Krimmel et al., respectively [18, 19]. Fractures occurring up to 28 days following surgery have been reported, and no spontaneous mandible fractures have been reported beyond six weeks after surgery [18, 19]. This time period for the fracture to occur correlates with increased masticatory forces due to decreased trismus, pain, and edema. Libersa et al., in their review of 37 fractures from 750 000 extractions, found that 8 of 10 late fractures occurred in men, with 6 occurring during mastication [17]. Risk factors for fracture include age >40, male sex, advanced atrophy, associated pathology such as cysts or tumors, osteoporosis, full dentition, and bruxism [17–19]. The angle region of the mandible is of particular risk for fracture due to its relatively decreased cross‐sectional area and nearly 90° bend from body to ramus. The presence of a deeply impacted, fully developed third molar can occupy a significant portion of this cross‐sectional area (especially the external oblique ridge) leaving little bone support following surgical extraction of a mandibular third molar [18]. Intraoperative mandibular fracture is almost exclusively due to the application of excessive, or inappropriately directed, forces applied during the third molar surgery. Often, it occurs during the use of dental elevators, combined with the application of heavy pressure beyond, which is typically required to extract the tooth [4]. In patients over 40 years of age presenting with partial bone impactions (loss of the external oblique ridge) and other risk factors, even light forces may induce a mandible fracture [17].
Fig. 2.1. Bilateral nondisplaced mandibular angle fracture following mandibular third molar extractions.
If a fracture occurs during, or after, third molar surgery, it should be managed promptly. Frequently, these immediate fractures are minimally displaced and favorable in nature. Open reduction and internal fixation can be easily accomplished in this region using the Champy monocortical plate and screw fixation technique with tension band plating (Figure 2.1). Alternatively, closed reduction with intermaxillary fixation may be appropriate in certain cases. Regardless of the technique, the complication should be communicated to the patient and/or guardian, and treatment initiated as soon as possible.
Oral–Antral Communication
Etiology: excessive force, sinus pneumatization, deficit maxillary bone, inadvertent perforation into the maxillary sinus
Management: observation, primary closure, local flaps, and layered closure
The extraction of maxillary molars can lead to a communication between the maxillary sinus and oral cavity. If this communication does not heal, or is treated inappropriately, it can lead to the development of an oral–antral fistula (OAF). The incidence of oral–antral communication (OAC) from third molar extraction ranges from 0.08% to 0.25%; however, documented cases may underrepresent the actual number of cases due to the self‐limiting nature of most OACs and immediate flap closure (effectively treating an OAC, if present) following impacted third molar removal [1–6]. It should be noted that OAC is more common at the maxillary first molar site, followed by the second molar site, and patients should be alerted to the possibility of OAC and even OAF following removal of maxillary molars [3, 4].
When extracting maxillary molars in close approximation to the sinus, especially when sinus pneumatization and widely divergent roots are noted radiographically, excessive forces should be avoided, and consideration should be given toward sectioning of the roots. Predisposing factors for OAC include pneumatization around the tooth roots, periapical infection, acute/chronic sinusitis, adjacent edentulous spaces, and traumatic extraction [3, 4, 6]. The assessment of an OAC should include the etiology, location, and size of the defect. Identification of an OAC can be assisted by having the patient perform the nose‐blow test, or Valsalva maneuver. The patient should pinch the nostrils together preventing air flow out of the nares. Next, have the patient attempt to blow gently though the nose while observing the extraction site. If an OAC exists, air will pass through it and bubbling of blood/fluid in the socket is observed. Another method involves again using the nose‐blow test but instead of observing the site directly, placing a mirror near the site and observing for fogging of the mirror. This test can be of particular use in third molar OAC due to the inability to visualize the depth of the socket in certain patients. Additionally, if upon inspection of the extracted tooth a segment of bone remains attached to the tooth toward the root apices, it is likely a communication exists. If no bone is present, this does not rule out the possibility of OAC. The surgeon must avoid the temptation to probe or explore the extraction site as this can perforate an intact membrane and introduce foreign material including bacteria into the sinus cavity.
Once the surgeon has determined that an OAC exists, the size of the defect should be determined. In general, the bony defect is larger than the soft tissue defect, so a needle can be used to probe the bony defect around the OAC to determine the exact dimensions of the bony defect. Defects <2 mm in diameter will usually close spontaneously. If desired, measures can be taken to ensure stability of an organized blood clot in the extraction site. Collagen plugs, gelfoam, and/or sutures can be placed to assist in clot formation and maintenance. A moderately sized defect of 2–6 mm in diameter will usually require additional measures to aid in closure of the OAC. A figure‐of‐eight stitch should be placed over the tooth socket to assist in clot maintenance and gelfoam or collagen plug can be placed within the socket to assist in formation of a stable clot. In addition, medications should be prescribed to prevent nasal and sinus congestion and prevent the development of maxillary sinusitis. Amoxicillin, cephalosporins, augmentin, or clindamycin can be prescribed. Nasal decongestants such as oxymetazoline and pseudoephedrine should be prescribed along with a nasal irrigant (saline nasal spray) to ensure patency of the ostium and normal sinus drainage. Oxymetazoline should only be used for a period of three days as rhinitis medicamentosa may occur from chronic usage. Also, patients should be placed on sinus precautions to avoid increasing or decreasing pressure within the sinus. Specific instructions should be given to the patient to sneeze with an open mouth, avoid smoking, avoid drinking with a straw, avoid bending over/heavy lifting, and avoid blowing their nose. Smokers who cannot abstain should be informed of an increased risk of OAF development and to consider smoking only in small puffs to avoid acute significant changes in sinus pressure. A large defect, >7 mm in diameter, will likely require additional surgical procedures. Buccal or palatal flaps can be rotated to allow for primary closure, as described below.
Patients with an OAF may present weeks, months, or even years following the extraction. Symptoms of unilateral sinus pain and pressure, nasal congestion, intraoral discharge/purulence, bad taste, breath malodor, or fluid communication between the mouth and nose may be noted. On examination, the area may be edematous and erythematous with granulation like tissue bulging from the fistulous tract, or there may be normal appearing mucosa without inflammation. Gentle probing of the area and radiographic examination with a radiopaque material (gutta percha) within the tract can confirm the presence of an OAF. Treatment usually involves an initial period using a systemic antibiotic, nasal decongestant, nasal irrigant, and sinus precautions. It is critical to ensure that a “safe sinus” exists prior to attempting OAF repair, since if the sinus drainage mechanism into the middle meatus is blocked, then the repair will fail. Following resolution of acute infection and decreased sinus inflammation, surgical repair can be undertaken. Following “sounding” the defect with a needle to determine the overall size of the bony defect, the fistula is “excised” 2 mm beyond the bony defect, and oversewn with a purse‐string suture and inverted into the sinus; this provides closure of the “sinus side” of the OAF. The “oral side” of the OAF can then be closed with a buccal mucosal advancement flap or palatal island “finger” flap; other options include using the buccal fat pad as an advancement flap, a pedicled tongue flap, cheek mucosal flap, facial artery myomucosal (FAMM) flap, or temporalis myofascial flap (Figure 2.2a–c). Excellent resources with detailed descriptions of