Extraction of third molar at risk of mandibular pathological fracture

OBJECTIVES The purpose of this article is to present and discuss the surgical management of a deeply impacted mandibular third molar associated with a follicular cyst. MATERIALS AND METHODS A 58-year-old woman with a negative anamnestic medical history for pathologies, smoking or drugs, was referred by her treating dentist to the Division of Maxillofacial Surgery, University of Novara (Italy), for the management of a cyst associated with a right third molar deeply impacted in the mandible. No signs of infection or dehiscence were observed during an intra-oral clinical examination. A panoramic radiograph showed that the mandibular left third molar was deeply impacted near the lower border of the mandible; it was surrounded by a well-circumscribed radiolucency. The diagnostic hypotheses formulated mainly included follicular cyst or odontogenic keratocyst. However, it was not possible to exclude other rarer conditions such as unicameral ameloblastoma. Treatment options considered included a first incisional biopsy or excision of the growth with simultaneous extraction of the impacted molar. In view of the unique and well-circumscribed nature of the transparent lesion, the authors opted for excision with simultaneous extraction of the impacted molar. RESULTS AND DISCUSSION Surgical extraction of deeply impacted mandibular third molars can be challenging, as several possible risks may be associated with it. Mandibular fracture during or after third molar extraction is an important although rare complication. Several factors predisposing to mandibular fracture must be considered and kept in mind: adult age, male sex, deep occlusion, dental ankylosis and associated bone pathology. CONCLUSIONS In third molar surgery, adequate surgical expertise is mandatory to ensure careful evaluation and technique. A comprehensive pre-operative analysis of the frequency of different risk factors related to mandibular fractures occurring after third molar removal is required. CLINICAL SIGNIFICANCE The authors suggest informing patients of the most common possible risks and complications. Scrupulous oral hygiene and a soft diet are recommended for up to 30 days after the removal of an included lower third molar.