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Iatrogenic Mandibular Fractures Following Removal of Impacted Third

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Iatrogenic Mandibular Fractures Following Removal of Impacted Third Iatrogenic mandibular IN BRIEF • Serves as a reminder of a rare but significant complication. PRACTICE fractures following removal • Highlights timing and presentation of the event. • Summarises potential risk factors and measures to minimise them. of impacted third molars: • Describes the treatment options. • Illustrates the role of the dentist in an analysis of 130 cases the management. M. Ethunandan,1 D. Shanahan2 and M. Patel3 VERIFIABLE CPD PAPER Immediate and late mandibular fractures are a rare complication of third molar removal. We analysed 130 cases of mandibular fractures following removal of impacted third molars reported in the literature, including four managed in the maxillofacial unit and identified potential risk factors. Its occurrence is likely to be multi-factorial, with age, gender, angulation, laterality, extent and degree of impaction and associated pathologies contributing to the risk of fracture. Postoperative fractures were more common than intra-operative fractures (2.7:1) and occurred most frequently in the second and third weeks (57%). A ‘cracking’ noise was the most frequent presentation (77%). Intra-operative fractures were more frequent among females (M:F – 1:1.3), and differed from postoperative fractures (M:F – 3.9:1). This study analyses the results, providing suggestions to minimise the risk and to manage a mandibular fracture following removal of a third molar. INTRODUCTION seek to identify potential risk factors and Removal of third molars is a common preventive measures. surgical procedure carried out by a den- tal surgeon and can result in a variety MATERIALS AND METHODS complications, which include dry socket, We undertook a Medline search cover- bleeding, infection, trismus and nerve ing the period 1970–2011 and identified damage.1–3 Mandibular fracture is rare, English articles in the literature, which but a very serious complication following reported the occurrence of mandibu- Fig. 1 Pre-extraction bilateral impacted third third molar removal with a reported inci- lar fractures following removal of third molars dence of 0.0033% to 0.0049%.4–6 These molars. The search terms and strategy is fractures could occur in the intra-opera- documented in Table 1. We selected articles tive or postoperative period and can cause which documented original patient data significant distress to the patient and the and included four patients treated in the practitioner (Figs 1-2). Most publications maxillofacial unit, which together form the in the literature are in the form of iso- basis of this analysis. lated case reports and small case series,5–22 Titles and abstracts of all relevant which makes the evaluation of potential articles published in the literature were risk factors difficult. In this study, we ana- screened. Full text analysis of potentially Fig. 2 Post-extraction bilateral mandibular lysed 130 cases of mandibular fractures relevant publications was performed and fractures following third molar removal reported included a hand search of their bibliog- RESULTS in the literature, including 4 cases man- raphy. Articles providing original patient aged in the local maxillofacial unit, and information were selected for analysis. The search strategy identified 113 potential The factors analysed were the demo- articles, which were analysed further to see graphic details of the patients, side of if they conformed to the inclusion crite- 1*-3Department of Oral and Maxillofacial Surgery, St. fracture, extent of impaction (Pell and ria (Table 1). A total of 18 articles, which Richards Hospital, Western Sussex Hospitals NHS Trust, Gregory),23 angulation (vertical, hori- reported original patient data on 126 cases Spitalfield Lane, Chichester, PO19 6SE 5–22 *Correspondence to: Madan Ethunandan zontal, mesioangular, distoangular), were identified and listed in Table 2. The Email: [email protected]; Tel: 0124 383 1531 /0124 degree of impaction (partial/full),23 asso- details of the four patients treated in our 383 1532 ciated pathologies, type of anaesthesia unit are presented in Table 3. A summary Refereed Paper employed for tooth removal, presenta- of all post- and intra-operative mandibular Accepted 21 December 2011 DOI: 10.1038/sj.bdj.2012.135 tion of fracture, time to fracture and fractures following wisdom tooth removal is ©British Dental Journal 2012; 212: 180-185 management of fracture. presented in Table 4. BRITISH DENTAL JOURNAL VOLUME 212 NO. 4 FEB 25 2012 179 © 2012 Macmillan Publishers Limited. All rights reserved. PRACTICE Demographic details Type of anaesthesia Table 1 Search terms and strategy. employed for tooth removal Bracketed figures indicate number The age and sex of the patient were docu- of publications mented in 123 and 129 cases respectively. The type of anaesthesia employed to Database: Ovid MEDLINE ® There was an overall male predominance, remove the wisdom teeth was documented <1948-Nov 2011> with a male:female ratio of 2.4:1. Intra- in 37 cases and was distributed between 1 Molar, Third (4,077) operative fractures were more common general (17) and local (20) anaesthesia. 2 Third molar (5,151) among females (M:F – 1:1.3) and postop- erative fractures were more common among Presentation of fracture 3 Wisdom tooth (329) males (M:F – 3.9:1). The age range of sub- The mode of presentation of the fracture 4 Wisdom teeth (552) jects was from 19 to 79 years of age, with was documented in 88 cases. Sixty-eight 5 1 or 2 or 3 or 4 (6,892) a peak incidence in the 36 to 60-year age patients (77%) noted a ‘cracking’ noise at 6 Mandibular fractures (5,315) group. Intra-operative fractures occurred the time of fracture. Ten patients presented over the age range of 26 to 79 years, with with a history of pain/swelling (11%), five 7 Fracture mandible (441) a peak incidence in the 36 to 45-year age patients with a history of trauma (5%), four 8 6 or 7 (5,395) group. Postoperative fractures occurred with malocclusion (4.5%) and two with 9 5 and 8 ( 133) numbness (2%). between 20 and 78 years of age, with a peak 10 limit 9 to year 1970-current (131) incidence in the 36 to 60-year age group. Time of fracture 11 Limit 10 to English language (113) Side of fracture The time of fracture was documented in Details of the side of fracture were docu- 118 cases and occurred postoperatively in Table 2 Articles documenting mandibular fractures associated with impacted third mented in 53 cases. Postoperative fractures 86 cases and intra-operatively in 32 cases molar removal occurred more frequently on the right side (postoperative:intra-operative – 2.7:1). Author and Year No. of cases (right:left – 1.9:1) and intra-operative Postoperative fractures occurred between fractures were more common on the left the following 1 and 70 days and were De Silva 19847 1 side (right:left – 1:1.6). Three fractures most frequent in the second and third Dunstan et al. 19978 2 were bilateral. weeks (57%). Iizuka et al. 19979 12 10 Angulation (vertical, horizontal, Treatment of fracture Krimmel et al. 2000 6 Perry et al. 20005 28 mesioangular and distoangular) The management of the fractured mandible The angulation of the tooth was docu- was noted in 92 cases and included a range Libersa et al. 20026 27 mented in 101 cases. Fractures occurred of modalities. Thirty-nine cases (42%) were Wagner et al. 200511 17 most frequently in the mesioangu- treated by closed reduction/intermaxillary Wermeister et al. 200512 1 lar (32.6%) and least frequently in the fixation (IMF), 28 (30%) by open reduc- Komerik et al. 200613 1 distoangular (12.8%) group. tion and internal fixation (ORIF), 9 (10%) Kunkel et al. 200714 11 by ORIF + IMF and 16 (17%) by soft diet. Degree of impaction (partial/full) Wagner et al. 200715 1 The degree of impaction was noted in DISCUSSION Woldenberg et al. 200716 1 92 cases. Mandibular fractures occurred Fracture of the mandible is a rare but rec- Khan et al. 200917 1 most frequently following removal of fully ognised complication following lower third Vialati et al. 200918 1 impacted teeth (72%). molar removal. Accurate estimates are dif- Kao et al. 201019 1 ficult to ascertain, though questionnaire Extent of impaction (Pell reports suggest an incidence of between Chrcanovic et al. 201020 2 and Gregory classification)23 0.0033% and 0.0049%.4–6 Various factors Grau-Manclus et al. 2011 21 11 The extent of impaction was documented have been implicated in the increased Cankaya et al. 2011 22 2 in 41 cases. Mandibular fractures were frequency of mandibular fractures.5–22,24 Current series 4 more common in the Class II/III and Type Our case series and those reported in Total 130 B/C compared to Class I and Type A impac- the literature confirm increasing age as tions. Intra-operative and postoperative a predictor of mandibular fractures, with fractures were more common following the a peak incidence in the 36–60 year age complications and the prolonged healing removal of Class II and Type C impactions. group.5,6,9,10,21 Wisdom teeth were most phase, have all been considered to con- frequently removed in patients below tribute to the increased risk of mandibular Associated pathologies 25 years of age,1,2,25 whereas mandibular fractures in the older age group.9–11,19,26,27 Pre-operation infective episodes associated fractures in this age group were not the Though the total number of fractures in with the wisdom tooth were documented in most common. The decreased elasticity, the above 60 year age group was small (15 63 cases. The others pathologies included risk of osteoporosis, bone atrophy, greater patients, 12%), the relative frequency of cysts (10 cases), enlarged follicle (14 cases) potential of tooth ankylosis, higher inci- fracture is likely to be much higher, as only and postoperative infection (4 cases).
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