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30. Moxon-Emre I, Schlichter LC. Evolution of inflammation and white matter injury in a model of transient focal ischemia. J Neuropathol Exp Neurol 2010;69:1Y15

Iatrogenic Mandibular Fracture Associated With Third Molar Removal After Mandibular Angle Osteotectomy Jia-Jie Xu, MD, Li Teng, MD, Xiao-Lei Jin, MD, Jian-Jian Lu, MD, Chao Zhang, MD Abstract: The extraction of mandibular third molars is a common dental procedure. The complications include hemorrhage, pain, dental fracture, the displacement of teeth or fragments, iatrogenic damage or luxation of the second molar, neurologic injuries, soft tissue damage, subcutaneous emphysema, trismus, swelling, infection, and iatrogenic mandibular fracture. Fracture of the angle of the mandible associated with third molar removal is a rare but severe complication. This article describes a case of mandibular angle fracture associated with third molar extraction after mandibular angle osteotectomy, including a brief review of the literature. The removal of the mandibular angle and the outer cortex of the mandible, especially the external oblique ridge, may contribute to the bone fracture. We conclude that the extraction of the lower third molar must be before the removal of the mandibular angle, and a soft diet for at least 4 weeks postoperatively is essential to prevent late mandible fracture. Key Words: Mandibular angle fracture, third molar extraction, complication, mandibular angle osteotectomy

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hinese traditional esthetic view has deemed that women with ovoid and slender faces are beautiful, and mandibular shape is an important factor in facial esthetics. Mandibular angle protrusion results in a wide, square lower face, which is considered to be unattractive. Thus, mandibular angle osteotectomy becomes one of the most popular esthetic facial contouring surgeries in China.1Y3 Because the operation is under general anesthesia, many patients request the third molar to be removed simultaneously. The extraction of mandibular third molars is a common dental procedure. The incidence of complications ranges from 3.47% to 9.1%,4Y7 including hemorrhage, pain, dental or bone fracture, the displacement of teeth or fragments, iatrogenic damage or luxation of the second molar, neurologic injuries, soft tissue damage, subcutaneous emphysema, trismus, swelling, and infection. Mandibular angle fracture associated with third molar removal is a rare but severe complication, From the Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Beijing, China. Received June 25, 2013. Accepted for publication November 13, 2013. Address correspondence and reprint requests to Li Teng, MD, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Beijing, China 100144; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000566

Brief Clinical Studies

which can occur during the procedure or at a later time. Here, we present a case of mandibular angle fracture associated with third molar extraction after mandibular angle osteotectomy. The possible risk factors and ways of prevention are discussed.

CLINICAL REPORT A 20-year-old woman who asked to have her mandibular angle removed was admitted to our department. She was systemically healthy, and a panoramic radiograph revealed the presence of bilateral lower third molars (Fig. 1). Thus, she asked to get the third molars extracted at the same time. The patient was under general anesthesia using nasotracheal intubation, and 0.5% lidocaine with 1:200,000 epinephrine was infiltrated within the operative regions. After that, an intraoral incision was made in the mucous membrane on the labial side 0.5 to 1 cm away from the buccal sulcus, running from the anterior edge of the ascending ramus of the mandible to the second mandibular premolar tooth. Subperiosteal dissection was then performed to expose the ramus and the body of the mandible, and a curved periosteal elevator was used to detach the masseter muscle together with the medial pterygoid muscle from the angle. An elliptical bur was used to reduce the outer cortex thickness of the inferior part of the ramus and the mandible body. A mark line was drawn by a small round bur from the cross point of the posterior margin of the ramus and the occlusion plane to the inferior margin of the mandible body below the second premolar. Finally, an oscillating saw was used to finish the osteotomy. After removal of the bilateral mandibular angle, we started to remove the third molar. The left third molar was extracted smoothly, but a cracking noise was heard during the attempt to luxate the right third molar using a straight elevator between the second and the third molar with a normal application of force. We realized that a fracture must have occurred, and internal fixation with titanium plate and screw was performed immediately. The third molar was removed by forceps, and then a panoramic radiograph was taken, revealing a nondisplaced fracture line extending from the base of the alveolar margin to the lower mandibular border (Fig. 2). Because the occlusion was normal, no intermaxillary fixation was performed. Clinically, the patient showed no limitation or restriction of movement and could open her mouth freely after operation. A 3-day course of antibiotics and an antimicrobial mouthwash were prescribed as usual. A 4-week soft diet and follow-up were recommended. During the follow-up visit, the patient was symptom-free, and the plate was removed half a year after the operation.

DISCUSSION The incidence of intraoperative or postoperative fracture of the mandibular angle after lower third molar surgical removal is approximately 0.05%.8Y11 The risk factors of fractures are multifactorial, including age, sex, dentition status, angulation and impaction of tooth, surgical technique and experience, the relation of the third molar to the inferior alveolar nerve, existence of preoperative infection or bone lesions, systemic diseases, and medication.8Y13

FIGURE 1. Preoperative panoramic radiograph of the patient.

* 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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and axial planes, in turn eliminating the superimposition of anatomic structures.20,24

CONCLUSIONS The extraction of the lower third molar must be before the removal of the mandibular angle, and a soft diet for at least 4 weeks postoperatively is essential to prevent late mandible fracture.

REFERENCES FIGURE 2. Postoperative panoramic radiograph showing a nondisplaced fracture line extending from the base of the alveolar margin to the lower mandibular border.

The presence of local bone lesions is a predisposing risk factor of bone fracture. Even minor changes such as follicular widening or radiolucency around the crown of the third molar can weaken the mandible.9,14,15 Grau-Manclu´s et al16 reported that 81.8% of mandibular fractures were associated with radiotransparent lesions: 2 follicular cysts and 7 dental follicle widenings (2Y4 mm on panoramic radiograph). In our case, removal of the mandibular angle and the outer cortex of the mandible body seriously weakened the mandible and resulted in mandibular fracture even under normal extraction force. Thereby, we regulated our operative plan and concluded that extraction of the lower third molar must be before the removal of the mandibular angle. The relative space occupied by the third molar in relation to mandibular height is also an important factor. One mechanism by which third molars have been hypothesized to increase the risk for angle fractures is by occupying osseous space, thereby weakening the angle region by decreasing the cross-sectional area of bone.17 Fracture risk is increased when the relative portion of the mandible exceeds 50%.18 Wagner et al11 reported on 17 cases and found that the mean ratio was 62%. In the study of Iizuka et al,19 the ratio indicating the space occupied by the third molar in the bone greatly varied from 44% to 84% in panoramic images. Chrcanovic and Custo´dio20 reported 2 cases, and the ratios were 62.4% and 77.4%. On the other hand, the extraction of these teeth usually requires massive bone removal, such as buccal bone, especially along the external oblique ridge, which provides significant strength to the mandibular angle. Its removal weakens the mandible and makes the mandible easy to fracture.21,22 In our case, the removal of the mandibular angle and the outer cortex of the mandible, particularly the external oblique ridge, may contribute to the bone fracture. The postoperative fractures usually occurred within the first 4 weeks and were most frequent in the second and third weeks.8Y15,18Y22 These fractures mostly happened when chewing relatively hard foods.16,21 In this period, the granulation tissue was replaced by connective tissue in the extraction zone. Usually, patients are feeling better at the end of the second week. They can chew normally, thus leading to an increased risk for fracture.16,20 Therefore, a soft diet for at least 4 weeks postoperatively was recommended to all of our patients after mandibular angle osteotectomy, and no late fracture has been found so far. A cracking noise is an important indication of a possible fracture. Ethunandan et al22 reported that 77% of the patients noted a cracking noise at the time of fracture. Adequate clinical and radiologic evaluations are required to establish a correct diagnosis of postoperative mandibular fracture. However, in some cases, the fracture lines are not identifiable on the radiograph taken when the fracture was first suspected.20,23 Because Iizuka et al19 proposed that all fractures that occurred in the early postoperative stage were nondisplaced, the negative radiologic finding did not exclude the possibility of a fracture. In the suspected cases, three-dimensional computed tomography, digital volume tomography, or cone-beam computed tomography may provide additional insight and generate images easily on sagittal, coronal,

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1. Gui L, Yu D, Zhang Z, et al. Intraoral one-stage curved osteotomy for the prominent mandibular angle: a clinical study of 407 cases. Aesthetic Plast Surg 2005;29:552Y557 2. Liu D, Huang J, Shan L, et al. Intraoral curved ostectomy for prominent mandibular angle by grinding, contiguous drilling, and chiseling. J Craniofac Surg 2011;22:2109Y2113 3. Pu Z, Zhang Y, Yang J, et al. Mandibular angle ostectomy for Chinese women: approaches and extent determined by cephalometric analysis. J Craniofac Surg 2009;20:105Y110 4. Muhonen A, Venta¨ I, Ylipaavalniemi P. Factors predisposing to postoperative complications related to wisdom tooth surgery among university students. J Am Coll Health 1997;46:39Y42 5. Chiapasco M, De Cicco L, Marrone G. Side effects and complications associated with third molar surgery. Oral Surg Oral Med Oral Pathol 1993;76:412Y420 6. Bui CH, Seldin EB, Dodson TB. Types, frequencies, and risk factors for complications after third molar extraction. J Oral Maxillofac Surg 2003;61:1379Y1389 7. Contar CM, de Oliveira P, Kanegusuku K, et al. Complications in third molar removal: a retrospective study of 588 patients. Med Oral Patol Oral Cir Bucal 2010;5:e74Ye78 8. Perry PA, Goldberg MH. Late mandibular fracture after third molar surgery: a survey of Connecticut oral and maxillofacial surgeons. J Oral Maxillofac Surg 2000;58:858Y861 9. Krimmel M, Reinert S. Mandibular fracture after third molar removal. J Oral Maxillofac Surg 2000;58:1110Y1112 10. Libersa P, Roze D, Cachart T, et al. Immediate and late mandibular fractures after third molar removal. J Oral Maxillofacial Surg 2002;60:163Y165 11. Wagner KW, Otten JE, Schoen R, et al. Pathological mandibular fractures following third molar removal. Int J Oral Maxillofacial Surg 2005;34:722Y726 12. Cutilli T, Bourelaki T, Scarsella S, et al. Pathological (late) fractures of the mandibular angle after lower third molar removal: a case series. J Med Case Rep 2013;7:121 ¨ z0akir-Tomruk C, Arslan A. Mandibular angle fractures during third 13. O molar removal: a report of two cases. Aust Dent J 2012;57:231Y235 14. Cankaya AB, Erdem MA, Cakarer S, et al. Iatrogenic mandibular fracture associated with third molar removal. Int J Med Sci 2011;8:547Y553 15. Tieghi R, Consorti G, Clauser LC. Patholologic fracture of the mandible after removal of follicular cyst. J Craniofac Surg 2011;22:1779Y1780 16. Grau-Manclu´s V, Gargallo-Albiol J, Almendros-Marque´s N, et al. Mandibular fractures related to the surgical extraction of impacted lower third molars: a report of 11 cases. J Oral Maxillofac Surg 2011;69:1286Y1290 17. Hanson BP, Cummings P, Rivara FP, et al. The association of third molars with mandibular angle fractures: a meta-analysis. J Can Dent Assoc 2004;70:39Y43 18. Bodner L, Brennan PA, McLeod NM. Characteristics of iatrogenic mandibular fractures associated with tooth removal: review and analysis of 189 cases. Br J Oral Maxillofac Surg 2011;49: 567Y572 19. Iizuka T, Tanner S, Berthold H. Mandibular fractures following third molar extraction. A retrospective clinical and radiological study. Int J Oral Maxillofac Surg 1997;26:338Y343 20. Chrcanovic BR, Custo´dio AL. Considerations of mandibular angle fractures during and after surgery for removal of third molars: a review of the literature. Oral Maxillofac Surg 2010;14:71Y80

* 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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21. Boffano P, Roccia F, Gallesio C, et al. Pathological mandibular fractures: a review of the literature of the last two decades. Dent Traumatol 2013;29:185Y196 22. Ethunandan M, Shanahan D, Patel M. Iatrogenic mandibular fractures following removal of impacted third molars: an analysis of 130 cases. Br Dent J 2012;212:179Y184 23. De Silva BG. Spontaneous fracture of the mandible following third molar removal. Br Dent J 1984;156:19Y20 24. Sever C, Kulahci Y, Uygur F, et al. Unusual split fracture of the mandible. J Craniofac Surg 2011;22:e10Ye11

A Rare Cause of Unilateral Parotid Gland Swelling: Compensatory Hypertrophy Due to the Aplasia of the Contralateral Parotid Gland Hediye Pinar Gu¨nbey, MD,* Emre Gu¨nbey, MD,Þ Fatma Tayfun, MD,þ Selda Kargin Kaytez, MD§ Abstract: In this clinical report, 3 cases, admitted to the ears, nose, throat outpatient clinic with the complaints of unilateral swelling in the parotid region and facial asymmetry, are presented. In the etiology, contralateral parotid gland aplasia with compensatory hypertrophy and sialosis was detected. With this rare condition, clinical and radiological features of this anomaly are discussed. Key Words: Parotid aplasia, sialadenosis, parotid gland masses

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n the patients presenting with parotid region swelling, inflammatory and tumoral lesions first come to mind. Also, a rare cause of such a complaint is the contralateral aplasia of the parotid gland associated with facial asymmetry caused by unilateral parotid gland hypertrophy.1 Parotid gland aplasia is a very rare condition reported in a few cases in the literature. Congenital aplasia of the parotid gland may be alone as well as may be associated with other salivary gland abnormalities.1,2 It may be unilateral or bilateral and may be accompanied by numerous congenital anomalies.3,4 The patients with parotid gland aplasia also can present with a number of xerostomia symptoms such as dental problems.5 In this clinical report, 3 cases, who presented to an ears, nose, throat (ENT) outpatient clinic with complaints of unilateral swelling in the parotid region and facial asymmetry, are reported. In the etiology,

From the *Department of Radiology, Samsun Training and Research Hospital; and †Department of Otorhinolaryngology, Ondokuz Mayis University School of Medicine, Samsun; and Departments of ‡Radiology and §Otolaryngology, C ¸ ankiri State Hospital, C ¸ ankiri, Turkey. Received October 7, 2013. Accepted for publication December 2, 2013. Address correspondence and reprint requests to Emre Gu¨nbey, MD, Department of Otorhinolaryngology, Ondokuz Mayis University School of Medicine, Kurupelit, Samsun, Turkey 55139; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000629

Brief Clinical Studies

contralateral parotid gland aplasia and compensatory hypertrophy and sialosis were detected. Herein, with this rare condition, clinical and radiological features of this rare anomaly are reviewed.

CLINICAL REPORT Patient 1 A 45-year-old female patient presented with a 3-month history of a swelling in the left side of her face. In the last 2 years, there were increasing complaints of xerostomia. There was no history of systemic disease or drug use. Her physical examination revealed a painless swelling in the left parotid gland. However, there was not a palpable mass lesion. Intraoral examination revealed a clear left Stensen duct papilla, but the right papilla was not observed. Oral mucosa was dry, and oral hygiene was disturbed. The other otorhinolaryngologic examination was unremarkable. First, a neck ultrasonography (USG) was performed. Ultrasonography revealed a hypertrophic left parotid gland and aplasia of the right parotid gland. To detect the possible accompanying anomalies, a magnetic resonance imaging (MRI) including axial spin echo T1-weighted, T1-weighted with contrast medium, T1-weighted (STIR [short tau inversion recovery]) with fat suppression, and T2-weighted sequences was then performed. Magnetic resonance imaging revealed a complete aplasia of both the right parotid gland and Stensen duct. There was a homogen hypertrophy on the left parotid gland (Figs. 1A, B). There was no other anomaly. Hydration was recommended to the patient, and moisturizing gels were prescribed.

Patient 2 A 52-year-old female patient presented to the ENT outpatient clinic with complaints of swelling in the right side of his face. Her medical history was unremarkable. Physical examination revealed a painless swelling in the right parotid region, but there was no palpable mass. Other ENT examination findings and oral hygiene were normal. The neck USG revealed aplasia of the right parotid gland. To confirm the diagnosis and to determine other possible accompanying anomalies, a contrast neck MRI was then performed. Magnetic resonance imaging revealed a complete aplasia of the left parotid gland and Stensen duct. There was homogeny hypertrophy on the right parotid gland (Figs. 2A, B). Follow-up was recommended to the patient without any medical treatment.

Patient 3 A 63-year-old male patient presented to the ENT outpatient clinic with a 6-month history of swelling under the right ear. In his previously obtained cranial MRI scan, which was requested by the Neurology Clinic to investigate the etiology of headache, the left parotid gland was not observed within the sections. Then, a neck USG and MRI were performed. On his neck USG and neck MRI, there was no anomaly except left parotid gland and Stensen duct aplasia and

FIGURE 1. Axial T1-weighted MRI scan at the level of the angle of the mandible (A) and coronal STIR-weighted MRI scan (B) show the absence of the right parotid gland and hypertrophy of left the side (arrows).

* 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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Iatrogenic mandibular fracture associated with third molar removal after mandibular angle osteotectomy.

The extraction of mandibular third molars is a common dental procedure. The complications include hemorrhage, pain, dental fracture, the displacement ...
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