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Dental Traumatology 2016; 32: 286–295; doi: 10.1111/edt.12259

Impact of the lower third molar and injury

mechanism on the risk of mandibular angle
and condylar fractures

Svetlana Antic1,2, Biljana Milicic3,4,
Drago B. Jelovac5, Marija Djuric2
1
Center for Radiological Diagnostics, School of
Dentistry, University of Belgrade; 2Laboratory
for Anthropology, School of Medicine, Institute
of Anatomy, University of Belgrade;
3
Department of Statistics, School of Dentistry,
University of Belgrade; 4Department of
Anesthesiology, Clinical Center of Serbia;
5
Clinic of Maxillofacial Surgery, School of
Dentistry, University of Belgrade, Belgrade,
Serbia
Key words: fracture; lower third molar;
mandible
Correspondence to: Marija Djuric, Laboratory
for Anthropology, Institute of Anatomy,
University of Belgrade – School of Medicine
Dr Subotica 4/2 11000 Belgrade, Serbia
Tel./Fax: +381 11 2686 172
e-mail: marijadjuric5@gmail.com
Accepted 8 December, 2015
Abstract – Background: Previous studies have shown the influence of the
mandibular third molar on mandibular angle and condylar fractures, but
have not comparatively analyzed the impact of the injury mechanism on
these fractures. The purpose of this study was to evaluate the influence of
the lower third molar (M3) and injury-related factors (fracture etiology
and site of impact of the traumatic force) on the risk of mandibular angle
and condylar fractures. Material and methods: The study included 615
patients who sustained a mandibular fracture in a 13-year period (from
January 2000 to December 2013). The independent variables were pres-
ence, position and the root number of the M3, fracture etiology, and site
of impact of the force. The outcome variables were mandibular angle and
condylar fractures. Other variables included in the study were patients’
gender and age. The data were analyzed using the chi-square test. Univari-
ate and multivariate binary logistic regression analyses were used to evalu-
ate the relationship between angle and condylar fractures and to show
potential determinants. Results: Angle fractures were significantly influ-
enced by the M3, site of impact, and age, but the main predictors were
the eruption status and vertical position of the M3 (classified by Pell and
Gregory) and site of impact of the force. Condylar fractures were signifi-
cantly influenced by the M3 and site of impact of the force, but only the
last showed as a predictor. Conclusions: Factors related to the M3
showed more significant influence on angle fractures than on condylar
fractures.

The mandible is frequently injured bone of the facial
skeleton, along with zygomatic and nasal bones.
According to the literature, mandible fractures vary
from 15.5% to 59% of all facial fractures (1–5). Other
epidemiological data, including the cause of injury,
fracture type, gender, and age distribution, are not
quite consistent and depend on characteristics of the
population included in the study, comprising its envi-
ronment, culture, and social and economic develop-
ment. However, as leading causes of mandibular
fractures, assaults and traffic accidents are mostly
reported (6).
There are various studies suggesting that mandibular
third molar (M3) contributes to the weakness of the
angle region of the mandible and increase the risk of
its fracture for even two to fourfolds (7–12). Bezerra
et al. (13). noticed that traumatic impacts of lower
intensity (such as assaults and sport injuries) resulted
in energy transmission along the lesioned body and
were more frequently associated with mandibular angle
fractures, especially in cases with third molar. Support-
ing this theory, the study of Ugboko et al. (14).
demonstrated the low prevalence of angle fractures
related to M3 with dominating traffic accident as etio-
logical factor, where fractures probably occurred after
transmission of high amount of energy to the site of
impact. Still, it is not clear what is the relative contri-
bution of force direction and its site of impact vs fac-
tors related to M3 on the angle fractures.
To prevent angle fractures, some authors even sug-
gested removal of the M3s, especially in persons
involved in contact sports (7, 8). However, other stud-
ies reported that the absence of M3 was related to
the increased risk of condylar fractures (15, 16), the
treatment of which is a greater challenge. The impacts
of M3 presence, position, and eruption status on
angle and condylar fractures were evaluated in
various studies (16–18), but the results were quite
inconsistent.
As an answer to controversial epidemiological data,
we created a comprehensive epidemiological study with
the aim to evaluate the influences of the M3 and injury
factors such as fracture etiology and site of impact of
the force on the mandibular angle and condylar frac-
tures. The aim was also to reveal potential predictors
of these fractures.

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Impact of lower third molar on the mandibular fractures 287

Materials and methods
Study design, sample, and variables
This study followed the Declaration of Helsinki on
medical protocol and ethics, and the regional Ethical
Committee on human research of the School of Den-
tistry, University of Belgrade approved the study.
A cohort study comprised 615 patients who pre-
sented to the management of mandibular fracture to
the Clinique of Maxillofacial Surgery, Faculty of Den-
tistry, University of Belgrade, in the period from Jan-
uary 1, 2000, to December 31, 2013. Patients under the
age of 15 years, with the fractures caused by gunshot
wounds, and with pathological fractures were excluded
from the study. The collected data included patients’
gender, age, fracture type and pattern, and mechanism
of injury. Patients were classified into three age groups:
15–25, 26–55, and over 55 years.
The primary independent variables were the proper-
ties of the M3 including the presence an eruption state,
vertical and horizontal positions – classified by Pell
and Gregory (19), angulation, relation to the inferior
border of the mandible, and the number of roots, and
the injury factors including fracture etiology and site of
impact of the traumatic force. The main outcome vari-
ables were the frequencies of the mandibular angle and
condylar fractures.
Data collection – M3 properties
Properties of the M3 were evaluated using panoramic
radiographs.
Eruption status of the M3 was defined as follows:
1 M3 absent,
2 M3 completely erupted: The occlusal surface of M3
is reaching the mandibular occlusal plane, and the
posterior part of the crown is not covered by the
anterior border of the ascending mandibular ramus.
3 M3 partially impacted: The occlusal surface of M3 is
below the mandibular occlusal plane or the posterior
part of the crown is covered by the anterior border
of the ascending mandibular ramus, with discontinu-
ation of the external oblique line.
4 M3 completely impacted: M3 is completely occupied
by the surrounding bone and without discontinua-
tion of the external oblique line.
In the analysis of the position of M3, Pell and Gre-
gory Classification (19) was used to define the vertical
position (Class A, Class B, Class C) and horizontal
position (Class I, Class II, Class III) (Fig. 1).
Angulation of M3 was defined by the angle of inter-
section between the long axis of the tooth and the
mandibular occlusal plane (10) (Fig. 2) and was classi-
fied according to Ma’aita & Alwrikat (20) as follows:
1 Distoangular: more than 100°;
2 vertical: 80–100°;
3 mesioangular: 20–80°;
4 horizontal: <20°.
The position of the M3 in relation to the inferior
border of the mandible was determined by comparing
the shortest distance between the M3 and the inferior
border to that of the adjacent second molar (Fig. 3).
Two classes were defined as follows (21):
1 Class a – The shortest distance between the M3 and
the inferior border is equal or longer than that of
the second molar,
2 Class b – The shortest distance between the M3 and
the inferior border is shorter than that of the second
molar.
The number of visible dental roots was determined
on the panoramic radiographs and categorized as fol-
lows:
1 tooth germ without formed roots,
2 single (conical) root,
3 two or more roots.
Data collection – mechanism of injury
The data regarding mechanism of injury were obtained
from medical history based on anamnesis and clinical

(a)

(b)

Fig. 1. Schematic presentation of the classification system given by Pell and Gregory. (a) Vertical position of the M3: Class A –
occlusal plane of the M3 is at the same level like occlusal plane of the adjacent second molar, Class B – occlusal plane of the M3
is between the occlusal plane of the second molar and its cement–enamel junction, Class C – occlusal plane of the M3 is below
the cement–enamel junction of the second molar. (b) Horizontal position of the M3: Class I – adequate space available for the
M3, between the anterior border of the ramus and the second molar, Class II– inadequate space available, Class III– M3 located
all or mostly within the ascending ramus.

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

288 Antic et al.
Fig. 2. Angulation of the M3: defined by the angle of
intersection between the longitudinal axis of the tooth and
the mandibular occlusal plane, and classified as follows –
distoangular more than 100; vertical: 80–100; mesioangular:
20–80; horizontal: <20.
Fig. 3. Relation of the M3 to the inferior border of the
mandible: determined by comparing the shortest distance
between the lowest point of the M3 and the inferior border of
the mandible (d’), compared to those of the adjacent 2nd
molar (d).
examination. The fracture etiology was classified into
six categories:
1 assault,
2 fall,
3 traffic accident,
4 sport accident,
5 injury at work – caused by a blow from a working
machine or tool,
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6 and iatrogenic injury.
Site of the impact/direction of the traumatic force
was defined as follows:
1 A blow to the region of the symphysis – frontal
trauma.
2 A blow to the lateral body or to the lateral angle
region of the mandible – lateral trauma (ipsilateral
and contralateral, depending on the site of fracture).
Fracture pattern was categorized as follows:
1 mono-fracture,
2 unilateral bi-fracture,
3 bilateral bi-fracture,
4 and multifracture.
Mandible angle and condylar fractures were deter-
mined in accordance with the definition given by Kelly
and Harrigan (22). Angle fracture was defined as a
fracture located posterior to the second molar that
extends from any point of the curve formed by the
junction of the body and ramus in the retromolar
region to any point of the curve formed by the inferior
border of the body and posterior border of the ramus
of the mandible. Condylar fracture was defined as any
fracture that runs from the sigmoid notch to the poste-
rior border of the ramus of the mandible.
Data analysis
Statistical analyses were performed using SPSS software
version 18.0 (Chicago, IL, USA). Descriptive data
were expressed as mean  SD for continuous mea-
sures, or percentage of a group for discrete measures.
The Kruskal–Wallis test was used to assess differences
in age (continuous data) between different fracture
etiologies. Categorical data were analyzed using the
chi-square test. Univariate and multivariate binary
logistic regression analyses were used to evaluate the
relationship between angle and condylar fracture and
potential determinants. Results are expressed as the
odds ratios (ORs) and their 95% confidence intervals
(CI). A P value <0.05 was required to reject the null
hypothesis.
Results
The study cohort of 615 patients obtained 1035
mandibular fractures and consisted of 527 (85.7%)
males and 88 (14.3%) females. Mean age of the
patients at the time of injury was 33.67  14.94 years,
ranging from 15 to 85 years. Statistical post hoc analy-
sis showed that the most frequent etiology of fracture
was assault (339, 55.1%), while others showed the fol-
lowing order: fall (145, 23.6%), traffic accident (85,
13.8%), sport accident (24, 3.9%), injury at work –
caused by a blow from working machine or tool (16,
2.6%), and iatrogenic injury (6, 1.0%). Among males,
the most frequent fracture etiology was assault, and
among females, it was fall (P < 0.01), Table 1. Average
age of patients injured in the assault was
31.53  13.05, in fall 37.67  17.31, in a traffic acci-
dent 33.46  14.85, in sport accident 25.54  7.69, at
work 48.25  12.43, and with iatrogenic injury
55.33  22.18.
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Impact of lower third molar on the mandibular fractures 289

Table 1. Frequencies of the angle and condylar fractures in males and females
Angle fracture
Patient gender Absent, N = 339 (%) Present, N = 276 (%) Risk Relative risk 95% confidence interval
Male 286 (54.3) 241 (45.7) 1.150 1
(N = 527)
Female 53 (60.2) 35 (39.8) 0.869 0.756 0.575–0.993
(N = 88)

Condylar fracture
Absent Present
N = 378 (%) N = 237 (%)

Male 325 (61.7) 202 (38.3) 0.964 1

(N = 527)
Female 53 (60.2) 35 (39.8) 1.037 1.076 0.756–1.322
(N = 88)

The most frequent type of fracture was bilateral bi-
fracture (43.6%), followed by mono-fracture (41.5%).
Multifractures (8.1%) and unilateral bi-fractures
(6.8%) were less frequent, Table 2. Mono-fractures
were the most frequently obtained in the assault and
multifractures in the fall. The distribution of fractures
by site, presented on Fig. 4, shows that the most fre-
quently fractured mandibular regions in the present
study were the angle (27.7%) and the condyle (27.1%).
Angle fractures
A total of 276 patients sustained an angle fracture. The
frequency of angle fractures was higher in male
patients, but without statistical significance (Table 1).
Statistical post hoc analysis showed that the frequency
of angle fractures was significantly more frequent in
the patient group aged between 15 and 25 years, in
comparison with the other two groups. The relative
risk for sustaining an angle fracture is estimated to be
approximately 1.7 folds higher in the age group 15–
25 years than in the other two groups (Table 2).
Of total 276 patients with angle fracture, 115 had
isolated angle fracture, while 161 patients had an angle
fracture associated with a fracture/fractures of other
mandibular region(s) – concomitant angle fractures.
Frequency of concomitant angle fractures showed the
highest association with the assault (28.6%), but with-
out significant difference when compared with other
fracture etiologies. In all fracture etiologies, concomi-
tant angle fractures were more frequent than isolated
angle fractures, with the exception of iatrogenic frac-
tures. Iatrogenic fractures were least represented (five
cases) and only as isolated fractures (Table 3).
Of total 276 patients with diagnosed angle fracture,
11 had bilateral angle fracture, so total number of

Table 2. Frequency of mandibular angle and condylar fractures in different age periods
Angle fracture
Absent Present
Patients’ age N = 339 (%) N = 276 (%) Risk Relative risk 95% confidence interval
15–25 years 118 (46.6) 135 (53.4)* 1.370 1 1.152–1.629
(N = 253)
26–55 years 176 (60.1) 117 (39.9) 0.809 0.590 0.493–0.705
(N = 293)
Over 55 years 45 (65.2) 24 (34.8) 0.754 0.550 0.393–0.769
(N = 69)

Condylar fracture
Absent Present
N = 378 (%) N = 237 (%)

15–25 years 162 (64.0) 91 (36.0) 0.892 1

(N = 253)
26–55 years 173 (59.0) 120 (41.0) 1.127 1.263 1.034–1.542
(N = 293)
Over 55 years 43 (62.3) 26 (37.7) 0.975 1.093 0.793–1.507
(N = 69)
*P = 0.001 (Pearson chi-square).

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290 Antic et al.

Fig. 4. The distribution of mandibular

fractures by site.

angle fractures was 287 (106 angle mono-fractures and
181 angle fractures as a part of bi- and multifractures).
Table 4 presents the distribution of angle fractures in
relation to the site of impact of the traumatic force.
Angle mono-fractures showed the highest association
with the ipsilateral blow, and angle fractures in double
and multifractures with the frontal blow directed to the
symphyseal region.
To evaluate the influence of the M3 properties on
the angle and condylar fractures, we analyzed 1230
mandibular halves of the total 615 patients (403
mandibular halves without M3 and 827 with M3).
Frequency of mandibular angle fractures was signifi-
cantly lower in mandibular halves without M3 than in
mandibular halves with M3. Groups of mandibular
halves with half-impacted and totally impacted M3
showed significantly higher frequency of angle fractures
than the group with erupted M3. However, the differ-
ence between groups with half-impacted and totally
impacted M3 was not significant. The highest risk of
sustaining an angle fracture is recorded in the group
with partially impacted M3 (Table 5).
Comparing the groups with M3, significantly higher
frequency of angle fractures was recorded in the classes
B (38.8%) and C (32.8%) of the vertical position than
in the Class A (22.6%), while the difference between
Class B and Class C was not significant. In the classes
II and III of the horizontal position of the M3, the

Table 3. Frequency of the angle and condylar fractures in patients with different fracture etiology
Angle fracture Condylar fracture
Present as isolated fracture Present as concomitant fracture Present as isolated fracture Present as concomitant fracture
Facture etiology N = 115 (18.7%) N = 161 (26.8%) N = 56 (9.1%) N = 181 (29.4%)
Assault 73 (21.5) 97 (28.6) 25 (7.4) 97 (28.6)
Fall 18 (12.4) 37 (25.5) 21 (14.5)* 55 (37.9)*
Traffic accident 11 (12.9) 17 (20.0) 9 (10.6) 22 (25.9)
Sport accident 4 (16.7) 6 (25.0) 1 (4.2) 3 (12.5)
Iatrogenic injury 5 (83.3) 0 (0) 0 (0) 0 (0)
Work injury 4 (25.0) 4 (25.0) 0 (0) 4 (25.0)
*P < 0.05 (Pearson chi-square).

Table 4. Distribution of angle and condylar fractures, in relation to the site of impact of the traumatic force
Angle fractures Condylar fractures
Angle mono-fractures Concomitant angle fractures Condylar mono-fractures Concomitant condylar fractures
Site of impact of the traumatic force N (%) N (%) N (%) N (%)
Symphyseal region 14 (13.2) 67 (37.0) 16 (35.6) 130 (55.3)
Ipsilateral body/angle region 30 (28.3) 15 (8.3) 5 (11.1) 7 (3.0)
Contralateral body/angle ragion 7 (6.6) 38 (21.0) 2 (4.4) 40 (17.0)
Low reliability of the impact site 55 (51.9) 61 (33.7) 22 (48.9) 58 (24.7)
Total 106 (100) 181 (100) 45 (100) 235 (100)

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Impact of lower third molar on the mandibular fractures 291

frequency of angle fractures was equal (38.1%) and sig-
nificantly higher than in the Class I. Class B and Class
II showed the highest risks of sustaining an angle frac-
ture (Table 6).
According to the results of the statistical post hoc
analysis, the frequency of angle fractures was signifi-
cantly higher in cases with mesially angulated M3 than
in cases with other M3 positions (Table 7).
Considering the position of the M3 relative to the
inferior border of the mandible, significantly higher fre-
quency of angle fractures was recorded in the Class b
than in the Class a. Relative risk of angle fracture is
estimated to be approximately 2.6 folds higher in the
Class b than in the Class a (Table 8).
Statistical post hoc analysis showed significantly
higher frequency of angle fractures in the group with

Table 5. Frequency of the angle and condylar fractures in relation to the M3 presence and eruption status
Angle fracture
Absent Present
M3 Presence and eruption status N (%) N (%) Risk Relative risk 95% confidence interval
Absent, N = 403 344 (85.4) 59 (14.6) 0.531 1
Present, N = 827 599 (72.4) 228 (27.6)* 1.883 3.546 2.73–4.594
Erupted, N = 447 360 (80.5) 87 (19.5) 0.762 1.435 1.146–1.794
Partially impacted, N = 249 156 (62.7) 93 (37.3)* 1.889 3.557 2.889–4.362
Impacted, N = 131 83 (63.4) 48 (36.6)* 1.685 3.173 2.467–4.081

Condylar fracture
Absent Present
N (%) N (%)

Absent, N = 403 294 (73.0) 109 (27.0)† 1.308 1

Present, N = 827 656 (79.3) 171 (20.7) 0.764 0.584 0.474–0.719
Erupted, N = 447 338 (75.6) 109 (24.4)† 1.117 0.854 0.691–1.053
Partially impacted, N = 249 208 (83.5) 41 (16.5) 0.676 0.516 0.382–0.697
Impacted, N = 131 110 (84.0) 21 (16.0) 0.680 0.519 0.346–0.780
*P < 0.001 (Pearson chi-square).
†
P < 0.05 (Pearson chi-square).

Table 6. Frequency of angle and condylar fractures in relation to the vertical position and horizontal position of the M3
(classified by Pell and Gregory)
Angle fracture
Absent Present
N (%) N (%) Risk Relative risk 95% confidence interval
M3 vertical position
Class A 407 (77.4) 119 (22.6) 0.625 1
Class B 104 (61.2) 66 (38.8)* 1.575 2.52 1.998–3.174
Class C 88 (67.2) 43 (32.8)* 1.235 1.976 1.502–2.60
M3 horizontal position
Class I 393 (79.6) 101 (20.4) 0.536 1
Class II 180 (61.9) 111 (38.1)* 1.747 3.259 2.624–4.049
Class III 26 (61.9) 16 (38.1)* 1.411 2.632 1.759–3.934
Condylar fracture
Absent Present
N (%) N (%) Risk Relative risk 95% confidence interval

M3 vertical position
Class A 403 (76.6) 123 (23.4)† 1.466 1
Class B 144 (84.7) 26 (15.3) 0.693 0.473 0.323–0.692
Class C 109 (83.2) 22 (16.8) 0.784 0.534 0.356–0.803
M3 horizontal position
Class I 377 (76.3) 117 (23.7)† 1.543 1
Class II 243 (83.5) 48 (16.5) 0.719 0.465 0.345–0.629
Class III 36 (85.7) 6 (14.3) 0.680 0.441 0.207–0.936
*P < 0.001 (Pearson chi-square).
†
P < 0.05 Class A vs Class B; Class I vs Class II (Pearson chi-square).

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292 Antic et al.

one/fusioned-conical root M3 than in the other two
groups (Table 9).
Univariate logistic regression revealed that the pres-
ence, eruption status, vertical and horizontal position,
angulation, and number of roots of the M3 had a sig-
nificant influence on angle fractures, as well as patient
age and site of impact of the traumatic force (all the
factors listed in Table 10). Fracture etiology did not
show a significant influence on angle fractures.
In multivariate regression model, only factors that
segregated as possible predictors of an angle fracture
were M3 eruption status, M3 vertical position (Pell and
Gregory), and site of impact of the traumatic force
(Table 10).
Condylar fractures
Condylar fracture was diagnosed in 237 patients, 202
males and 35 females. There was no significant differ-
ence in the condylar fracture frequency between males
and females (Table 1).
Further analysis showed that the frequency of
condylar fractures was the highest in the group of
patients aged between 26 and 55 years (41.0%), but
without significant difference, when compared with the
other two groups (Table 2).
Of total 237 patients with diagnosed condylar frac-
ture, 56 had isolated condylar fracture and 181 patients
had condylar fracture associated with a fracture/frac-
tures of other mandibular region(s) – concomitant
condylar fractures. The frequencies of both isolated and
concomitant condylar fractures were significantly higher
in the patient group injured by fall when compared with
groups with other fracture etiologies (Table 3).
Of total 237 patients with condylar fracture, 43
had bilateral condylar fracture, so the total number
of condylar fractures was 280 (45 condylar mono-
fractures and 235 condylar fractures as a part of

Table 7. Frequency of angle and condylar fractures in relation to the angulation of the M3
Angle fracture
Absent Present
M3 angulation N (%) N (%) Risk Relative risk 95% confidence interval
Vertical 398 (78.2) 111 (21.8) 0.593 1
Mesioangular 168 (61.8) 104 (38.2)* 1.711 2.885 0.637–3.583
Distoangular 7 (70.0) 3 (30.0) 1.089 1.836 0.708–4.764
Horizontal 26 (72.2) 10 (27.8) 1.008 1.670 0.991–2.911

Condylar fracture
Absent Present
N (%) N (%)

Vertical 393 (77.2) 116 (22.8) 1.318 1

Mesioangular 225 (82.7) 47 (17.3) 0.773 0.556 0.433–0.794
Distoangular 9 (90.0) 1 (10.0) 0.481 0.365 0.056–2.352
Horizontal 29 (80.6) 7 (19.4) 0.938 0.712 0.361–1.403
*P < 0.001 (Pearson chi-square).

Table 8. Frequency of angle and condylar fractures depending on the M3 position relative to the inferior border of the mandible
Angle fracture
Absent Present
M3 position relative to the inferior border of the mandible N (%) N (%) Risk Relative risk 95% confidence interval
Class a 521 (75.1) 173 (24.9) 0.621 1
Class b 73 (59.8) 49 (40.2)* 1.611 2.594 2.016–3.338
Could not be classified 349 (84.3) 65 (15.7)

Condylar fracture
Absent Present
N (%) N (%)

Class a 538 (77.5) 156 (22.5)† 1.959 1

Class b 108 (88.5) 14 (11.5) 0.511 0.260 0.156–0.434
Could not be classified 304 (73.4) 110 (26.6)
*P < 0.001 (Pearson chi-square).
†
P = 0.006 (Pearson chi-square).

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Impact of lower third molar on the mandibular fractures 293

Table 9. Frequency of the angle and condylar fractures in relation to the root number of the M3
Angle fracture
Absent Present
M3 position M3-number of the roots N (%) N (%) Risk Relative risk 95% confidence interval
One/fusioned 97 (66.5) 51 (34.5)* 1.322 1
Two or more 489 (74.0) 172 (26.0) 0.771 0.583 0.454–0.748
Germ 13 (72.2) 5 (27.8) 1.008 0.762 0.358–1.618

Condylar fracture
Absent Present
N (%) N (%)

One/fusioned 119 (80.4) 29 (19.6) 0.937 1

Two or more 524 (79.3) 137 (20.7) 1.012 1.080 0.773–1.509
Germ 13 (72.2) 5 (27.8) 1.634 1.744 0.895–3.399
*P = 0.038 (Pearson chi-square).

Table 10. Risk factors in the angle and condylar fractures –
univariate and multivariate logistic regression
Risk factors Angle fracture
Patient age 0.755
Site of impact of the 0.0311
traumatic force
M3 presence 0.731
M3 eruption status 0.0041
M3 vertical position 0.0361
(Pell-Gregory)
M3 horizontal position 0.210
(Pell-Gregory)
M3 angulation 0.245
M3 position relative to the inferior 0.737
border of the mandible
M3 number of roots 0.117
Predictors – Multivariate logistic regression (P < 0.05).
1 different M3 angulation.
double and multifractures). Table 4 shows the distri-
bution of condylar fractures in relation to the site of
impact of the traumatic force. Both types of condylar
fractures (mono-fractures and condylar fractures in
double and multifractures) showed the highest associ-
ation with the frontal blow directed to the region of
the symphysis.
The frequency of condylar fractures was significantly
higher in the group of mandibular halves without M3
than in the group with M3. Among mandibular halves
with M3, the group with erupted M3 showed signifi-
cantly higher frequency of condylar fractures than the
groups with partially and totally impacted M3. There
was no significant difference between the groups with
partially an totally impacted M3. The highest risk of
condylar fractures was recorded in the group of
mandibular halves without M3 (Table 5).
Among mandibular halves with M3, the highest fre-
quency of condylar fractures was recorded in the Class
A of the vertical position (Pell and Gregory). Statistical
analysis showed that the frequency of condylar frac-
tures in the Class A was significantly higher than in the
Class B, but without significance when compared with
the Class C. Also, there was no significant difference
between classes B and C. The highest risk of condylar
fractures was recorded in the Class A.
Condylar fracture The highest frequency of condylar fractures was
recorded in the Class I of the horizontal position (Pell
– and Gregory). Statistical analysis showed that the fre-
0.0201 quency of condylar fractures in the Class I was signifi-
cantly higher than in the Class II, but without
0.524 significance when compared with the Class III. Also,
0.364
0.669 there was no significant difference between classes II
and III. The highest risk of condylar fractures was
0.674 recorded in the Class I (Table 6).
Furthermore, the frequency of condylar fractures
0.707 was the highest in the group with the vertical position
0.269 and the lowest in the group with the distoangular posi-
tion of M3. However, statistical post hoc analysis
0.765
showed no significant difference among groups with
The highest risk of condylar fractures was associated
with the vertical position of M3 (Table 7).
Regarding the M3 position related to the inferior
border of the mandible, significantly higher frequency
of condylar fractures was recorded in the Class a than
in the Class b. The risk of condylar fractures is esti-
mated to be approximately fourfolds higher in the
Class a than in the Class b (Table 8).
Regarding the number of roots, the group with
tooth germ was associated with the highest frequency
of condylar fractures, but without significance when
compared with other groups (Table 9).
Univariate logistic regression revealed a significant
influence of the site of impact of the traumatic force
and M3 properties (presence, eruption status, vertical
and horizontal positions, angulation, and number of
roots) on the condylar fractures (all the risk factors
numbered in Table 10). However, in a multivariate
regression model, only the site of impact of the trau-
matic force segregated as a possible predictor of condy-
lar fractures (Table 10).
Discussion
The presence of the M3 is considered as a factor that
increases the risk of fracture of the mandibular angle

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

294 Antic et al.
region (23). Furthermore, clinical data suggest that
eruption state and position of M3 also influence the
risk of angle fractures. An experimental study con-
ducted on monkey mandibles revealed that mandibles
containing unerupted third molars fractured at about
60% of the force required to fracture mandibles with
erupted third molars (24). The theory postulated in the
mentioned study suggested that the bone space occu-
pied by tooth (M3) makes the angle region weaker and
prone to fracture, so deeper localization of the M3
would increase the risk for angle fracture. In the stud-
ies of Fuselier et al. (25). and Ma’aita & Alwrikat (20),
deeply impacted M3 was suggested as the main factor
responsible for higher the risk of angle fractures. In
contrast, Lee and Dodson (11) noted that completely
impacted M3s did not increase the relative risk of angle
fractures, compared to fully erupted M3s. Halmos
et al. (26). agreed but added that partially impacted
M3s might be the main contributors to angle fractures.
Thangavelu et al. (16). also observed an association
between higher incidence of angle fractures and par-
tially impacted M3s, specifically Class IIB and
mesioangular position. Recently, Naghipur et al. (27).
found the highest relative risk of angle fractures in the
Class IIB, but statistical significance was not reached.
In addition, biomechanical study conducted by Mei-
sami et al. (28). suggested that the continuity of the
external oblique ridge was the main factor of resistance
of the angle region. This means that partially impacted
M3 with disrupted integrity of oblique ridge, will con-
tribute to the increased angle fragility.
In the present study, the greatest incidence of angle
fractures was recorded in cases with partially impacted
M3 and Class B, with statistical significance, that sup-
ports studies conducted by Thangavelu et al. (16). and
Meisami et al. (28). Regarding the horizontal position,
we found the highest frequency of angle fractures in
the Class II, followed by the Class III. However,
according to our results of significantly higher angle
fracture frequency in Class b, the shortened distance
between the M3 and inferior border of the mandible
also contributes to the angle fragility. The single coni-
cal root of the M3 also showed significant association
with angle fractures. The reason is probably in concen-
trated stress around the single root apex that over-
comes the bone strength. Mono-fractures of the angle
were highly associated with iatrogenic injury, followed
by assault and with a lateral blow directed to the ipsi-
lateral body or angle region, which suggests that they
are mostly caused by direct trauma. In contrast, angle
fractures as a part of bi- and multifractures were
mostly caused by indirect trauma.
Age differences related to the bone quality might
affect angle and condylar fractures, with an expectation
of greater frequency of these fractures in the older
patient groups. In the present study, the highest fre-
quency of angular fractures found in the age group of
15–25 years could be explained by greater frequency of
unerupted or partially erupted third molars in these
patients. In addition, the lowest frequency of condylar
fractures found in this age group is in agreement with
this assumption.
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Univariate logistic regression revealed significant
association of the presence, eruption status, position
and number of roots of the M3, and the site of impact
of the force with angle fractures. However, only site of
impact of the force, the eruption status, and vertical
position of the M3 were segregated as predictors in a
multivariate regression model. Thus, only these factors
could be directly liable for the angle fracture. The frac-
ture etiology did not show a significant impact on
angle fractures.
Previous studies have demonstrated that the presence
of the M3 reduced the risk of condylar fractures (15–
18, 21, 28), which is confirmed by the present study.
We found the highest frequency of condylar fractures
when the M3 was absent, followed by the group with
the vertical position Class IA, which is contrary to the
study of Thangavelu et al. (16) but in agreement with
the studies of Patil (18) and Naghipur et al. (28) In our
study, the risk of sustaining a condylar fracture is esti-
mated to be approximately 1.7 folds higher in cases
without M3 than in cases with M3 and 4 folds higher
in the Class a than in the Class b.
Regarding the number of roots, the highest fre-
quency of condylar fractures was recorded in the cases
with M3 tooth germs, without formed roots. The rea-
son is probably that more of the stress was conveyed
to the condylar region predisposing it to fracture, in
contrast to the increased risk of angle fractures in cases
with single conical roots.
Fracture of the condyle was mostly associated with
fractures of other mandibular regions, within double and
multifractures, and frontal blow directed to the symphy-
seal region. This could be expected, as the condylar frac-
tures are usually caused by indirect trauma that affects
other regions of the mandible, and the fracture often
occurs at the point of impact, too. Direct condylar
trauma is rare, because the condyle is usually protected
by the zygomatic arch, muscles, and the structures of
temporomandibular joint. Factors related to the M3
showed a significant influence on condylar fractures, but
did not segregated as predictors, in contrast to the site of
impact of the traumatic force. It seems that the injury
mechanism plays a more important role in condylar frac-
ture development. In addition, condylar fractures mostly
occur as a part of bi- and multifractures, and their devel-
opment is characterized with a great complexity.
Conclusion
The results of the present study demonstrated that M3
presence, position, eruption status, and root number
influence the risk of mandibular angle and condylar
fractures. This influence is more pronounced on the
risk of angle than on the risk of condylar fractures.
The main predictors of angle fractures were showed
to be lower third molar eruption status and vertical
position (Pell and Gregory), and the site of impact of
the traumatic force.
The main predictor of condylar fractures were
showed to be the site of impact of the traumatic force.
Although factors related to the lower third molar
showed an influence on the risk of condylar fractures,

Impact of lower third molar on the mandibular fractures
injury mechanism plays more important role in their
development.
Acknowledgements
The authors acknowledge support from the Ministry of
Science of the Republic of Serbia: 45005.
Conflict of interest
None of the authors or the author’s institutions had finan-
cial or personal relationships with other people or organi-
sations that inappropriately influence (bias) his or her
actions. There are no conflicts based on personal relation-
ships, academic competition, or intellectual passion.
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