Otolaryngology–Head and Neck Surgery (2009) 140, 845-848

ORIGINAL RESEARCH—FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY

The effects of molar tooth involvement in

mandibular angle fractures treated with
rigid fixation
Jeevan Ramakrishnan, MD, Alexander Shingleton, PhD,
Dawn Reeves, MD, J. Michael Key, MD, and Emre Vural, MD, Little Rock,
AR; and East Lansing, MI
No sponsorships or competing interests have been disclosed for
this article.
ABSTRACT
OBJECTIVE: To determine whether the presence of a tooth in
the line of mandibular angle fracture increases the incidence of
complications and whether removing these teeth has an effect on
complication rates.
DESIGN: Case series with chart review.
SUBJECTS AND METHODS: The analysis was performed on
83 patients who underwent open reduction and internal fixation for
mandibular angle fractures. Lower molar teeth involved in the
fracture line were extracted if they were loose, fractured, or grossly
infected or prevented satisfactory reduction. Data regarding demo-
graphics, involvement of a molar tooth, management of the in-
volved tooth, and postoperative outcome were analyzed. Statistical
analysis was performed by using likelihood ratio ␹2 and logistic
regression.
RESULTS: The revision surgery in fractures with molar tooth
involvement was 28.9 percent, compared to 12.9 percent when no
tooth was involved (P ⫽ 0.084). When a tooth was involved in the
fracture, the revision surgery rate was 25 percent when it was
removed and 30% when it was preserved (P ⫽ 0.734).
CONCLUSION: Postoperative complications, especially the re-
vision surgery rates, may not increase by involvement of lower
molar teeth in the fracture line and selective removal of these teeth
by using commonly accepted guidelines may not decrease com-
plication rates in angle fractures.
© 2009 American Academy of Otolaryngology–Head and Neck
Surgery Foundation. All rights reserved.
fracture and advised removal of these teeth only if they were
severely infected or loose.3 Finally, some surgeons stated
that the complications would be higher if the teeth involved
in mandibular fracture lines were removed.4
Contrary to the wide belief that the management of the
teeth involved in mandibular fracture lines was well estab-
lished in the literature, this topic is still obscure due to two
major drawbacks of previously published studies. First, al-
most all of the publications regarding the outcome of man-
dibular fractures with tooth involvement came from the
period when current standard treatment of mandibular frac-
tures in the form of open reduction and internal rigid fixa-
tion with plates and screws (ORIF) was not available.1-4
Secondly, none of these studies was site specific in terms of
location of the fracture line involving tooth.
Mandibular angle is one of the most commonly fractured
sites of the mandible.5 These fractures have been a subject
of special interest because of their close or direct relation-
ship with the lower molar teeth (LMT).6 The purpose of this
study is to compare the complication rates in mandibular
angle fractures treated with ORIF, based on the presence of
LMT in the fracture line and if removal of these teeth based
on historically accepted guidelines decreased the complica-
tion rates in patients with involved LMT.
METHODS
The facial trauma database at the University of Arkansas for

C omplications following the treatment of mandibular

fractures such as infection and nonunion were histori-
cally attributed to the presence of the tooth involvement in
the fracture line.1 Since it was long believed that the tooth
in the fracture line became a source for chronic infection,
some surgeons recommended removal of these teeth regard-
less of the condition of the involved teeth.2 The others
considered the condition of the teeth involved in the line of
Medical Sciences was retrospectively reviewed for mandib-
ular angle fractures treated between January 1998 and Jan-
uary 2007 after obtaining an exempt status from the Insti-
tutional Review Board. Patients were included in the review
if they had a mandibular angle fracture that was repaired by
using ORIF, and if there were adequate medical records
available regarding the surgical treatment and the postop-
erative outcome.

Received 22 October 2008; revised 14 January 2009; accepted 22 January 2009.

0194-5998/$36.00 © 2009 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
doi:10.1016/j.otohns.2009.01.037
846 Otolaryngology–Head and Neck Surgery, Vol 140, No 6, June 2009
Table 1
Rate (%) of minor complication and revision surgery among patients with and without tooth involvement
Tooth involvement No tooth involvement
Minor complications 9.6% (5 of 52) 9.7% (3 of 31)
Revision surgery 28.9% (15 of 52) 12.9% (4 of 31)
The surgical repairs were performed by two senior sur-
geons (EV, JMK) who treat the majority of maxillofacial
trauma at our institution, with the assistance of residents.
All of the cases were treated with open reduction and
internal fixation through an intraoral with or without trans-
buccal approach. The technique used for plating the angle
fractures was one of the following: Champy technique using
a 2.0-mm miniplate, a 2.0-mm tension band plate with a
2.0-mm bicortical plate, dual monocortical miniplates, or a
2.0-mm biplanar curved-angle strut plate (Synthes Inc, West
Chester, PA). Perioperative and postoperative antibiotics
were routinely administered in all cases in addition to chlo-
rhexidine gluconate mouth wash.
In addition to demographics, data were collected regard-
ing the presence or absence of teeth in the fracture line, the
management of these teeth, and the development of major or
minor postoperative complications. Major postoperative
complication was defined as any complication necessitating
a second surgery at the site of angle due to exposed hard-
ware, nonunion, loose hardware, nonunion or intractable
infection unresponsive to conservative measures. Postoper-
ative infections completely resolved after antibiotic treat-
ment without further interventions or initial plate exposure
spontaneously closed with conservative management with
continuing oral hygiene were considered as minor compli-
cations. Commonly accepted guidelines were used in deci-
sion making of removing the involved LMT, which are
loose, fractured, grossly infected, or carious tooth, and tooth
preventing satisfactory reduction.1,7 If any of these condi-
tions was present, the tooth was removed. The data were
analyzed using likelihood ratio ␹2 and logistic regression to
examine factors that may affect the incidence of minor
complications or major complications necessitating a revi-
sion surgery. Confidence intervals were calculated with a
continuity correction. All data analyses were conducted
using JMP 5.0 (SAS Institute, Cary, NC). Significance was
taken at the 5 percent level.
RESULTS
A total of 83 patients met the criteria to be included in the
study. Eighty-eight percent (73/83) of the patients were
males, and 12 percent (10/83) were females. The patients’
ages ranged from 17 to 62 years with a median of 32 years.
Forty-three (52%) of the patients were Caucasians, 39
(47%) were African-Americans, and one patient (1%) was
Difference in rate (95% CI) P value
0.1% (⫺14.1%-18.3%) P ⫽ 0.992
15.9% (⫺5.2%-32.8%) P ⫽ 0.084
Hispanic in origin. The majority of the fractures were
caused by assault and accident (89%).
The time that elapsed between the injury and surgical
repair ranged from less than 1 day to 90 days with a median
of 7 days. Twenty-six patients (31%) had a unilateral man-
dibular angle fracture, two patients (0.2%) had bilateral
angle fractures, and 55 patients had another fracture site in
addition to the angle fracture. Follow-up ranged from 1 to
12 months, with a median of 2.5 months.
Overall major postoperative complication rate necessi-
tating a second surgical intervention was 23 percent (19 of
83). The reasons for second surgical intervention were loose
hardware, exposed hardware, intractable infection, non-
union, or combination of these. A molar tooth was involved
in the line of the fracture in 63 percent (52 of 83) of the
patients, and there was no LMT involvement in 37 percent
(31 of 83) of the patients.
Table 1 shows the rate of minor complications and major
complications (ie, revision surgery) for patients with and
without tooth involvement. Tooth involvement did not in-
crease the occurrence of minor complications (likelihood
ratio: ␹2 ⬍ 0.001, n ⫽ 83, P ⫽ 0.992): the rate of postop-
erative infection was 9.6 percent and 9.7 percent for patients
with and without tooth involvement, respectively. Among
the patients with a tooth in the fracture line, 28.9 percent (15
out of 52 patients) developed a major postoperative com-
plication necessitating a second surgery, while this rate was
12.9 percent (4 out of 31 patients) for patients without LMT
involvement. Although the rate of revision surgery in-
creased by 16 percent (95% CI: ⫺5.2% to 32.8%) for those
with a LMT in the fracture line compared to those without,
this difference was not statistically significant (likelihood
ratio: ␹21 ⫽ 2.980, n ⫽ 83, P ⫽ 0.084).
Table 2 shows the rate of minor complications and revi-
sion surgery for patients with LMT involvement in the
fracture line, based on whether the tooth was left in place or
removed. Removal of the tooth had no effect on the rate of
minor complications (likelihood ratio: ␹21 ⫽ 0.797, n ⫽ 52,
P ⫽ 0.32) or the rate of secondary surgery (likelihood ratio:
␹21 ⫽ 0.115, n ⫽ 52, P ⫽ 0.734).
DISCUSSION
The only comprehensive study that was published in the
literature regarding the comparison of complication rates
Ramakrishnan et al The effects of molar tooth involvement in . . .
Table 2
Rate (%) of minor complication and revision surgery among patients with tooth involvement where tooth was
retained or extracted
Tooth retained Tooth extracted
Minor complications 7.5% (3 of 40) 16.7% (2 of 12)
Revision surgery 30.0% (12 of 40) 25.0% (3 of 12)
following ORIF in mandibular angle fractures with or with-
out LMT involvement was performed by Ellis in 2002.8 In
this retrospective analysis of 402 patients, he did not find
any statistically significant difference in infection or hard-
ware removal rates between patients with or without LMT
involvement, although the complication rate was higher in
the group with LMT involvement. In the same study there
was no statistically significant difference in these compli-
cation rates between the patients who underwent extraction
of the involved tooth and the ones who did not. Ellis con-
cluded that the complication rates might be different if he
had removed only mobile, fractured, or infected teeth in his
series and retained the ones that were removed just because
they had root exposure. We did not remove any tooth
because of root exposure in our series, unless root exposure
caused a loose tooth. However, we still could not find any
difference in complication rates between patients who un-
derwent tooth extraction and the patients who did not.
One other important aspect of our study that comple-
ments Ellis’s study was separating simple infectious epi-
sodes that responded to conservative management with an-
tibiotics and the major complications necessitating revision
surgery in the analysis. Since ORIF involves exposure of the
fracture site and hardware to the oral cavity flora, infections
can be seen after surgical treatment of any mandibular
fracture regardless of tooth involvement or the location of
the fracture. Some of these infections may respond to con-
servative management without any revision surgery, while
the more serious ones can lead to hardware failure, non-
union, or malunion necessitating a revision surgery. Com-
paring overall infection rates in these cases based on LMT
involvement or removal/retention status may obscure the
effects of LMT involvement in angle fractures, since some
of the revision surgeries are performed due to intractable
infections and their hardware-related consequences. In or-
der to determine the true effects of LMT involvement and
their removal on the outcome of theses fractures, we have
divided the complications in our series into minor and
major, and compared separately among groups in order to
determine the effect of LMT involvement and its selective
extraction on the outcome of mandibular fractures. How-
ever, we still could not find any significant difference
among groups in terms of minor or major complications.
Therefore LMT involvement in the fracture line may not be
solely held responsible for relatively common infectious or
hardware-related complications seen after the treatment of
mandibular angle fractures. There might be other possible
847
Difference in rate (95% CI) P value
9.2% (⫺10.4%-42.1%) P ⫽ 0.32
5.0% (⫺29.7%-29.8%) P ⫽ 0.734
contributing factors involved in the development of postop-
erative complications in this particular location such as bone
quality and thickness, biting forces, nutritional oral hygienic
status of the patient, and patient compliance.
The postoperative complication rates in angle fractures
did not change significantly by involvement of a LMT in the
fracture line or by selectively removing the involved LMT
using commonly accepted guidelines, in this study. How-
ever, it is highly probable that significantly higher compli-
cation rates would be observed if fractured, carious, grossly
infected, or loose LMT involved in angle fractures are
retained instead of removed. The major drawback of the
results presented in this study is the lack of power due to
relatively small sample size. Therefore, further studies with
larger sample size with more statistical power are necessary
to find out if LMT involvement and removal of these LMT
would change the postoperative outcome in the manage-
ment of mandibular angle fractures with ORIF. Until then,
patients with mandibular angle fractures involving a LMT
should be counseled properly in the preoperative period
about the chances of having additional surgical interven-
tion(s) regardless of the LMT involvement or selective
removal of the involved teeth. Informing this group of
patients about possible postoperative unwanted events ne-
cessitating additional surgical intervention(s) should be an
integral part of daily practice of otolaryngologists treating
such patients, especially from a medicolegal standpoint.
CONCLUSION
LMT involvement in mandibular angle fractures and selec-
tive removal of the involved LMT based on commonly used
guidelines may not change the rate of minor complications
responsive to conservative measures or major complications
necessitating revision surgery.
AUTHOR INFORMATION
From the Department of Otolaryngology–Head and Neck Surgery (Drs
Ramakrishnan, Reeves, Key, and Vural), University of Arkansas for Med-
ical Sciences; the Ecology, Evolutionary Biology & Behavior Program (Dr
Shingleton), Genetics Program, Department of Zoology, Michigan State
University; and the Section of ENT (Dr Vural), John McClellan VA
Hospital, Central Arkansas Veterans Healthcare System.
848 Otolaryngology–Head and Neck Surgery, Vol 140, No 6, June 2009
Corresponding author: Emre Vural, MD, Department of Otolaryngology–
Head and Neck Surgery, University of Arkansas for Medical Sciences,
4301 W. Markham, Slot 543, Little Rock, AR 72205.
E-mail address: vuralemrea@uams.edu.
AUTHOR CONTRIBUTIONS
Jeevan Ramakrishnan, MD, data collection, writing; Alexander
Shingleton, PhD, statistical analysis; Dawn Reeves, MD, data collection;
J. Michael Key, MD, critical review, performing surgeries; Emre Vural,
MD, study design, writing, performing surgeries, critical review.
DISCLOSURES
Competing interests: None.
Sponsorships: None.
REFERENCES
1. Shetty V, Freymiller E. Teeth in the line of fracture: A review. J Oral
Maxillofac Surg 1989;47:1303– 6.
2. Bradley RL. Treatment of fractured mandible. Am Surg 1965;31:
289 –90.
3. Wilkie CA, Diecidue AA, Simses RT. Management of teeth in the line
of mandibular fracture. J Oral Surg 1953;11:227–30.
4. Neal DC, Wagner WF, Alpert B. Morbidity associated with teeth in the
line of mandibular fractures. J Oral Surg 1978;36:859 – 62.
5. King R, Scianna J, Petruzzelli G. Mandible fracture patterns: a suburban
trauma center experience. Am J Otolaryngol 2004;25:301–7.
6. Halmos DR, Ellis E, Dodson TB. Mandibular third molars and angle
fractures. J Oral Maxillofac Surg 2004;62:1076 – 81.
7. James R, Fredrickson C, Kent J. Prospective study of mandibular
fractures. J Oral Surg 1981;39:275– 81.
8. Ellis E. Outcomes of patients with teeth in the line of mandibular angle
fractures treated with stable internal fixation. J Oral Maxillofac Surg
2002;60:863–5.