Iatrogenic Mandibular Fractures Following Removal of Impacted Third

Home , Tooth ankylosis

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 dental 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.

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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 postoperative 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). dence of pathologies, postoperative a small proportion of patients have their

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Table 3 Details of patients managed in the local maxillofacial unit

No. Age/ Tooth Pre-operative Pathological Extent of Angulation Pell & Gregory Presentation Time to Treatment Sex symptoms bone process impaction classification fracture 1 49/M 48 Pericoronitis Enlarged follicle Full Distoangular III / C Pain and swelling 3 weeks postop Soft diet

2 67/M 48 Pericoronitis Resorption Full Mesioangular III / C Pain and swelling 10 weeks postop ORIF

3 (a) 28/M 38 Pericoronitis Enlarged follicle Partial Mesioangular I / B Mild trauma 2 weeks postop Soft diet

3 (b) 28/M 48 Pericoronitis None Partial Mesioangular I / B Mild trauma 2 weeks postop Soft diet

4 79/F 48 Pericoronitis Enlarged follicle Full Mesioangular III / C Crack / Mobility Intra-operative ORIF + IMF

Key: ORIF = open reduction internal fixation; IMF = intermaxillary fixation.

wisdom teeth removed in this age group Table 4 Summary of mandibular fractures following third molar removal (5–10%).28,29 There was a higher frequency of fractures among males which is thought Parameters Intra-operative Postoperative Total to be secondary to the increased mastica- Age (years) 32 cases 91 cases 123 cases tory forces generated5,6,30 and the increased <19 2 - 2 risk of trauma. Mandibular fractures were more com- 20-25 2 10 12 mon following removal of mesioangu- 26-35 11 18 29 lar, vertical, horizontal and distoangular 36-45 11 24 35 teeth respectively and were similar to the relative frequency of these impactions 46-60 5 25 30 in the general population (mesioangular > 61 1 14 15 (45%), vertical (40%), horizontal (10%) Sex 32 cases 97 cases 129 cases and distoangular (5%)).31 The angulation of the wisdom tooth has been reported Male 14 77 91 as a factor determining the difficulty of Female 18 20 38 removal, with mesioangular, horizontal/ vertical and distoangular impactions con- Side of fracture 13 cases 40 cases 53 cases sidered to be progressively more difficult.31 Right 5 24 29 This review does not support a direct rela- Left 8 13 21 tionship between the presumed difficulty of removal based on angulation and the Bilateral - 3 3 risk of mandibular fracture. The relatively Angulation 12 cases 89 cases 101 cases increased risk of fractures associated with Vertical 1 27 28 horizontal impactions could be related to the need for additional bone removal Horizontal 2 25 27 and deeper point of application often Mesioangular 9 24 33 required.32 Distoangular - 13 13 Mandibular fractures were in general, more common following removal of right Degree of impaction 2 cases 90 cases 92 cases sided wisdom teeth (right:left – 1.8:1), Partial - 26 26 though interestingly intra-operative Full 2 64 66 fractures were more common following removal of left sided teeth (right:left – Extent of impaction (Pell & Gregory classification) 1O cases 31 cases 41 cases 1:1.6). It is difficult to explain the asso- Class I - 2 2 ciation between laterality and the risk of mandibular fractures. Class II 6 19 25 The degree (partial/complete) and the Class III 4 10 14 23 extent (Pell and Gregory) of impaction Type A - 2 2 were found to be predictors of mandibular fractures.5,6,9,10,13,21 Fully impacted and Type B 2 13 15 Class B/C and Type II/III impactions were Type C 8 16 24 more frequently associated with mandib- Continued on page 182 ular fractures. These teeth proportionally

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occupy a greater volume of the mandibular bone and their extraction is likely to Table 4 Summary of mandibular fractures following third molar removal necessitate more bone removal, resulting Continued from page 181 in a reduction in the remaining bone stock and weakening of the mandible, predis- Associated pathologies 9 cases 54 cases 63 cases posing it to fractures.5,6,9,10,13 Buccal bone, Pre-operative infections - 35 35 especially along the external oblique ridge, Cysts 3 7 10 provides significant strength to the mandibular angle and its removal to facilitate Enlarged follicle 6 8 14 extraction further weakens the mandible. Postoperative infections - 4 4 Awareness of these factors and attempts to Type of anaesthesia employed for tooth removal 4 cases 33 cases 37 cases minimise the amount and location of bone removed by judicious tooth/root division Local 3 17 20 can potentially reduce the risk of fractures. General 1 16 17 Garcia et al.33 did not find Pell and Gregory Presentation of fracture 5 cases 83 cases 88 cases classification to be useful in predicting the difficulty of wisdom teeth removal and Trauma - 5 5 32 Renton et al. found patient factors also Crack 4 64 68 played an important role in determining the difficulty of removal. Pain/swelling 1 9 10 Pre-operative infections associated with Numbness 2 2 the impacted tooth have been suggested to Malocclusion 2 2 4 predispose to postoperative fractures.5,9,12,21 All patients in our series had episodes of Unnoticed - 1 1 infection before tooth removal. In the Time of fracture (days postop) 32 cases 86 cases 118 cases United Kingdom, where only symptomatic 1-7 19 19 wisdom teeth are currently considered for removal in line with the NICE guidelines,34 8-14 27 27 it is interesting that only two previous 15-21 22 22 reports of fractures have been recorded in 22-29 6 6 the last 29 years.7,8 Large cysts can cause ‘significant’ reduction in the bone volume 30-60 9 9 and predispose to fractures, though this >61 3 3 should be obvious pre-operatively. Severe postoperative infections and osteomyeli- Management of fracture 13 cases 79 cases 92 cases tis can similarly cause bone resorption Soft diet 1 14 15 and result in a pathological fracture.5,15 Intermaxillary fixation (IMF)/Closed reduction 3 36 39 The use of pre- or postoperative antibiot- ics and their relationship to mandibular Open reduction internal fixation (ORIF) 5 23 28 fractures was not always available in the ORIF + IMF 4 5 9 reported articles. No treatment - 1 1 Postoperative fractures were much more frequent than intra-operative fractures (postoperative:intra-operative – 2.7:1) and in this postoperative period.5,6,20 Al-Belasy reported in the previous studies and high- the magnitude of this discrepancy has not et al., however, did not find any rela- lights the merit of analysing a large group always been highlighted in the previous tionship between masticatory forces and of patients. Some authors have suggested reports. Postoperative fractures occurred mandibular fractures following removal of that intra-operative fractures are subse- most frequently (57%) in the second and wisdom teeth.35 quent to improper instrumentation, exces- third week following tooth removal.5,6,20 Intra-operative fractures were more sive use of force and poor technique.9,20 Most patients reported a crack (77%), his- common in the 26‑45 year age group Though it has been suggested that poor tory of trauma or pain/swelling before the and differed from postoperative frac- technique is a potential cause of iatrogenic fracture. This period would be consistent tures, which were more common in the mandibular fracture, there is little informa- with the predominantly osteoclastic phase 36–60 year age group. Intra-operative tion about the specific techniques used in of bone healing.26 In these circumstances, fractures were more common in females these reports. In current practice, the bone excessive masticatory forces and relatively (M:F – 1:1.3), and markedly differed to removal and tooth division is performed minor trauma could precipitate a fracture the male predominance of postoperative by high speed surgical handpieces and the and account for the increased frequency fractures (M:F – 3.9:1). This has not been tooth/root fragments extirpated with fine

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wisdom teeth and ‘difficult’ wisdom teeth swelling, altered bite) and the necessity Table 5 Roll of the clinician in particular. to seek immediate help is essential and in Diagnosis of postoperative fractures keeping with good clinical practice. Prevention can be difficult, with only a small minor- Finally, the maintenance of accurate • Accurate assessment of impaction ity presenting with obvious malocclusion. and contemporaneous notes cannot be • Correct Instrumentation Initial radiographs can fail to reveal a frac- overstressed. The patient should be fully • Avoid excessive force ture and a high index of suspicion and informed of the events and arrangements • Consider sectioning teeth rather than more bone removal repeat imaging a few days later may be made for immediate transfer to the maxil- 13,20 • Advise soft diet for four weeks postoperatively necessary to visualise the fracture line. lofacial unit, in case of the fracture occur- • Avoid trauma/contact sports for at least four This could account for some of the delayed ring/presenting to a dental practitioner. In weeks post-operatively ‘presentation’ in the postoperative group. the case of the event occurring/present- • Refer ‘high risk’ patients to oral Mandibular fractures following wisdom ing in the hospital, arrangements must be & maxillofacial department teeth removal were treated by differing made for the patient to be evaluated by a Management by dentist modalities. Interestingly, the majority of senior practitioner and decisions made of (A) Intra-operative fracture fractures (58%) were managed ‘conserva- the most appropriate management. In both • Stop treatment tively’ with soft diet, IMF/closed reduction. circumstances, it is also prudent to inform • Re-assure patient Open reduction internal fixation (30%) and and seek advice from the dental/medical • Confirm fracture with orthopantomo- additional intermaxillary fixation (10%) insurance provider (Table 5). gram, if available were utilised in the remaining cases. The • Analgesia/chlorhexidine mouth wash 1. Goldberg M H, Nemarich A N, Marco W P. reasons for this discrepancy is not obvious Complications after mandibular third molar • Nil by mouth in the reported cases, but could include surgery: a statistical analysis of 500 consecutive • Immediate referral to oral & maxillofacial procedures. J Am Dent Assoc 1985; 111: 277–279. department the obvious diagnosis and configuration 2. Osborn T R, Frederickson G Jr, Small I A, Torgerson T S. A prospective study of complications related to • Maintain contemporaneous records of the fracture, easier access to instrumen- mandibular third molar surgery. J Oral Maxillofac • Inform your defence union tation, personnel and theatre time in the Surg 1985; 43: 767–769. 3. Bouloux G F, Steed M B, Perciaccante V J. (B) Postoperative fracture case of intra-operative fractures and the Complications of third molar surgery. Oral • Assess and manage as above relative lack of symptoms, malocclusion Maxillofac Surg Clin North Am 2007; 19: 117–128. 4. Alling C C, Alling R D. Indications for management Management by oral & and delayed presentation in the case of of impacted teeth. In Alling C C, Helfrick J F, Alling maxillofacial department postoperative fractures. R D (eds) Impacted teeth. pp 46–64. Philadelphia: W B Saunders, 1993. • Arrange immediate assessment of patient by The risk of fractures can be minimised by 5. Perry P A, Goldberg M H. Late mandibular fracture senior clinician accurate diagnosis, thorough assessment after third molar surgery: a survey of Connecticut oral and maxillofacial surgeons. J Oral Maxillofac • Organise appropriate imaging (orthopanto- of the difficulty of extraction, identifying mogram / postero-anterior view mandible / Surg 2000; 58: 858–861. CT scan) high risk patients and formulating a com- 6. Libersa P, Roze D, Cachart T, Libersa J C. Immediate and late mandibular fractures after third molar • Discuss treatment options (conservative/ prehensive treatment plan, which includes removal. J Oral Maxillofac Surg 2002; 60: 163–165. surgical) the most appropriate surgical approach, 7. de Silva B G. Spontaneous fracture of the mandible • Organise surgical treatment and/or follow up following third molar removal. Br Dent J 1984; extent and location of bone removal, sec- 156: 19–20. • Inform referring clinician of outcome tioning of the tooth and the necessity for 8. Dunstan S P, Sugar A W. Fractures after removal of wisdom teeth. Br J Oral Maxillofac Surg 1997; prophylactic plating. A sensitive surgical 35: 396–397. elevators. Grau–Monclas et al. reported technique is mandatory and in the case 9. Iizuka T, Tanner S, Berthold H, Mandibular fractures following third molar extraction. A retrospective that the use of the Winter’s elevator was of deeply impacted/displaced teeth, con- clinical and radiological study. Int J Oral Maxillofac associated with intra-operative fractures.21 sideration should be given to prophylac- Surg 1997; 26: 338–343. 10. Krimmel M, Reinert S. Mandibular fracture after 36,37 These large, thick elevators allow the tic plating or an extra-oral approach. third molar removal. J Oral Maxillofac Surg 2000; application of significant force and their Coronectomy, which has principally been 58: 1110–1112. 11. 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