Objectives Mandibular third molar extraction is among the most commonly performed dental procedures. Fracture of the angle of mandible after third molar extraction is a rare complication of this procedure.Case Herein, we report fracture of the right angle of mandible immediately after extraction of mandibular right third molar in a 38-year old healthy female patient, which was surgically managed. A review of the relevant literature is also presented. Thirty four cases of mandibular fracture following third molar extraction are reported in the literature. Most of these cases were removed surgically.Conclusion Systematic review of papers showed that angulation of impacted third molar is one of the most related factors in following fractures of mandibular angle

Dehghanpour barouj, Mehrdad

Esmaeelinejad, Mohammad

Latifi, Fatemeh

English

Journals Portal, Shahid Beheshti University of Medical Sciences

                                           Review Article                                                                                                                                                                                                                       ISSN 2645-4351   Copyright© 2018, Author(s). This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License   Mandibular angle fracture following closed extraction of lower third molar: A case report and systematic review  Fatemeh Latifi a, Mehrdad Dehghanpour barouj a, Mohammad Esmaeelinejadb,Mahtab Kheirkhahic  a Dept. of Oral & Maxillofacial Surgery, School of Dentistry,  Shahid Beheshti University of Medical Sciences, Tehran, Iran. b Dept. of Oral & Maxillofacial Surgery, School of Dentistry,  Semnan University of Medical Sciences, Semnan, Iran. c Dept. of Oral & Maxillofacial Radiology, School of Dentistry,  Semnan University of Medical Sciences, Semnan, Iran. Correspondence to Mehrdad Dehghanpour Barouj (email: mdmehrdad26@yahoo.com). (Submitted: 3 July 2018 – Revised version received: 1 December 2018 – Accepted: 5 December 2018– Published online: Summer 2018) Objectives Mandibular third molar extraction is among the most commonly performed dental procedures. Fracture of the angle of mandible after third molar extraction is a rare complication of this procedure. Case Herein, we report fracture of the right angle of mandible immediately after extraction of mandibular right third molar in a 38-year old healthy female patient, which was surgically managed. A review of the relevant literature is also presented. Thirty four cases of mandibular fracture following third molar extraction are reported in the literature. Most of these cases were removed surgically. Conclusion Systematic review of papers showed that angulation of impacted third molar is one of the most related factors in following fractures of mandibular angle. Keywords Third molar, Mandible, Mandibular fractures  Introduction Mandibular third molar extraction is among the most commonly performed dental procedures1, 2. Major peri-operative complications of this procedure include fracture of the adjacent tooth, trauma to the inferior alveolar nerve or lingual nerve, displacement of tooth into the sublingual or submandibular space and rarely mandibular fracture3. Pain, swelling, trismus, infection and delayed jaw fracture are among the most common postoperative complications 3-5. Mandibular fracture occurs in case of applying excessive force or inadequate bone strength. Reduction in bone strength often occurs due to physiological factors such as osteoporosis and ridge atrophy or pathological factors such as presence of cysts and tumors in bone. Applying excessive force for tooth extraction or during the surgical procedure may result in mandibular fracture during or after surgery6, 7. Immediate mandibular fracture following third molar extraction has been rarely reported8, 9. Herein, we report a mandibular fracture case following third molar removal as it has been operated soon after the occurrence of the fracture.  Review of the literature   The PICO (population, intervention, comparison, and outcome) question was stated as follows: In patients with impacted third molar does different impaction types effect on the following mandibular fracture? An electronic search was carried out in PubMed; Embase and Cochrane databases according to Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) 2015 statement10 and after screening (Figure 1), nine relevant articles were chosen out of 144. The searched keywords were “surgical extraction”, “extraction”, “lower third molar” and “mandibular fracture”.  The inclusion criteria were case reports on closed extraction or surgical extraction of mandibular third molars and fracture of mandible following tooth extraction.  The data extracted from the articles are categorized in Table 1 under titles of author(s), publication year, tooth number, method of extraction, type of fracture, and treatment/management.  Literature Review  Thirty four mandibular fracture cases following third molar extraction are reported in nine papers. All the cases were removed surgically. Most of them were in mesioangular position and fully impacted. All fractures happened either immediately or within 6 months. Most of the cases were treated by open reduction and internal fixation technique.   Materials and methods  Case  A 38 year-old female patient was referred to the Oral and Maxillofacial Surgery Department of Shahid Beheshti University of Medical Sciences, Tehran, Iran by her general dentist due to fracture of the angle of mandible noticed after extraction of her mandibular right third molar. On extra-oral clinical examination, a step was palpated in the right inferior border of the mandible. The patient complained of hypoesthesia in the path of the inferior alveolar nerve at the right side. Intraoral clinical examination revealed that the patient’s occlusion was off and she had right posterior open bite. Empty socket of right mandibular third molar was evident. Review Article Mandibular angle fracture following lower third molarextraction                                                                                          Fatemeh Latifi, et al.                                                                                                           105   Journal Dental School; Vol 36, No.3, Summer 2018; 104-107   Table 1- Categorized papers reported the mandibular fracture following third molar extraction References Number of patients Patients age Patients gender Type of impaction Type of fracture Time of fracture Procedure Krimmel et al. (2000)20 6 45 5 M and one F Fully impacted Without displacement Within two weeks ORIF Wagner et al. (2005)18 17 49 One female patient and the others were male All types of pell and Gregory classification Displacement in 5 cases Intraoperative or Within a month ORIF in 6 cases, CR in 8 cases and no treatment in 3 cases Woldenberg et al. (2007)9 1 37 Female Vertical fully impacted Without displacement At the time of surgery CR Kao et al. (2010)11 1 54 Male Mesioangular fully impacted Without displacement After 6 weeks Open reduction without fixation Cankaya et al. (2011)8 2 33 and 35 year old Male and female Mesioangular/ one deeply impacted and one of them partially impacted Without displacement At the time of surgery CR and the other no treatment O¨zcakir-Tomruk and Arslan (2012) 21 2 32 and 34 year old patients Both female Partially erupted With dispalcement During surgery ORIF Cutilli et al. (2013)17 3 32 male Two mesioangular and one verticall case Without displacement After surgery and within three weeks ORIF Xu et al. (2014) 22 1 20 Female Mesioangular fully impacted Without displace ment At the time of surgery ORIF Correa et al. (2014)23  1 52 Male Disto angular and fully impacted With displacement After 15 dayes ORIF   Figure 1- Flowchart diagram of included articles.  Patient’s medical history was unremarkable and she had no systemic condition. After clinical examination, a panoramic              Review Article Fatemeh Latifi, et al.     Mandibular angle fracture following lower third molarextraction                                                                                                              Journal Dental School; Vol 36, No.3, Summer 2018; 104-107  106  radiograph was obtained (Figure 2), which revealed fracture of the right angle of the mandible and empty socket of mandibular right third molar tooth.     Figure 2- Radiographic images of the patient’s mandible immediately after tooth extraction. A- Panoramic view. B- Poster anterior (PA) view of the mandible.  Figure 3- Radiographic images of the patient’s mandible after open reduction and internal fixation. A- Panoramic view. B- Poster anterior (PA) view of the mandibleThe patient underwent fixation surgical procedure and the broken pieces were fixed with two mini-plates, the superior one in monocortical manner to prevent the teeth roots damage and the inferior one was applied bicortically11 (Figure 3). The patient was discharged from the hospital two days after surgery. Elastic guides were used at both sides to limit jaw movements during the six-week follow up period. After six weeks, the patient had normal occlusion and could open her mouth by 45 mm. The arch bar was then removed since the patient gained full recovery. Discussion Fracture of the angle of mandible following third molar extraction is extremely rare. Fracture may occur during surgery, which is referred to as immediate fracture, or may occur within four weeks after completion of surgical procedure7, 12, 13, which is classified as late/delayed fracture. Determining the prevalence rate of mandibular fracture following mandibular third molar extraction is difficult. Mandibular fracture following third molar extraction is multifactorial and depends on patient’s age, sex, level of impaction of tooth, ratio of space occupied by the impacted tooth in the jaw, presence of bone defects, cysts and tumors, having a hard diet after surgery and technique of surgery 6, 8. The mandible becomes weak by aging due to the reduction in elasticity of bone. The majority of mandibular fractures following mandibular third molar extraction have been reported in patients over 40 years of age. Moreover, ankylosis of third molars in the elderly further complicates their extraction and necessitates osteotomy in most patients 14, 15, 16. Thus, sectioning of the tooth into smaller pieces is highly recommended in the elderly in order to prevent excessive bone removal.  The role of gender in mandibular fracture is related to the bite force. The frequency of mandibular fracture is higher in males due to having a stronger bite force than females6. Level of impaction of tooth is another important factor in this respect. The higher the level of impaction (the deeper the tooth), the greater the amount of removed bone and the greater the magnitude of jaw weakening.  The space occupied by the impacted tooth in the jaw is another important factor in this respect. The ratio of occupied space to the entire jaw can be assessed via buccal and lingual image reconstruction by computed tomography (CT) scan. If this ratio is >50%, the patient would be classified as having a high risk of mandibular fracture following extraction. In such cases, special care must be taken during and after surgery17, 18. Bone defects, odontogenic cysts and tumors and periodontal disease can all weaken the jawbone; all these conditions are more common in patients older than 40 years3, 6.  Mandibular fracture during surgical procedures occurs due to inappropriate use of instruments or applying excessive force, mainly by young, inexperienced dentists. Postoperative mandibular fracture often occurs due to excessive bite force. It is often reported by patients as crepitation and is not radiographically detectable in early phases19, 20, 21. The incidence of mandibular fracture in the right and left sides has not been commonly reported. Wagner et al. reported that 70% of the cases of mandibular fractures Review Article Mandibular angle fracture following lower third molarextraction                                                                                          Fatemeh Latifi, et al.                                                                                                           107   Journal Dental School; Vol 36, No.3, Summer 2018; 104-107  occurred in the left side; the reason was explained to be the easier application of instruments, applying a more controlled force and better accessibility in the right side of patients22, 23. The presented patient was a 38 year-old female with a fully erupted mandibular right third molar. She was systemically healthy and had no jaw pathology. To the best of authors’ knowledge, there is no reported case of fracture of the angle of mandible following closed extraction of third molar in a healthy patient in the literature. The only reported case of fracture following closed extraction of third molar occurred in a 31 year-old male with osteogenesis imperfecta, who was under treatment with alendronate19. Thus, the current report is the only one reporting immediate fracture of the angle of mandible following closed extraction of third molar in a healthy patient.  Conclusion Systematic review of papers showed that angulation of impacted third molar is one of the most related factors in following fractures of mandibular angle. Acknowledgements: We would like to express our gratitude and appreciation to Dr Mojdeh Kalantar Motamedi for editing the manuscript. Conflict of Interests None Declared ■ ___________________________________________________________________________________________________ References  1. Haug RH, Perrott DH, Gonzalez ML, Talwar RM. The american association of oral and maxillofacial surgeons age-related third molar study. J Oral Maxillofac Surg. 2005 Aug; 63(8):1106-14. 2. Msagati F, Simon EN, Owibingire S. Pattern of occurrence and treatment of impacted teeth at the Muhimbili National Hospital, Dar es Salaam, Tanzania. BMC Oral Health. 2013 Aug;13:37. 3. Bouloux GF, Steed MB, Perciaccante VJ. Complications of third molar surgery. Oral Maxillofac Surg Clin North Am. 2007 Feb;19(1):117-28. 4. Blondeau F, Daniel NG. Extraction of impacted mandibular third molars: postoperative complications and their risk factors. J Can Dent Assoc. 2007 May;73(4):325. 5. Janakiraman EN, Alexander M, Sanjay P. Prospective analysis of frequency and contributing factors of nerve injuries following third-molar surgery. J Craniofac Surg. 2010 May;21(3):784-6. 6. Chrcanovic BR, Custodio AL. Considerations of mandibular angle fractures during and after surgery for removal of third molars: a review of the literature. Oral Maxillofac Surg. 2010 Jun;14(2):71-80. 7. Libersa P, Roze D, Cachart T, Libersa JC. Immediate and late mandibular fractures after third molar removal. J Oral Maxillofac Surg. 2002 Feb;60(2):163-5. 8. Cankaya AB, Erdem MA, Cakarer S, Cifter M, Oral CK. Iatrogenic mandibular fracture associated with third molar removal. Int J Med Sci. 2011;8(7):547-53. 9. Woldenberg Y, Gatot I, Bodner L. Iatrogenic mandibular fracture associated with third molar removal. Can it be prevented? Med Oral Patol Oral Cir Bucal. 2007 Jan;12(1):E70-2. 10. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015 Jan 1;4:1. 11. Haug RH1, Barber JE, Reifeis R. A comparison of mandibular angle fracture plating techniques. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996 Sep;82(3):257-63.. 12. Al-Belasy FA, Tozoglu S, Ertas U. Mastication and late mandibular fracture after surgery of impacted third molars associated with no gross pathology. J Oral Maxillofac Surg. 2009 Apr;67(4):856-61. 13. Kao YH, Huang IY, Chen CM, Wu CW, Hsu KJ, Chen CM. Late mandibular fracture after lower third molar extraction in a patient with Stafne bone cavity: a case report. J Oral Maxillofac Surg. 2010 Jul;68(7):1698-700. 14. Alessandri Bonetti G, Pelliccioni GA, Checchi L. Management of bilaterally impacted mandibular second and third molars. J Am Dent Assoc. 1999 Aug;130(8):1190-4. 15. Franklin CD. Ankylosis of an unerupted third molar by inostosis of enamel. A case report. Br Dent J. 1972 Oct;133(8):346-7. 16. Murakami K, Yamamoto K, Tsuyuki M, Sugiura T, Tsutsumi S, Kirita T. Theoretical efficacy of preventive measures for pathologic fracture after surgical removal of mandibular lesions based on a three-dimensional finite element analysis. J Oral Maxillofac Surg. 2014 Apr;72(4):833.e1-18. 17. Cutilli T, Bourelaki T, Scarsella S, Fabio DD, Pontecorvi E, Cargini P, et al. Pathological (late) fractures of the mandibular angle after lower third molar removal: a case series. J Med Case Rep. 2013 Apr 30;7:121. 18. Wagner KW, Schoen R, Wongchuensoontorn C, Schmelzeisen R. Complicated late mandibular fracture following third molar removal. Quintessence Int. 2007 Jan;38(1):63-5. 19. Gallego L, Junquera L, Pelaz A, Costilla S. Pathological mandibular fracture after simple molar extraction in a patient with osteogenesis imperfecta treated with alendronate. Med Oral Patol Oral Cir Bucal. 2010 Nov 1;15(6):e895-7. 20. Krimmel M, Reinert S. Mandibular fracture after third molar removal. J Oral Maxillofac Surg. 2000 Oct;58(10):1110-2. 21. Özçakir‐Tomruk C, Arslan A. Mandibular angle fractures during third molar removal: a report of two cases. Aust Dent J. 2012 Jun;57(2):231-5 22. Xu JJ, Teng L, Jin XL, Lu JJ, Zhang C. Iatrogenic mandibular fracture associated with third molar removal after mandibular angle osteotectomy. J Craniofac Surg. 2014 May;25(3):e263-5. 23. Correa AP, Faverani LP, Ramalho-Ferreira G, Ferreira S, Avila Souza F, de Oliveira Puttini I, et al. Unerupted lower third molar extractions and their risks for mandibular fracture. J Craniofac Surg. 2014 May;25(3):e228-9.     _________ _______ _______ __---_----------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- How to cite: Fatemeh Latifi, Mehrdad Dehghanpour barouj, Mohammad Esmaeelinejad, Mahtab Kheirkhahi. Mandibular angle fracture following closed extraction of lower third molar: A case report and systematic review. J Dent Sch 2018;36(3):104-107 

Mandibular angle fracture following closed extraction of lower third molar: A case report and systematic review

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Mandibular angle fracture following closed extraction of lower third molar: A case report and systematic review

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