A 49-year-old Caucasian male presents to the emergency department 12 days post removal of his mandibular right third molar. He describes pain, swelling and a distinct cracking noise after eating.
1. What do you see radiographically?
2. What is the initial management?
3. How can this rare complication be avoided?
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Quiz answers
- There is an undisplaced fracture of the right angle of the mandible.
- Manage the patient as per the advanced trauma life support (ATLS) protocol. The patient should be admitted to hospital under the care of the oral and maxillofacial surgery team. The patient should be kept nil by mouth, and broad-spectrum antibiotics commenced. The patient should have analgesia regularly and intravenous fluids to prevent dehydration while awaiting further management.
- Late fracture of the mandible after third molar surgery is a rare event (0.005%). These fractures predominantly occur in patients older than 25 years, who are fully dentate, and those with deeply impacted third molars. The greatest risk is two to three weeks post removal due to replacement of the granulation tissue with connective tissue at the extraction site.
It is necessary to warn patients that the removal of wisdom teeth may weaken the mandible and that activities that increase the risk of injury, including sports and heavy masticatory forces, should be avoided for four weeks post removal.
It is appropriate, before surgery:
- to make an appropriate assessment of the wisdom teeth and the amount of bone removal required, and to warn the patient of the possibility of late mandible fracture during chewing.
During surgery:
- to be conservative with the amount of bone removed, to divide the tooth where appropriate and to avoid excessive force on the mandible.
After surgery:
- especially if it is a difficult operation with significant bone removal, to advise the patient to continue a soft diet for four weeks and avoid excessive masticatory force.