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We retrospectively evaluated the impact of mandibular third molars on the occurrence of angle and condyle fractures. This was a retrospective investigation using patient records and radiographs.
The sample set consisted of patients with mandibular fractures. Eruption space, depth and angulation of the third molar were measured. Of the angle fracture patients, patients had third molars and 14 patients did not. The ratio of angle fractures when a third molar was present 1. Of the condyle fractures patients, the third molar was present in 84 patients and absent in 57 patients. The ratio of condyle fractures when a third molar was present 0.
The increased ratio of angle fractures with third molars and the ratio of condyle fractures without a third molar were statistically significant.
The occurrence of angle and condyle fractures was more affected by the continuity of the cortical bone at the angle than by the depth of a third molar.
These results demonstrate that a third molar can be a determining factor in angle and condyle fractures.
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Among the facial bones, the mandible is the strongest and most solid bone. However, it is also the most vulnerable to fractures, mainly because it protrudes more than any other facial bone 1. The mandible includes mechanically fragile regions, such as the mandibular angle, the mandibular condyle, and the symphysis 4.
Mandibular fractures occur when excessive local stress is transferred to the mandible. The fracture site is determined by the position, direction, and strength of the external force, as well as by the properties of the bone 5.
Generally, the lower part of the mandibular condylar process is fractured by forces applied horizontally to the mandibular symphysis, and the symphysis and the mandibular condyle are fractured by vertical forces 67. The bone quality of the mandibular angle is poor and stress is easily concentrated when force is applied to the symphysis or condyle 8.
Clinically, mandibular fractures occur in diverse regions. Many authors have observed that the presence of a mandibular third molar was associated with mandibular angle fractures and could increase the likelihood of fractures. Safdar and Meechan 11 reported that an impacted mandibular third molar increased the likelihood of fractures by reducing the bone quality of the mandibular angle and reducing its bone mass.
Tevepaugh and Dodson 12 observed that patients with mandibular third molars were 3. Lee and Dodson 13 also reported that the presence of a mandibular third molar increased the likelihood of mandibular angle fractures by 1.
On this basis, some authors have recommended the early removal of an asymptomatic impacted third molar to prevent mandibular angle fractures 1415 In contrast, a recent study reported that the absence of an impacted mandibular third molar was closely associated with mandibular condyle fractures in that it increased the likelihood of mandibular condyle fractures and reduced the incidence of mandibular angle fractures 171819 In this study, we investigated the impact of the presence of an impacted mandibular third molar and the type and position of the impaction on the occurrence of mandibular angle and condyle fractures.
A retrospective study was conducted on patients who visited the Department of Oral and Maxillofacial Surgery, Chosun University Dental Hospital Gwangju, Koreaprimarily because of mandibular fractures, between January and June Data were collected from the electronic medical records and panoramic radiographs of the patients.
The subjects were classified by gender, age, cause of the fracture, presence and impaction type of the mandibular third molar, and the mandibular fracture site. Causes of injury were classified as falls, slips, traffic accidents, assault, and other. Based on the classification scheme of Kelly and Harrigan 21mandibular fracture sites were classified into the condylar process, coronoid process, ramus, angle, body, and symphysis.
A mandibular angle fracture was defined as a fracture occurring at a site ranging from a point on the curve in the connecting part between the posterior region of the mandibular second molar and the ramus to a point on the curve formed by the lower and posterior borders of the mandible.
A mandibular condyle fracture was defined as a fracture above a line drawn from the mandibular notch to the posterior border of the ramus, and fractures in the condyle head, condyle neck, and subcondyle were considered to be in this category.
When the mandibular third molar was present, classification was decided by eruption space and impaction depth, according to the method of Pell and Gregory An additional classification was made based on the angulation of the mandibular third molar, following the method of Shiller The horizontal positions of mandibular third molars were evaluated by eruption space on the basis of the relationship between the anterior border of the ramus and the distal side of the mandibular second molar.
The crown and width of the mandibular third molar was measured. Then, the presence of sufficient eruption space between the distal side of the mandibular second molar and the anterior border of the ramus was categorized as class I, insufficient space leading to incomplete eruption as class II, and the presence of most of the mandibular third molar within the ascending ramus resulting in no eruption as class III.
The vertical positions of the mandibular third molars were evaluated by impaction depth. When the highest point of the mandibular third molar was at the same position, or at a higher position, as the occlusal plane of the mandibular second molar, this was categorized as level A. When the highest point was found to be between the occlusal plane of the mandibular second molar and the cementoenamel junction, this was categorized as level B, and when the highest point was found to occur at the lower side of the cementoenamel junction, this was classified as level C.
The presence of a mandibular third molar with no root development was categorized as a tooth germ. On the basis of these classifications, the data were analyzed using the SPSS Statistics software version Statistical significance was determined using the chi-squared and Fisher’s exact tests.
In total, patients had a mandibular suvey males Among these patients, patients Of the fracture sites, sites Among the mandibular fracture patients, patients had a mandibular angle fracture at sites. These included males Of these, 58 patients were teenagers, 52 patients were in their twenties, 24 patients were in their thirties, and 13 patients were in their forties. In total, patients had mandibular condyle fractures at sites; males Of these, 46 patients were teenagers, 36 patients were in their twenties, 41 suevey were in their thirties, and 32 patients were in their forties.
The most frequent causes of mandibular angle fractures were assault 36 patients, To investigate the association between mandibular third molars and mandibular angle and condyle fractures, patients with a unilateral mandibular fracture, due to lateral force, were categorized by the presence of mandibular third sufvey, angle fractures, and condyle fractures on the basis of age.
Patients whose fracture was not caused by lateral force, mon those with only a symphysis fracture or with a bilateral condyle fracture, and those with both angle and condyle fractures, were excluded. Of the mandibular angle fracture patients, patients had a mandibular third molar and 14 patients did not; the ratio of angle fractures was statistically significantly higher when the mandibular third molar was present 1. Of the survfy condyle fracture patients, 84 patients had a mandibular third molar and 57 patients did not; the ratio of condyle fractures was statistically significantly lower when a mandibular third molar was present 0.
Based on the classification of mandibular third molars by their eruption space and impaction depth, the ratio of angle fractures was highest in class II 1. The ratio of condyle fractures was highest in class 0 1. It was second highest in class I and level A with respect to condyle fractures.
Based on the angulation of the mandibular third molars, mandibular angle fractures were surbey frequent with horizontal angulation 2.
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Mandibular condyle fractures were most frequent with a tooth germ 1. Based on root development of the mandibular third surgey, mandibular angle fractures were more frequent when the mandibular third molar had a developed root 1. Mandibular condyle fractures were more frequent when roots were not yet developed 1. The frequency of mandibular fractures can vary for many reasons.
Mandibular fractures caused by assault occur most frequently in the mandibular body while those caused by falls occur most frequently in the mandibular condyle 24 The presence of the mandibular third molar can lead to the more frequent occurrence of mandibular angle fractures, as noted by many survsy.
Tevepaugh and Dodson 12 found that a mandibular angle fracture was 3. In contrast, Safdar and Meechan 11 observed that the presence of an impacted mandibular third molar could be a critical factor causing mandibular angle fractures because patients with it were more likely to get joon. Furthermore, the larger the volume the mandibular third molar occupied in the mandibular angle, the more likely a mandibular angle fracture was to occur, due to the smaller area of the broken bone in the mandibular angle.
They found that the mandibular angle and the neck of the survry condylar process, where the stress was concentrated, were most vulnerable to fractures under all load conditions of the mandible examined. They argued that this was eurvey because the mandibular angle has poor bone quality, that the root of the impacted mandibular third molar contributes to the occurrence of fractures, and because the mandibular condyle anatomically links this region to the upper skull and becomes a fixation site in the mandible 8.
The high frequency of mandibular angle and condyle fractures is due to anatomical and structural reasons: Some durvey have suggested that the impaction type, as well as the presence, of a mandibular third molar can affect mandibular fractures. Safdar and Meechan 11 reported that the more deeply the mandibular third molar was impacted, the more likely a mandibular angle fracture was to occur, although Tevepaugh and Dodson 12 failed to show this.
Many authors have indicated an association between mandibular third molars and mandibular angle fractures. In contrast, Zhu et al. Duan and Zhang 18 observed that patients without a eurvey third molar were relatively more likely to suffer a mandibular condyle fracture, that a mandibular angle fracture was most frequently found in class II and level B, ddeuk a mandibular condyle fracture was most frequently found in class 0 and level 0, and the absence mooj the mandibular third molar resulted in insignificant differences in other types of impaction.
They also reported that the mandibular third molar had no impact on simple fractures caused by mild external forces, but affected multiple fractures caused by moderate external force deu two regions: Furthermore, presence of a mandibular third molar was three times more likely to cause a mandibular angle fracture and was less likely to cause a mandibular condyle fracture than its absence. They reported that, based on mandibular third molar impaction, a mandibular angle fracture was more likely to occur in class II, level B, and with mesial angulation, and that a mandibular condyle fracture was most likely to occur when the mandibular third molar was absent, followed by cases of class III, level C, and distal angulation These results are consistent with the biomechanical model suggested by Kober et al.
Conversely, when the mandibular angle is intact, the external force is delivered to the mandibular condyle, causing a mandibular condyle fracture In this study, mandibular fractures were seen more frequently among young men, and the incidence of mandibular condyle fractures was more affected by age, compared with the incidence of mandibular angle fractures.
Mandibular angle fractures were more frequently caused by immediate external forces, such as an assault or being struck with an object, than were mandibular condyle fractures. Mandibular third molars were seen more frequently in teenage patients and in patients in their twenties than those in their thirties or forties.
This probably explains why mandibular angle fractures were more frequent among teenagers or people in their twenties, and why those in their thirties or forties are more vulnerable to a mandibular condyle fracture. Among patients with a mandibular angle fracture, the ratio of mandibular angle fractures was higher when the mandibular third molar was present 1.
Specifically, among patients with a mandibular angle fracture, the ratio of mandibular angle fractures was 6.
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The ratio of mandibular condyle fractures was lower when the mandibular third molar was present 0. Specifically, among patients with a mandibular condyle fracture, the ratio of mandibular condyle fractures was 3.
Mandibular angle fractures occurred most frequently with horizontal angulation, due to the root development of the mandibular third molar, while mandibular condyle fractures occurred most frequently with a tooth germ as the mandibular third molar. These results demonstrate that both mandibular angle and condyle fractures are significantly affected by the presence of the mandibular third molar and by the continuity of the cortical bone in the mandibular angle.
It is easy to take a therapeutic approach to a mandibular angle fracture, the fragments of which can be effectively reduced. The most frequent complication of a mandibular angle fracture is infection, which is most notable in the mandibular angle. However, this complication can be readily managed by sequestrectomy or, in many cases, by removing the metal plate under local anesthesia 31 In contrast, oral surgeons agree that a mandibular condyle fracture is substantially more difficult to treat because its poor accessibility makes it hard to remove the fracture fragments and difficult to correctly apply a small metal plate and screws.
These difficulties can lead to many complications 3334including malocclusion, mandibular hypomobility, facial asymmetry, dysfunction or degeneration, and facial nerve damage A mandibular condyle fracture is more severe, is more difficult to treat, and leads to complications that last longer than a mandibular angle fracture.