Journal of Cranio-Maxillo-Facial Surgery xxx (2018) 1e8

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Review

Association between third molar and mandibular angle fracture:

A systematic review and meta-analysis
Francesco Giovacchini a, Daniele Paradiso b, Caterina Bensi c, *, Stefano Belli c,
Giuseppe Lomurno b, c, Antonio Tullio a, d
a
Maxillo-Facial Surgery Unit, S. Maria della Misericordia Hospital, Piazza Menghini 1, San Sisto, Perugia, Italy
b
S.S.D. of Oral Surgery and Ambulatory, S. Maria della Misericordia Hospital, Piazza Menghini 1, San Sisto, Perugia, Italy
c
Department of Surgical and Biomedical Sciences, University of Perugia, Piazza Gambuli 1, San Sisto, Perugia, Italy
d
Maxillo-Facial Surgery Chief, University of Perugia, Piazza Gambuli 1, San Sisto, Perugia, Italy

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: The aim of this study was to investigate the risk of mandibular angle fracture associated with
Paper received 9 May 2017 the presence of a mandibular third molar and its position when the mandibular fracture occurs.
Accepted 14 December 2017 Methods: A systematic literary search was performed in Pubmed, Scopus, and the Cochrane Library for
Available online xxx
observational studies with at least 250 patients that included frequency of mandibular angle fracture,
presence of third molar, and its position.
Keywords:
Results: A total of seven studies were included in the review, from an initial search of 622 titles. The
Third molar
relative risk of mandibular angle fracture with third molar was 1.90 (95% CI ¼ 1.47e2.46). The relative
Mandibular angle fracture
Risk of fracture
risk of mandibular angle fracture related to third molar position (according to the Pell and Gregory
Pell and Gregory classification classification) was 1.18 (95% CI ¼ 0.62e2.25), 1.98 (95% CI ¼ 0.95e4.10), 2.72 (95% CI ¼ 1.78e4.16), 1.31
Meta-analysis (95% CI ¼ 0.80e2.14), 2.21 (95% CI ¼ 1.69e2.87) and 2.99 (95% CI ¼ 2.12e4.22) for Class A, Class B, Class C,
Class I, Class II, and Class III, respectively.
Conclusions: Our meta-analysis reported a two-fold increased risk of mandibular angle fracture with the
presence of a third molar in patients who presented with mandibular fractures. Even the third molar
position seemed to influence mandibular angle fracture, especially Class C, Class II, and Class III.
© 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.

1. Introduction muscles of mastication, the occlusal loading pattern, the exact

The mandible is the strongest and most rigid bone of the facial
skeleton, however, this region is more commonly fractured than
the other facial bones (Patil, 2012) accounting for 40e65% of all
facial fractures (Yadav et al., 2013); this is related to its prominence
and exposure to traumatic situations (Banks, 1991). The estimated
incidence of mandibular fracture is 11.5 cases per 10 000 in-
dividuals (Bezerra et al., 2011).
The mandibular angle is a frequent site of fracture, account-
ing for 25e33% of all mandibular fracture (Boffano and Roccia,
2010).
There are several variables that can influence this kind of
fracture, such as osseous anatomy, the forces exerted by the
* Corresponding author.
E-mail address: caterina.bensi@studenti.unipg.it (C. Bensi).
point of application, and the direction and severity of
the impact force, which plays an important role in determining
the side of fracture (Ma'aita and Alwrikat, 2000; Menon et al.,
2016).
Huelke et al. (Huelke et al., 1961; Huelke, 1964) reported that
mandibular fractures occur more frequently in dentate rather
than in edentulous regions of the mandible. Heulke, together
with Dodson (1997), described how bones fracture at sites of
tensile strain, because their resistance to compressive forces is
greater. Furthermore, Heulke (Huelke, 1964) pointed out that
the isolated mandible is liable to particular patterns of distri-
bution of tensile strain when forces are applied to it. Hagan and
Huelke (Hagan and Huelke, 1961) were responsible for detailing
the site of the injuring force from which clear-cut patterns
emerged, namely that the condylar region was the most com-
mon site of fracture, and that the angle was the second most
common site, but if only one fracture occurs. The lingual surface

https://doi.org/10.1016/j.jcms.2017.12.011
1010-5182/© 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Giovacchini F, et al., Association between third molar and mandibular angle fracture: A systematic review and
meta-analysis, Journal of Cranio-Maxillo-Facial Surgery (2018), https://doi.org/10.1016/j.jcms.2017.12.011
2 F. Giovacchini et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2018) 1e8
of the mandible in the region of the second and third molars is
one site of maximum tensile strain resulting from anterolateral
application of force on the same side. The abrupt curve in the
region of the angle is responsible for the weakness here. The
strength of the mandibular body in the area of the third molar
lies in the upper border, as evidenced by the thickness of the
cortical plate (Bradley, 1975). The presence of a partially erup-
ted or an unerupted tooth occupying a space that would
otherwise contribute materially to the strength of the mandible,
weakens this area.
An experimental study conducted on monkey mandibles
concluded that mandibles with unerupted third molars frac-
tured at about 60% of the force necessary to fracture mandibles
without third molars (Reitzik et al., 1978; Revanth Kumar et al.,
2015). The postulated theory in the above study affirmed that
the bone space occupied by the third molar makes the angle
region weaker and prone to fracture, and that deeper localiza-
tion of the third molar would increase the risk of mandibular
angle fracture (Antic et al., 2016a). Previous studies reported a
twoethreefold increased risk of angle fracture and a concomi-
tant reduction in the incidence of mandibular condylar fracture
with impacted third molar (Thangavelu et al., 2010). Bezerra
et al. (2011) noticed that traumatic impacts of lower intensity
resulted more frequently in mandibular angle fractures, espe-
cially with the presence of a third molar. However, Ugboko et al.
(2000) reported a low prevalence of angle fracture related to
third molar presence when the etiological factor was traffic
accident, in which there was transmission of high amount of
energy to the impact site.
A further study reported that third molar with a single
conical root showed significant association with angle fractures;
this was probably related to the concentrated stress around the
single root apex overcoming the bone strength (Antic et al.,
2016a).
Some authors have suggested prophylactic removal of the
third molar, especially in people involved in contact sports
(Hanson et al., 2004), in order to prevent mandibular angle
fracture. However, this kind of approach has not been
commonly accepted (Yamada et al., 1998; Antic et al., 2016b) e
other studies have reported that the absence of a third molar
was related to an increased risk of condylar fractures (Antic
et al., 2016a; Choi et al., 2011).
The aim of our meta-analysis was to systematically analyse the
relationship between mandibular angle fracture and the presence
of a third molar, and to study how its position can influence the
type of fracture.
2. Materials and methods
A systematic review protocol was performed according to the
PRISMA (Preferred.Reporting Items Systematic reviews and Meta-
Analyses) statement (Moher et al., 2009).
2.1. Focused question
The focused question was: Is the presence of a third molar
associated with an increased risk of mandibular angle fracture?
2.2. Eligibility criteria
Observational human studies in patients with mandibular angle
fracture, reporting data about the presence of a third molar and its
position, were considered eligible.
The inclusion criteria were as follows:
Please cite this article in press as: Giovacchini F, et al., Association between third molar and mandibular angle fracture: A systematic review and
meta-analysis, Journal of Cranio-Maxillo-Facial Surgery (2018), https://doi.org/10.1016/j.jcms.2017.12.011
 Study design: observational studies (prospective and
retrospective)
 Studies in English
 Studies with a sample size >250 (test group with mandibular
angle fracture þ control group without mandibular angle
fracture)
 Mandibular angle fracture caused only by trauma
The exclusion criteria were as follows:
 Study design: review, case report, book, letter
 Studies on animal models and on 3D models
 Studies in which a completely erupted third molar was included
in the missing teeth group
 Mandibular angle fracture caused by iatrogenic injury
2.3. Outcome measures
The main outcome was the frequency of mandibular angle
fracture, as defined by Kelly and Harrigan, 1975 fracture located
posterior to the second molar that extends from any point of the
curve formed by the junction of the body and ramus in the retro-
molar region to any point of the curve formed by the inferior border
of the body and posterior border of the ramus of the mandible.
The primary independent variable was the presence or the
absence of a third molar; the secondary independent variable was
the position of the third molar on the two axes, using the Pell and
Gregory classification (Pell and Gregory, 1933) (Fig. 1).
2.4. Information sources and search strategy
The literary search for this systematic review was conducted
using Pubmed, Scopus, and the Cochrane Library up to 3 February
2017.
The search strategy used a combination of different MESH terms
and keywords on the three databases: “Third Molar”, “Mandibular
Fractures”, “Jaw Fractures”, “Bone Fracture”, “Wisdom Tooth”,
“Wisdom Teeth”, and “Trauma”; the additional filter “Language:
English” was used.
2.5. Study selection
Studies were selected using a two-stage screening by two
independent reviewers; the first-stage screening of title and
abstract was carried out to eliminate irrelevant articles or ar-
ticles that did not meet the inclusion criteria. At the second-
stage screening of full-texts, the study eligibility was verified.
The level of agreement between the two reviewers was calcu-
lated using kappa statistics for the first- and second-stage
screening; disagreements about inclusion or exclusion of
studies were resolved by consensus.
2.6. Data collection process/data items
Data were extracted based on the general study characteristics
(author and year of publication, country, and study design) and
population characteristics (number of participants, mean age,
gender, kind of variable/outcome classifications, main cause of
mandibular angle fracture, and outcomes described).
2.7. Risk of bias in individual studies
The quality and risk of bias in all included studies were inde-
pendently assessed by two authors using the NewcastleeOttawa
Quality Assessment Scale.
 F. Giovacchini et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2018) 1e8 3

Fig. 1. Pell and Gregory classification: Vertical position of the third molar: Class A: the occlusal plane of the third molar is at the same level as the occlusal plane of the adjacent
second molar, Class B: the occlusal plane of the third molar is between the occlusal plane of the second molar and the cementeenamel junction, Class C: the occlusal plane of the
third molar is below the cementeenamel junction of the second molar. Horizontal position of the third molar: Class I: adequate space available for the third molar, between the
anterior border of the ramus and the second molar, Class II: inadequate space available, Class III: third molar located all or mostly within the ascending ramus.

3. Results
3.1. Study selection
A PRISMA flow chart, describing the study selection and inclu-
sion process, is shown in Fig. 2. The initial search resulted in 551
articles in Pubmed, Scopus, and the Cochrane Library, after exclu-
sion of 71 duplicates. After first-stage screening of titles and ab-
stracts, 24 articles qualified for second-stage screening of the full-
text: seven articles met the inclusion criteria and 17 were
excluded. The reasons for exclusion were as follows: four studies
were letters to the editor; one study included fewer than 250 pa-
tients; three full texts were not available; four studies had un-
completed data; one study reported unclear data; and four studies
analysed different variables.
The kappa value for inter-reviewer agreement was 0.96 at title
and abstract screening and 0.92 at full-text screening, demon-
strating good agreement between the reviewers.
3.2. Study characteristics
Table 1 summarises the study design and population charac-
teristics for each included article. All the studies were in English
and all were retrospective. The articles were published in four of
the leading journals on oral and maxillofacial surgery: four in the
Journal of Oral and Maxillofacial Surgery (Lee and Dodson, 2000;
Fuselier et al., 2002; Halmos et al., 2004; Subhashraj, 2009); one
in the International Journal of Oral and Maxillofacial Surgery
(Thangavelu et al., 2010); one in Dental Traumatology (Antic et al.,
2016a, b); and one in Oral Surgery, Oral Medicine and Oral Pathol-
ogy (Ma'aita and Alwrikat, 2000). The countries in which the
studies were conducted were the USA (n ¼ 3), India (n ¼ 2), Jordan
(n ¼ 1), and Serbia (n ¼ 1). The studies were published in two
decades, with five in the 2000s (Lee and Dodson, 2000; Ma'aita and
Alwrikat, 2000; Fuselier et al., 2002; Halmos et al., 2004;
Subhashraj, 2009) and two in the 2010s (Thangavelu et al., 2010;
Antic et al., 2016a, b). The patient sample ranged from 367 (Lee
and Dodson, 2000) to 2033 (Subhashraj, 2009). Five of the seven
papers focused only on mandibular angle fracture (Ma'aita and
Alwrikat, 2000; Lee and Dodson, 2000; Fuselier et al., 2002;
Halmos et al., 2004; Subhashraj, 2009), while two studies
described both condylar and mandibular angle fractures
(Thangavelu et al., 2010; Antic et al., 2016a, b).
3.3. Synthesis of results
All the studies used radiographic examination to assess the
defined predictor variable (presence or absence of third molar and
its position) and outcome variable (presence or absence of
mandibular angle fracture). Five studies also used patients' charts
to confirm both variables (Lee and Dodson, 2000; Ma'aita and
Alwrikat, 2000; Halmos et al., 2004; Subhashraj, 2009;
Thangavelu et al., 2010). All the included studies reported data on
presence/absence of a third molar and its position according to the
Pell and Gregory classification; mandibular angle fracture was al-
ways described according to the definition of Kelly and Harrigan
(Kelly and Harrigan, 1975). Two studies reported incomplete data
on third molar position and were excluded from third molar posi-
tion quantitative analysis; one study reported unclear data
(Thangavelu et al., 2010 (Thangavelu et al., 2010)) and the other
study described only a combination of Pell and Gregory classes
(Halmos et al., 2004).
3.4. Relative risk for mandibular angle fracture related to the
presence of mandibular third molar
Grouping studies reporting data on third molar presence/
absence and mandibular angle fracture presence/absence revealed
a total of 6034 third molars recorded in the seven studies.
Furthermore, 2329 mandibular angle fractures were described;
1852 (79.52%) of these fractures presented a third molar, while in
477 (20.48%) of them the tooth was missing. The mean inter-studies
incidence of third molar was 67.15%, ranging from 56.52%
(Thangavelu et al., 2010) to 72.11% (Subhashraj, 2009). The mean
inter-studies incidence of mandibular angle fracture with third
molar presence was 79.56%, ranging from 74.06% (Subhashraj,
2009) to 83.55% (Ma'aita and Alwrikat, 2000) (Table 1).

Please cite this article in press as: Giovacchini F, et al., Association between third molar and mandibular angle fracture: A systematic review and
meta-analysis, Journal of Cranio-Maxillo-Facial Surgery (2018), https://doi.org/10.1016/j.jcms.2017.12.011
4 F. Giovacchini et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2018) 1e8

Fig. 2. PRISMA flow chart of study inclusion.

Table 1
Summary of selected studies.

Mandibular angle fractures and

third molars

Author Year Study design Country Sample Third molar Main cause of Incidence of third Mean age Sex: Number Number Total
n classification/angle mandibular molar in angle M/F with third without
fracture classification fracture fracture groups molars third molars

Antic et al. 2016 Retrospective Serbia 615 Pell and Gregory/Kelly Assault 67.24 33.67 ± 14.94 527/ 228 59 287
cohort and Harrigan (range 15e85 88
years)
Fuselier 2002 Retrospective USA 1210 Pell and Gregory/Kelly N/A 69.17 30.8 ± 10.4 981/ 269 57 326
et al. cohort and Harrigan 229
Halmos 2004 Retrospective USA 1450 Pell and Gregory/Kelly N/A 67.90 30.6 ± 10.4 983/ 605 128 733
et al. cohort and Harrigan (range 2e87 466
years)
Lee and 2000 Retrospective USA 367 Pell and Gregory/Kelly Assault 67.85 31.7 ± 10 290/ 79 20 99
Dodson cohort and Harrigan 76
Ma'aita and 2000 Retrospective Jordan 615 Pell and Gregory/Kelly Road traffic 69.27 33.2 ± 11.4 488/ 127 25 152
Alwrikat cohort and Harrigan accident (range 17e75 127
years)
Subhashraj 2009 Retrospective India 2033 Pell and Gregory/Kelly Road traffic 72.11 29.8 ± 9.6 1617/ 394 138 532
cohort and Harrigan accident (range 15e69 416
years)
Thangavelu 2010 Retrospective India 460 Pell and Gregory/Kelly Road traffic 56.52 N/A (range 345/ 150 50 200
et al. cohort and Harrigan accident from 16 years) 115
Overall 6750 67.15 1852 477 2329

Please cite this article in press as: Giovacchini F, et al., Association between third molar and mandibular angle fracture: A systematic review and
meta-analysis, Journal of Cranio-Maxillo-Facial Surgery (2018), https://doi.org/10.1016/j.jcms.2017.12.011
 F. Giovacchini et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2018) 1e8 5

Table 2
Forest plot showing the risk ratio for mandibular angle fracture with the presence of third molar.

Author Risk ratio (95% CI) Weight (%)

Anc et al. 1.88 (1.45–2.44) 14.68
Fuselier et al. 2.10 (1.62–2.72) 14.72
Halmos et al. 2.23 (1.88–2.66) 16.00
Lee and Dodson 1.87 (1.21–2.90) 11.52
Ma’aita and Alwrikat 2.25 (1.52–3.34) 12.33
Subhashray 1.10 (0.93–1.31) 16.08
Thangavelu et al. 2.31 (1.78–3.00) 14.66
Overall 1.90 (1.47–2.46)
Heterogeneity I2 = 86.55; T2 = 0.10; df = 6
Test for overall effect Z = −0.45

Meta-analysis for the comparison of mandibular angle fracture The absence of publication bias for the correlation between
among selected studies is described in Table 2. The overall relative mandibular angle fracture and third molar presence can be
risk was 1.90 (95% CI ¼ 1.47e2.46) for third molar presence, sug- observed visually using the funnel plot in Fig. 3, which shows a
gesting a two-fold risk of mandibular angle fracture when the third symmetrical result. Furthermore, statistical analyses showed non-
molar is present. The comparison showed a high degree of het- significant results for both the Egger's linear regression test and
erogeneity among selected studies, with an I2 test value of 86.55%. the Begg and Mazumdar's rank correlation test. Even the Egger's
linear regression tests and Begg and Mazumdar's rank correlation
tests for the relation between mandibular angle fracture and the
3.5. Relative risk for mandibular angle fracture related to the
different third molar positions reported non-significant results. All
position of mandibular third molar
these analyses show that there is an overall Low risk of bias.
Five studies separately reporting third molar position on the
horizontal and vertical axes were included; one study was excluded
4. Discussion
for unclear Pell and Gregory classification data (Thangavelu et al.,
2010), while another study described the two-axes combination
There are many studies in the literature that underline the in-
only (Halmos et al., 2004). Three studies reported Class B as the
fluence of a third molar on mandibular angle fracture (Rahimi-
main third molar position on the vertical axis associated with
Nedjat et al., 2016; Meisami et al., 2002; Hasegawa et al., 2016;
mandibular angle fracture, with percentages of 38.8% (Antic et al.,
Iida et al., 2005).
2016a), 42.18% (Fuselier et al., 2002), and 48.65% (Lee and
The aim of the study was to evaluate the influence of the pres-
Dodson, 2000). Two studies reported Class C as the main third
ence and position of a third molar on mandibular angle fractures.
molar position on the vertical axis associated with mandibular
Some studies were excluded for placing completely erupted
angle fracture, with percentages of 83.33% (Ma'aita and Alwrikat,
third molars in the missing third molar group, so the described
2000) and 85.05% (Subhashraj, 2009). Two studies reported Class
association would be underestimated (Iida et al., 2004; Zhu et al.,
II as the main third molar position on the horizontal axis associated
2005; Duan and Zhang, 2008; Naghipur et al., 2014).
with mandibular angle fracture, with percentages of 37.13%
Some studies showed significant heterogeneity in relation to
(Fuselier et al., 2002) and 36% (Lee and Dodson, 2000). Two studies
many epidemiological aspects, such as the patient sample included
reported Class III as the main third molar position on the horizontal
in the study, as well as differences related to gender, age, and cause
axis associated with mandibular angle fracture, with percentages of
of injury.
80.49% (Ma'aita and Alwrikat, 2000) and 75.68% (Subhashraj,
In his study Subhashraj (2009) reported a statistically significant
2009). Antic et al. (2016a) described Class II/Class III as the main
difference between patients with angle fractures and those without
third molar position on the horizontal axis associated with
angle fractures in terms of gender, age, and mechanism of injury
mandibular angle fracture, with a percentage of 38.1%.
(p < 0.001).
Meta-analysis for the comparison of mandibular angle fracture
Halmos et al. showed that subjects with mandibular angle
among selected studies presented an overall relative risk of 1.18 (95%
fractures were statistically younger than subjects without angle
CI ¼ 0.62e2.25), 1.98 (95% CI ¼ 0.95e4.10), 2.72 (95% CI ¼ 1.78e4.16),
fracture (29.5 versus 30.8 years) (Halmos et al., 2004). In their
1.31 (95% CI ¼ 0.80e2.14), 2.21 (95% CI ¼ 1.69e2.87), and 2.99 (95%
study, Antic et al. (2016a) reported a statistically significant differ-
CI ¼ 2.12e4.22) for Class A (Table 3), Class B (Table 4), Class C
ence in patients with mandibular angle fracture aged between 15
(Table 5), Class I (Table 6), Class II (Table 7), and Class III (Table 8),
and 25 years, with a 1.7-fold higher relative risk. These studies
respectively. The comparisons presented a high degree of hetero-
confirmed a major incidence of mandibular angle fracture in
geneity for Class A, Class B, Class C, Class I, and Class III, with I2 test
younger patients, relating to their dentate condition and their
values of 94.70%, 95.67%, 87.45%, 92.00%, and 76.65%, respectively,
attitude to contact sports.
and a medium degree of heterogeneity for Class II (I2 ¼ 71,15%),
Our meta-analysis of selected studies gives an overall relative
among selected studies. This heterogeneity is due to the lack of
risk of 1.90 (95% CI ¼ 1.47e2.46) of developing mandibular angle
uniformity in the reporting of third molar position.
fracture with the presence of a third molar in patients who present
mandibular fractures.
3.6. Risk of bias assessment In his study, Subhashraj (2009) highlighted an inferior relative
risk (1.10; 95% CI ¼ 0.93e1.31) when compared with our overall
Risk of bias analyses were performed using the relative risk; this may be explained by the fact that the main
NewcastleeOttawa scale; all the studies were classified as five out cause of trauma was road traffic accidents (64%). Fridrich et al.
of eight stars, showing that included articles were of good quality (Fridrich et al., 1992; Bezerra et al., 2011) showed that when
(Table 9). considering fractures caused by car accidents, the condylar region

Please cite this article in press as: Giovacchini F, et al., Association between third molar and mandibular angle fracture: A systematic review and
meta-analysis, Journal of Cranio-Maxillo-Facial Surgery (2018), https://doi.org/10.1016/j.jcms.2017.12.011
6 F. Giovacchini et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2018) 1e8

Table 3
Forest plot and sensitivity analysis presenting risk ratio for mandibular angle fracture with Class A third molar position.

Author Risk ratio (95% Weight (%) Forest plot Sensitivity analysis
CI)
Anc et al. 1.55 (1.16–2.05) 20.53
Fuselier et al. 1.91 (1.45–2.51) 20.59
Lee and Dodson 1.81 (1.14–2.86) 19.30
Ma’aita and Alwrikat 1.04 (0.63–1.72) 18.97
Subhashray 0.41 (0.32–0.54) 20.60
Overall 1.18 (0.62–2.25)
Heterogeneity I2 = 94.70; T2= 0.51; df = 4
Test for overall effect Z = −0.49

Table 4
Forest plot and sensitivity analysis presenting risk ratio for mandibular angle fracture with Class B third molar position.

Author Risk ratio (95% Weight (%) Forest plot Sensitivity analysis
CI)
Anc et al. 2.65 (1.96–3.59) 20.35
Fuselier et al. 2.76 (2.03–3.74) 20.34
Lee and Dodson 2.87 (1.71–4.82) 19.05
Ma’aita and Alwrikat 2.61 (1.71–3.97) 19.71
Subhashray 0.58 (0.45–0.75) 20.54
Overall 1.98 (0.95–4.10)
Heterogeneity I2 = 95.67; T2 = 0.66; df = 4
Test for overall effect Z = 0.00

Table 5
Forest plot and sensitivity analysis presenting risk ratio for mandibular angle fracture with Class C third molar position.

Author Risk ratio (95% Weight (%) Forest plot Sensitivity analysis
CI)
Anc et al. 2.24 (1.60–3.15) 21.58
Fuselier et al. 2.07 (1.48–2.89) 21.67
Lee and Dodson 0.87 (0.35–2.14) 11.76
Ma’aita and Alwrikat 6.30 (4.28–9.27) 20.74
Subhashray 3.49 (3.00–4.07) 24.25
Overall 2.72 (1.78–4.16)
Heterogeneity I2 = 87.45; T2 = 0.19; df = 4
Test for overall effect Z = −0.49

Table 6
Forest plot and sensitivity analysis presenting risk ratio for mandibular angle fracture with Class I third molar position.

Author Risk ratio (95% Weight (%) Forest plot Sensitivity analysis
CI)
Anc et al. 1.40 (1.04–1.87) 20.60
Fuselier et al. 1.92 (1.46–2.52) 20.80
Lee and Dodson 1.78 (1.12–2.83) 18.54
Ma’aita and Alwrikat 1.33 (0.84–2.09) 18.68
Subhashray 0.64 (0.52–0.78) 21.39
Overall 1.31 (0.80–2.14)
Heterogeneity I2 = 92.00; T2 = 0.28; df = 4
Test for overall effect Z = 0.49

was the most common site of mandibular fracture. In contrast,
mandibular angle fractures were more commonly caused by lower-
intensity traumatic injury, such as assault or sport injuries.
Forest plots that showed the relationship between mandibular
angle fracture and different third molar positions showed statisti-
cally significant differences in Class C, Class II, and Class III.
Sensitivity analysis (Fig. 4) demonstrated that, without Sub-
hashraj's study (Subhashraj, 2009), all the six classes showed a
statistically significant difference between the groups for angle
fracture incidence, with a higher effect size for Class B (2.71; 95%
CI ¼ 2.26e3.24), Class C (2.42; 95% CI ¼ 1.26e4.62), Class II (2.51;
95% CI ¼ 2.12e2.99), and Class III (2.89; 95% CI ¼ 1.68e4,.98). This
result may be explained by the fact that the main cause of trauma in
Subhashraj's study was road traffic accidents: this may affect the
relative risk of each class of mandibular third molar position due to
the specific direction and intensity of the traumatic injury.

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 F. Giovacchini et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2018) 1e8 7

Table 7
Forest plot and sensitivity analysis presenting risk ratio for mandibular angle fracture with Class II third molar position.

Author Risk ratio (95% Weight (%) Forest plot Sensitivity analysis
CI)
Anc et al. 2.61 (1.97–3.44) 22.48
Fuselier et al. 2.43 (1.82–3.25) 21.94
Lee and Dodson 2.12 (1.23–3.66) 13.17
Ma’aita and Alwrikat 2.75 (1.80–4.22) 16.82
Subhashray 1.55 (1.27–1.88) 25.59
Overall 2.21 (1.69–2.87)
Heterogeneity I2 = 71.15; T2 = 0.06; df = 4
Test for overall effect Z = 0.00

Table 8
Forest plot and sensitivity analysis presenting risk ratio for mandibular angle fracture with Class III third molar position.

Author Risk ratio (95% Weight (%) Forest plot Sensitivity analysis
CI)
Anc et al. 2.60 (1.66–4.09) 18.81
Fuselier et al. 2.38 (1.60–3.55) 20.26
Lee and Dodson 1.69 (0.90–3.14) 14.56
Ma’aita and Alwrikat 6.08 (4.10–9.03) 20.36
Subhashray 3.11 (2.62–3.69) 26.02
Overall 2.99 (2.12–4.22)
Heterogeneity I2 = 76.65; T2 = 0.11; df = 4
Test for overall effect Z = −1.47

Table 9
Publication bias of included studies, according to the NewcastleeOttawa scale.

Study Selection Comparison Outcome

Antic et al., 2016a, b +++ + +

Fuselier et al. (2002) +++ + +
Halmos et al. (2004) +++ + +
Lee and Dodson (2000) +++ + +
Ma'aita and Alwrikat (2000) +++ + +
Subhashraj (2009) +++ + +
Thangavelu et al. (2010) +++ + +

The “+” is an approved symbol for Newcastle-Ottawa Quality Assessment Scale and
represents the quality of the study

Fig. 4. Sensitivity analysis of the relationship between mandibular angle fracture and
the presence of a third molar.

and Alwrikat, 2000) and Subhashraj (2009) showed that this kind
of fracture was most associated with Class C. On the other hand,
Fuselier et al., 2002 and Lee and Dodson (2000) described an
increased incidence of angle fracture with Class II, in contrast with
Ma'aita and Alwrikat (Ma'aita and Alwrikat, 2000) and Subhashraj
(2009) who reported a major association of this fracture with Class
III. Antic et al. (2016a) reported the same increased incidence of
mandibular angle fractures when both Class II and Class III
occurred.

5. Conclusion

Fig. 3. Funnel plot of the relationship between mandibular angle fracture and the
presence of a third molar.
This sensitivity analysis is in accordance with those reported in
single studies: Antic et al. (2016a), Lee and Dodson (2000), and
Fuselier et al., 2002 reported a major incidence of mandibular angle
fracture when Class B occurred, while Ma'aita and Alwrikat (Ma'aita
Our meta-analysis affirms that there is a statistically significant
association between mandibular angle fracture and third molar
presence in patients who present with mandibular fractures,
especially if the third molar is incompletely erupted. The strength
of this association is particularly relevant when the third molar is
located in Class C, Class II, and Class III, according to the Pell and
Gregory classification.

Please cite this article in press as: Giovacchini F, et al., Association between third molar and mandibular angle fracture: A systematic review and
meta-analysis, Journal of Cranio-Maxillo-Facial Surgery (2018), https://doi.org/10.1016/j.jcms.2017.12.011
8 F. Giovacchini et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2018) 1e8
Ethical approval
This article does not contain any studies with human partici-
pants or animals performed by any of the authors.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interest
None.
Informed consent
For this type of study, formal consent is not required.
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