Pathological mandibular fractures: a review of the literature of the last two decades

Full life cycle changes of low impacted mandibular third molar associated cystic lesions and adjacent tooth root resorption: a retrospective study

OBJECTIVE

Low impacted third molars are usually asymptomatic and are often found by X-ray examination. The removal of asymptomatic low impacted third molars is one of the most controversial clinical issues in oral and maxillofacial surgery.

METHODS

In this study, 806 patients with low impacted mandibular third molars (LIMTMs) (full bony impaction) were analyzed to determine the prevalence and risk factors for cystic lesions and adjacent tooth root resorption throughout the patients' entire life cycle.

RESULTS

The results showed that the prevalence of adjacent tooth root resorption and cystic lesions was age-related, exhibiting a trend of first increasing and then decreasing; prevalence peaked at the age of 41 to 45 years old, the prevalence rates were 12.50% and 11.11% respectively. And the lowest prevalence rate was 2.86% and 2.44% in ≥ 61 group and 56- to 60-year age group respectively. Age was an independent risk factor for adjacent tooth root resorption of LIMTMs, whereas age and impaction type (especially inverted impaction) were independent risk factors for cystic lesions.

CONCLUSIONS

The full life cycle management strategy for LIMTMs may need to be individualized. Surgical removal is recommended for LIMTMs in patients younger than 41 to 45 years, especially for inverted, mesioangular, and horizontally impacted LIMTMs. LIMTMs in patients older than 41 to 45 years may be treated conservatively with regular follow-up, but surgical removal of inverted impacted LIMTMs is still recommended to avoid cyst formation.

Influence of COVID-19 pandemic on mandible fracture patterns in a German cranio-maxillofacial trauma center: PreCOVID (2019) versus IntraCOVID (2020)

BACKGROUND/AIMS

The COVID-19 (Coronavirus Disease-2019) pandemic confronted the global healthcare system with a variety of challenges. The pandemic and the associated lockdowns also had an impact on multiple medical disciplines (i.e. delay of surgery, change of hospital admissions). The aim of this study was to analyze the impact of the COVID-19 pandemic on mandible fracture patterns/distributions and circumstances in a German cranio-maxillofacial trauma center.

MATERIALS AND METHODS

This retrospective study compared the mandible fracture patterns of patients in the PreCOVID (PC) era (February 2019-January 2020) with patients in the IntraCOVID (IC) era (February 2020-January 2021). In addition to baseline characteristics, the number/type of mandible fractures, location of the mandible fracture, circumstances leading to mandible fracture, and hospital admissions/treatments were analyzed.

RESULTS

A total of 127 patients was included in this study. In the IC period, the absolute frequencies of mandible fractures decreased (PC = 72 vs. IC = 55). There were minor changes in the mandible fracture locations. An increase of concomitant facial soft tissue injuries (IC = 69.1% vs. PC = 58.3%), as well as higher rates of traumatic tooth loss (IC = 32.7% vs. PC = 22.2%), was observed. Regarding the causes/accidents leading to mandible fractures, there were significant increases in falls and significant decreases in sports accidents as well as interpersonal violence during the IC period. A significant increase in accidents at home and domestic violence during the COVID-19 pandemic, with a simultaneous decrease in weekend and night-time trauma leading to mandible fractures was observed. Furthermore, a significant increase in days from trauma to surgery was recorded.

CONCLUSION

The COVID-19 pandemic had a significant impact on mandibular fracture patterns. The locations and types of mandibular fractures changed slightly. However, significant differences in the circumstances leading to mandible fractures (increased falls, decreased interpersonal violence) were recorded.

Spontaneous Recovery of Pathological Fracture Caused by Medication-Related Osteonecrosis of the Jaw

Pathological fracture is one of the most serious complications in medication-related osteonecrosis of the jaw (MRONJ). This case is a report of an 87-year-old woman who had been diagnosed with pathological fracture due to MRONJ. The authors performed minimally invasive and conservative treatment, such as intraoral dressing, antibiotic therapy, and simple debridement, for patients with pathologic fractures due to MRONJ. After 1 year, the inflammatory symptoms disappeared and pathological fractures spontaneously recovered.

Accidental Intraoperative Mandibular Fracture in a Third Molar Surgery: When Surgical Skills Are Mandatory in the Face of Empiricism

Iatrogenic mandible fractures are rare complications from third molar removal surgeries. While most documented cases stress risk factors inherent to the patient and tooth presentation in fractures' etiology, appreciation of the risk factors underlying the practitioner's skills is scarce. Here, we describe an intraoperative fracture in a healthy 26-year-old female resulting from an incompatible surgical technique during the right mandibular third molar removal. The patient showed facial swelling, pain, malocclusion, and significant mobility of the fractured segment. The surgical management involved an intraoral open reduction with the installation of titanium plates for the fixation of the bone segments. Thus, we highlight that acknowledging the extent of the operator's surgical skills should be part of comprehensive treatment planning, serving as a valuable measure to prevent iatrogenic mandible fractures besides avoiding a traumatic experience for the patient.

Incorporating Moldable Demineralized Dentin Matrix into Treatment for a Jaw Cyst

The enucleation procedure is a standard treatment for jaw cysts; however, it often results in post-operative bony defects. These defects can lead to serious complications such as the risk of pathologic fracture and delayed wound healing, especially in the case of large cysts where there may be soft tissue dehiscence. Even in the case of smaller cysts, most cystic defects remain visible on postoperative radiographs and can be mistaken for cyst recurrence during follow-up periods. To avoid such complications, the use of bone graft materials should be considered. While autogenous bone is the most ideal graft material as it can be regenerated into functional bone, it has limitations due to the inevitable harvesting surgery. Many tissue engineering studies have been conducted to develop substitutes for autogenous bone. One such material is moldable-demineralized dentin matrix (M-DDM), which can aid in regeneration in cases of cystic defects. This case report highlights a patient who demonstrated the efficacy of M-DDM in bone healing for filling the cystic defect.

Tooth in the line of a mandibular fracture: Retain it or remove it? Clinical case report

Defining the prognosis and treatment plan for teeth in the line of a mandibular fracture is a challenge for the maxillofacial surgeon. The periodontal ligament may provide a communication with the oral cavity and become a pathway for infection. There is currently no consensus on the management of teeth in mandibular fracture lines. This report outlines a case where a tooth was successfully retained in the line of fracture as well as providing a review of the literature on the best-accepted treatments for this scenario.

Volumetric analysis of spontaneous bone healing after jaw cyst enucleation

The purpose of this study is to evaluate the degree of spontaneous bone healing after cyst enucleation as well as its contributing factors. Pre- and post-operative computed tomography (CT) scans of consecutive patients who had undergone jaw cyst enucleation were retrospectively analyzed. The outcome variable was healing ratio, which was calculated using the volume of the cyst before surgery and the volume of the defect in the bone after surgery. Predictor variables including duration of observation, pre-operative cyst size, age, gender, and involved jaw were analyzed to determine their influence. Forty-four subjects (30 Male and 14 Female, average 40.7 ± 15.7 years) were included in this study. Healing ratio was significantly lower during the first year (33.5 ± 32.8%) compared to the second (74.5 ± 24.2%) and subsequent years (74.2 ± 17.8%). In 35 patients who had follow-ups of over 1 year, the healing ratio was not affected by the pre-operative cyst size and upper/lower jaw except gender (p = 0.037, female > male) and age (p = 0.021, younger than 30 years > 30 years and older). The residual defect was significant larger in cysts 3 cc or larger (1.64 ± 1.54 cc) compared to smaller cysts (0.43 ± 0.42 cc, p = 0.006). The residual defect volume of large cysts was similar to those of the pre-operative volume of small cysts (1.47 ± 0.72 cc). In conclusion, spontaneous bone healing ratio of post-enucleation defects was about 73.5% after 12 months. Large cysts (> 3 cc) had larger defect, comparable to the volume of small cysts, but with altered contour. Additional treatment such as a bone graft may be considered especially in large cysts.

Prediction models for early diagnosis of actinomycotic osteomyelitis of the jaw using machine learning techniques: a preliminary study

BACKGROUND

This study aimed to develop and validate five machine learning models designed to predict actinomycotic osteomyelitis of the jaw. Furthermore, this study determined the relative importance of the predictive variables for actinomycotic osteomyelitis of the jaw, which are crucial for clinical decision-making.

METHODS

A total of 222 patients with osteomyelitis of the jaw were analyzed, and Actinomyces were identified in 70 cases (31.5%). Logistic regression, random forest, support vector machine, artificial neural network, and extreme gradient boosting machine learning methods were used to train the models. The models were subsequently validated using testing datasets. These models were compared with each other and also with single predictors, such as age, using area under the receiver operating characteristic (ROC) curve (AUC).

RESULTS

The AUC of the machine learning models ranged from 0.81 to 0.88. The performance of the machine learning models, such as random forest, support vector machine and extreme gradient boosting was significantly superior to that of single predictors. Presumed causes, antiresorptive agents, age, malignancy, hypertension, and rheumatoid arthritis were the six features that were identified as relevant predictors.

CONCLUSIONS

This prediction model would improve the overall patient care by enhancing prognosis counseling and informing treatment decisions for high-risk groups of actinomycotic osteomyelitis of the jaw.

Minimally Invasive Two-Staged Surgery in the Treatment of Large Cystic Lesions of the Jaw

Background: Cystic lesions of the jaw are commonly found in clinical practice. Large, expansive cysts raise challenges for the clinician from both diagnostic and surgical perspectives. The aim of our work is to present a combined, two-staged surgical approach in histologically confirmed non-aggressive cystic lesions of the jaw. Methods and Results: We report the case of an extensive mandibular cyst, associating a high risk of bone fracture, that is treated in the initial stage by cystic decompression through marsupialization with concomitant histological diagnostic confirmation, followed in the second stage by radical excision and mandibular reconstruction with titanium mesh, with the purpose of prevention for oro-cystic chronic fistula formation. Conclusions: Large odontogenic mandibular cysts imply a meticulously conducted assessment and treatment. Marsupialization should be taken into consideration for the treatment of large cystic lesions, followed by secondary enucleation, with minimal risks for the patient. The soft tissue healing process can be optimized with the use of titanium meshes, as an alternative for other reconstructive techniques, in the management of large cystic lesions.

Reconstruction of a pathologic fracture following osteomyelitis of the mandible using a fibula osteocutaneous flap

The use of a fibula osteocutaneous flap is currently the mainstay of segmental mandibular reconstruction. This type of flap is used to treat tumors, trauma, or osteoradionecrosis of the mandible. However, a fibula osteocutaneous flap may also be a good option for reconstructing the mandible to preserve oropharyngeal function and facial appearance in cases of pathological fracture requiring extensive segmental bone resection. Chronic osteomyelitis is one of the various causes of subsequent pathologic mandibular fractures; however, it is rare, and there have been few reports using free flaps in osteomyelitis of the mandible. We share our experience with a 76-year-old patient who presented with a pathologic fracture following osteomyelitis of the mandible that was reconstructed using a fibula osteocutaneous flap after wide segmental resection.

Complications of Dentoalveolar Surgery

This article explores how to prevent and manage complications of dentoalveolar surgery. Many complications are avoidable. Surgical skills and knowledge of anatomy play an important role in prevention of complications. Prevention starts with detailed history and physical examination of the patient. Key to perioperative management of patients is risk assessment. Without a proper history and physical examination, the clinician is unable to assess the risk of performing surgery and anesthesia for each patient. Some illnesses and medications increase the risk of complications. The following complications are discussed: alveolar osteitis, displacement, fracture, hemorrhage, infection, nonhealing wound, oroantral communication, swelling, and trismus.

Mandibular Fracture as First Sign of an Occult Intraosseous Hemangioma

Intraosseous hemangioma (IH) in the maxillofacial area is a very uncommon neoplasm. Here, the authors show an exceptional case not previously reported in the literature of a 65-year-old man who presented with a pathological mandibular fracture following a facial trauma that was the first sign of an occult cavernous IH. Complete excision of the tumor in the mandibular ramus reduced the risk of severe bleeding and prevented long-term recurrence, whereas immobilization of the fracture obtained an excellent functional result. This clinical report highlights the possibility that a previously unknown primary IH may debut as a pathological fracture and the importance of differential diagnosis in this location.

Osteoradionecrosis of the jaws triggered by dental implants placement: A case report

Background

The decision-making process about how to rehabilitate edentulous osseous defects in patients with head and neck cancer history can be complex. Even though, endosseous dental implants could be considered to be the first choice for treating these patients, it is highly important to be aware of the complications that might occur. The aim of this report was to describe the clinical features of mandibular fracture after dental implants placement on a cancer irradiated patient and update the available information about this event.

Case report

The case describes a 70-year-old man, with medical background of radiotherapy in jaw bones to treat a carcinoma in the floor of the mouth and later on in the soft palate and cheek. One week after dental implant surgery, the patient presented a mandibular osteoradionecrosis that healed in 8 months. A fracture on the right side of the body mandible was diagnosed one year after implant placement. Although several options were suggested in order to repair the fracture, the patient did not accept any further treatment despite the callus formation not being radiographically evident. The implant-supported prosthesis is functionally useful for more than 8 years of follow-up without significant problems.

Conclusions

The implant treatment and management of oncologic irradiated patients require special considerations due to the risk of osteoradionecrosis and its possible complications, such as pathologic fracture. It is necessary to provide full information to the patient about risk factors and complications.

Key words:Dental implants, mandibular fracture, osteoradionecrosis jaw, complications, fracture, cancer.

Case Report and Literature Review of a Pathologic Mandibular Fracture from Metastatic Esophageal Adenocarcinoma

Distant metastasis to the jaws, including the maxilla or mandible, is very rare. Although the mandible is the preferred sight of these rare metastases, it is extremely rare for oral cavity malignancies to present as pathological mandibular fractures. Here, we present a case of esophageal adenocarcinoma metastasizing to the mandible, and the first reported case presenting with a pathological mandibular fracture secondary to esophageal adenocarcinoma. We also review the 9 other reported cases of metastatic esophageal adenocarcinoma to either the maxilla or mandible.

Mandibular Body Fracture during Inferior Alveolar Nerve Transposition: Review of Literature

Inferior alveolar nerve transposition is a useful adjunctive surgery in implant dentistry when there is insufficient bone between the ridge crest and the inferior dental canal. However, if this surgery is done carelessly, complications such as mandibular fracture and permanent lower lip numbness can occur. This article reports the first case of bilateral mandibular body fracture occurring during inferior alveolar nerve transposition. The surgical management of a complicated bilateral displaced mandibular body fracture is explained herein. A literature review of mandibular fracture after inferior alveolar nerve transposition is also presented. Adhering to the principles of fracture, treatment is mandatory for the successful management of mandibular fracture after inferior alveolar nerve transposition.

Pathological fracture of the mandible caused by radicular cyst: A case report and literature review

RATIONALE

Pathological fracture of the mandible caused by radicular cyst is rare. This report describes a unique case of a mandibular pathological fracture caused by radicular cyst, arising from an endodontically treated molar.

PATIENT CONCERN

A 49-year-old female was referred to our department with persistent pain in left mandibular angle, accompanying with restricted mouth opening and malocclusion.

DIAGNOSE

An orthopantomograph (OPG) showed a unilocular lesion with a relatively well-defined border, and the lesion was associated with a fracture in the inferior border of the mandible.

INTERVENTION

This patient was treated through curettage of the cyst combined with open reduction and internal fixation of the fracture.

OUTCOMES

At the 1-year follow-up visit, the patient did not have any complaints, and the radiographs indicated the consolidation of the fracture without recurrence of cyst.

LESSONS

This case report highlights the routine follow-up of endodontically treated teeth in order to check for apical healing and detect the cystic change at early stages.

Chronic invasive fungal sinusitis causing a pathologic Le Fort I fracture in an immunocompetent patient

We describe the case of a 77-year-old immunocompetent woman with a history of chronic rhinosinusitis who presented with a pathologic Le Fort I fracture after a forceful sneeze. Imaging revealed diffuse sinus opacification and a Le Fort type I complex fracture involving the maxilla, pterygoid plates, clivus, and right nasal bridge. The patient underwent endoscopic debridement of her sinuses, which revealed mucosal dehiscence and otherwise normal healthy bleeding tissue. Anatomic pathology identified necrotic bone with invasive fungal hyphae. Cultures demonstrated Burkholderia cepacia, diphtheroid organisms, and Enterococcus and Serratia spp. The patient was administered an intravenous antibiotic and antifungal for several months, but interval imaging found no significant improvement in bone healing although the stability of her palate had improved on clinical examination. Chronic rhinosinusitis has been found to be a complication of soft-tissue, orbital, and intracranial infections but, to the best of our knowledge, a pathologic facial fracture secondary to chronic invasive fungal and bacterial rhinosinusitis has not been previously reported in the literature.

Deep head and neck infection causing pathological fracture of the mandibular condyle

We report an unusual case of a 46-year-old male with a severe deep head and neck infection after extraction of two mandibular molars that led to a potentially life-threatening condition and caused pathological fracture of the mandibular condyle. This is the first published spontaneous pathological fracture of the mandibular condyle caused by an infection spread from a lower molar tooth. Based on CT scan we discuss the pathways of infection of odontogenic origin and the reflections of treatment. This case report illustrates an unusual presentation of a spontaneous pathological condylar fracture caused by a severe life-threatening infection after tooth extraction. It details the examination and management of the patient and reflections about the treatment.

A 5-year perspective on a removable overdenture appliance for a patient with osteonecrosis of the jaw, a mandibular resection, and rampant caries

A 78-year-old man with a history osteonecrosis of the jaw and 2 subsequent surgeries to repair a fractured mandible had a condition that contraindicates most dentoalveolar procedures to restore his failing dentition. A Snap-On-Smile overdenture restored his opportunity for natural speech, occlusal function, and esthetics.

Spontaneous fractures of the mandible concept & treatment strategy

Background

Spontaneous fractures of the mandible dispose a surgical challenge in comparisons to fractures caused by trauma due to several complicating factors. Additionally: controversies exist concerning the terminology of the field.

Material and Methods

We conducted a retrospective study of all patients with mandibular fractures, with exclusion of fractures of the coronoid process and the alveolar process, treated at the Department of Oral and Maxillofacial Surgery, Aalborg University Hospital, Denmark between February 2003 and February 2013. Data collected from the medical records included sex, age, cause of fracture, site of fracture, and treatment.

Results

We identified 517 patients with 684 mandible fractures. Twenty-five of these were spontaneous fractures and 659 fractures were of traumatic origin. Condylar fractures rarely occur spontaneously, but constitute the majority of the traumatic fractures. Excluding these fractures from the analysis, we found a non-surgical approach in 14 of 24 (58%) of the spontaneous fractures and 110 of 376 (29%) of the traumatic fractures. This was statistically significant.

Conclusions

We found a statistical significant difference in favor of non-surgical approach in spontaneous fractures and we discussed the treatment challenges of these fractures. We addressed the terminological controversies regarding pathological fractures, and suggested the term spontaneous fractures denoting a fracture occurring during normal jaw function being either pathological or non-pathological.

Key words:Mandibular fractures, spontaneous fractures, pathological fractures, traumatic fractures, treatment.

Mandibular Fracture Associated with a Dentigerous Cyst: Report of a Case and Literature Review

Background and aims. Pathological fractures are rare in the maxillofacial region and account for less than 2% of all fractures in this site. They are defined as fractures that take place when bone has been weakened by an underlying pathologic process. Among all pathoses, cysts (although so common in the maxillofacial region) constitute a very small part. Here we report a case of a dentigerous cyst in a 38-year-old man.The cyst was associated with a mandibular second premolar tooth and resulted in a pathologic fracture. Excision of the lesion was performed and bony union was observed after 6 months. In the literature review, only one case of dentigerous cyst causing pathologic fracture was found. In addition to the report of the present case, pathologic fractures associated with all types of odontogenic cysts (totally just 12 cases) are reviewed in this article to provide a comprehensive and detailed collection.

Treatment of pathologic fracture following postoperative radiation therapy: clinical study

Background

Pathologic fractures are caused by diseases that lead to weakness of the bone structure. This process sometimes occurs owing to bony change after radiation therapy. Treatment of pathologic fractures may be difficult because of previous radiation therapy.

Methods

In this study, we analyzed clinical and radiographic data and progress of five patients with mandibular pathological fractures who had received postoperative radiation therapy following cancer surgery.

Result

Patients received an average radiation dose of 59.2 (SD, 7.2) Gy. Four of five patients exhibited bone union regardless of whether open reduction and internal fixation (OR/IF) was performed. Patients have the potential to heal after postoperative radiation therapy. Treatment of a pathologic fracture following postoperative radiation therapy, such as traditional treatment for other types of fractures, may be performed using OR/IF or CR. OR/IF may be selected in cases of significant bone deviation, small remaining bone volume, or occlusive change.

Conclusion

Patients have the potential to heal after postoperative radiation therapy.

Fatal Progression of Gorham Disease: A Case Report and Review of the Literature

Gorham disease is an idiopathic massive osteolysis, and maxillofacial involvement is rare. This report describes a case of a 12-year-old boy with severe progressive osteolysis in the mandible, hyoid bone, mastoid process, and cervical spine. Radiation therapy and interferon-α therapy were followed by bisphosphonate therapy. The patient died of respiratory failure. To describe the clinicopathologic features of Gorham disease of the jaws with an emphasis on the fatal types, 64 cases in the literature were reviewed (female-to-male ratio, 1:1.78; average age, 33.02 ± 19.38 yr). Most lesions were located only in the mandible or in other locations in combination with the mandible, except for 3 cases. During follow-up, there were 7 cases of disease-specific death, resulting in a mortality rate of 10.94%. The main causes of death were chylothorax, rib fractures secondary to osteolysis, or spinal fractures. Although most patients received surgical treatment (43.75%), the type of treatment was not related to prognosis.

Mandibular trauma treatment: a comparison of two protocols

Objectives: The aim of this study was to evaluate the treatment of mandibular fractures treated in two European centre in 10 years. Study Design: This study is based on 2 systematic computer-assisted databases that have continuously recorded patients hospitalized with maxillofacial fractures in two centers in Turin, Italy and in Amsterdam, the Netherlands for ten years. Only patients who were admitted for mandibular fractures were considered for this study. Results: Between 2001 and 2010, a total of 752 patients were admitted at Turin hospital with a total of 1167 mandibular fractures not associated with further maxillofacial fractures, whereas 245 patients were admitted at Amsterdam hospital with a total of 434 mandibular fractures. At Amsterdam center, a total of 457 plates (1.5 - 2.7 mm) were used for the 434 mandibular fracture lines, whereas at Turin center 1232 plates (1.5 – 2.5 mm) were used for the management of the 1167 mandibular fracture lines. At Turin center, 190 patients were treated primarily with IMF, whereas 35 patients were treated with such treatment option at Amsterdam center. Conclusions: Current protocols for the management of mandibular fractures are quite efficient. It is difficult to obtain a uniform protocol, because of the difference of course of each occurring fracture and because of surgeons’ experiences and preferences. Several techniques can still be used for each peculiar fracture of the mandible.

Key words:Mandibular fracture, facial trauma, maxillofacial, treatment, multicentre, database.

Chronic osteomyelitis of the mandible: diagnosis and management--an institution's experience over 7 years

PURPOSE

The objective of this study was to retrospectively evaluate and report the associated factors with the diagnosis and management of 24 patients with chronic osteomyelitis of the mandible seen at the authors' institution during the past several years.

PATIENTS AND METHODS

Only cases of chronic osteomyelitis of the mandible not associated with antiresorptive medications or radiotherapy to the maxillofacial region were included in the study. After confirmation of the diagnosis, initial clinical and radiologic findings, treatment approach, and outcome were evaluated for each patient. Fourteen male and 10 female patients (average age, 53.75 yr; range, 22 to 83 yr) were included.

RESULTS

The peak incidence of the disease was recorded in the fifth and sixth decades of life. An uneventful healing was observed in 20 patients (83.3%). One of 18 patients (5.5%) who underwent segmental resections developed a secondary infection and was managed with intravenously administered antibiotics. Three of 6 patients (50%) who were treated with marginal resections remained symptomatic after surgery.

CONCLUSION

Independent of the cause and presentation of the disease, complete resolution of the infection should be the main focus of management in patients with chronic osteomyelitis of the mandible, and findings of this retrospective study indicate that a conservative surgical approach is more likely to result in a less than ideal outcome.

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 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.