The aim of this review was to answer the question: Which is the best procedure to follow when there is tooth involvement in the line of mandibular angle fracture, taking into consideration the occurrence of postoperative infection? A systematic literature review using the PubMed (MEDLINE), Virtual Health Library (VHL), Cochrane Library, and Scopus databases was done, and a total of 1007 articles were found. Among these, 13 articles were included in the final review after the papers were read. A series of 1542 mandibular angle fractures with the presence of teeth in the fracture line was obtained. Of 788 cases where the tooth was removed, a postoperative infection occurred in 84 cases; of 754 cases where the tooth was retained, postoperative infection also occurred in 84 cases. Through this review it was observed that there was no significant statistical difference between removing or retaining the tooth in the line of fracture and the occurrence of postoperative infection.
The treatment of patients with mandibular fractures is a common event in oral and maxillofacial surgery. With frequent changes in treatment protocols for these fractures, a regular review of different concepts is needed in order to improve techniques and avoid unnecessary procedures.
The angle is one of the most affected sites in fractures of the mandible, and this may be closely related to impacted molars. In this area, where the mandible is thinner, tooth extraction further reduces the contact between fracture segments. Studies have also shown that the angular area is subject to a higher occurrence of postoperative complications.
One of the controversies in maxillofacial surgery is related to the approach to be taken in mandibular angle fracture cases involving the presence of teeth in the line of the fracture. Historically, some dental surgeons have condemned the tooth in the fracture line, regardless of its condition, in order to avoid complications – a potential source of infection – following the treatment of these fractures ; others, however, will only consider tooth removal when it is severely infected, stating that complications due to extraction are even more serious, since there is an additional trauma that may affect healthy bone and slow down the process of fracture repair.
Shetty and Freymiller suggest some guidelines regarding the procedure to be followed when teeth are present in the line of fracture: healthy teeth in the line of fracture should be kept when they do not show great mobility or evidence of pathological alterations; impacted molars should be kept to provide a wider repositioning surface, except when associated with cysts or pericoronitis; teeth that prevent fracture reduction should be removed; teeth with a coronal fracture should be kept, provided emergency endodontic therapy is applied; teeth with fractured roots should be removed; tooth apices with exposed roots, or when the line of fracture follows a root surface (from the apex to the gingival margin) should be removed, as they tend to develop pulp or periodontal complications; non-vital teeth at the moment of injury should be treated in a traditional way, considering their recovery potential as well as their relevance to fracture treatment simplification and subsequent prosthetic rehabilitation; the condition of the alveolus and periodontium is crucial for an uneventful consolidation of fractures; time elapsed between fracture and treatment should be taken into account in tooth extraction decision-making.
Each case must be treated independently, and the dental professional should make sure that the tooth extraction decision is made on the basis of each individual clinical situation.
The aim of this study was to perform a systematic literature review, as well as to conduct a meta-analysis, of the occurrence of postoperative infection following the procedure performed in the presence of teeth in the line of mandibular angle fracture – either tooth removal or maintenance of the tooth.
Materials and methods
This study was motivated by the AO Foundation (Arbeitsgemeinschaft für Osteosynthesefragen) – AOCMF (Craniomaxillofacial Surgery) Section, which deals with the treatment of mandibular angle fractures with the presence of teeth in the line of fracture.
For the initial selection, article titles and/or abstracts were analyzed, and the following inclusion criteria were observed: studies published in English without time delimitations; studies of human beings; specific studies that included teeth in the line of mandibular angle fracture (whether impacted or not). For the final selection, the criteria shown in Table 1 were applied, following a full reading of the previously selected articles. The selection criteria were established by the authors prior to commencement of this study.