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Identifying the risk factors causing iatrogenic mandibular fractures associated

with exodontia: a systemic meta-analysis of 200 cases from 1953 to 2015

Article in Oral and Maxillofacial Surgery · December 2016

DOI: 10.1007/s10006-016-0579-9

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Oral Maxillofac Surg
DOI 10.1007/s10006-016-0579-9
ORIGINAL ARTICLE
Identifying the risk factors causing iatrogenic mandibular
fractures associated with exodontia: a systemic meta-analysis
of 200 cases from 1953 to 2015
Ajit Joshi 1 & Manu Goel 1 & Ashutosh Thorat 1
Received: 13 February 2016 / Accepted: 9 September 2016
# Springer-Verlag Berlin Heidelberg 2016
Abstract
Purpose Iatrogenic fracture of mandible (IFM) associated
with exodontia though rare, they do occur with an incidence
ranging from 0.0034 to 0.0075 %. Most of the data is in the
form of case reports or a small case series. This is an attempt to
amass the data available in literature since the last 62 years.
The purpose of this meta-analysis is to identify the etiologies
and risk factors leading to IFM associated with exodontia and
also the measures to minimize the complication.
Methods Articles published between 1953 and 2015 were
searched in Medline database. Data was collected and ana-
lyzed based on age, gender, extracted tooth, status of dentition,
pathological bone lesion adjacent to the tooth, type of impac-
tion, angulation of the impacted third molar, site of fracture,
side of fracture, time of fracture, and treatment of fracture.
Results A review identified 200 documented cases of IFM
associated with the removal of teeth. The reasons for its oc-
currence found to be multifactorial with a higher incidence in
the fifth decade of life with male prevalence. Risk factors
more commonly identified were removal of the third molar,
fully dentate patient, associated pathology, impacted tooth,
angle region, left quadrant, and time interval of 3 weeks
postoperatively.
Conclusions IFM related to the removal of teeth is a rare
complication. Identifying and addressing the risk factors will
enable the surgeon to avoid the complication of IFM associ-
ated with exodontia.
* Ashutosh Thorat
drashutoshthorat@gmail.com
1
Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital,
Nagpur, India
Keywords Iatrogenic mandible fracture . Tooth extraction .
Complication . Meta-analysis . Risk factor
Introduction
Dental extraction is a routine procedure in oral surgery; the
reasons for extraction include the presence of caries, mobility,
cysts or tumor, periodontal problems, acute or chronic
pericoronitis, and preparation for orthodontic treatment or
orthognathic surgery [1]. The most common associated com-
plications are alveolar osteitis, secondary infection,
dysaesthesia, and bleeding [2–4], and the most severe compli-
cation during and after removal of teeth is mandibular fracture.
Mandibular fracture is rare, but a very serious complication
with a reported incidence ranging from 0.0034 to 0.0075 %
[5–8]. A significant distress can cause to the patient and the
practitioner if these fractures occur in the intraoperative or
postoperative period. These types of mandibular fractures
are most commonly associated with the removal of the third
molars and are presented in isolated case reports or small
series of cases. The objectives of this study were to analyze
the available published literature regarding iatrogenic fracture
of mandible (IFM) associated with the extraction of tooth,
either intraoperatively or postoperatively, and to rule out the
risk factors and preventive measures.
Material and methods
This meta-analysis includes the articles published between
1953 and 2015 using PubMed-Medline to amass the most
authentic and reliable statistics to identify the incidence and
risk factor causing IFM associated with tooth extraction. The
keywords used were iatrogenic; mandible fracture; third
 Author's personal copy
molar; second molar; first molar; premolars; canine; incisors,
and dental extractions (Fig. 1). Full text articles and abstracts
providing detailed result along with the material and methods
of relevant articles published in the English, German, French,
and Polish literatures were screened and included in the
analysis.
Data were collected and analyzed on the basis of age, gen-
der, extracted tooth, status of dentition (full, partial, edentu-
lous), pathological bone lesion adjacent to the tooth, type of
impaction (soft tissue, partial bony, full bony), site of fracture
(symphysis, canine, body, angle), side of fracture (left or
right), time of fracture and treatment of fracture, angulation
of the impacted third molar (vertical, mesioangular, horizon-
tal, distoangular), and the treatment provided (closed reduc-
tion, open reduction, and no treatment).
Results
A list of 47 reports on 200 cases of IFM associated with the
removal of teeth is shown in Table 1. Age and gender were
documented significantly in 177 cases, and most of the IFM
occurred in the fifth decade of life (Table 2), with a male/
female ratio of 2.2:1. The extractions of the mandibular third
Fig. 1 Schematic representation
of search strategy and type of
articles included
Oral Maxillofac Surg
molars were the common cause of IFM than the extraction of
other teeth (Table 3). It accounted for 75 % of all the IFM
followed by the second molar (8 %), second premolar (8 %),
first molar (6 %), and canine (3 %). Out of 200 cases, status of
dentition was mentioned in 189 cases in which 55 % of the
patients had full dentition, 32 % were partial, and 13 % were
edentulous. Fractures were significantly more common in pa-
tients who were fully dentate followed by partially dentate and
edentulous, respectively (Table 4). Preoperative pathological
findings at the extraction site such as pericoronitis, periodontal
pockets, and cysts were found to be significant in 30 % cases.
The type of impaction was reported in 138 cases of which
54 % were full bony, 30 % were partial bony, and 16 % were
soft tissue impaction. IFM associated with complete bony
impaction was significant (Table 5). Angulation was reported
noteworthy in 137 cases; 33 % were vertical, 28 % were
mesioangular, 27 % were horizontal, and 12 % were
distoangular. Teeth that were either vertically or
mesioangularly placed were consequential for IFM
(Table 6). IFM following extractions usually occurred in man-
dibular angle region accounting for 75 % of all the IMF
(Table 7). The side of the mandible was documented in 182
cases. Right side was involved in 49 % and left side in 51 %
patients (Table 8). In 25 % patients, fractures occurred
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Oral Maxillofac Surg

Table 1 A list of 47 reports on 200 cases of IFM associated with the Table 2 Age
removal of teeth distribution of the Age (years) No. of cases % of cases
reported cases
Sr no. Author Year Cases 10–19 3 2
20–29 27 15
1. Ekholm [9] 1953 6
30–39 39 22
2. Belveze [10] 1954 1
40–49 51 29
3. Hammer [11] 1955 3
50–59 32 18
4. Nyul [5] 1959 5
60–69 21 12
5. Ohm [12] 1965 2
70–79 4 2
6. Necek [13] 1965 4
7. Lautenbach [14] 1966 1
8. Barclay [15] 1969 1 intraoperatively, while in the remaining 75 % cases, it oc-
9. Von Allmen [16] 1971 1 curred postoperatively (Table 9). The time interval between
10. Harnisch [17] 1971 3 tooth extraction and diagnosis of fracture was 1–5 weeks. In
11. Farish [18] 1972 1 86 % of the cases, the fracture occurred between the first and
12. Haunfelder [19] 1972 10 third week postoperatively (Table 10). Treatment of fractures
13. Ellis [20] 1974 1 included closed reduction 39 %, open reduction 37 %, and no
14. Berlin [21] 1977 5 treatment in 24 %.
15. de Carvalho [22] 1977 1
16. Borea [23] 1977 1
17. Einrauch [24] 1980 1 Discussion
18. Barsekow [25] 1981 1
19. Roth [26] 1981 1 Mandibular fracture related to the removal of teeth is a rare
20. Schroll [27] 1984 1 complication. It may occur either as an immediate or as a late
21. de Silva [28] 1984 1 complication, usually within the first 4 weeks after extraction.
22. Paszek-Chromik [29] 1984 1 The true incidence of postoperative mandibular fractures as a
23. Litwan [30] 1987 4 result of extraction is difficult to establish as some mandibular
24. Panos [31] 1987 1 fractures could have happened intraoperatively which over the
25. Härtel [32] 1988 4 weeks after extraction could have exceeded. Iatrogenic frac-
26. Guzmán [33] 1988 2 ture of mandible is thought to be multifactorial, and the factors
27. Iizuka [34] 1990 13 discussed below have been shown to have a significant impact
28. Dunstan [35] 1997 2 on risk.
29. Becktor [36] 1997 1 Patients in their fifth decade were most commonly affected;
30. Krimmel [37] 1998 6 weakening of the mandible as a result of a reduction in bony
31. Perry [7] 2000 28 elasticity during aging may be the cause of greater incidence
32. Libersa [8] 2000 27 of fractures reported among patients in their fifth decade. Also
33. Arrigoni [38] 2002 7 in older age, the bone is much brittle which fractures easily
34. Kunkel [39] 2004 2 due to inadvertent force. Emphasizing gender, there seems to
35. Werkmeister [40] 2005 1 have a particular importance in postoperative fractures, with
36. Wagner [41] 2005 17 the highest incidence for men, possibly due to greater masti-
37. Komerik [42] 2006 1 catory force employed in male patients, emphasizing the need
38. Wagner [43] 2007 1 for soft diet during the first week post-surgery [41]. Intuitively,
39. Kunkel [44] 2007 11 a higher rate of fracture might be expected among older,
40. Woldenberg [45] 2007 1
Table 3 Extracted teeth involved in IFM
41. Orihovac [46] 2008 1
42. Khan A [47] 2009 1 Tooth No. of cases % of cases
43. Valiati [48] 2009 1
Kao Third molar 136 75
44. [49] 2010 1
Second molar 14 8
45. Chrcanovi [50] 2010 2
First molar 12 6
46. Grau-Manclus [51] 2011 11
Second premolar 14 8
47. Cankaya [52] 2011 2
Canine 6 3
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Oral Maxillofac Surg

Table 4 Status of Table 10 Time interval between tooth removal and mandible fracture
dentition Status of dentition % of cases postoperatively

Full dentition 55 Time (weeks) No. of cases (n = 141) % of cases

Partial dentition 32
1 34 24.11
Edentulous 13
2 41 29
3 42 30
4 14 10
5 6 4
Table 5 Type of tooth impaction
6 2 1
Type of impaction No. of cases % of cases 7 1 0.7
8 1 0.7
Full bony impaction 74 54
Partial bony impaction 42 30
Soft tissue impaction 22 16 perhaps osteoporotic women, but the data available did not
allow multivariate analysis of age and gender, so it was not
taken into account further.
The peak levels of biting forces are produced in patients,
having full dentition, which are then transmitted to the
Table 6 Angulation of the impacted third molar according to Winter’s
classification of the impacted third molar weakest area of mandible during mastication, and consequent-
ly, the risk of mandible fracture increases in the area of ex-
Angulation of impacted third molar No. of cases % of cases tracted tooth [53]; this might be the reason for fractures being
significantly more common in patients who were fully den-
Vertical 46 33
tate. Pre-existing bone lesions, such as periodontal disease,
Mesioangular 38 28
cyst, and pericoronitis, were noted in 30 % of the cases.
Horizontal 37 27
These lesions found to be weakening the mandible and further
Distoangular 16 12
predispose it to fracture. All of these were also more frequent-
ly found among patients 40 years of age or older [54]. Fracture
following the removal of the mandibular third molar was
found to be more common than fracture associated with other
Table 7 Fracture site: tooth regions and accounted for 75 % of all the fractures fol-
according to Dingman Site No. of cases % of cases lowing tooth removal. The incidence of iatrogenic mandibular
and Natvig’s fractures following the mandibular third molar surgery is
classification Angle 136 75
0.0046–0.0075 % [7, 41]. The degree of tooth impaction is
Body 40 22
also an important factor. Significant number of fractures was
Canine 6 3
found to be associated with fully bony impaction (54 %)
followed by partial bony (30 %) and soft tissue impaction
(16 %). Fully impacted teeth will have higher incidence of
Table 8 Fracture involving the left or right side of mandible mandibular fracture, presumably due to the greater volume
of bone necessary to be removed during the surgery to get
Side No. of cases (n = 182) % of cases
access to the tooth [8]. In such cases, extensive osteotomy
Right 89 49 may weaken the mandible and make it more susceptible to
Left 93 51 fracture [37]. Sectioning of tooth is highly recommended in
order to reduce the amount of bone removal. In cases of im-
paction near the lower border of the mandible, the extraoral
approach seems to be a reasonable one [55]. Another cause
may be mandible is anatomically weak angle region of man-
Table 9 Intraoperative and postoperative incidence of IFM in reported
cases dible due to junction between dentate alveolus converging
with non-dentate ramus and mandible is also bending up-
Time of fracture No. of cases (n = 174) % of cases wards, so the amount of bone grain is reduced at the angle
region.
Intraoperative 44 25
Iatrogenic mandibular fractures were found to be more
Postoperative 130 75
common following the removal of vertical impacted tooth,
 Author's personal copy
Oral Maxillofac Surg
Table 11 Identified variables
with high risk (%) causing IFM in Parameter
descending order among the
reported cases (N = 200) Extracted tooth
Fracture site
Time of fracture
Gender
Status of dentition
Type of impaction
Fracture side
Time between tooth removal and fracture
Pathological bone lesion adjacent to the tooth
Age
which was followed by mesioangular, horizontal, and
distoangular teeth. In the angle region, fractures were found
to be 75 %. The angle of the mandible is an area of lowered
resistance to fracture, due to its specific osseous anatomy and
its location between the ramus and the corpus. It is also an area
harboring the third molar, which reduces the bone volume in
this region. One mechanism that has been hypothesized, by
which the third molars tend to increase the risk of angle frac-
tures, is by occupying osseous space and thereby weakening
the angle region by decreasing the cross-sectional area of the
bone [56]. In this review, the fracture was most commonly
observed to occur on the left side (51 %) as compared to the
right side (49 %). This could be explained by better visualiza-
tion and control of applied forces by the surgeon on the right
side of the patient as compared to the left side. Wagner et al.
noticed a significant prevalence of fracture on the left side as
compared to right side [41].
Most fractures occurred postoperatively (75 %) and usually
during the first or third week. In this period, the granulation
tissue is replaced by the connective tissue at the extraction
zone; therefore, an increased risk of fracture is to be expected.
However, some studies have reported mandibular fractures as
long as 6 weeks after removal of the tooth [41]. Another pos-
sibility is that the postoperative fractures may have been in-
complete intraoperative fractures, which over the weeks after
extraction could have exceeded the corresponding tolerance or
stress limits as at the end of the second week the patient feels
better, the painful symptoms almost disappear, and they be-
lieve they can chew normally. Intraoperative iatrogenic man-
dibular fractures may occur with improper instrumentation
whereas late fractures generally occur during chewing some-
thing and with an audible click to the patient. The period of the
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 [57]. In 79 % of the
cases, in this review, iatrogenic mandible fracture was treated
by closed reduction. The treatment objective of mandibular
fracture is to restore the contour, occlusion, and temporoman-
dibular joint function. Open reduction and fixation with
High-risk variable (%)
Third molar (75)
Angle (75)
Postoperative (75)
Male (69)
Fully dentate (55)
Full bony impaction (54)
Left (51)
3rd week postoperative (30)
Pericoronitis, periodontal pockets, and cysts (30)
5th decade of life (29)
miniplates and monocortical screws is currently preferable in
patients with unfavorable mandibular fractures [58]. Table 11
represents the identified high-risk variables favoring IFM.
Iatrogenic mandibular fractures subsequent to extractions
are rare, but they do occur and may lead to medicolegal pro-
ceedings as well as mental stress for the patient. Dental pro-
fessionals should be very skilled and cautious while extracting
teeth to avoid any prospective morbidity. IFM associated with
procedures like exodontia should be reported and critically
evaluated, which will layout the guidelines for surgeons to
be attentive while operating. Addressing the risk factors will
enable the uneventful surgical procedures. If such advent
complication occurs, surgeons should be competent in man-
aging and treating on priority to avoid inconvenience to the
patient.
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