Is it safe to remove wisdom teeth in a patient with a fractured mandible?

Wisdom Teeth Removal in Patients with Mandibular Fractures

Wisdom teeth removal should be delayed until after the mandibular fracture has healed, unless the tooth is severely damaged, infected, or directly interfering with fracture reduction and fixation. This approach minimizes the risk of complications and optimizes fracture healing outcomes.

Assessment of Wisdom Teeth in Mandibular Fractures

When evaluating wisdom teeth in the line of mandibular fractures, consider:

• Imaging assessment: CT with multiplanar reformations is the gold standard for evaluating mandibular fractures, with nearly 100% sensitivity and improved interobserver agreement compared to radiography 1.

• Fracture characteristics: Location, displacement, and comminution are critical factors that determine management approach.

• Tooth condition: Assess for pre-existing pathology, damage from trauma, or position relative to the fracture line.

Management Algorithm

When to Remove Wisdom Teeth During Fracture Treatment:

1. Immediate removal indicated when:

   • Tooth is severely damaged or fractured
   • Active infection is present
   • Tooth prevents proper fracture reduction
   • Tooth is partially erupted with pericoronitis

2. Delayed removal (after fracture healing) when:

   • Tooth is asymptomatic
   • No pre-existing pathology
   • Tooth is not interfering with fracture reduction
   • Fracture is uncomplicated and can be treated with closed reduction

When to Retain Wisdom Teeth:

Evidence suggests that asymptomatic impacted teeth in uncomplicated mandibular fracture lines do not cause delayed healing when treated with closed reduction 2. In fact, a retrospective study showed that removing wisdom teeth in the line of mandibular angle fractures was associated with more infections (p=0.04) and overall complications (p=0.02) 3.

Special Considerations

Radiation History

For patients with prior radiation therapy to the head and neck region:

• Patients who received ≥50 Gy to the mandible are at significant risk for osteoradionecrosis (ORN) 1, 4
• Dental extractions in irradiated areas should be avoided if possible 1
• If extraction is necessary, consider:
  • Pentoxifylline (400 mg twice daily) and tocopherol (1,000 IU daily) for at least 1 week before and 4 weeks after the procedure 1
  • Prophylactic antibiotics before and after the procedure 1
  • Antiseptic mouth rinses (chlorhexidine or povidone-iodine) 1

Fracture Fixation Techniques

The choice of fixation method impacts the decision about wisdom tooth removal:

• Closed reduction: Asymptomatic wisdom teeth can often be retained 2
• Open reduction with internal fixation: May require tooth removal if it interferes with plate placement, though sagittal split osteotomy plates or 2.0-mm plates on the lateral aspect of the mandible are commonly used options 3

Potential Complications

• Infection: The most common complication (37.2%) in mandibular angle fractures 3
• Plate removal: Required in 26.9% of cases 3
• Non-union: Occurs in approximately 6.4% of cases 3
• Osteoradionecrosis: A serious complication in patients with history of radiation therapy 1, 4

Follow-up Recommendations

• Regular clinical and radiographic monitoring during fracture healing
• Assessment of occlusion and mandibular function
• Evaluation for signs of infection or delayed healing
• Long-term dental follow-up, especially for patients with retained wisdom teeth

By carefully weighing these factors, clinicians can optimize outcomes while minimizing complications in patients with mandibular fractures involving wisdom teeth.