Late treatment of mandible fracture after third molar removal

Surgical management of impacted third molars is a treatment performed by dentists and its indicated for various conditions, among the indications has the prevention of mandibular fracture, but this is a factor that has been discussed and is controversial. Fractures caused by a third molar can occur, and on the other hand, the fractures after or during the management of impacted third molar are a possible complication. Surgical planning as the indication to the surgery has to be performed to avoid complications as the fracture. Thus this study aims to report a case about a mandible fracture after third molar extraction, presenting edema, pain, and restriction in mandible mobility in 01-day follow-up. A 27-year-old female was referred to the oral and maxillofacial surgery service of the Santa Casa Hospital of Araçatuba (Araçatuba, Brazil), reporting dental history of third molar removal, with immediately chief complaints. Research, Society and Development, v. 11, n. 2, e25311225673, 2022 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v11i2.25673 2 In the assessment, the patient presented edema, pain, malocclusion, and restriction in mandible mobility, and the panoramic X-ray showed a mandible fracture with displacement. The patient underwent surgery under general anesthesia to open reduction with internal fixation (ORIF) through an intraoral approach. On the follow-up, the patient showed an improvement in mouth opening and mandibular mobility without pain or infection signs. The panoramic X-Rays showed us the bone fracture healing.


Introduction
Surgical management of impacted third molars is a common treatment performed for general dentists and oral maxillofacial surgeons. The third molar management presents various indications as pericoronitis prevention or treatment, management of unexplained pain, prevention of caries, root resorption of adjacent teeth, orthodontic considerations, teeth under dental prosthesis, crowding of mandibular incisors, obstruction of orthodontic treatment, systemic health considerations, prevention of odontogenic cysts and tumors, economic considerations, periodontal disease and preparation for orthognathic surgery (Peñarrocha-Diago et al. 2021;Marciani, 2007).
Besides the cases cited before jaw fracture prevention is another factor to perform the extraction, but this is a controversial factor (Ventä, 2012;Seeley-Hacker et al. 2020). Mandible is considered the strongest bone commonly fractured because of its anatomic position (Miloro et al. 2008;Banks, 1991). The presence of the third molar in the mandible increased 2.18-fold for an angle fracture, on the cases of class IC, IIC, IIIB, or IIIC of Pell-Gregory scales increased 3.6-fold (Soós et al. 2020).
Fractures caused by a third molar can occur, and on the other hand, the fractures after or during the management of impacted third molar are a possible complication. Therefore, the surgical management of the surgeon should plan the surgery for each case of third molar extraction because it requires accurate clinical examination and image evaluation to lessen the risk of fracture.
Planning surgery and the surgical techniques are the principal points observed in the third molar surgery. The extensive ostectomy (Pires et al. 2017) and the force (Liu et al. 2018) in extraction can cause the mandible fracture, such as the late fracture associated with mandible fragility after ostectomy (Pires et al. 2017). The aim is to report a case about a mandible fracture after third molar extraction, presenting in 01-day follow-up edema, pain, and restriction in mandible mobility.

Methodology
The present paper consists of a case report of a patient evaluated in Santa Casa Hospital of Araçatuba with a mandibular fracture in third molar removal conducted with surgical management presenting satisfactory results. This study applied the methodology described in Pereira (2018) and a Free and Clarified Term Consent.

Case Report
A 27-year-old female was referred to the oral and maxillofacial surgery service of the Santa Casa Hospital of Araçatuba (Araçatuba, Brazil), in April 2021, complaining of facial edema, pain and restriction of mandible mobility. The patient reported that was performed a surgery for tooth extraction and immediately the patient presented the chief complains.
These were maintained in the follow-ups that were performed by patient's dentist, who did the surgery. Without improvement of complains, radiographic examination was performed in 30 days postoperative, and was observed the mandible fracture and the patient was referred to the hospital. At the hospital patient was assessment by the team and the chief complains was noted as restriction of mandible mobility, associated to a pain, malocclusion, bone crepitation during mandible manipulation and submandibular edema. In panoramic X-ray was noted the mandible fracture with displacement and was confirmed with CT (computed tomography) Scan. (Figure 1)

Discussion
The literature reports very well about the mandibular fractures associated with the third molar and the indication for  Krimmel & Reinert, 2000). This fracture is either related to perioperative due to factors such as wide ostectomy as the not respect of orientations, chewing hard foods (Özçakir-Tomruk & Arslan, 2012;Grau-Manclús et al. 2011). In our case report patient did not hear any sound in postoperative, but immediately after the surgery presented complaints as moderate pain, malocclusion, and limited movement of the mandible, but related this with the surgery and maintained a soft food. These factors suggested that the fracture happened in the perioperative moment. Mandible fractured in the right side do not corroborate with some authors that report that a higher incidence of fractures on the left side reflects the dentist's position that applies an uncontrolled force by a right-handed surgeon (Pires et al. 2017;Cankaya et al. 2011).
However, the fracture in this side relates to the ostectomy, and the force applied for the surgeon. These occur even been a A)

B)
Research, Society and Development, v. 11, n. 2, e25311225673, 2022 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v11i2.25673 right-handed surgeon and a right third molar. In the postoperative, the bite force can generate a considerable amount of stress in the bone region, which already has less volume due to the ostectomy and/or local alterations (Pires et al. 2017).
Injuries Mandibles are related to a dentistry practice and reported in the literature (He et al. 2011;Koskela et al. 2017). The dentist's attention is crucial for all treatments moments and in the postoperative to avoid malpractice. In literature, the third molar extractions are the chief causes of malpractice that results in injuries, ranging from lingual nerve injury to death, including the mandible fracture (He et al. 2011). The experience and the skills of the operator is imperative to reducing complications in extractions of the third molar this way can see that the general dentists were responsible for the majority, 78 % of complications, whereas oral and maxillofacial surgeons accounted for 15 % (Ventä et al. 1998;Jerjes et al. 2010).
However, despite attention and planning, to avoid complications such as fractures, these can happen and need attention to the first complaints must be analyzed. Early diagnosis of fractures allows an improvement of the condition, as well as patient comfort. Therefore, in addition to clinical evaluation with manipulation of the mandible and occlusion assessment (Chrcanovic & Custódio, 2010), the chief complaint about the patient's pain should not be neglected (Grau-Manclús et al. 2011). Because of these positives signs of the bone crackles, or bone steps, factors that facilitate the diagnosis, imaging exams allow closing the diagnosis (Chrcanovic & Custódio, 2010;Grau-Manclús et al. 2011). The best and easiest accessibility exam for the patient is the panoramic radiography, which allows immediate assessment of the fracture, and determines the treatment depends on the displacement level. However, exams such as tomography assess displacements, loss of bone fragments, and displacement of dental elements and help to carry out a better planning (Chrcanovic & Custódio, 2010;Pires et al. 2017).
Clinical and imaging diagnoses determine the treatment planning that will depend on fracture displacement. Nondisplacement or minor displacement fractures, the treatment option is closed reduction with IMF, allowing good results (Cankaya et al. 2011). This treatment can be performed by a general dental surgeon in an outpatient setting for these professionals.
However, in fractures like the case report in which the patient presents occlusion complains, and observe in imaging exams a fracture displacement the treatment with IMF not indicated. The best option is an open fracture treatment to allow better reduction, fixation of fractures, and stability of results. In addition, post-operative care should be advised as a soft diet for 45 days, as implemented in the case reported (Pires et al. 2017;Özçakir-Tomruk & Arslan, 2012;Cankaya et al. 2011).

Final Considerations
Therefore, the points raised and presented with the case report we believe the important and the immediate care and investigation when patients present complaints after third molar removal. For this investigation, the clinical and imaging exam is important to apply the treatment as soon as possible.