results contrast with those of EW~RSet a l l who found they susbequently extracted 14% of retained "fracture line" teeth and STOLE et al. 16 who reported 20% of retained teeth were later extracted (Table 2). A higher proportion (22%) of retained "fracture line" teeth in our study were observed to have become nonvital; however, a literature review revealed similar findings from other workers 2'3'6's'16(Table 3). The periodontal condition of teeth retained in the fracture line was another aspect of our study. There is no obvious reason why such teeth should show an increase in gingival pocket depth after post-operative healing is complete. We found 88% of patients showed no increase in pocket depth around such teeth when compared with the corre-
146
Berg and Pape
Table 1. Primarily extracted teeth during the operative management Author Schmitz et al/4 Ewers et al. ~ Stoll et al. 16 Gfinther et al. 6 Krenkel & Grunert 8 Cologne 1990
n (n=?) (n = 52) (n=268) (n=72) (n= 56) (n=78)
%
? ? 3 6 15 5 18 25 0 0 18 23
Table 2. Secondarily extracted teeth during the postoperative period. Author Schmitz et al) 4 Ewers et al. 2 Stoll et al. 16 Giinther et al. 6 Krenkel et al. 8 Cologne 1990
n (n= 19) (n=49) (n=255) (n = 54) (n=48) (n = 59)
%
2 1 7 14 51 20 0 0 3 6 1 2
Table 3. Devitalized teeth in the fracture line Author Sch6nberger 15 Fuhr & Setz3 Rottke & Kark 13 Schmitz et al. ~4 Ewers et al. 2 Gfinther et al. 6 Krenkel et al? Cologne 1990
(n = 19) (n=214) (n=49) (n = 19) (n=49) (n = 54) (n=48) (n=59)
n
%
8 39 9 9 9 1 11 13
42 18 18 47 18 2 23 22
s p o n d i n g contra-lateral t o o t h . HOFFMEISTER7, Gf0NTHER et al. 6 a n d o t h e r a u t h o r s 13'14'15, f o u n d n o significant differences in similar studies. Moreover, HOFFMEISTER r e p o r t e d the h o r i z o n t a l mobility o f retained " f r a c t u r e line" teeth, once healing is complete, does n o t a p p e a r to differ f r o m the n o r m a l
physiological r a n g e for h e a l t h y teeth. SCHMITZ et a l l 4 a n d KRENKEL et al. s published similar results. This study supports their results in t h a t we f o u n d n o instance o f increased m o b i l i t y o f "fracture line" teeth over their c o n t r a lateral c o u n t e r p a r t s . R a d i o g r a p h i c evidence o f r o o t res o r p t i o n was observed in 5% (n = 4) o f the patients. KRENKEL et al. 8 r e p o r t e d a similar finding in 4 % (n = 2) o f his cases. N o n e o f the teeth in o u r study was f o u n d to h a v e a periapical osteitis, a finding also r e p o r t e d by G ~ T H E R et al. 6 a n d SCH(3NBERGER 13, b u t in c o n t r a s t to SCHMITZ et al. TMa n d S~TZ3 w h o f o u n d periapical osteitis with 11%0 a n d 11.7% o f teeth in their studies, respectively. T h e results of this study, w h i c h indicate a good prognosis for the retained tooth, s u p p o r t a future strategy o f ext r a c t i n g " f r a c t u r e line" teeth only w h e n absolutely indicated.
References 1. CHAMPY M, PAPE HD, GERLACH KL, LODDE JP. The StraBhourg miniplate osteosynthesis: oral and maxillofacial traumatology. Berlin: Die Quintessenz, 1986:19 43. 2. EWERS R, REUTER E, STOLL W. Die parodontale Situation des Zahnes im BruchspaR. Dtsch Zahnfirztl Z 1976: 31:251-3. 3. Ftrrm K, SExz D. Nachuntersuchungen yon Z/ihnen die zum Bruchspalt in Beziehung stehen. Dtsch Zahnfirztl Z 1963: 18: 638-40. 4. GERLACHKL, PAPEHD. Untersuchungen zur Antibiotikaprophylaxe bei der operativen Behandlung yon Unterkeiferfrakturen. Dtsch Z Mund Kiefer GesichtsChir 1988: 12:497 500. 5. GLICKMANN J. Clinical periodontology. Philadelphia: WB Saunders, 1972: 49%507. 6. GONTHER K, GUNDLACHKKH, SCHW1P-
PER V. Der Zahn im Bruchspalt. Dtsch Zahn/irztl Z 1983: 38:346 8. 7. HOFFMEISTER B. Die parodontale Reaktion im Bruchspalt stehender Z/ihne bei Unterkieferfrakturen. Dtsch Zahnfirztl Z 1985: 40: 3~6. 8. KRgNKEL C, GRUNERT I. Der. Zahn im und am Bruchspalt bei Unterkieferfrakturen, versorgt mit SilcadrahtKlebeschienen. Dtsch Z Mund Kiefer GesichtsChir 1987: 11: 208-10. 9. MAYER R. Zur Feststellung derVitalitfit der Pulpa. Dtsch Zahnfirztl Z 1975: 30: 307-11. 10. MOLLER W. Hfiufigkeit und Prophylaxe der Bruchspaltostitiden im Zeitalter der Antibiotika. Dtsch Stomat 1968: 21: 110-14. 11. ORBAN JB. Parodontologie. Berlin: Die Quintessenz, 1965: 185. 12. ORBAN TR, ORBAN JB. Three-dimensional roentgenographic interpretation in periodontal disease. J Periodont 1960: 31: 275-82. 13. RoTTKE B, KARK U. Zur Frage der Extraktion im Bruchspalt stehender Zfihne. Ost Z Stomat 1969: 62: 465-8. 14. SCHMITZ R, H()LTJE W, CORDES V. Vergleichende Untersuchungen fiber die Regeneration des parodontalen Gewebes nach Unfallverletzungen und Osteotomien des Alveolarfortsatzes. Dtsch Zahn/trztl Z 1973: 28: 219-23. 15. SCHt)NBERGERA. Behandlung der Zfihne im Bruchspalt. Fortschr Kiefer GesichtsChir 1956: 2:108 ll. 16. STOLLP, NIEDERDELLMANNH, SAUTERR. Zahnbeteiligung bei Unterkieferfrakturen. Dtsch Zahn~rztl Z 1983: 38: 349-51.
Address:
St. Berg Department of Maxillo-Facial Surgery University of Cologne Joseph-Stelzmann-Strafle 9 D-5000 K6ln 41 Germany
Stefan Berg, Hans-Dieter Pape Department of Maxillo-Facial Surgery, University of Cologne, Germany
S. Berg, H.-D. Pape." Teeth in the fracture line. Int. J. Oral Maxillofac. Surg. 1992; 21: 145-146. Abstract. The department of maxillo-facial surgery in Cologne University has, for some 15 years, routinely treated patients with mandibular fractures, in which a tooth lies in the fracture line, by means of Champy miniplates. A review of such cases was conducted to determine the viability of such teeth not electively extracted at the time of fracture reduction. It was found that only rarely did the "salvaged" tooth subsequently require extraction and we believe our results should encourage the clinician to attempt to retain "fracture line" teeth unless there is an absolute contraindication.
The indications for extracting teeth in the fracture line, as well as the prognosis for such teeth as are retained, have been the subject of many papers 3,6,7,1°. The large number of trauma cases seen in our maxitlo-facial unit provided the opportunity for conducting a retrospective survey of the fate of "fracture line" teeth. Since 1977 patients with mandibular fractures have been treated in the department by means of small-plate osteosynthesis ~. To minimise the risk of infection, any cases where a tooth lay in the fracture line were treated under antibiotic cover 5 Material and methods From 1977 to 1990, 1,341 patients with a total of 1,995 mandibular fractures have been treated in the department. A total of 178 patients treated in the years 1988-89 for fractures involving a tooth in the fracture line were invited to attend a reviewclinic. Of these patients 41 attended, giving us a total of 78 "fracture line" teeth to consider. The involvement of a particular tooth in a fracture was checked by analysis of preoperative X-rays and notes made at the time of operation. Vitality testing of the tooth was conducted according to the method described by MAYER9. The depth of the gingival cuff around the tooth was measured by probing and compared with the corresponding contra-lateral tooth. Similarly comparisons were made between 'fracture line' teeth and their contra-lateral counterparts for analysis of tooth mobility following ORBANH. A radiographic examination of the teeth was also made using both panoramic and intraoral views and comparing these with previous X-rays. Results The 41 patients reviewed consisted of 33 males and 8 females. They had an
average age of 23 years with a range from 12 to 50 years. The mean period of treatment from presentation to final review was 15 months. These patients had originally presented a total of 78 "fracture line" teeth, 18 of which had been removed at the time of fracture reduction (9 being impacted wisdom teeth and 6 having fractured crowns). It was found that only one tooth had subsequently required extraction due to a post-operative infection, leaving a total of 59 retained teeth for examination. Thirteen of these 59 teeth were found to be non-vital when subjected to the provotest. Radiographic examination revealed apical root resorption in 3 cases, external root resorption in one case and a further tooth demonstrated obliteration of the root canal. None of the non-vital teeth showed any radiographic evidence of periapical osteitis. At the time of post-treatment discharge all 59 teeth had been stable within the mandible and no differences in tooth mobility were found in comparison with the corresponding contralateral teeth. With regard to gingival pocket depth t tooth in comparison with its contralateral counterpart showed an increase of 2 mm, 6 teeth showed increases of 1 mm, whilst for the other 52 teeth there was no recordable increase in pocket depth. Discussion The policy within the maxillo-facial unit in Cologne University has been to extract as part of the primary procedure any "fracture line" teeth which demon-
Key words: trauma; mandibular fractures;
teeth in fracture line Accepted for publication 21 February 1992
strate apical or marked periodontal bone loss, or which are badly damaged either by caries or trauma. Further, it has been our general practice to remove impacted wisdom teeth from the fracture line, unless they can be utilised for the fixation of a small-plate osteosynthesis, or their removal would cause a loss of bone from the fracture margins. In the former circumstances the wisdom tooth is removed together with the osteosynthesis material in a second procedure under local anaesthetic 3 months after fracture reduction. Following the application of these criteria 23% (n = 18) of the 78 "fracture line" teeth were extracted as a primary measure, a result comparable to that of G0YTI~R et al. 6 (Table 1). Only one of the teeth electively retained subsequently required extraction, so that 98% (n = 58) were successfully salvaged. Our results contrast with those of EW~RSet a l l who found they susbequently extracted 14% of retained "fracture line" teeth and STOLE et al. 16 who reported 20% of retained teeth were later extracted (Table 2). A higher proportion (22%) of retained "fracture line" teeth in our study were observed to have become nonvital; however, a literature review revealed similar findings from other workers 2'3'6's'16(Table 3). The periodontal condition of teeth retained in the fracture line was another aspect of our study. There is no obvious reason why such teeth should show an increase in gingival pocket depth after post-operative healing is complete. We found 88% of patients showed no increase in pocket depth around such teeth when compared with the corre-
146
Berg and Pape
Table 1. Primarily extracted teeth during the operative management Author Schmitz et al/4 Ewers et al. ~ Stoll et al. 16 Gfinther et al. 6 Krenkel & Grunert 8 Cologne 1990
n (n=?) (n = 52) (n=268) (n=72) (n= 56) (n=78)
%
? ? 3 6 15 5 18 25 0 0 18 23
Table 2. Secondarily extracted teeth during the postoperative period. Author Schmitz et al) 4 Ewers et al. 2 Stoll et al. 16 Giinther et al. 6 Krenkel et al. 8 Cologne 1990
n (n= 19) (n=49) (n=255) (n = 54) (n=48) (n = 59)
%
2 1 7 14 51 20 0 0 3 6 1 2
Table 3. Devitalized teeth in the fracture line Author Sch6nberger 15 Fuhr & Setz3 Rottke & Kark 13 Schmitz et al. ~4 Ewers et al. 2 Gfinther et al. 6 Krenkel et al? Cologne 1990
(n = 19) (n=214) (n=49) (n = 19) (n=49) (n = 54) (n=48) (n=59)
n
%
8 39 9 9 9 1 11 13
42 18 18 47 18 2 23 22
s p o n d i n g contra-lateral t o o t h . HOFFMEISTER7, Gf0NTHER et al. 6 a n d o t h e r a u t h o r s 13'14'15, f o u n d n o significant differences in similar studies. Moreover, HOFFMEISTER r e p o r t e d the h o r i z o n t a l mobility o f retained " f r a c t u r e line" teeth, once healing is complete, does n o t a p p e a r to differ f r o m the n o r m a l
physiological r a n g e for h e a l t h y teeth. SCHMITZ et a l l 4 a n d KRENKEL et al. s published similar results. This study supports their results in t h a t we f o u n d n o instance o f increased m o b i l i t y o f "fracture line" teeth over their c o n t r a lateral c o u n t e r p a r t s . R a d i o g r a p h i c evidence o f r o o t res o r p t i o n was observed in 5% (n = 4) o f the patients. KRENKEL et al. 8 r e p o r t e d a similar finding in 4 % (n = 2) o f his cases. N o n e o f the teeth in o u r study was f o u n d to h a v e a periapical osteitis, a finding also r e p o r t e d by G ~ T H E R et al. 6 a n d SCH(3NBERGER 13, b u t in c o n t r a s t to SCHMITZ et al. TMa n d S~TZ3 w h o f o u n d periapical osteitis with 11%0 a n d 11.7% o f teeth in their studies, respectively. T h e results of this study, w h i c h indicate a good prognosis for the retained tooth, s u p p o r t a future strategy o f ext r a c t i n g " f r a c t u r e line" teeth only w h e n absolutely indicated.
References 1. CHAMPY M, PAPE HD, GERLACH KL, LODDE JP. The StraBhourg miniplate osteosynthesis: oral and maxillofacial traumatology. Berlin: Die Quintessenz, 1986:19 43. 2. EWERS R, REUTER E, STOLL W. Die parodontale Situation des Zahnes im BruchspaR. Dtsch Zahnfirztl Z 1976: 31:251-3. 3. Ftrrm K, SExz D. Nachuntersuchungen yon Z/ihnen die zum Bruchspalt in Beziehung stehen. Dtsch Zahnfirztl Z 1963: 18: 638-40. 4. GERLACHKL, PAPEHD. Untersuchungen zur Antibiotikaprophylaxe bei der operativen Behandlung yon Unterkeiferfrakturen. Dtsch Z Mund Kiefer GesichtsChir 1988: 12:497 500. 5. GLICKMANN J. Clinical periodontology. Philadelphia: WB Saunders, 1972: 49%507. 6. GONTHER K, GUNDLACHKKH, SCHW1P-
PER V. Der Zahn im Bruchspalt. Dtsch Zahn/irztl Z 1983: 38:346 8. 7. HOFFMEISTER B. Die parodontale Reaktion im Bruchspalt stehender Z/ihne bei Unterkieferfrakturen. Dtsch Zahnfirztl Z 1985: 40: 3~6. 8. KRgNKEL C, GRUNERT I. Der. Zahn im und am Bruchspalt bei Unterkieferfrakturen, versorgt mit SilcadrahtKlebeschienen. Dtsch Z Mund Kiefer GesichtsChir 1987: 11: 208-10. 9. MAYER R. Zur Feststellung derVitalitfit der Pulpa. Dtsch Zahnfirztl Z 1975: 30: 307-11. 10. MOLLER W. Hfiufigkeit und Prophylaxe der Bruchspaltostitiden im Zeitalter der Antibiotika. Dtsch Stomat 1968: 21: 110-14. 11. ORBAN JB. Parodontologie. Berlin: Die Quintessenz, 1965: 185. 12. ORBAN TR, ORBAN JB. Three-dimensional roentgenographic interpretation in periodontal disease. J Periodont 1960: 31: 275-82. 13. RoTTKE B, KARK U. Zur Frage der Extraktion im Bruchspalt stehender Zfihne. Ost Z Stomat 1969: 62: 465-8. 14. SCHMITZ R, H()LTJE W, CORDES V. Vergleichende Untersuchungen fiber die Regeneration des parodontalen Gewebes nach Unfallverletzungen und Osteotomien des Alveolarfortsatzes. Dtsch Zahn/trztl Z 1973: 28: 219-23. 15. SCHt)NBERGERA. Behandlung der Zfihne im Bruchspalt. Fortschr Kiefer GesichtsChir 1956: 2:108 ll. 16. STOLLP, NIEDERDELLMANNH, SAUTERR. Zahnbeteiligung bei Unterkieferfrakturen. Dtsch Zahn~rztl Z 1983: 38: 349-51.
Address:
St. Berg Department of Maxillo-Facial Surgery University of Cologne Joseph-Stelzmann-Strafle 9 D-5000 K6ln 41 Germany
