Int. J. Oral Maxillofac. Surg.

2010; 39: 136–139

doi:10.1016/j.ijom.2009.12.005, available online at http://www.sciencedirect.com

Clinical Paper
Trauma

Impact of impacted mandibular A. Thangavelu, R. Yoganandha,

A. Vaidhyanathan
Division of Oral and Maxillofacial Surgery,

third molars in mandibular angle

Rajah Muthiah Dental College and Hospital,
Chidambaram, Tamil Nadu 608002, India

and condylar fractures

A. Thangavelu, R. Yoganandha, A. Vaidhyanathan: Impact of impacted mandibular
third molars in mandibular angle and condylar fractures. Int. J. Oral Maxillofac.
Surg. 2010; 39: 136–139. # 2010 International Association of Oral and Maxillofacial
Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. Previous retrospective analyses prove that impacted mandibular third

molars (M3s) increase the risk of angle fractures and decrease the risk of
concomitant fractures to the condyle. The authors have attempted to verify these
relationships and identify the underlying mechanism of injury. A retrospective
cohort was designed for patients attending the Division of Oral and Maxillofacial
Surgery from January 2001 till October 2008. The primary predictor variable was
M3. The secondary predictor variables were: M3 position, classified using the Pell
and Gregory system; angulation, classified using Shiller’s method; and the number
of visible dental roots. The outcome variables were angle and condyle fractures.
Hospital charts and radiographs were used to determine and classify these variables.
The study sample comprised 1102 mandibular fractures in 600 patients. For patients
injured by moderate traumatic force resulting in two fractures of the mandible, the
presence/absence of impacted M3s played an important role in angle/condylar
Keywords: impacted third molars; condylar
fractures. Patients with impacted M3s were three times more likely to develop angle fracture; angle fracture.
fractures and less likely to develop condylar fractures than those without impacted
M3s. This study provides clinical evidence to suggest that the removal of unerupted Accepted for publication 7 December 2009
mandibular third molars predisposes the mandible to condyle fractures. Available online 18 January 2010

Recent literature has led credence to the
fact that the presence and state of eruption
of mandibular third molars (M3s) contri-
bute appreciably to the weakness of the
angle region, thereby predisposing it to
fracture4,8,10. This is regardless of the fact
that fractures of the mandible are usually
influenced by factors such as the direction,
severity and impact of force, the presence
of soft tissue bulk, occlusal loading pattern
and biomechanical characteristics such as
bone density, mass and anatomic struc-
tures creating weak areas4,5.
Reitzik hypothesized that, as sharp
angulation concentrates stress, the angle
of the mandible becomes a ‘weak’ area,
and certain injuries deform the mandible
beyond its yield point7. The ‘weakest’ area
of the dentulous mandible is the condyle
and, if forces inflicted remain well
absorbed at the angle, the mandible frac-
tures at the angle, sparing the condyle.
Recently, many studies have reported a
two- to threefold increased risk for man-
dibular angle fractures and a concomitant
reduction in the incidence of condyle frac-
tures when impacted mandibular M3s are
present1,11. Based on the current biome-
chanical model, it has been hypothesized
that the M3 weakens the angle by decreas-
ing the bone mass in the region, making
the mandibular angle more susceptible to
fracture4, probably preventing another
fracture at the condyle. If this model is
correct, the risk of angle and condyle
fractures would vary as a function of the
position of the M3.
Despite the consistency of the reported
relationships, between M3s, angle and

0901-5027/020136 + 04 $36.00/0 # 2010 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

condyle fractures, there are theoretical
concerns that the relationship may be
spurious and confounding. There has been
no formal critique, but fracture risk and the
influence of impacted M3 remains
unclear. The purpose of this study was
to clarify, the relationships between M3
presence and position and the risk for
angle and condyle fracture. The authors
hypothesize that: the previously observed
relationship between M3 presence and
subsequent angle and condyle fractures
were not spurious; and different M3 posi-
tions are associated with risks of angle and
condyle fracture.
Patients and methods
A retrospective cohort was designed, con-
sisting of 600 patients who presented for
treatment of mandibular fractures between
January 2001 and October 2008. Hospital
case records and panoramic radiographs
were used to assess the presence, position
and angulation of impacted M3s (predictor
variables) and the incidence of mandibular
angle and condyle fractures (outcome
variables) were determined.
Excluded from the study were 72
patients aged 16 years and under and 68
patients for whom there was inadequate
follow up. To analyze the position of M3s
the Pell and Gregory Classification was
used to identify horizontal position (Class
I, Class II and Class III) and vertical
position (Class A, Class B and Class C)6
(Table 1). The absence of M3s was indi-
cated by Class 0.
Angulation of M3s was measured using
Shiller’s method. The inclination of the
occlusal surface of the M3 was measured
in relation to the occlusal surface of the
second molar. The M3s were classified as:
vertical if they were 0–108; mesioangu-
lar and distoangular if they were 11–
708; and horizontal if they were more than
7189 The number of visible dental roots
was counted from panoramic radiographs.
Mandibular angle fracture was deter-
mined using the definition given by Kelly
and Harrigan: a fracture located posterior
to the second molar, extending from any
point on the curve formed by the junction
of the body and ramus in the retromolar
Table 3. Demographic variables grouped by impacted M3s, mandibular angle and condylar fractures.
Impacted M3s
Variable [3_TD$IF]Present, N = 260
Age 25.8  9.2
Sex
Male (345) 205
Female (115) 55
Impact of impacted mandibular third molars 137
Table 1. Pell and Gregory classification.
Horizontal and vertical position of M3s
Horizontal Amount of space available between ramus and second molar
Class I Adequate space for eruption
Class II Inadequate space for eruption
Class III M3 located partially or completely in ramus
Vertical Relationship of M3 crown to second molar crown
Class A Level at occlusal plane
Class B Between the cemento-enamel junction of the second molar
and occlusal plane
Class C Below the cemento-enamel junction of the second molar
Table 2. Distribution by fracture pattern and site.
Most common fracture pattern Sites
Bi-fracture (216 patients, 47%) Symphysis/parasymphysis (287, 33%)
Mono fracture (147 patients, 32%) Condyle (261, 30%)
Multiple fractures (97 patients, 21%) Angle (200, 23%)
Body (100, 11%)
Ramus (22, 2%)
area to any point on the curve formed by mandibular symphysis were observed
the inferior border of the body and poster- most frequently (33%), followed by con-
ior border of the ramus of the mandible2. dyle (30%), angle (23%), body (11%) and
Condylar fracture was defined as a frac- ramus (2%). Distribution by site and pat-
ture with the fracture line superior to the tern are shown in Table 2.
sigmoid notch. Mandibular angle fractures were seen in
The database was constructed and ana- 175 patients, with 25 patients presenting
lysis performed using SPSS version 10.0 with bilateral angle fractures. Mandibular
(SPSS, Inc., Chicago, IL, USA). Data condyle fractures were seen in 187
were analyzed by calculating the means patients, with 74 patients presenting with
and standard deviation, and the cohort bilateral condyle fractures.
comparisons were made using the x2-test, The cohort of 460 patients had 920
Student’s t-test, and analysis of variance. mandibular halves, of which 200 patients
Data were considered significant if had no M3s (43%). Among the remaining
P < 0.05. 260 patients (57%), 520 mandibular
halves, impacted mandibular M3s were
present in the positions listed in Table 3.
Results
The unerupted M3 present group
The cohort consisted of 460 patients with (n = 260 patients) sustained 442 fractures.
870 mandibular fractures caused by: road The unerupted M3 absent group (n = 200
traffic accident (49%), assault (35%) and patients) sustained 428 fractures. There
fall (16%). The only method for assessing were no significant differences between
severity of the trauma force was on the the groups for incidence of fractures. In
basis of the number of fracture sites. Low accordance with the authors’ hypothesis,
trauma force was considered to produce there were significant differences between
one fracture, a moderate trauma force both groups in the incidence of angle and
produced two fractures and a high trauma condyle fractures. The unerupted M3 pre-
force produced three or more fracture sent group had a higher proportion of
sites. The most common fracture pattern angle fracture (150 patients, 75%) than
was a bi-fracture pattern (216; 47%), fol- those in the unerupted M3 absent group
lowed by mono-fracture (147; 32%) and (50 patients, 25%). Condyle fractures
multi-fracture (97; 21%). Fractures of the were more common in the unerupted
Angle fracture Condyle fracture
Absent, N = 200 Present, N = 175 Absent, N = 285 Present, N = 187 Absent, N = 273
32.6  8.6 29.3  10.8 29.7  10.6 35.8  10.1 30.0  11.6
140 115 (33%) 230 103 (30%) 242
60 60 (52%) 55 84 (73%) 31
138 Thangavelu et al.

Table 4. Relationship between impacted M3s and the risk of angle and condyle fracture.
Condyle fractures * Angle fracturesy
No. of patients with impacted M3s Absent Present Absent Present
Absent (n = 200) 28 (14%) 172 (86%) 150 (75%) 50 (25%)
Present (n = 260) 171 (65%) 89 (35%) 110 (42%) 150 (75%)
*
Relative risk: 2.5124; 95% CI: 2.1037–3.0004; P < 0.0001.
y
Relative risk: 0.43333; 95% CI: 0.336–0.5629; P < 0.0001.

Table 5. Variables further quantified.

Ramus position
Class I – 234 (45%)
Class II – 188 (36%)
Class III – 98 (19%)
Occlusal position Angulation Number of dental roots
Class A – 218(42%) Mesioangular – 250 (48%) Single – 302 (58%)
Two or more – 202 (39%)
Class B – 197 (38%) Distoangular – 75(14%) Tooth germ only – 15 (3%)
Vertical – 151 (29%)
Class C – 105 (20%) Horizontal – 35(6%)
Germ – 9 (2%)

M3 absent group (172 patients, 86%) than partially impacted, it can be rationalized incidence of condyle fractures1,11. This
in the unerupted M3 present group (89 that the tension line will be disrupted, study revealed that the highest risk of
patients, 35%) (Table 4). The frequency weakening the mandibular angle and mak- condylar fractures was noticed typically
of fractures at the other sites did not show ing it more susceptible to fracture5. Con- in the absence of the impacted M3. The
a significant difference between the two sistent with other studies, the results of this next highest risk of condyle fracture was
groups. study confirmed an increased risk of angle noticed in patients with M3 position Class
Details of ramus position, occlusal posi- fractures when impacted M3s were pre- III C, distoangular impactions.
tion, angulation of M3s, as well as number sent4,8,10; specifically associated with The present study demonstrated that in
of dental roots were determined (Table 5). Class II B, mesioangular impacted M3s. patients who had multiple fractures, when
Concerning the ramus position of impacted Previous authors have postulated that the unerupted M3s were present, the
M3s, the highest incidence of angle frac- the presence of impacted M3s reduces the patient’s injuries were often associated
tures was observed in Class II (53%). The
highest incidence of condylar fractures was
typically seen in the absence of the Table 6. Relationship between M3 position and risk of condylar and angle fracture.
impacted M3, designated as Class 0 fol- Condylar fractures, Angle fractures,
lowed by Class III (27%) (Table 6). Inter- P < 0.0001 P < 0.0001
esting correlations were observed between Ramus position Present, N = 261 Absent [15_TD$IF]Present, N = 200 Absent
the two sites of fractures and M3 vertical
position. The highest incidence of angle Class 0 (n = 400) (missing) 150 (37%) 250 (63%) 20 (5%) 380 (95%)
Class I (n = 234) 50 (21%) 184 (79%) 30 (13%) 204 (87%)
fractures was observed in Class B (41%).
Class II (n = 188) 33 (17%) 155 (83%) 100 (53%) 88 (47%)
In keeping with the authors’ hypothesis, the Class III (n = 98) 27 (27%) 71(73%) 50 (51%) 48 (49%)
highest incidence of condylar fractures was
noted in the absence of M3, followed by
Class C (25%) (Table 7).
Mesioangular impactions were the most Table 7. Relationship between M3 position and risk of condylar and angle fracture.
common type of M3 angulation that Condylar fractures P < 0.0001 Angle fractures, P < 0.0001
proved to be responsible for fractures of
Occlusal position Present, N = 261 Absent [17_TD$IF]Present, N = 200 Absent
the mandibular angle and distoangular
impactions were the most common type Class 0 (n = 400) 160 (40%) 240 (60%) 20 (5%) 380 (95%)
of M3 angulation that proved responsible Class A (n = 218) 51 (23%) 167 (77%) 70 (32%) 148 (68%)
Class B (n = 197) 23 (11%) 174(89%) 82 (41%) 115 (59%)
for condylar fractures (Table 8).
Class C (n = 105) 27 (25%) 78 (75%) 28 (26%) 77 (74%)

Discussion
The external oblique ridge provides Table 8. Relationship between M3 angulation and risk of condylar and angle fracture.
strength for the mandible in that region Angulation Condylar fractures, P < 0.0002 Angle fractures, P < 0.0001
of the jaw, when a tooth is completely in (Schiller’s method)
occlusion, the widest portion of the tooth (n = 520) Present, N = 261 Absent [23_TD$IF]Present, N = 200 Absent
is in the mouth and the external oblique Mesioangular (n = 250) 83 (33%) 167 (66%) 150 (60%) 100 (40%)
ridge remains intact. When the tooth is Distoangular (n = 75) 64 (85%) 11 (15%) 23 (31%) 52 (69%)
completely impacted, the widest portion Vertical (n = 151) 75 (49%) 76 (51%) 17 (11%) 134 (89%)
of the tooth is generally found below the Horizontal (n = 35) 29 (82%) 6 (18%) 9 (28%) 26 (72%)
external oblique ridge. When the tooth is Germ (n = 9) 4 (44%) 5 (56%) 1 (11%) 8 (89%)

with both symphysis and angle fractures.
When the unerupted M3s were absent, the
patient’s injuries were more associated
with both symphysis and condyle frac-
tures. This suggests that when the uner-
upted M3s are absent, more of the force
may be conveyed to the condylar region;
hence, the increased incidence of asso-
ciated fractures of the condyloid process.
This study reports that in the absence of
impacted mandibular M3s, the condyle
was 2.5 times more prone to injury com-
pared with cases where impacted M3s
were present.
KOBER et al. proposed a biomechanical
model that is in agreement with the
findings of this study. He suggested that
if the angle was weakened by incomple-
tely erupted M3s, the possibility of con-
dylar fractures would be decreased, as
impact forces would be dissipated by the
angle fracture. If the angle was intact,
with no impacted M3s, it would be
resistant to fracture and more impact
forces would transmit to the condyle
and result in fracture3.
When considering precise reduction and
fixation of mandibular fractures, difficul-
ties are often encountered in repositioning
the condylar fragments and performing
accurate placement of the plates and
screws; there is also the possibility of
facial nerve injury. Excellent reduction
and stable fixation for angle fractures
are easily performed because the access
and visibility for plating is much better.
The authors state that it might not be
appropriate to strengthen the mandibular
angle region and make the mandible more
vulnerable to condylar fractures by remov-
ing the unerupted M3s. The treatment of
condylar fractures is more challenging
than that of angle fractures.
Impact of impacted mandibular third molars
From this retrospective cohort it can be
concluded that the presence of impacted
M3 predisposes the angle to fracture and
reduces the risk of a concomitant condylar
fracture. Unlike previous reports, the pre-
sent study has analyzed and validated the
importance of the angulation of M3s with
regard to risk of mandibular angle and
condylar fractures in addition to other para-
meters, rendering the study significant.
Funding
None.
Competing interests
None declared.
Ethical approval
Not required.
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Address:
Annamalai Thangavelu
Division of Oral and
Maxillofacial Surgery
Rajah Muthiah Dental College and
Hospital, Annamalai University
Annamalai Nagar
Chidambaram
Tamil Nadu 608002
India
Tel: +91 94432 44213
fax: +91 4144 238080
E-mail: omfsvat@hotmail.com