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LATE MANDIBULAR ANGLE FRACTURE AFTER IMPACTED THIRD MOLAR

EXTRACTION - CASE REPORT AND REVIEW OF PREDISPOSING FACTORS


Valdir Cabral Andrade; Patrcio Jos de Oliveira Neto; Mrcio de Moraes & Luciana
Asprino
Department of Oral Diagnosis, Oral and Maxillofacial Surgery Division, State
University of Campinas-UNICAMP, Piracicaba, So Paulo State, Brazil.
Correspondence to:
ABSTRACT: Third molar surgery is the most common surgical procedure in the
oral cavity. Whenever extraction is indicated, careful planning based on clinical and
radiographic examinations is essential to guard against postoperative
complications like: bleeding, alveolitis, infections, injury to adjacent teeth, oroantral
communications, or even mandibular fractures. Although rare, the risk of
postoperative mandibular fractures after third molar impaction surgery is related to
some factors. Our case report a 50-year-old white female patient with a complaint
of pain in the region of the left mandibular angle and stated that three weeks before
she had the left mandibular third molar extracted, which computerized tomographic
confirmed the presence of a fracture in the mandibular angle. However, our report
contributes to showing the predisposing factors to cause this injury after a review of
the literature, showing the clinician what they should take like consideration when
they indicate the extraction of third molars. To avoid this complication, factors like
bony impaction, depth of tooth within bone, proximity to the inferior dental canal,
tooth position in relation to adjacent teeth, the presence of root dilacerations and
others must be taken into account. A case of late mandibular fracture that occurred
21 days after third molar extraction is reported. Conservative treatment was
adopted and after six-months of radiographic and clinical follow-up, the patient had
fully preserved mandibular function, normal occlusion and no discomfort.
INTRODUCTION
The surgical removal of impacted third molars is a procedure frequently performed
by oral and maxillofacial surgeons. Third molar removal needs to be carefully
planned with strict reference to the clinical and radiographic examinations because
of associated risks of complications such as bleeding, damage to the inferior
alveolar nerve, alveolitis, secondary infections and even mandibular fractures.
Mandibular fracture during third molar removal or afterwards is a rare event with an
incidence of 0.0049%, as reported by Libersa, et al. (2002) and Perry & Goldberg
(2000). Several aspects need to be analyzed in the preoperative period to ensure
that the removal of such teeth has been correctly indicated and is carried out using
the appropriate surgical technique (Custdio et al., 2007; Ellis & Sinn, 1993)
among which are depth of impaction, tooth angulation, and the patient's age.
Furthermore, the mandibular angle is an area of low resistance with a compact
upper border but thin basilar bone (Assael, 1994), and the removal of the impacted
third molar makes it even more fragile (Kruger, 1982; Krimmel & Reinert, 2000).
This clinical report describes a case of late mandibular fracture following third
molar extraction.
CASE REPORT
A 50-year-old white female patient, was referred to our department with a
complaint of pain in the region of the left mandibular angle. During anamnesis the
patient stated that three weeks before she had the left mandibular third molar
extracted. When she was chewing a piece of bread, she heard a click and
immediately began to feel pain in the region. Physical examination revealed a soft
swelling, painful on palpation, in the left mandibular angle region. Mandibular
movements were all normal and there were no observable changes in the patient's
dental occlusion. The alveolar mucosa of left mandibular third molar was healing
and there was a slight purulent secretion. There was no mobility in the surrounding
region in response on palpation. Records of the patient case showed that surgery
had been difficult and lasted longer than planned; extensive osteotomy was
performed and heavy bleeding had been controlled using bone wax. The
preoperative panoramic radiograph showed that the lower left third molar was
mesioangular (Pell and Gregory Class II, position B) and very close to the
mandibular canal (Figure 1). A postoperative panoramic radiograph was taken and
it revealed signs of a fracture involving the angle of the left mandible (Figs. 1 and
2). Computerized tomographic imaging was used to obtain a better visualization of
the affected region and confirmed the presence of a fracture in the mandibular
angle but with no apparent displacement of the fragments (Fig. 3). In view of these
clinical and radiographic signals, it was decided to opt for a conservative treatment
of the fracture, avoiding any surgical intervention Accordingly, the patient was
advised to make a soft and liquid diet for 45 days. The patient was advised that
surgery would be considered only if alterations to the patient's occlusion, abnormal
mandibular movement or mobility and displacement of the fracture fragments were
detected.
Weekly follow up was maintained for the first month to check for signs of infection
or occlusion alterations. After 2 months the patient's mandibular movements and
occlusion were perfectly preserved, she no longer felt any pain and the swelling in
the region of the left mandibular angle had gone down. Clinical and radiological
follow up after 6 months (Figs. 4 and 5) showed that the patient's dental occlusion
and mandibular function were perfectly preserved and the patient herself had no
discomfort.

Fig. 1. Preoperative panoramic radiograph.


Fig. 2. Postoperative panoramic radiograph.

Fig. 3. CT scan, 30 days after third molar extraction.

Fig. 4. Dental occlusion, 85 days after angle fracture.


Fig. 5. Panoramic Radiographic, 85 days after angle fracture.

DISCUSSION
Although surgical removal of impacted third molars is an operation that oral and
maxillofacial surgeons perform frequently, mandibular fractures after third molar
extractions are rare. In a retrospective study, Libersa et al., interviewed 150 oral
and maxillofacial surgeons in northern France about their experiences with
intraoperative and late mandibular fractures after third molar surgery. Among all the
750,000 extractions they had made, only 37 cases of fracture had been registered
and subjected to clinical and radiograph examination (an incidence of 0.0049%). Of
those, however, only 27 had accurate descriptions; 17 of them had occurred in the
intraoperative phase and 10 were late fractures. The authors found that: the
highest incidence of immediate and late mandibular fractures was associated to
patients aged 25 and over, men were more liable to have late fractures (8 cases
out of 10). The mean age of intraoperative fracture patients was 37 and of late
fracture patients, 47. Similarly, in 2000, Perry & Goldberg investigated incidence
and the etiological factors involved in late mandibular fractures after third molar
surgery over a 10-year period. A questionnaire was sent out to 106 surgeons in
Connecticut asking them to register their experiences with this type of
complication. 79% of the surgeons responded and indicated that only 28 fractures
had been registered for a total of 611,000 extractions; an incidence of 0.0046%.
The factors involved were: age, gender, type of impactation, pre-existing infection,
and failure to adhere to an appropriate diet in the postoperative period. Most
fractures had occurred between the first and 21st days of the postoperative period.
Based on those results, the authors concluded that men over 25 years old should
be specifically informed about the risks of late mandibular fracture after third molar
surgery and of the need to adhere to a light diet during the postoperative period
(Ferre et al., 1981; Libersa et al.).
Some factors may be related to the occurrence of this kind of complication such as
type of impaction, age, sex, presence of infection, bone lesions, the surgical
technique employed and chewing solid foods after extraction (Libersa et al.; Al-
Belasy et al., 2009). Impaction is a fundamental factor, because the greater the
depth of impaction in relation to the neighboring second molar (Pell and Gregory
Class B/C), the greater the amount of bony tissue that needs to be removed to get
access to the tooth (Libersa et al.). In such cases, extensive osteotomy may
weaken the mandible and make it more susceptible to fracturing (Krimmel &
Reinert, 2000), mainly because the angle of the jaw is an area of decreased
resistance to fracture, due to its characteristic bony anatomy and its location
between the branch and the body (Ferre et al.).
Age is another important risk factor for fracture, and Libersa et al., reported that
85% of patients presenting mandibular fractures after third molar extraction were
over 25, with a mean age of 40. Because the natural process of bone density
increasing with age, in the older age group a greater amount of bone tissue will
need to be removed, thereby weakening the mandible (Libersa et al.; Obiechina et
al., 2001).
Regarding sex, there seems to have a particular importance in postoperative
fractures, with the highest incidence for men, possibly due to greater masticatory
force employed in male patients, emphasizing the need for soft diet during the first
weeks post-surgery (Ferre et al.; Anil et al., 1998; Wagner et al., 2005). Late
fractures generally occur during the act of chewing something and with a click
audible to the patient, even like in this patient, however the same complication has
been reported as a result of vigorous mouth rinsing (Custdio et al.; Assael; Perry
& Goldgerg; Woldenberg et al., 2007). The period of greatest risk appears to be
actually the second and third weeks after surgery when granulation tissue is still
being substituted by connecting tissue inside the alveolus. It seems that the end of
the second week the patients are feeling better, the painful symptoms is already
disappearing, and they believe they can chew normally. In the clinical case being
reported here, some of these observations are applicable. The patient was a 50-
year-old and about three weeks later, the removal of the left third molar, she
chewed a piece of bread and her mandible fractured. In patients aged around 40
with a significant degree of impaction, the risk of fracture is heightened by the
fragility of the bone resulting from the difficult nature of third molar removal
procedure, which calls for a sizeable osteotomy. Records of the patient case
showed that extensive osteotomy was performed. Most patients that suffered this
complication reported hearing a sharp crack while they were chewing and
simultaneously feeling a sharp pain. These patients would benefit from guidance
on the possibility of mandibular fracture, and the benefit of dietary restriction to a
liquid and soft diet for 45 days after extraction. Prophylactic extraction of third
molars before age 20 could reduce the risks of such fractures (Libersa et al.; Al-
Belasy et al.; Kao et al., 2010).
Reports of mandibular fractures subsequent to third molar extractions are rare,
nevertheless, it is important to be aware of all the risk factors that favor such
complications and addressing them enables the surgeon to individualize surgical
procedures to ensure that they do not occur. When they do, however, the main
goal of treatment must be to re-establish dental occlusion and full mandibular
function, whether it be conservative or surgical treatment (Ellis & Sinn; Woldenberg
et al.).
ESPAOL
FRACTURA TARDA DE NGULO DE MANDIBULA POST EXTRACCIN DE
TERCER MOLAR IMPACTADO - REPORTE DE UN CASO Y REVISIN DE
FACTORES PREDISPONENTES
RESUMEN: La ciruga del tercer molar es el procedimiento quirrgico ms comn
en la cavidad oral. Siempre que se indique la extraccin, la planificacin cuidadosa
basada en exmenes clnicos y radiogrficos es esencial para prevenir las
complicaciones postoperatorias como: sangrado, alveolitis, infecciones, lesiones
en los dientes adyacentes, comunicaciones oroantrales o incluso fracturas
mandibulares. Aunque rara, el riesgo de fracturas mandibulares postoperatorias
despus de la ciruga de impactacin del tercer molar est relacionado con
algunos factores. En nuestro caso, una paciente blanca de 50 aos de edad, con
una queja de dolor en la regin del ngulo mandibular izquierdo, indic que tres
semanas antes de extraer el tercer molar mandibular izquierdo, la tomografa
computarizada confirm la presencia de una fractura en El ngulo mandibular. Sin
embargo, nuestro informe contribuye a mostrar los factores predisponentes para
causar esta lesin despus de una revisin de la literatura, mostrando al clnico lo
que deben tomar como consideracin cuando indican la extraccin de terceros
molares. Para evitar esta complicacin deben tenerse en cuenta factores como la
impactacin sea, la profundidad del diente dentro del hueso, la proximidad al
canal dental inferior, la posicin del diente en relacin con los dientes adyacentes,
la presencia de dilaceraciones radiculares y otras. Se describe un caso de fractura
mandibular tarda ocurrida 21 das despus de la extraccin del tercer molar. El
tratamiento conservador fue adoptado y despus de seis meses de seguimiento
radiogrfico y clnico, el paciente tena una funcin mandibular completamente
preservada, una oclusin normal y ninguna molestia.
INTRODUCCIN
La extirpacin quirrgica de terceros molares impactados es un procedimiento
frecuentemente realizado por cirujanos orales y maxilofaciales. La remocin del
tercer molar debe planificarse cuidadosamente con estricta referencia a los
exmenes clnicos y radiogrficos debido a riesgos asociados de complicaciones
tales como sangrado, dao al nervio alveolar inferior, alveolitis, infecciones
secundarias e incluso fracturas mandibulares. La fractura mandibular durante la
remocin del tercer molar o despus es un evento raro con una incidencia de
0,0049%, segn lo informado por Libersa, et al. (2002) y Perry y Goldberg (2000).
Varios aspectos deben ser analizados en el perodo preoperatorio para asegurar
que la remocin de dichos dientes ha sido correctamente indicada y se lleva a
cabo utilizando la tcnica quirrgica apropiada (Cust et al., 2007, Ellis & Sinn,
1993) Impactacin, angulacin de los dientes y edad del paciente. Adems, el
ngulo mandibular es un rea de baja resistencia con un borde superior compacto
pero hueso basilar delgado (Assael, 1994), y la remocin del tercer molar
impactado lo hace an ms frgil (Kruger, 1982; Krimmel y Reinert, 2000) . Este
informe clnico describe un caso de fractura mandibular tarda despus de la
extraccin del tercer molar.
REPORTE DE UN CASO
Una paciente blanca de 50 aos de edad, fue remitida a nuestro departamento con
una queja de dolor en la regin del ngulo mandibular izquierdo. Durante la
anamnesis, la paciente declar que tres semanas antes de extraer el tercer molar
mandibular izquierdo. Cuando estaba masticando un pedazo de pan, oy un
chasquido e inmediatamente comenz a sentir dolor en la regin. El examen fsico
revel una hinchazn suave, dolorosa en la palpacin, en la regin del ngulo
mandibular izquierdo. Los movimientos mandibulares eran normales y no haba
cambios observables en la oclusin dental del paciente. La mucosa alveolar del
tercer molar mandibular izquierdo fue la curacin y hubo una ligera secrecin
purulenta. No hubo movilidad en la regin circundante en respuesta a la palpacin.
Los registros del caso del paciente mostraron que la ciruga haba sido difcil y
dur ms de lo planeado; Se realiz una osteotoma extensa y el sangrado intenso
se haba controlado con cera sea. La radiografa panormica preoperatoria
mostr que el tercer molar inferior izquierdo era mesioangular (Pell y Gregory
Clase II, posicin B) y muy cerca del canal mandibular (Figura 1). Se realiz una
radiografa panormica postoperatoria y se observaron signos de fractura en el
ngulo de la mandbula izquierda (Figuras 1 y 2). Se utiliz imgenes tomogrficas
computarizadas para obtener una mejor visualizacin de la regin afectada y
confirmar la presencia de una fractura en el ngulo mandibular pero sin
desplazamiento aparente de los fragmentos (Fig. 3). En vista de estas seales
clnicas y radiogrficas, se decidi optar por un tratamiento conservador de la
fractura, evitando cualquier intervencin quirrgica. En consecuencia, se aconsej
al paciente hacer una dieta blanda y lquida durante 45 das. Se inform al
paciente de que la ciruga slo sera considerada si se detectaran alteraciones en
la oclusin del paciente, movimientos mandibulares anormales o movilidad y
desplazamiento de los fragmentos de la fractura.
El seguimiento semanal se mantuvo durante el primer mes para detectar signos de
infeccin o alteraciones de la oclusin. Despus de 2 meses los movimientos
mandibulares y la oclusin del paciente estaban perfectamente conservados, ya
no senta ningn dolor y la hinchazn en la regin del ngulo mandibular izquierdo
haba disminuido. El seguimiento clnico y radiolgico despus de 6 meses
(Figuras 4 y 5) mostr que la oclusin dental y la funcin mandibular del paciente
estaban perfectamente conservadas y la propia paciente no tena molestias.

Fig. 1. Radiografa panormica preoperatoria.


Fig. 2. Radiografa panormica postoperatoria.
Fig. 3. Tomografa computarizada, 30 das despus de la extraccin del tercer
molar.
Fig. 4. Oclusin dental, 85 das despus de la fractura angular.
Fig. 5. Radiografa panormica, 85 das despus de la fractura angular.
DISCUSIN
Aunque la extirpacin quirrgica de terceros molares impactados es una operacin
que los cirujanos orales y maxilofaciales realizan frecuentemente, las fracturas
mandibulares despus de extracciones de terceros molares son raras. En un
estudio retrospectivo, Libersa et al., Entrevistaron a 150 cirujanos orales y
maxilofaciales en el norte de Francia acerca de sus experiencias con fracturas
intraoperatorias y mandibulares tardas despus de la ciruga del tercer molar.
Entre las 750.000 extracciones realizadas, slo se registraron 37 casos de fractura
y se sometieron a un examen clnico y radiogrfico (una incidencia de 0,0049%).
De stos, sin embargo, slo 27 tenan descripciones precisas; 17 de ellos haban
ocurrido en la fase intraoperatoria y 10 eran fracturas tardas. Los autores
encontraron que: la mayor incidencia de fracturas mandibulares inmediatas y
tardas estaba asociada a pacientes de 25 aos o ms, los hombres eran ms
propensos a presentar fracturas tardas (8 de cada 10). La edad media de los
pacientes con fracturas intraoperatorias fue de 37 y de pacientes con fracturas
tardas, 47. De forma similar, en 2000, Perry & Goldberg investig la incidencia y
los factores etiolgicos involucrados en las fracturas mandibulares tardas despus
de la ciruga del tercer molar en un perodo de 10 aos. Se envi un cuestionario a
106 cirujanos en Connecticut para pedirles que registraran sus experiencias con
este tipo de complicaciones. El 79% de los cirujanos respondi e indic que slo
se haban registrado 28 fracturas para un total de 611.000 extracciones; Una
incidencia de 0,0046%. Los factores involucrados fueron: edad, sexo, tipo de
impactacin, infeccin preexistente y falta de adherencia a una dieta adecuada en
el postoperatorio. La mayora de las fracturas se haban producido entre el primer
y el 21 da del postoperatorio. Con base en estos resultados, los autores
concluyeron que los hombres mayores de 25 aos deban ser informados
especficamente sobre los riesgos de fractura mandibular tarda despus de la
ciruga del tercer molar y sobre la necesidad de adherirse a una dieta ligera
durante el perodo postoperatorio (Ferre et al., 1981 Libersa et al.).
Algunos factores pueden estar relacionados con la ocurrencia de este tipo de
complicaciones como el tipo de impactacin, la edad, el sexo, la presencia de
infeccin, las lesiones seas, la tcnica quirrgica empleada y la masticacin de
alimentos slidos despus de la extraccin (Libersa et al., Al-Belasy et al. Al.,
2009). La impactacin es un factor fundamental, ya que cuanto mayor es la
profundidad de impactacin en relacin con el segundo molar vecino (Pell y
Gregory Clase B / C), mayor es la cantidad de tejido seo que necesita ser
removido para tener acceso al diente (Libersa Et al.). En tales casos, la
osteotoma extensa puede debilitar la mandbula y hacerla ms susceptible a la
fractura (Krimmel y Reinert, 2000), principalmente porque el ngulo de la
mandbula es un rea de menor resistencia a la fractura, debido a su caracterstica
anatoma sea y su ubicacin Entre la rama y el cuerpo (Ferre et al.).
La edad es otro importante factor de riesgo para la fractura, y Libersa et al.,
Informaron que el 85% de los pacientes que presentaban fracturas mandibulares
despus de la extraccin del tercer molar tenan ms de 25 aos, con una edad
media de 40. Debido a que el proceso natural de densidad sea aumenta con la
edad, En el grupo de edad ms avanzada una mayor cantidad de tejido seo
tendr que ser eliminado, debilitando as la mandbula (Libersa et al., Obiechina et
al., 2001).
En cuanto al sexo, parece tener una importancia particular en las fracturas
postoperatorias, con la mayor incidencia en hombres, posiblemente debido a la
mayor fuerza masticatoria empleada en pacientes masculinos, enfatizando la
necesidad de una dieta blanda durante las primeras semanas posteriores a la
ciruga (Ferre et al. Anil et al., 1998, Wagner et al., 2005). Las fracturas tardas
generalmente ocurren durante el acto de masticar algo y con un clic audible para
el paciente, incluso como en este paciente, sin embargo la misma complicacin ha
sido reportada como resultado del enjuague bucal vigoroso (Custdio et al.,
Assael, Perry & Goldgerg Woldenberg et al., 2007). El perodo de mayor riesgo
parece ser en realidad la segunda y tercera semanas despus de la ciruga
cuando el tejido de granulacin se sigue sustituyendo por la conexin de tejido
dentro del alveolo. Parece que al final de la segunda semana los pacientes se
sienten mejor, los sntomas dolorosos ya estn desapareciendo, y creen que
pueden masticar normalmente. En el caso clnico que se informa aqu, algunas de
estas observaciones son aplicables. La paciente tena 50 aos de edad y unas
tres semanas despus, la extirpacin del tercer molar izquierdo, masticaba un
pedazo de pan y la mandbula se fractur. En los pacientes de alrededor de 40
con un grado significativo de impactacin, el riesgo de fractura se ve agravado por
la fragilidad del hueso resultante de la difcil naturaleza del procedimiento de
extraccin del tercer molar, lo que requiere una osteotoma considerable. Los
registros del caso del paciente mostraron que se realiz una osteotoma extensa.
La mayora de los pacientes que sufrieron esta complicacin reportaron haber odo
una grieta aguda mientras masticaban y simultneamente sentan un dolor agudo.
Estos pacientes se beneficiaran de la orientacin sobre la posibilidad de fractura
mandibular, y el beneficio de la restriccin diettica a una dieta lquida y suave
durante 45 das despus de la extraccin. La extraccin profilctica de los terceros
molares antes de los 20 aos podra reducir los riesgos de tales fracturas (Libersa
et al., Al-Belasy et al., Kao et al., 2010).
Los informes de fracturas mandibulares posteriores a las extracciones de terceros
molares son raros, sin embargo, es importante conocer todos los factores de
riesgo que favorecen dichas complicaciones y abordarlas permite al cirujano
individualizar los procedimientos quirrgicos para asegurarse de que no ocurren.
Cuando lo hacen, sin embargo, el objetivo principal del tratamiento debe ser
restablecer la oclusin dental y la funcin mandibular completa, ya sea
tratamientos conservadores o quirrgicos (Ellis & Sinn; Woldenberg et al.).