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Root resection in the management of fractures of the mandible
ROOT RESECTION IN THE M A N A G E M E N T OF FRACTURES OF THE MANDIBLE
By J. S. KNIGHT,B.D.S., H.D.D.(Ed.), L.D.S., R.C.S.(Eng.)
Birmingham Regional Plastic Surgery Centre INTRODUCTION THIS method of treatment has been evolved for those cases of fracture of the mandible in which there is a single molar standing in the posterior fragment, and where the fracture line runs down the anterior root. Under such circumstances it is recognised that the removal of such a single tooth might change the treatment from the simplest form to one requiring external pin fixation or lower border wiring. On the other hand, retention of the tooth is fraught with danger because of the possibility of infection of the fracture. METHOD OF INFECTION The dangers resulting from the presence of a tooth in the line of fracture may arise from two sources :-i. The Tooth P u l p . - - I f the tooth is non-vital at the time of fracture the possibility of infection will be immediate and will contraindicate this method of treatment. If, however, the tooth is vital, the periapical vessels of the root involved may be severed ; the pulp may not survive, and there will be danger of infection arising from this source. Infection of the fracture from such a necrosis of the pulp will probably take ten days or more to develop. 2. The C e m e n t u m on the Exposed Root S u r f a e e . m T h i s exposed cementum rapidly becomes necrotic and may itself infect the fracture. Also, granulations will not grow out from it to meet those growing from the bony surface opposite, so that a potential space is left for mouth infection to enter the fracture and infect it. To overcome these difficulties it appeared to the writer that it should be possible to excise the root involved in the fracture and treat the exposed pulp in such a way that it would not become necrotic, but remain healthy during the four to eight weeks required for bony union. This leaves the posterior root and the crown firmly attached to the posterior fragment and available to prevent displacement and provide fixation. When union is complete the tooth is then removed. TECHNIQUE The posterior fragment in such a fracture is displaced upwards, and on looking in the patient's mouth the exposed tooth root will be visible (Fig. I). In ascertaining whether the plane of the fracture runs down the tooth root, the 3o degree lateral radiograph may be slightly misleading, because many 3o4
ROOT
RESECTION
IN
THE
MANAGEMENT
OF
FRACTURES
OF
TIlE
MANDIBLE
305
fractures run obliquely, and in the radiograph the position of the fracture, determined by the edge o f the outer or inner cortical plate, appears to be some distance from the root (Figs. 2 ; 5, A; and 6, A). At operation the toilet of the mouth should be carried out very thoroughly. The root is then cut from the tooth with a No. 8 round bur i n the straight handpiece. The cut should start at the amelocemental junction in such a direction that it will reach the bifurcation of the roots (Figs• 3 ; 5, B ; and 6, B). The resection should be carried out under dripping water to avoid heat and to wash the debris away from the fracture. When the root is divided it should be dislodged anteriorly
'"°:°*•' l :FIG. 2
FIG. I
".':'2.:.5:
!i:i!!:
/.'.:...:.
•. . . : . : . •
~:.:.:.:
:':" ":'"
.'.." ....1 ..o. °.
Z':':"""
• ," "." ::...-.
t .•" • -." ,~........
_ _ . . d '.L-- . FIG.
FIG. 3
4
Figs. I to 4 . - - D i a g r a m m a t i c illustrations of the technique of resection.
by a gentle twist of the fine straight elevator. Care must be taken not to lose it in the fracture. The root socket and fracture are then lightly packed with ½ in. ribbon gauze and the exposed pulp surface is treated with a minute quantity of pure phenol. The ribbon gauze is immediately removed in case any of the phenol has soaked into it. The fracture is then reduced and immobilised by the most suitable method (Fig. 4). CASE REPORTS
Case z.--Male, aged 21 (Fig. 5). Fracture of the left angle of the mandible occurred whilst the patient was boxing• Two days after injury the anterior root of /7 was excised from the fracture line and the mandible immobilised by eyelet wiring. 4v
306
BRITISH JOURNAL OF PLASTIC SURGERY
The posterior fragment remained in a satisfactory position in occlusion with /7. The, patient was discharged from hospital on the sixth day. In four weeks the intermaxillary fixation was undone and there was sound clinical union. The mucosa around the crown o f / 7 appeared normal and only with a probe could the loss of the anterior root be detected. There had been no pain from the tooth. Two weeks later the remainder of the tooth
AI
]3i
A2
]32 FIG. 5 Case I. Male, aged 2I.
was extracted under local anmsthesia and sectioned in order to ascertain the condition of the pulp. Case 2.--Male, aged 36 (Fig. 6). Bilateral fracture of the mandible through the left canine region and right angle. The fight lower second molar was in the fracture line. Four days after injury the anterior root of 7-/was excised and removed from the fracture line. Following this the fractures were reduced and immobilised by eyelet
ROOT RESECTION
IN
THE
MANAGEMENT OF FRACTURES OF
THE MANDIBLE
307
wiring. The 7/ occluded with two very carious upper molars, which retained the posterior fragment in a reasonable position. In five weeks the fixation was undone: and clinical union was satisfactory. The 7/ was firm with a space under the crown where the root had been removed.
AI
]31
J
A2
B2 Case 2.
FIG. 6 Male~ aged 36.
There had been no pain from the tooth. One week later it was removed under locai anmsthesia and sectioned for histological examination. H i s t o l o g y o f t h e P u l p . - - I n both cases the pulps were found to be vital, with no evidence o f gross infection. Fig. 7 is a section o f the tooth from Case I, seen under low magnification. Towards the cut surface there is an increase in the n u m b e r o f fibroblasts and capillaries (Fig. 8). T h e presence o f inflammatory cells appears to be confined to the surface region o f the cut. At one side o f the cut surface there is evidence
SO8
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
FIG. 7 Photomicrograph of the tooth from Case I. x4-75.
FIG. 8 Photomicrograph of the pulp from near the cut surface, x 200.
ROOT
RESECTION
IN
THE
MANAGEMENT
OF FRACTURES
OF
THE
MANDIBLE
309
of calcific tissue of repair being laid down around particles of dentine which have been deposited in the pulp from the bur. The pulp tissue in the rest of the root is normal (Fig. 9).
FI~. 9 P h o t o m i c r o g r a p h of the periphery of the pulp away from the cut surface,
x 225.
From these appearances it may be concluded that the pulp of a tooth from which a root has been excised need not become grossly infected in the limited period during which union of the fracture is taking place. SUMMARY A method of treatment of fractures of the mandible is described where a single molar tooth is present on the posterior fragment, and the line of fracture runs down the anterior root. The excision of the involved root and subsequent use of the treated tooth for immobilisation has simplified the treatment of these fractures.
My grateful thanks are due to Mr O. T. MansfieM for his helpful advice and criticism, and to Professor E. B. Manley of the Department of Dental Pathology of the University of Birmingham for help and advice with the histology, and Mr E. B. Brain of that department for the photomicrographs.
By J. S. KNIGHT,B.D.S., H.D.D.(Ed.), L.D.S., R.C.S.(Eng.)
Birmingham Regional Plastic Surgery Centre INTRODUCTION THIS method of treatment has been evolved for those cases of fracture of the mandible in which there is a single molar standing in the posterior fragment, and where the fracture line runs down the anterior root. Under such circumstances it is recognised that the removal of such a single tooth might change the treatment from the simplest form to one requiring external pin fixation or lower border wiring. On the other hand, retention of the tooth is fraught with danger because of the possibility of infection of the fracture. METHOD OF INFECTION The dangers resulting from the presence of a tooth in the line of fracture may arise from two sources :-i. The Tooth P u l p . - - I f the tooth is non-vital at the time of fracture the possibility of infection will be immediate and will contraindicate this method of treatment. If, however, the tooth is vital, the periapical vessels of the root involved may be severed ; the pulp may not survive, and there will be danger of infection arising from this source. Infection of the fracture from such a necrosis of the pulp will probably take ten days or more to develop. 2. The C e m e n t u m on the Exposed Root S u r f a e e . m T h i s exposed cementum rapidly becomes necrotic and may itself infect the fracture. Also, granulations will not grow out from it to meet those growing from the bony surface opposite, so that a potential space is left for mouth infection to enter the fracture and infect it. To overcome these difficulties it appeared to the writer that it should be possible to excise the root involved in the fracture and treat the exposed pulp in such a way that it would not become necrotic, but remain healthy during the four to eight weeks required for bony union. This leaves the posterior root and the crown firmly attached to the posterior fragment and available to prevent displacement and provide fixation. When union is complete the tooth is then removed. TECHNIQUE The posterior fragment in such a fracture is displaced upwards, and on looking in the patient's mouth the exposed tooth root will be visible (Fig. I). In ascertaining whether the plane of the fracture runs down the tooth root, the 3o degree lateral radiograph may be slightly misleading, because many 3o4
ROOT
RESECTION
IN
THE
MANAGEMENT
OF
FRACTURES
OF
TIlE
MANDIBLE
305
fractures run obliquely, and in the radiograph the position of the fracture, determined by the edge o f the outer or inner cortical plate, appears to be some distance from the root (Figs. 2 ; 5, A; and 6, A). At operation the toilet of the mouth should be carried out very thoroughly. The root is then cut from the tooth with a No. 8 round bur i n the straight handpiece. The cut should start at the amelocemental junction in such a direction that it will reach the bifurcation of the roots (Figs• 3 ; 5, B ; and 6, B). The resection should be carried out under dripping water to avoid heat and to wash the debris away from the fracture. When the root is divided it should be dislodged anteriorly
'"°:°*•' l :FIG. 2
FIG. I
".':'2.:.5:
!i:i!!:
/.'.:...:.
•. . . : . : . •
~:.:.:.:
:':" ":'"
.'.." ....1 ..o. °.
Z':':"""
• ," "." ::...-.
t .•" • -." ,~........
_ _ . . d '.L-- . FIG.
FIG. 3
4
Figs. I to 4 . - - D i a g r a m m a t i c illustrations of the technique of resection.
by a gentle twist of the fine straight elevator. Care must be taken not to lose it in the fracture. The root socket and fracture are then lightly packed with ½ in. ribbon gauze and the exposed pulp surface is treated with a minute quantity of pure phenol. The ribbon gauze is immediately removed in case any of the phenol has soaked into it. The fracture is then reduced and immobilised by the most suitable method (Fig. 4). CASE REPORTS
Case z.--Male, aged 21 (Fig. 5). Fracture of the left angle of the mandible occurred whilst the patient was boxing• Two days after injury the anterior root of /7 was excised from the fracture line and the mandible immobilised by eyelet wiring. 4v
306
BRITISH JOURNAL OF PLASTIC SURGERY
The posterior fragment remained in a satisfactory position in occlusion with /7. The, patient was discharged from hospital on the sixth day. In four weeks the intermaxillary fixation was undone and there was sound clinical union. The mucosa around the crown o f / 7 appeared normal and only with a probe could the loss of the anterior root be detected. There had been no pain from the tooth. Two weeks later the remainder of the tooth
AI
]3i
A2
]32 FIG. 5 Case I. Male, aged 2I.
was extracted under local anmsthesia and sectioned in order to ascertain the condition of the pulp. Case 2.--Male, aged 36 (Fig. 6). Bilateral fracture of the mandible through the left canine region and right angle. The fight lower second molar was in the fracture line. Four days after injury the anterior root of 7-/was excised and removed from the fracture line. Following this the fractures were reduced and immobilised by eyelet
ROOT RESECTION
IN
THE
MANAGEMENT OF FRACTURES OF
THE MANDIBLE
307
wiring. The 7/ occluded with two very carious upper molars, which retained the posterior fragment in a reasonable position. In five weeks the fixation was undone: and clinical union was satisfactory. The 7/ was firm with a space under the crown where the root had been removed.
AI
]31
J
A2
B2 Case 2.
FIG. 6 Male~ aged 36.
There had been no pain from the tooth. One week later it was removed under locai anmsthesia and sectioned for histological examination. H i s t o l o g y o f t h e P u l p . - - I n both cases the pulps were found to be vital, with no evidence o f gross infection. Fig. 7 is a section o f the tooth from Case I, seen under low magnification. Towards the cut surface there is an increase in the n u m b e r o f fibroblasts and capillaries (Fig. 8). T h e presence o f inflammatory cells appears to be confined to the surface region o f the cut. At one side o f the cut surface there is evidence
SO8
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
FIG. 7 Photomicrograph of the tooth from Case I. x4-75.
FIG. 8 Photomicrograph of the pulp from near the cut surface, x 200.
ROOT
RESECTION
IN
THE
MANAGEMENT
OF FRACTURES
OF
THE
MANDIBLE
309
of calcific tissue of repair being laid down around particles of dentine which have been deposited in the pulp from the bur. The pulp tissue in the rest of the root is normal (Fig. 9).
FI~. 9 P h o t o m i c r o g r a p h of the periphery of the pulp away from the cut surface,
x 225.
From these appearances it may be concluded that the pulp of a tooth from which a root has been excised need not become grossly infected in the limited period during which union of the fracture is taking place. SUMMARY A method of treatment of fractures of the mandible is described where a single molar tooth is present on the posterior fragment, and the line of fracture runs down the anterior root. The excision of the involved root and subsequent use of the treated tooth for immobilisation has simplified the treatment of these fractures.
My grateful thanks are due to Mr O. T. MansfieM for his helpful advice and criticism, and to Professor E. B. Manley of the Department of Dental Pathology of the University of Birmingham for help and advice with the histology, and Mr E. B. Brain of that department for the photomicrographs.